Script Care 2017 Premier Plus Formulary List
The 2017 Premier Plus Formulary drug list is shown below. The formulary is the list of drugs included in your prescription drug benefit plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter (OTC) product and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes. PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for your prescription drug benefit program. For specific questions about your coverage, please call the phone number printed on your member ID card. KEY [INJ] – Injectable Drug [OTC] – Over-the-counter Product [SP] – Specialty Drug Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY Generic drugs are listed in lower-case letters. Example: ibuprofen
For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, although they may look different in color or shape. They have been FDAapproved under strict standards. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.
A abacavir [SP] abacavir/lamivudine [SP] abacavir/lamivudine/zidovudine [SP] ABELCET [INJ] ABILIFY MAINTENA [INJ] ABRAXANE [INJ] [SP] ABSORICA acamprosate delayed-release ACANYA acarbose ACCU-CHEK FASTCLIX LANCETS [OTC] ACCU-CHEK MULTICLIX LANCET KIT [OTC] ACCU-CHEK MULTICLIX LANCETS [OTC] ACCU-CHEK SOFTCLIX LANCET KIT [OTC] ACCU-CHEK SOFTCLIX LANCETS [OTC] acebutolol acetaminophen/codeine acetaminophen/phenyltoloxamine acetazolamide acetazolamide ext-release acetazolamide sodium [INJ] acetic acid ear solution acetic acid irrigation solution acetic acid/aluminum acetate ear solution acetic acid/hydrocortisone ear solution acetic acid/oxyquinoline vaginal acetylcysteine [INJ] acetylcysteine inhalation solution acitretin ACTEMRA [INJ] [SP] ACTHAR H.P. [INJ] [SP] ACTHIB [INJ] ACTHREL [INJ] ACTIMMUNE [INJ] [SP] ACTIVASE [INJ] ACTOPLUS MET XR acyclovir acyclovir ointment acyclovir sodium [INJ] ADACEL [INJ] ADAGEN [INJ] [SP] adapalene ADCETRIS [INJ] [SP] ADCIRCA [SP] ADDAMEL N [INJ] adefovir ADEMPAS [SP] adenosine [INJ] ADVAIR DISKUS ADVAIR HFA advanced am/pm
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ADVATE [INJ] [SP] ADYNOVATE [INJ] [SP] AFINITOR [SP] AFINITOR DISPERZ [SP] AFLURIA [INJ] AFLURIA QUAD [INJ] AKYNZEO ALBENZA albumin human [INJ] albuterol albuterol ext-release albuterol nebulization solution alclometasone ALDURAZYME [INJ] [SP] alendronate alfentanil [INJ] ALFERON N [INJ] alfuzosin ext-release ALIMTA [INJ] ALINIA ALKERAN TABLETS allopurinol allopurinol sodium [INJ] almotriptan alosetron ALOXI [INJ] ALPHAGAN P 0.1% ALPHANATE [INJ] [SP] ALPHANINE SD [INJ] [SP] alphaquin hp alprazolam alprazolam ext-release alprazolam orally disintegrating tablets ALPROLIX [INJ] [SP] alprostadil [INJ] ALREX altavera alyacen amabelz amantadine AMBISOME [INJ] amcinonide amethia amethia lo amethyst AMICAR amifostine [INJ] amikacin [INJ] amiloride amiloride/hydrochlorothiazide amino acid [INJ] aminocaproic acid aminocaproic acid [INJ] aminophylline [INJ] AMINOSYN [INJ] amiodarone
amiodarone [INJ] AMITIZA amitriptyline amitriptyline/chlordiazepoxide amlodipine amlodipine/atorvastatin amlodipine/benazepril amlodipine/valsartan amlodipine/valsartan/hydrochlorothiazide AMMONIUM CHLORIDE [INJ] ammonium lactate 12% topical AMMONUL [INJ] amoxapine amoxicillin amoxicillin/potassium clavulanate amoxicillin/potassium clavulanate ext-release amphotericin [INJ] ampicillin ampicillin sodium [INJ] ampicillin sodium/sulbactam [INJ] AMPYRA [SP] AMYTAL [INJ] anagrelide anastrozole ANDROGEL 1.62% GEL ANORO ELLIPTA anthralin APLISOL [INJ] APOKYN [INJ] [SP] apraclonidine eye solution apri APRISO APTIVUS [SP] AQUASOL A [INJ] ARALAST NP [INJ] [SP] aranelle arbinoxa ARCALYST [INJ] [SP] ARCAPTA NEOHALER ARGATROBAN [INJ] ARGATROBAN/SODIUM CHLORIDE ISO-OSMOTIC [INJ] aripiprazole aripiprazole orally disintegrating tablets ARISTADA [INJ] ARISTOSPAN [INJ] armodafinil ARMOUR THYROID ARNUITY ELLIPTA ARRANON [INJ] [SP] ARZERRA [INJ] [SP] ascorbic acid [INJ] ashlyna ASMANEX HFA ASMANEX TWISTHALER aspirin/dipyridamole ext-release Page 1
atenolol atenolol/chlorthalidone ATGAM [INJ] atorvastatin atovaquone atovaquone/proguanil ATRIPLA [SP] atropine [INJ] atropine sulfate eye ointment atropine sulfate eye solution ATROVENT HFA aubra AUGMENTIN 125-31.25 MG/5 ML AVASTIN [INJ] [SP] AVELOX IV [INJ] aviane avo cream AVONEX [INJ] [SP] AVYCAZ [INJ] AXIRON azacitidine [INJ] [SP] AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] AZASAN [SP] AZASITE azathioprine [SP] azathioprine sodium [INJ] [SP] azelastine eye solution azelastine nasal spray AZILECT azithromycin azithromycin [INJ] AZOR aztreonam [INJ] azuphen mb azurette
B bacitracin [INJ] bacitracin eye ointment bacitracin/polymyxin eye ointment baclofen BAL IN OIL [INJ] balanced salt eye irrigation solution bal-care dha prenatal vitamins balsalazide balziva BANZEL BARACLUDE SOLUTION b-complex [INJ] BEBULIN [INJ] [SP] bekyree benazepril benazepril/hydrochlorothiazide BENDEKA [INJ] [SP] BENEFIX [INJ] [SP] BENICAR BENICAR HCT
Rev 11012016 Please note that this document is subject to change.
BENLYSTA [INJ] [SP] benoxinate/fluorescein eye solution benzonatate benzoyl peroxide benzphetamine benztropine benztropine [INJ] BEPREVE BERINERT [INJ] [SP] betamethasone acetate/betamethasone sodium phosphate [INJ] betamethasone dipropionate betamethasone dipropionate augmented betamethasone valerate BETASERON [INJ] [SP] betaxolol betaxolol eye solution bethanechol BETHKIS [SP] BEVESPI AEROSPHERE bexarotene [SP] BEXSERO [INJ] bicalutamide BICILLIN C-R [INJ] BICILLIN L-A [INJ] BICNU [INJ] BILTRICIDE bimatoprost eye solution BIOTHRAX [INJ] bisoprolol bisoprolol/hydrochlorothiazide bivalirudin [INJ] blanche bleomycin [INJ] BLINCYTO [INJ] [SP] blisovi 24 fe blisovi fe BLOXIVERZ [INJ] BOOSTRIX [INJ] BOSULIF BOTOX [INJ] [SP] bp vit 3 bp vit 3 plus BREO ELLIPTA BREVITAL [INJ] briellyn BRILINTA brimonidine eye solution BRISDELLE bromfenac eye solution bromocriptine brompheniramine/pseudoephedrine/ codeine brompheniramine/pseudoephedrine/ dextromethorphan budesonide ext-release budesonide nasal spray budesonide nebulization suspension bumetanide bumetanide [INJ] BUPHENYL TABLETS bupivacaine [INJ] bupivacaine/dextrose [INJ] bupivacaine/epinephrine [INJ] buprenorphine buprenorphine [INJ] buprenorphine/naloxone bupropion bupropion ext-release bupropion ext-release (smoking deterrent) buspirone BUSULFEX [INJ] butalbital/acetaminophen butalbital/acetaminophen/caffeine butalbital/acetaminophen/caffeine/ codeine butalbital/aspirin/caffeine butalbital/aspirin/caffeine/codeine
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butorphanol [INJ] butorphanol nasal BUTRANS BYDUREON [INJ] BYETTA [INJ] BYSTOLIC BYVALSON
C cabergoline caffeine citrated caffeine citrated [INJ] caffeine/sodium benzoate [INJ] calcipotriene calcipotriene/betamethasone dipropionate calcitonin salmon nasal calcitriol calcitriol [INJ] calcitriol ointment calcium acetate calcium chloride [INJ] CALCIUM DISODIUM VERSENATE [INJ] calcium gluconate [INJ] calcium-folic acid plus d calcium-pnv 28-1-250 prenatal vitamins CALDOLOR [INJ] camila CAMPATH [INJ] camrese camrese lo CANASA CANCIDAS [INJ] candesartan candesartan/hydrochlorothiazide CAPASTAT SULFATE [INJ] capecitabine [SP] CAPRELSA [SP] captopril captopril/hydrochlorothiazide CARAC CARAFATE SUSPENSION carbachol [INJ] CARBAGLU [SP] carbamazepine carbamazepine ext-release carbidopa carbidopa/levodopa carbidopa/levodopa ext-release carbidopa/levodopa orally disintegrating tablets carbidopa/levodopa/entacapone carbinoxamine carboplatin [INJ] carteolol eye solution carvedilol CATHFLO ACTIVASE [INJ] CAVERJECT [INJ] CAYSTON [SP] caziant cefaclor cefaclor ext-release cefadroxil cefazolin [INJ] cefazolin/dextrose [INJ] cefdinir cefditoren cefepime [INJ] cefepime/dextrose [INJ] cefixime cefotaxime [INJ] cefotetan [INJ] cefoxitin [INJ] cefoxitin/dextrose [INJ] cefpodoxime cefprozil ceftazidime [INJ] CEFTAZIDIME/DEXTROSE [INJ] ceftibuten ceftriaxone [INJ] ceftriaxone/dextrose [INJ] Page 2
cefuroxime axetil cefuroxime sodium [INJ] celacyn celecoxib CELLCEPT [INJ] [SP] CELONTIN centratex cephalexin CEPROTIN [INJ] [SP] CERDELGA [SP] CEREZYME [INJ] [SP] CERVARIX [INJ] cetirizine syrup CETROTIDE [INJ] [SP] cevimeline CHANTIX chateal CHEMET CHENODAL [SP] chloramphenicol [INJ] chlorcyclizine/pseudoephedrine/codeine chlordiazepoxide chlordiazepoxide/clidinium chlorhexidine gluconate chloroquine chlorothiazide chlorothiazide sodium [INJ] chlorpheniramine/phenylephrine/ dextromethorphan chlorpromazine chlorpromazine [INJ] chlorthalidone chlorzoxazone choice-tabs CHOLBAM [SP] cholestyramine cholestyramine light choline salicylate/magnesium salicylate CHORIONIC GONADOTROPIN [INJ] [SP] chromium chloride [INJ] CIALIS ciclopirox ciclopirox shampoo cidofovir [INJ] ciferex cilostazol cimetidine CINRYZE [INJ] [SP] CIPRODEX ciprofloxacin ciprofloxacin ear solution ciprofloxacin ext-release ciprofloxacin eye solution ciprofloxacin lactate [INJ] ciprofloxacin lactate/dextrose [INJ] cisplatin [INJ] citalopram citric acid/sodium citrate cladribine [INJ] clarithromycin clarithromycin ext-release clemastine clindamycin hcl clindamycin palmitate clindamycin phosphate [INJ] clindamycin phosphate topical clindamycin phosphate vaginal clindamycin phosphate/benzoyl peroxide clindamycin phosphate/dextrose [INJ] clindamycin phosphate/tretinoin CLINIMIX [INJ] CLINIMIX E [INJ] clobetasol propionate clobetasol propionate shampoo clobetasol propionate/emollient CLOLAR [INJ] clomiphene citrate clomipramine clonazepam
clonazepam orally disintegrating tablets clonidine clonidine [INJ] clonidine ext-release clonidine patches clonidine/chlorthalidone clopidogrel clorazepate clotrimazole topical clotrimazole troche clotrimazole/betamethasonedipropionate clozapine clozapine orally disintegrating tablets c-nate dha prenatal vitamins COAGADEX [INJ] [SP] COARTEM cocaine topical solution codeine sulfate colchicine/probenecid COLCRYS colestipol colistimethate [INJ] COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMPLERA [SP] complete natal dha prenatal vitamins completenate prenatal vitamins CONDYLOX GEL constulose COPAXONE 40 MG [INJ] [SP] copper chloride [INJ] COREG CR CORIFACT [INJ] [SP] CORLANOR CORTIFOAM cortisone acetate corvita corvita 150 COSENTYX [INJ] [SP] cosyntropin [INJ] CREON CRESEMBA CRESEMBA [INJ] CRINONE 4% CRINONE 8% [SP] CRIXIVAN [SP] CROFAB [INJ] cromolyn sodium eye solution cromolyn sodium nebulization solution cromolyn sodium oral solution cryselle CUBICIN [INJ] cyanocobalamin [INJ] cyclafem cyclobenzaprine cyclopentolate eye solution cyclophosphamide [INJ] CYCLOPHOSPHAMIDE CAPSULES cyclosporine [INJ] [SP] cyclosporine [SP] cyclosporine modified [SP] cyproheptadine CYRAMZA [INJ] [SP] cyred CYSTADANE [SP] CYSTAGON [SP] CYSTARAN [SP] cytarabine [INJ] CYTOGAM [INJ] [SP] cytra-3
D dacarbazine [INJ] DAKLINZA DALVANCE [INJ] danazol dantrolene dantrolene [INJ] dapsone Rev 11012016 Please note that this document is subject to change.
DAPTACEL [INJ] daptomycin [INJ] DARAPRIM [SP] darifenacin ext-release DARZALEX [INJ] [SP] dasetta daunorubicin [INJ] DAUNOXOME [INJ] daysee DAYTRANA deblitane decitabine [INJ] [SP] deferoxamine [INJ] delflex with dextrose [INJ] delyla demeclocycline DEMSER DEPEN DEPOCYT [INJ] DEPO-ESTRADIOL [INJ] DEPO-PROVERA 400 MG/ML [INJ] DESCOVY [SP] desipramine desloratadine desloratadine orally disintegrating tablets desmopressin acetate desmopressin acetate [INJ] [SP] desmopressin nasal desogestrel-ethinyl estradiol desonide desoximetasone dexamethasone dexamethasone sodium phosphate [INJ] dexamethasone sodium phosphate eye solution DEXCOM G4 DEXCOM G5 dexmedetomidine [INJ] dexmethylphenidate dexmethylphenidate ext-release dexrazoxane [INJ] dextran/dextrose [INJ] dextran/normal saline [INJ] dextroamphetamine dextroamphetamine ext-release dextroamphetamine/amphetamine dextroamphetamine/amphetamine ext-release dextrose/lactated ringers [INJ] dextrose/sodium chloride [INJ] dextrose/water [INJ] dialyvite dialyvite/zinc diazepam diazepam [INJ] diazepam rectal gel diclofenac eye solution diclofenac potassium diclofenac sodium delayed-release diclofenac sodium ext-release diclofenac sodium gel diclofenac sodium topical solution diclofenac sodium/misoprostol extrelease dicloxacillin dicyclomine dicyclomine [INJ] didanosine delayed-release [SP] diethylpropion diethylpropion ext-release diflorasone diflorasone/emollient diflunisal digoxin digoxin [INJ] dihydrocodeine/acetaminophen/caffeine dihydrocodeine/aspirin/caffeine dihydroergotamine [INJ] dihydroergotamine nasal
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DILANTIN 30 MG CAPSULES DILATRATE-SR diltiazem diltiazem [INJ] diltiazem ext-release dimenhydrinate [INJ] diphenhydramine diphenhydramine [INJ] diphenoxylate/atropine DIPHTHERIA-TETANUS TOXOIDSPED [INJ] dipyridamole dipyridamole [INJ] disulfiram divalproex sodium divalproex sodium delayed-release divalproex sodium ext-release DIVIGEL dobutamine [INJ] dobutamine/dextrose [INJ] DOCEFREZ [INJ] docetaxel [INJ] dofetilide donepezil donepezil orally disintegrating tablets dopamine [INJ] dopamine/dextrose [INJ] DORIBAX [INJ] dorzolamide eye solution dorzolamide/timolol eye solution dothelle dha prenatal vitamins doxazosin doxepin doxepin cream doxercalciferol doxercalciferol [INJ] doxorubicin [INJ] doxorubicin/liposomal [INJ] doxycycline hyclate doxycycline hyclate [INJ] doxycycline hyclate delayed-release doxycycline monohydrate dronabinol droperidol [INJ] drospirenone-ethinyl estradiol drospirenone-ethinyl estradiol-levomefolate DROXIA DUAVEE DULERA duloxetine delayed-release dutasteride dutasteride/tamsulosin ext-release DYMISTA
E econazole edrophonium [INJ] EDURANT [SP] EFFIENT EGRIFTA [INJ] [SP] ELAPRASE [INJ] [SP] electrolyte-48 solution/dextrose [INJ] ELELYSO [INJ] [SP] eletone ELIDEL ELIGARD [INJ] [SP] elinest eliphos ELIQUIS elite ob prenatal vitamins ELITEK [INJ] elite-ob prenatal vitamins ELMIRON ELOCTATE [INJ] [SP] EMCYT EMEND EMEND [INJ] emoquette EMTRIVA [SP] emulsion sb Page 3
EMVERM enalapril enalapril/hydrochlorothiazide enalaprilat [INJ] ENBREL [INJ] [SP] ENGERIX-B [INJ] ENJUVIA enoxaparin [INJ] [SP] enpresse enskyce ENSTILAR entacapone entecavir ENTRESTO ENTYVIO [INJ] [SP] EOVIST [INJ] ephedrine [INJ] EPIDUO EPIDUOFORTE epinastine eye solution epinephrine auto-injector [INJ] EPIPEN [INJ] EPIPEN JR. [INJ] epirubicin [INJ] EPIVIR HBV SOLUTION eplerenone epoprostenol [INJ] [SP] epoprostenol diluent [INJ] [SP] eprosartan eptifibatide [INJ] ERAXIS [INJ] ERBITUX [INJ] [SP] ergocalciferol ergoloid mesylates ergotamine tartrate/caffeine suppositories ERIVEDGE [SP] errin ERYTHROCIN [INJ] erythromycin erythromycin delayed-release erythromycin ethylsuccinate erythromycin eye ointment erythromycin stearate erythromycin topical erythromycin/benzoyl peroxide ESBRIET [SP] escitalopram esmolol [INJ] esomeprazole magnesium delayed-release esomeprazole sodium [INJ] estarylla estazolam esterified estrogens/methyltestosterone ESTRACE CREAM estradiol estradiol patches estradiol valerate [INJ] estradiol/norethindrone acetate estropipate eszopiclone ethacrynate [INJ] ethacrynic acid ethambutol ETHAMOLIN [INJ] ethosuximide ethyl alcohol [INJ] ethyl chloride spray etidronate etodolac etodolac ext-release etomidate [INJ] ETOPOPHOS [INJ] etoposide etoposide [INJ] EUFLEXXA [INJ] [SP] EVEKO exemestane
EXJADE [SP] EXTAVIA [INJ] [SP] EXTRANEAL ICODEXTRIN DIALYSIS SOLUTION [INJ] EYLEA [INJ] [SP]
F fabb FABRAZYME [INJ] [SP] falmina famciclovir famotidine famotidine [INJ] famotidine/sodium chloride [INJ] FARESTON FARXIGA FASLODEX [INJ] fe c plus FEIBA NF [INJ] [SP] felbamate felodipine ext-release fenofibrate fenofibrate micronized fenofibric acid fenofibric acid delayed-release fenoprofen fentanyl citrate [INJ] fentanyl citrate lozenges fentanyl patches FERAHEME [INJ] ferocon ferraplus 90 ferrex 150 forte ferrex 150 forte plus ferrex 28 FERRIPROX [SP] ferrocite plus ferrogels forte FETZIMA FINACEA finasteride FIRAZYR [INJ] [SP] FIRMAGON [INJ] [SP] flavoxate flecainide FLOLAN [INJ] [SP] FLOLAN DILUENT [INJ] [SP] FLOVENT DISKUS FLOVENT HFA floxuridine [INJ] FLUAD [INJ] FLUARIX QUAD [INJ] FLUBLOK [INJ] FLUCELVAX QUAD [INJ] fluconazole fluconazole/dextrose [INJ] fluconazole/normal saline [INJ] flucytosine fludarabine [INJ] fludrocortisone acetate FLULAVAL QUAD [INJ] flumazenil [INJ] flunisolide nasal spray fluocinolone fluocinolone acetonide oil ear solution fluocinonide fluocinonide/emollient fluorescein [INJ] fluorescein eye strips fluorometholone eye suspension fluorouracil fluorouracil [INJ] fluoxetine fluoxetine delayed-release fluoxymesterone fluphenazine decanoate [INJ] fluphenazine hcl fluphenazine hcl [INJ] flurandrenolide flurazepam Rev 11012016 Please note that this document is subject to change.
flurbiprofen flurbiprofen sodium eye solution flutamide fluticasone nasal spray fluticasone topical fluvastatin fluvastatin ext-release FLUVIRIN [INJ] fluvoxamine fluvoxamine ext-release FLUZONE [INJ] FLUZONE QUAD [INJ] FML S.O.P. focalgin 90 dha prenatal vitamins focalgin ca prenatal vitamins focalgin dss FOCALIN XR 25 MG, 35 MG folbecal prenatal vitamins folbee folbee ar folbee plus folbee plus cz folbic folic acid folic acid [INJ] folic acid/cyanocobalamin/pyridoxine folivane-f folivane-ob prenatal vitamins folivane-plus FOLOTYN [INJ] [SP] folplex 2.2 fomepizole [INJ] fondaparinux [INJ] [SP] FORA LANCING DEVICE [OTC] FORACARE 30G LANCETS [OTC] FORTAZ-ISO-OSMOTIC DEXTROSE [INJ] FORTEO [INJ] [SP] foscarnet [INJ] fosinopril fosinopril/hydrochlorothiazide fosphenytoin [INJ] FOSRENOL FRAGMIN [INJ] [SP] FREAMINE HBC [INJ] freamine iii [INJ] frovatriptan furosemide furosemide [INJ] FUZEON [INJ] [SP] fyavolv FYCOMPA G gabapentin GABITRIL 12 MG, 16 MG GABLOFEN [INJ] galantamine galantamine ext-release GAMASTAN S-D [INJ] [SP] GAMMAGARD LIQUID [INJ] [SP] GAMMAGARD S-D [INJ] [SP] GAMUNEX-C [INJ] [SP] ganciclovir [INJ] GARDASIL [INJ] GARDASIL 9 [INJ] gatifloxacin eye solution gavilyte h + bisacodyl kit gavilyte-c gavilyte-g gavilyte-n GAZYVA [INJ] [SP] GELNIQUE gemcitabine [INJ] gemfibrozil GENOTROPIN [INJ] [SP] gentamicin [INJ] gentamicin eye ointment gentamicin eye solution gentamicin topical
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IMPAVIDO inatal advance prenatal vitamins inatal ultra prenatal vitamins INCRELEX [INJ] [SP] INCRUSE ELLIPTA indapamide indomethacin indomethacin ext-release indomethacin sodium [INJ] INFANRIX [INJ] infed [INJ] INFUMORPH [INJ] INFUVITE [INJ] INLYTA [SP] INTELENCE [SP] intralipid 20% [INJ] INTRON A [INJ] [SP] introvale INVANZ [INJ] INVIRASE [SP] INVOKAMET INVOKANA iodine/potassium IODOPEN [INJ] IONOSOL/DEXTROSE [INJ] IPOL [INJ] ipratropium bromide nasal spray ipratropium bromide nebulization solution ipratropium/albuterol sulfate nebulization solution irbesartan irbesartan/hydrochlorothiazide IRESSA [SP] irinotecan [INJ] ISENTRESS [SP] ISOLYTE [INJ] isometheptene/caffeine/acetaminophen isometheptene/dichloralphenazone/ acetaminophen isoniazid isoniazid [INJ] isosorbide dinitrate isosorbide dinitrate ext-release isosorbide mononitrate isosorbide mononitrate ext-release isotretinoin isoxsuprine isradipine ISTODAX [INJ] [SP] itraconazole ivermectin IXEMPRA [INJ] [SP] IXIARO [INJ] IXINITY [INJ] [SP]
homatropine eye solution hpr emollient foam hpr plus hpr plus hydrogel HUMALOG [INJ] HUMATE-P [INJ] [SP] HUMATROPE [INJ] [SP] HUMIRA [INJ] [SP] HUMULIN [INJ] [OTC] HUMULIN R 500 UNITS [INJ] HYCAMTIN CAPSULES [SP] hydralazine hydralazine [INJ] hydrochlorothiazide hydrocodone/acetaminophen hydrocodone/chlorpheniramine polistirex ext-release hydrocodone/chlorpheniramine/ pseudoephedrine hydrocodone/homatropine hydrocodone/ibuprofen hydrocortisone hydrocortisone acetate suppositories hydrocortisone butyrate hydrocortisone butyrate/emollient hydrocortisone enema hydrocortisone sodium succinate [INJ] hydrocortisone topical hydrocortisone valerate hydrocortisone/iodoquinol hydrocortisone/iodoquinol/aloe hydrocortisone/lidocaine hydrocortisone/pramoxine hydromorphone hydromorphone [INJ] hydromorphone ext-release hydromorphone suppositories hydroquinone hydroquinone microspheres hydroxocobalamin [INJ] hydroxychloroquine hydroxyprogesterone hydroxyurea hydroxyzine hcl hydroxyzine hcl [INJ] hydroxyzine pamoate hyolev mb hyophen hyoscyamine hyoscyamine ext-release hyoscyamine orally disintegrating tablets HYPERHEP B S-D [INJ] HYPERRAB S-D [INJ] HYPERRHO S-D [INJ] HYPERTET S-D [INJ] HYSINGLA ER
gentamicin/normal saline [INJ] GENTAMICIN/NORMAL SALINE 100 MG/50 ML [INJ] GENVOYA [SP] gianvi gildagia gildess gildess 24 fe gildess fe GILENYA [SP] GILOTRIF [SP] glatopa [INJ] [SP] GLEOSTINE glimepiride glipizide glipizide ext-release glipizide/metformin GLUCAGEN [INJ] GLUCAGON [INJ] glyburide glyburide micronized glyburide/metformin glycine irrigation solution glycolax GLYCOPHOS [INJ] glycopyrrolate glycopyrrolate [INJ] GLYXAMBI GONAL-F [INJ] [SP] GONAL-F RFF [INJ] [SP] GONAL-F RFF REDI-JECT [INJ] [SP] GRALISE granisetron granisetron [INJ] GRANIX [INJ] [SP] GRASTEK griseofulvin microsize griseofulvin ultramicrosize guaifenesin/codeine guaifenesin/phenylephrine guanfacine guanfacine ext-release guanidine H HALAVEN [INJ] [SP] halobetasol haloperidol haloperidol decanoate [INJ] haloperidol lactate haloperidol lactate [INJ] HARVONI [SP] HAVRIX [INJ] heather HECTOROL 2 MCG/ML [INJ] HELIXATE FS [INJ] [SP] HEMABATE [INJ] hematinic with folic acid hematinic-vitamin-mineral hematogen hematogen fa hematogen forte hemenatal ob + dha prenatal vitamins hemenatal ob prenatal vitamins hemetab HEMOFIL-M [INJ] [SP] HEPAGAM B [INJ] heparin lock flush [INJ] heparin sodium [INJ] heparin sodium/dextrose [INJ] heparin sodium/sodium chloride [INJ] HEPATAMINE [INJ] HERCEPTIN [INJ] [SP] hetastarch/normal saline [INJ] HEXALEN HEXTEND LACTATED ELECTROLYTE [INJ] HIBERIX [INJ] HIZENTRA [INJ] [SP]
J JADENU [SP] JAKAFI [SP] JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR JETREA [INJ] [SP] jeantique lo JEVTANA [INJ] [SP] jinteli jolessa jolivette juleber junel junel fe JUXTAPID [SP] K
I ibandronate ibandronate [INJ] [SP] IBRANCE [SP] ibuprofen ibuprofen lysine [INJ] ibutilide [INJ] ICLUSIG [SP] idarubicin [INJ] iferex 150 forte ifosfamide [INJ] ifosfamide/mesna [INJ] ILARIS [INJ] [SP] ILEVRO imatinib [SP] IMBRUVICA [SP] imipenem/cilastatin [INJ] imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT [INJ] IMOVAX RABIES VACCINE [INJ] Page 4
KADCYLA [INJ] [SP] kaitlib fe
Rev 11012016 Please note that this document is subject to change.
KALBITOR [INJ] [SP] KALETRA [SP] KALYDECO [SP] KANUMA [SP] kariva kelnor KEPIVANCE [INJ] [SP] ketamine [INJ] ketoconazole ketoconazole shampoo ketoconazole topical ketoprofen ketoprofen ext-release ketorolac ketorolac [INJ] ketorolac eye solution KEYTRUDA [INJ] [SP] kimidess KINEVAC [INJ] KITABIS PAK [SP] KOATE-DVI [INJ] [SP] KOGENATE FS [INJ] [SP] k-phos neutral K-PHOS ORIGINAL KRYSTEXXA [INJ] [SP] kurvelo KUVAN [SP] KYPROLIS [INJ] [SP]
L labetalol labetalol [INJ] lactic acid 10% topical lactulose LAMICTAL XR STARTER KITS LAMISIL GRANULES lamivudine [SP] lamivudine hbv lamivudine/zidovudine [SP] lamotrigine lamotrigine ext-release lamotrigine orally disintegrating tablets LANOXIN PEDIATRIC [INJ] lansoprazole delayed-release lansoprazole delayed-release +amoxicillin+clarithromycin LANTUS [INJ] larin larin fe larissia latanoprost eye solution LATUDA layolis fe LAZANDA l-cysteine [INJ] leena leflunomide LEMTRADA [INJ] [SP] LENVIMA [SP] lessina LETAIRIS [SP] letrozole leucovorin leucovorin [INJ] LEUKERAN LEUKINE [INJ] [SP] leuprolide [INJ] [SP] levalbuterol nebulization solution LEVEMIR [INJ] levetiracetam levetiracetam [INJ] levetiracetam ext-release levobunolol eye solution levocarnitine levocarnitine [INJ] levocetirizine levofloxacin levofloxacin [INJ] levofloxacin eye solution
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levofloxacin/dextrose [INJ] levoleucovorin [INJ] levonest levonorgestrel-ethinyl estradiol levora levorphanol levothyroxine sodium levothyroxine sodium [INJ] LEVOTHYROXINE SODIUM 100 MCG [INJ] LEVSIN [INJ] LEXISCAN [INJ] LEXIVA [SP] LIALDA lidocaine [INJ] lidocaine hcl/glycerin lidocaine jelly lidocaine patches lidocaine topical lidocaine viscous lidocaine/dextrose [INJ] lidocaine/epinephrine [INJ] lidocaine/glycerin lidocaine/hydrocortisone lidocaine/prilocaine lincomycin [INJ] lindane lindane shampoo linezolid linezolid [INJ] linezolid/sodium chloride [INJ] LINZESS LIORESAL [INJ] liothyronine liothyronine [INJ] LIPOFEN lisinopril lisinopril/hydrochlorothiazide lithium carbonate lithium carbonate ext-release lithium citrate LIVALO LO LOESTRIN FE lomedia 24 fe LONSURF [SP] loperamide lopreeza lorazepam lorazepam [INJ] loryna losartan losartan/hydrochlorothiazide LOTEMAX lovastatin low-ogestrel loxapine LUCENTIS [INJ] [SP] LUMIGAN LUMIZYME [INJ] [SP] LUPRON DEPOT [INJ] [SP] LUPRON DEPOT-PED [INJ] [SP] lutera luxamend LYNPARZA [SP] LYRICA LYSODREN lyza
manganese chloride [INJ] manganese sulfate [INJ] mannitol [INJ] maprotiline marlissa MARQIBO [INJ] [SP] MATULANE mb hydrogel md-gastroview meclizine meclofenamate medroxyprogesterone medroxyprogesterone (contraceptive) [INJ] mefenamic acid mefloquine megestrol MEKINIST [SP] meloxicam melpaque hp melphalan [INJ] melquin-3 memantine hcl MENACTRA [INJ] MENOMUNE-A-C-Y-W-135 [INJ] MENOPUR [INJ] [SP] MEPHYTON mepivacaine [INJ] mercaptopurine meropenem [INJ] MEROPENEM/SODIUM CHLORIDE [INJ] mesalamine enema mesalamine kit mesna [INJ] MESNEX TABLETS MESTINON SYRUP metaproterenol metaxalone metformin metformin ext-release methadone methadone [INJ] methamphetamine methazolamide methenamine hippurate methenamine mandelate methanamine/sodium phosphate/ methylene blue/hyoscyamine methimazole METHITEST methocarbamol methocarbamol [INJ] methotrexate methotrexate [INJ] methoxsalen methyclothiazide methyldopa methyldopa/hydrochlorothiazide methyldopate [INJ] methylergonovine methylergonovine [INJ] methylphenidate methylphenidate ext-release methylprednisolone methylprednisolone acetate [INJ] methylprednisolone sodium succinate [INJ] methyltestosterone metipranolol eye solution metoclopramide metoclopramide [INJ] metoclopramide hcl orally disintegrating tablets metolazone metoprolol succinate ext-release metoprolol tartrate metoprolol tartrate [INJ] metoprolol/hydrochlorothiazide metronidazole metronidazole topical
M m.v.i. adult [INJ] M.V.I. PEDIATRIC [INJ] M.V.I.-12 [INJ] macnatal cn dha prenatal vitamins magnesium chloride [INJ] magnesium sulfate [INJ] MAGNESIUM/DEXTROSE 1 GM/ 100 ML [INJ] MAKENA [INJ] [SP] malathion Page 5
metronidazole vaginal metronidazole/sodium chloride [INJ] mexiletine MIACALCIN [INJ] miconazole vaginal microgestin microgestin fe midazolam midazolam [INJ] midodrine miglitol milrinone [INJ] milrinone/dextrose [INJ] mimvey mimvey lo MINASTRIN 24 FE MINIMED INFUSION SET MINIMED RESERVOIR MINIVELLE MINOCIN [INJ] minocycline minocycline ext-release minoxidil MIRENA [SP] mirtazapine mirtazapine orally disintegrating tablets MIRVASO misoprostol MITIGARE mitomycin [INJ] mitoxantrone [INJ] [SP] M-M-R II [INJ] modafinil moderiba [SP] moexipril moexipril/hydrochlorothiazide molindone mometasone momestasone nasal spray MONOCLATE-P [INJ] [SP] mono-linyah mononessa MONONINE [INJ] [SP] MONOVISC [INJ] [SP] montelukast morphine sulfate morphine sulfate [INJ] morphine sulfate ext-release morphine sulfate suppositories morphine sulfate/nacl [INJ] MOVANTIK MOXEZA moxifloxacin MOXIFLOXACIN [INJ] MOZOBIL [INJ] [SP] multigen folic multigen plus MULTI-LANCET DEVICE [OTC] MULTITRACE-4 [INJ] MULTITRACE-5 [INJ] multivitamins/fluoride multivitamins/fluoride/iron mupirocin MUSE MUSTARGEN [INJ] MYALEPT [INJ] [SP] MYCAMINE [INJ] mofetil mycophenolate [SP] mycophenolic acid delayed-release [SP] myferon-150 forte MYLERAN mynatal advance prenatal vitamins mynatal plus prenatal vitamins mynatal prenatal vitamins mynatal ultracaplet prenatal vitamins mynatal-z prenatal vitamins mynate 90 plus prenatal vitamins mynephrocaps
Rev 11012016 Please note that this document is subject to change.
MYOBLOC [INJ] [SP] MYOZYME [INJ] [SP] MYRBETRIQ myzilra N nabumetone nadolol nadolol/bendroflumethiazide nafcillin [INJ] nafcillin/dextrose [INJ] naftifine NAGLAZYME [INJ] [SP] nalbuphine [INJ] naloxone [INJ] naltrexone NAMENDA XR NAMZARIC naphazoline eye solution naproxen naproxen delayed-release naproxen sodium naproxen sodium ext-release naratriptan NARCAN NASAL SPRAY NASCOBAL NATACYN NATAZIA nateglinide NATPARA [INJ] [SP] NATRECOR [INJ] NEBUPENT necon NEMBUTAL [INJ] neomycin neomycin/bacitracin/polymyxin eye ointment neomycin/bacitracin/polymyxin/ hydrocortisone eye ointment neomycin/polymyxin irrigation solution neomycin/polymyxin/dexamethasone eye ointment neomycin/polymyxin/dexamethasone eye suspension neomycin/polymyxin/gramicidin eye solution neomycin/polymyxin/hydrocortisone ear solution neomycin/polymyxin/hydrocortisone ear suspension neomycin/polymyxin/hydrocortisone eye suspension neostigmine [INJ] nephplex rx NEPHRAMINE [INJ] nephro-vite rx NEULASTA [INJ] [SP] NEUPOGEN [INJ] [SP] NEUT [INJ] NEVANAC nevirapine [SP] nevirapine ext-release [SP] newgen prenatal vitamins NEXAVAR NEXIUM [INJ] NEXIUM PACKETS NEXPLANON [INJ] [SP] NEXTERONE [INJ] niacin ext-release nicardipine nicardipine [INJ] nifedipine ext-release nikki nilutamide nimodipine NINLARO [SP] nisoldipine ext-release nitrofurantoin nitrofurantoin macrocrystal
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nitrofurantoin monohydrate/macrocrystal nitroglycerin nitroglycerin [INJ] nitroglycerin ext-release nitroglycerin ointment nitroglycerin patches nitroglycerin spray nitroglycerin/dextrose [INJ] nivatopic plus nizatidine nora-be NORDITROPIN [INJ] [SP] norepinephrine [INJ] norepinephrine/nacl [INJ] norethindrone norethindrone acetate norethindrone acetate-ethinyl estradiol norethindrone acetate-ethinyl estradiol + iron norgestimate-ethinyl estradiol norlyroc NORMOSOL-M AND DEXTROSE [INJ] NORMOSOL-R AND DEXTROSE [INJ] NORMOSOL-R PH 7.4 [INJ] nortrel nortriptyline NORVIR [SP] NOVAREL [INJ] [SP] NOVOFINE 30G, 32G NEEDLES [OTC] NOVOFINE AUTOCOVER [OTC] NOVOSEVEN RT [INJ] [SP] NOVOTWIST 30G, 32G NEEDLE [OTC] NOXAFIL NOXAFIL [INJ] NPLATE [INJ] [SP] NUCALA [INJ] [SP] NUCYNTA NUCYNTA ER NUEDEXTA NULOJIX [INJ] [SP] nutrilyte [INJ] NUVARING nystatin nystatin topical nystatin/triamcinolone O OBIZUR [INJ] [SP] obstetrix dha prenatal vitamins OCALIVA [SP] ocella octreotide [INJ] [SP] ODEFSEY [SP] OFEV [SP] OFIRMEV [INJ] ofloxacin ofloxacin ear solution ofloxacin eye solution ogestrel olanzapine olanzapine [INJ] olanzapine orally disintegrating tablets olanzapine/fluoxetine olopatadine eye solution olopatadine nasal spray omega-3 ethyl esters capsules omeprazole delayed-release omeprazole/sodium bicarbonate OMNIPAQUE [INJ] ONCASPAR [INJ] ondansetron ondansetron [INJ] ondansetron orally disintegrating tablets ONETOUCH DELICA LANCETS [OTC] ONETOUCH ULTRA 2 SYSTEM [OTC] ONETOUCH ULTRA TEST STRIPS [OTC] ONETOUCH ULTRAMINI METER [OTC] ONETOUCH ULTRASOFT LANCETS [OTC] Page 6
ONETOUCH VERIO FLEX [OTC] ONETOUCH VERIO IQ METER [OTC] ONETOUCH VERIO METER SYSTEM [OTC] ONETOUCH VERIO SYNC SYSTEM [OTC] ONETOUCH VERIO TEST STRIPS [OTC] ONEXTON ONFI ONIVYDE [INJ] [SP] OPANA ER OPDIVO [INJ] [SP] opium tincture opium/belladonna alkaloids suppositories OPSUMIT [SP] ORACEA ORBACTIV [INJ] ORFADIN [SP] ORKAMBI [SP] orphenadrine [INJ] orphenadrine ext-release orsythia ortho d ORTHOVISC [INJ] [SP] OTEZLA [SP] OTOVEL OTREXUP [INJ] oxacillin [INJ] oxacillin/dextrose [INJ] oxaliplatin [INJ] oxandrolone oxaprozin oxazepam oxcarbazepine oxiconazole OXSORALEN 1% LOTION oxybutynin oxybutynin ext-release oxycodone oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen OXYCONTIN oxymorphone oxymorphone ext-release oxytocin [INJ] OZURDEX [INJ] [SP] P paclitaxel [INJ] paliperidone ext-release pamidronate [INJ] PANHEMATIN [INJ] pantoprazole [INJ] pantoprazole delayed-release papaverine [INJ] PARADIGM INFUSION SETS PARADIG RESERVOIRS PARADIGM SILHOUETTE SETS paregoric paricalcitol paricalcitol [INJ] paromomycin paroxetine paroxetine ext-release PATADAY PAZEO PEDIARIX [INJ] pediatric multivitamins/vitamin d/ vitamin k PEDITRACE [INJ] PEDVAXHIB [INJ] peg 3350 with flavor packets peg 3350/electrolytes powder for 4000 ml solution PEGANONE PEGASYS [INJ] [SP] peg-prep kit penicillin g potassium [INJ] penicillin g procaine [INJ]
penicillin g sodium [INJ] PENICILLIN GK/DEXTROSE [INJ] penicillin v potassium PENTACEL [INJ] PENTACEL ACTHIB COMPONENT [INJ] PENTASA pentoxifylline ext-release PERFOROMIST perindopril PERJETA [INJ] [SP] permethrin perphenazine perphenazine/amitriptyline phenazopyridine phendimetrazine phendimetrazine ext-release phenelzine phenobarbital phenobarbital sodium [INJ] phenobarbital/hyoscyamine/atropine/ scopolamine phenoxybenzamine phentermine phentolamine [INJ] phenylbutyrate phenylephrine [INJ] phenylephrine eye solution phenylephrine/chlorpheniramine phenytoin phenytoin sodium [INJ] phenytoin sodium extended philith phospha 250 neutral phosphasal PHOSPHOLINE IODIDE PHOTOFRIN [INJ] physostigmine [INJ] phytonadione [INJ] PHYTONADIONE 1 MG/0.5 ML SYRINGE [INJ] PICATO pilocarpine pilocarpine eye solution pimozide pimtrea pindolol pioglitazone pioglitazone/glimepiride pioglitazone/metformin piperacillin/tazobactam [INJ] pirmella piroxicam PLASMA-LYTE [INJ] plasmanate [INJ] PLEGRIDY [INJ] [SP] PNEUMOVAX 23 [INJ] pnv 29-1 prenatal vitamins pnv ob+dha prenatal vitamins pnv-dha + docusate prenatal vitamins pnv-dha prenatal vitamins pnv-ferrous fumarate-docu-fa prenatal vitamins pnv-omega prenatal vitamins pnv-select prenatal vitamins pnv-vp-u prenatal vitamins podofilox POLOCAINE [INJ] polyethylene glycol 3350 POLYFIN QR INFUSION SET poly-iron 150 forte polymyxin [INJ] polymyxin/trimethoprim eye solution POMALYST [SP] portia potassium acetate [INJ] potassium bicarbonate/citric acid effervescent tablets potassium chloride [INJ] potassium chloride ext-release Rev 11012016 Please note that this document is subject to change.
potassium chloride oral solution potassium chloride powder packets for solution potassium chloride/dextrose [INJ] potassium chloride/dextrose/ sodium chloride [INJ] potassium chloride/lactated ringers/ dextrose [INJ] potassium chloride/sodium chloride [INJ] potassium citrate ext-release potassium citrate/citric acid potassium citrate/sodium citrate/citric acid potassium iodide/iodine solution potassium phosphate [INJ] POTIGA pr natal 400 ec prenatal vitamins pr natal 400 prenatal vitamins pr natal 430 ec prenatal vitamins pr natal 430 prenatal vitamins PRADAXA PRALUENT [INJ] [SP] pramipexole pramipexole ext-release pravastatin prazosin PRECISION XTRA B-KETONE STRIPS [OTC] PRECISION XTRA MONITOR [OTC] PRED MILD prednicarbate prednisolone prednisolone acetate eye suspension prednisolone sodium phosphate prednisolone sodium phosphate disintegrating tablets prednisolone sodium phosphate eye solution prednisone PREMARIN [INJ] PREMARIN CREAM PREMARIN TABLETS premasol [INJ] PREMASOL 6% [INJ] PREMPHASE PREMPRO prena1 chew prenatal vitamins prena1 pearl prenatal vitamins prena1 true prenatal vitamins prenaissance plus prenatal vitamins prenaissance prenatal vitamins prenatabs fa prenatal vitamins prenatabs rx prenatal vitamins prenatal low iron prenatal vitamins prenatal plus iron prenatal vitamins prenatal plus prenatal vitamins prenatal-u prenatal vitamins preplus prenatal vitamins PREPOPIK pretab 29-1 prenatal vitamins previfem PREVNAR 13 [INJ] PREZISTA [SP] PRIALT [INJ] [SP] PRIFTIN PRIMAQUINE primidone PRISTIQ ER PRIVIGEN [INJ] [SP] PROAIR HFA PROAIR RESPICLICK probenecid procainamide [INJ] PROCALAMINE [INJ] prochlorperazine edisylate [INJ] prochlorperazine maleate prochlorperazine maleate suppositories PROCRIT [INJ] [SP] PROCTOFOAM-HC PRODIGY INSULIN SYRINGE
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ranitidine [INJ] RAPAFLO RAPAMUNE SOLUTION [SP] RAPIVAB [INJ] RASUVO [INJ] RAVICTI [SP] REBIF [INJ] [SP] reclipsen RECOMBINATE [INJ] [SP] RECOMBIVAX HB [INJ] RECTIV REGRANEX RELENZA RELISTOR [INJ] relnate dha prenatal vitamins RELPAX REMICADE [INJ] [SP] REMODULIN [INJ] [SP] RENACIDIN renal caps rena-vite rx reno caps RENVELA REOPRO [INJ] repaglinide repaglinide/metformin hcl REPATHA [INJ] [SP] REPATHA PUSHTRONEX [INJ] [SP] RESCRIPTOR [SP] RESECTISOL reserpine RESTASIS RETROVIR [INJ] [SP] REVLIMID [SP] REYATAZ [SP] R-GENE 10 [INJ] RIASTAP [INJ] [SP] ribavirin capsule, tablets [SP] RIDAURA rifabutin rifampin rifampin [INJ] riluzole rimantadine ringers irrigation solution ringers lactated irrigation solution ringers solution [INJ] ringers solution lactated [INJ] risedronate risedronate delayed-release RISPERDAL CONSTA [INJ] risperidone risperidone orally disintegrating tablets RITUXAN [INJ] [SP] rivastigmine rivastigmine patches rizatriptan rizatriptan orally disintegrating tablets ropinirole ropinirole ext-release ropivacaine [INJ] rosuvastatin ROTATEQ ROZEREM rulavite dha prenatal vitamins
PROFILNINE SD [INJ] [SP] progesterone in oil [INJ] [SP] progesterone micronized PROGLYCEM PROGRAF [INJ] [SP] PROLASTIN C [INJ] [SP] PROLENSA PROLEUKIN [INJ] [SP] PROMACTA [SP] promethazine promethazine [INJ] promethazine suppositories promethazine/codeine promethazine/dextromethorphan promethazine/phenylephrine promethazine/phenylephrine/codeine propafenone propafenone ext-release proparacaine eye solution proparacaine/fluorescein eye solution propofol [INJ] propranolol propranolol [INJ] propranolol ext-release propranolol/hydrochlorothiazide propylthiouracil PROQUAD [INJ] PROSOL [INJ] protamine [INJ] PROTOPAM [INJ] protriptyline PROVENGE [INJ] [SP] pruclair prumyx prutect pseudoephedrine/chlorpheniramine/ methscopolamine ext-release pseudoephedrine/codeine/ chlorpheniramine pseudoephedrine/codeine/guaifenesin PULMICORT FLEXHALER PULMOZYME [SP] purevit dualfe plus PURIXAN [SP] PYLERA pyrazinamide pyridostigmine pyridostigmine [INJ] pyridostigmine ext-release pyridoxine [INJ] Q QNASL QUADRACEL DTAP-IPV [INJ] quasense quazepam QUDEXY XR quetiapine QUICK RELEASE TEFLON CANNULA QUILLICHEW ER QUILLIVANT XR quinapril quinapril/hydrochlorothiazide quinidine gluconate [INJ] quinidine gluconate ext-release quinidine sulfate quinidine sulfate ext-release quinine sulfate QVAR
S SABRIL [SP] SAFYRAL salicylic acid shampoo salicylic acid topical salsalate SAMSCA [SP] SANCUSO SANDIMMUNE SOLUTION [SP] SANDOSTATIN LAR 10 MG, 20 MG, 30 MG KIT [INJ] [SP] SANDOSTATIN LAR DEPOT [INJ] [SP] SANTYL
R RABAVERT [INJ] rabeprazole delayed-release RAGWITEK rajani raloxifene ramipril RANEXA ranitidine Page 7
SAVELLA SCOPOLAMINE [INJ] secobarbital selegiline selenium [INJ] selenium sulfide selenium sulfide shampoo SELZENTRY [SP] se-natal 19 prenatal vitamins SENSIPAR SENSORCAINE-EPI 0.75%-0.0005%[INJ] SEREVENT DISKUS SEROQUEL XR SEROSTIM [INJ] [SP] sertraline se-tan dha prenatal vitamins se-tan plus setlakin sharobel SIGNIFOR [INJ] [SP] sildenafil [INJ] [SP] sildenafil [SP] SILHOUETTE INFUSION SETS silver nitrate silver sulfadiazine SIMCOR SIMPONI 100 MG (for ulcerative colitis only ) [INJ] [SP] SIMULECT [INJ] [SP] simvastatin sirolimus [SP] SIRTURO SIVEXTRO [INJ] SNAP INSULIN PUMP CONTROLLER SNAP INSULIN PUMP-INFUSION SET sodium acetate [INJ] sodium benzoate/sodium phenylacetate [INJ] sodium bicarbonate [INJ] sodium chloride [INJ] sodium chloride 0.45% [INJ] sodium chloride 0.9% [INJ] sodium chloride 3% [INJ] sodium chloride 5% [INJ] sodium chloride irrigation solution sodium chloride nebulization solution sodium chloride, bacteriostatic [INJ] sodium ferric gluconate complex [INJ] sodium fluoride sodium fluoride dental cream, gel sodium fluoride dental rinse sodium lactate [INJ] sodium phosphate [INJ] sodium polystyrene sulfonate sodium polystyrene sulfonate rectal sodium thiosulfate [INJ] SOF-SET MICRO INFUSION SET SOF-SET ULTIMATE QR SET SOFT TOUCH LANCETS [OTC] SOFTCLIX LANCET DEVICE [OTC] SOFTCLIX LANCETS [OTC] SOLIRIS [INJ] [SP] SOLODYN SOLU-CORTEF [INJ] SOMATULINE DEPOT [INJ] [SP] SOMAVERT [INJ] [SP] sonafine SOOLANTRA sotalol SOTALOL [INJ] SOTRADECOL [INJ] SOTYLIZE sp antipruritic sp scar spinosad SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone/hydrochlorothiazide Rev 11012016 Please note that this document is subject to change.
SPORANOX SOLUTION sprintec SPRYCEL [SP] sronyx stavudine [SP] STELARA SYRINGE [INJ] [SP] STIMATE [SP] STIOLTO RESPIMAT STIVARGA [SP] STRATTERA STREPTOMYCIN SULFATE [INJ] STRENSIQ [INJ] [SP] STRIBILD [SP] STRIVERDI RESPIMAT SUBOXONE SL FILM SUCRAID [SP] sucralfate sufentanil [INJ] sulfacetamide eye ointment sulfacetamide eye solution sulfacetamide sodium shampoo sulfacetamide sodium topical sulfacetamide sodium/sulfur sulfacetamide sodium/sulfur/urea sulfacetamide/prednisolone eye solution sulfadiazine sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim [INJ] SULFAMYLON CREAM sulfasalazine sulfasalazine delayed-release sulindac sumatriptan sumatriptan [INJ] sumatriptan nasal SUMAVEL DOSEPRO [INJ] SUPREP SURE-T INFUSION SET SUSTIVA [SP] SUTENT [SP] syeda SYLATRON [INJ] [SP] SYLVANT [INJ] [SP] SYMBICORT SYMLINPEN [INJ] SYNAGIS [INJ] [SP] SYNAREL SYNERCID [INJ] SYNJARDY SYNRIBO [INJ] [SP] T TABLOID TACLONEX SUSPENSION tacrolimus [SP] tacrolimus topical TAFINLAR [SP] TAGRISSO [SP] TAMIFLU tamoxifen tamsulosin ext-release TARCEVA TARGRETIN GEL [SP] tarina fe taron forte taron-c dha prenatal vitamins taron-prex dha prenatal vitamins TASIGNA [SP] TAYTULLA TAZORAC TECENTRIQ [INJ] [SP] TECFIDERA [SP] TECHLITE BLOOD LANCETS [OTC] TECHNIVIE [SP] TEFLARO [INJ] TEKAMLO TEKTURNA TEKTURNA HCT telmisartan
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telmisartan/amlodipine telmisartan/hydrochlorothiazide temazepam TEMODAR [INJ] [SP] temozolomide [SP] TENIPOSIDE [INJ] terazosin terbinafine terbutaline terbutaline [INJ] terconazole vaginal testosterone testosterone cypionate [INJ] testosterone enanthate [INJ] TETANUS DIPHTHERIA TOXOIDS [INJ] tetrabenazine [SP] tetracaine [INJ] tetracaine eye solution tetracycline THALOMID [SP] theophylline theophylline ext-release theophylline/dextrose [INJ] THERACYS [INJ] thiamine [INJ] thioridazine thiotepa [INJ] thiothixene thrivite 19 prenatal vitamins THROMBATE III [INJ] THYMOGLOBULIN [INJ] [SP] THYROGEN [INJ] [SP] thyroid tiagabine TICE BCG [INJ] tilia fe timolol maleate timolol maleate eye solution tinidazole TIVICAY [SP] tizanidine tl gard rx tl g-fol os tl icon tl-hem 150 tl-select prenatal vitamins TOBI PODHALER [SP] TOBRADEX OINTMENT TOBRADEX ST tobramycin [INJ] tobramycin eye solution tobramycin nebulization solution [SP] tobramycin/dexamethasone eye suspension tobramycin/sodium chloride [INJ] tolazamide tolbutamide tolcapone tolmetin tolterodine tolterodine ext-release topiramate topotecan [INJ] [SP] TORISEL [INJ] [SP] torsemide TOUJEO SOLOSTAR [INJ] TOVIAZ TPN ELECTROLYTES [INJ] TRACE ELEMENTS-4 [INJ] TRACLEER [SP] TRADJENTA tramadol tramadol ext-release tramadol/acetaminophen trandolapril trandolapril/verapamil ext-release tranexamic acid tranexamic acid [INJ] tranylcypromine
travasol [INJ] TRAVATAN Z travoprost eye solution trazodone TREANDA [INJ] [SP] TRESIBA [INJ] tretinoin tretinoin microspheres tretinoin topical tretinoin/emollient TRETTEN [INJ] [SP] TREXALL triadvance prenatal vitamins triamcinolone [INJ] triamcinolone dental paste triamcinolone topical triamterene/hydrochlorothiazide triazolam TRIBENZOR tricitrates tricon tri-estarylla trifluoperazine trifluridine eye solution trigels-f forte trihexyphenidyl tri-legest fe tri-linyah tri-lo estarylla tri-lo marzia tri-lo sprintec trilyte with flavor packets trimethobenzamide trimethoprim trimipramine trinatal gt prenatal vitamins trinatal rx 1 prenatal vitamins trinate prenatal vitamins trinessa trinessa lo triphrocaps tri-previfem TRISENOX [INJ] tri-sprintec tri-tabs dha prenatal vitamins TRIUMEQ [SP] triveen-duo dha prenatal vitamins triveen-one prenatal vitamins triveen-prx rnf prenatal vitamins triveen-u prenatal vitamins tri-vitamin/fluoride tri-vitamin/iron/fluoride trivora TROPHAMINE [INJ] tropicamide eye solution trospium trospium ext-release TRULICITY [INJ] TRUMENBA [INJ] trust natal dha prenatal vitamins TRUVADA [SP] TUBERSOL [INJ] TUDORZA PRESSAIR TUSSICAPS TWINRIX [INJ] TYGACIL [INJ] TYKERB [SP] TYPHIM VI [INJ] TYSABRI [INJ] [SP] TYVASO [SP] TYZEKA U UCERIS TABLETS ULORIC ultimatecare one nf prenatal vitamins ultimatecare one prenatal vitamins ULTIVA [INJ] UNITUXIN [INJ] [SP] Page 8
UPTRAVI [SP] ur n-c uramit mb urea urea/hyaluronate urea/lactic acid/salicylic acid urea/lactic acid/zinc undecylenate uretron d-s urimar-t urin d.s. uro-458 uro-blue urogesic uro-l urolet mb uro-mp urophen mb ursodiol uryl ustell utira-c UVADEX [INJ] V VAGIFEM valacyclovir VALCHLOR [SP] valganciclovir valproate sodium [INJ] valproic acid valsartan valsartan/hydrochlorothiazide VALSTAR [INJ] [SP] vancomycin vancomycin [INJ] VANCOMYCIN/DEXTROSE 500 MG/ 100 ML, 1G/200 ML [INJ] VANCOMYCIN/DEXTROSE 750 MG/ 150 ML [INJ] VANCOMYCIN-NS [INJ] VANTAS [SP] VAQTA VIALS [INJ] VARIVAX [INJ] VARIZIG [INJ] VARUBI VASCEPA vasopressin [INJ] v-c forte VECTIBIX [INJ] [SP] VELCADE [INJ] [SP] velivet VELTASSA [SP] vemavite-prx 2 prenatal vitamins vena-bal dha prenatal vitamins VENCLEXTA [SP] venlafaxine venlafaxine ext-release VENOFER [INJ] VENTAVIS [SP] VENTOLIN HFA verapamil verapamil [INJ] verapamil ext-release veripred VESICARE vestura VGO VIAGRA VIBATIV [INJ] VIBERZI vi-c forte VIDEX SOLUTION [SP] vienva VIGAMOX VIIBRYD VIMIZIM [INJ] [SP] VIMPAT VIMPAT [INJ] vinacal prenatal vitamins Rev 11012016 Please note that this document is subject to change.
vinate care prenatal vitamins vinate dha prenatal vitamins vinate gt prenatal vitamins vinate ii prenatal vitamins vinate one prenatal vitamins vinate pn care prenatal vitamins vinate ultra prenatal vitamins vinate-m prenatal vitamins vinblastine [INJ] vincristine [INJ] vinorelbine [INJ] VIOKACE viorele VIRACEPT [SP] VIREAD [SP] virt nate prenatal vitamins virt-advance prenatal vitamins virt-c dha prenatal vitamins virt-gard virt-nate dha prenatal vitamins virt-phos 250 neutral virt-pn dha prenatal vitamins virt-pn plus prenatal vitamins virt-pn prenatal vitamins virtrate-3 virt-select prenatal vitamins virt-vite virt-vite forte virt-vite gt prenatal vitamins VISTOGARD VISUDYNE [INJ] [SP] vitafol-ob prenatal vitamins VIVITROL [INJ] [SP] VIVOTIF vol-care rx vol-nate prenatal vitamins
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vol-plus prenatal vitamins vol-tab rx prenatal vitamins VOLUVEN [INJ] VONVENDI [INJ] [SP] VORAXAZE [INJ] voriconazole voriconazole [INJ] VOTRIENT [SP] vp-ch plus prenatal vitamins vp-ch-pnv prenatal vitamins vp-heme ob prenatal vitamins vp-heme one prenatal vitamins VPRIV [INJ] [SP] vp-vite rx vp-zel vyfemla VYTORIN VYVANSE
XIFAXAN XIGDUO XR XIIDRA XOFIGO [INJ] [SP] XOLAIR [INJ] [SP] xulane patches XURIDEN [SP] XYNTHA [INJ] [SP] XYREM [SP] Y YERVOY [INJ] [SP] YF-VAX [INJ] YONDELIS [INJ] [SP] Z zafirlukast zaleplon ZALTRAP [INJ] [SP] ZANOSAR [INJ] zarah ZARXIO [INJ] [SP] zatean-ch prenatal vitamins zatean-pn dha prenatal vitamins zatean-pn plus prenatal vitamins zavara ZAVESCA [SP] ZELBORAF [SP] ZEMAIRA [INJ] [SP] zenchent zenchent fe ZENPEP zeosa ZERBAXA [INJ] ZETIA ZEVALIN [INJ]
W warfarin water for injection, bacteriostatic [INJ] water for injection, sterile [INJ] water for irrigation; sterile WELCHOL wera WILATE [INJ] [SP] wymzya fe X XALKORI [SP] XARELTO XELJANZ [SP] XELJANX XR [SP] XGEVA [INJ] [SP] XIAFLEX [INJ] [SP]
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ZIAGEN SOLUTION [SP] zidovudine [SP] zinc chloride [INJ] zinc sulfate [INJ] ziprasidone ZODRYL AC 40 ZODRYL DEC 30 ZOLADEX [SP] zolate zoledronic acid [INJ] [SP] zoledronic acid/mannitol [INJ] [SP] ZOLINZA [SP] zolmitriptan zolmitriptan orally disintegrating tablets zolpidem zolpidem ext-release ZOMETA 4 MG/100 ML [INJ] [SP] ZOMIG NASAL zonisamide ZONTIVITY ZORTRESS [SP] ZORVOLEX ZOSTAVAX [INJ] ZOSYN GALAXY BAGS [INJ] zovia ZOVIRAX CREAM ZUBSOLV ZYDELIG [SP] ZYKADIA [SP] ZYLET ZYTIGA [SP] ZYVOX 200 MG/100 ML [INJ] ZYVOX SUSPENSION
Rev 11012016 Please note that this document is subject to change.
Examples of Nonformulary Medications With Selected Formulary Alternatives The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the formulary. Column 1 lists examples of nonformulary medications. Column 2 lists some alternatives that can be prescribed.
Nonformulary Medications
Formulary Alternative(s)
ABSTRAL
fentanyl citrate lozenges, LAZANDA
ACCU-CHEK METERS/STRIPS
ONETOUCH METERS/STRIPS
ACUVAIL
bromfenac, diclofenac, ketorolac, ILEVRO, NEVANAC, PROLENSA
ADLYXIN
BYDUREON, BYETTA, TRULICITY
ADVOCATE METERS/STRIPS
ONETOUCH METERS/STRIPS
ALOGLIPTIN
JANUVIA, TRADJENTA
ALOGLIPTIN/METFORMIN
JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
ALVESCO
ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR
APIDRA
HUMALOG
ARANESP
PROCRIT
ASACOL HD
balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA
BECONASE AQ
budesonide, flunisolide, fluticasone, mometasone, QNASL
BRAVELLE
GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT
BREEZE, CONTOUR METERS/STRIPS
ONETOUCH METERS/STRIPS
CETRAXAL
ciprofloxacin ear solution, ofloxacin ear solution, CIPRODEX, OTOVEL
CIMZIA
ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
COLCHICINE
COLCRYS, MITIGARE
DAKLINZA (EXCLUDED FOR GENOTYPE 1)
HARVONI
DELZICOL
balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA
DIPENTUM
balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA
DOXYCYCLINE 40 MG CAPSULES
ORACEA
DUEXIS
ibuprofen + famotidine
EMBRACE, VICTORY METERS/STRIPS
ONETOUCH METERS/STRIPS
ENDOMETRIN
CRINONE 8% GEL
EPOGEN
PROCRIT
ESTROGEL
DIVIGEL
EVZIO
naloxone syringe, NARCAN NASAL SPRAY
FENTORA
fentanyl citrate lozenges, LAZANDA
FLUOROURACIL 0.5% CREAM
diclofenac 3% gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod 5% cream, CARAC, PICATO
FOLLISTIM AQ
GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT
FORTESTA FREESTYLE, PRECISION METERS/STRIPS GANIRELIX ACETATE
ANDROGEL 1.62%, AXIRON
CETROTIDE
GEL-ONE
EUFLEXXA, MONOVISC, ORTHOVISC
GELSYN-3
EUFLEXXA, MONOVISC, ORTHOVISC
GENVISC 850
EUFLEXXA, MONOVISC, ORTHOVISC
GLUMETZA
metformin extended-release
ONETOUCH METERS/STRIPS
HYALGAN
EUFLEXXA, MONOVISC, ORTHOVISC
HYMOVIS
EUFLEXXA, MONOVISC, ORTHOVISC
ISTALOL
betaxolol, levobunolol, timolol, ALPHAGAN P 0.1%, COMBIGAN
KAZANO
JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
KINERET (EXCLUDED FOR RA)
ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR
KOMBIGLYZE XR
JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
LEVALBUTEROL HFA
PROAIR HFA, PROAIR RESPLICLICK, VENTOLIN HFA
LEVITRA
CIALIS, VIAGRA
MESALAMINE 800 MG DELAYED-RELEASE
balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA
MIRCERA
PROCRIT
NATESTO
ANDROGEL 1.62%, AXIRON
NESINA
JANUVIA, TRADJENTA
NOVOLIN
HUMULIN
NOVOLOG
HUMALOG
NUTROPIN AQ
GENOTROPIN, HUMATROPE, NORDITROPIN
OLYSIO
HARVONI, TECHNIVIE
OMNARIS
budesonide, flunisolide, fluticasone, mometasone, QNASL
© 2017 All Rights Reserved
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Rev 11012016 Please note that this document is subject to change.
OMNITROPE
GENOTROPIN, HUMATROPE, NORDITROPIN
ONGLYZA
JANUVIA, TRADJENTA
ORENCIA (IV AND SC)
ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR
PANCREAZE
CREON, ZENPEP
PERTZYE
CREON, ZENPEP
PROVENTIL HFA
PROAIR HFA, PROAIR RESPICLICK, VENTOLIN HFA
QSYMIA
benzphetamine, diethylpropion, phentermine
ribasphere ribapak
moderiba, ribavirin capsules, ribavirin tablets
RIBATAB
moderiba, ribavirin capsules, ribavirin tablets
SAIZEN
GENOTROPIN, HUMATROPE, NORDITROPIN
SIMPONI 50 MG
ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR
SOVALDI (EXCLUDED FOR GENOTYPE 1 & 4)
HARVONI, TECHNIVIE
STAXYN
CIALIS, VIAGRA
STENDRA
CIALIS, VIAGRA
SUBSYS
fentanyl citrate lozenges, LAZANDA
SUPARTZ, SUPARTZ FX
EUFLEXXA, MONOVISC, ORTHOVISC
SYNVISC, SYNVISC-ONE
EUFLEXXA, MONOVISC, ORTHOVISC
TALTZ
COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA
TANZEUM
BYDUREON, BYETTA, TRULICITY
TESTIM
ANDROGEL 1.62%, AXIRON
TESTOSTERONE GEL TRUETEST, TRUETRACK METERS/STRIPS ULTRESA
ANDROGEL 1.62%, AXIRON
UNISTRIP METERS/STRIPS
ONETOUCH METERS/STRIPS
VELTIN
clindamycin phosphate + tretinoin, ACANYA, ONEXTON
VERAMYST
budesonide, flunisolide, fluticasone, mometasone furoate, QNASL
VICTOZA
BYDUREON, BYETTA, TRULICITY
VIMOVO
omeprazole delayed-release + naproxen sodium
VOGELXO
ANDROGEL 1.62%, AXIRON
XOPENEX HFA
PROAIR HFA, PROAIR RESPICLICK, VENTOLIN HFA
ONETOUCH METERS/STRIPS CREON, ZENPEP
ZEPATIER
TECHNIVIE, HARVONI
ZETONNA
budesonide, flunisolide, fluticasone, mometasone, QNASL
ZIOPTAN
bimatoprost, latanoprost, LUMIGAN, TRAVATAN Z
ZOMACTON
GENOTROPIN, HUMATROPE, NORDITROPIN
ZYCLARA
diclofenac 3% gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod 5% cream, CARAC, PICATO
© 2017 All Rights Reserved
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Rev 11012016 Please note that this document is subject to change.
