Post on 31-May-2020
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 1
Effective: November 1, 2018 Large Group Health Plans
Small Group Health Plans
2018 Commercial 5-Tier Formulary (List of Covered Drugs)
What is the Drug List? Also called a “formulary” by doctors and pharmacists, the Drug List is an extensive list of safe and effective, FDA-approved, brand name and generic prescription drugs used to treat the most common medical conditions.
The Health First Pharmacy and Therapeutics Committee (P&T), a panel of physicians and pharmacists, developed our Drug List and updates it regularly. The list includes quality drugs available to you at a reasonable cost. Only those medications that have successfully passed federally required clinical testing and evaluation and have been proven effective are included. The P&T Committee reviews and evaluates all available literature about a drug when updating the list.
About Tiers
Most covered prescription drugs will be categorized into one of five cost-sharing tiers. Drug costs vary widely, even though several different medications may be used to treat the same condition. What you pay for the prescription depends upon what tier the drug is listed in. Florida Hospital Care Advantage (FHCA) offers many benefit plans that can vary in coverage for each tier. Details about your specific benefit for each tier are included in the FHCA Summary of Benefits.
Prescriptions that exceed a 30-day supply will default to a 90-day supply copay (this does not apply to coinsurances). For coinsurances, you will always pay a percentage of the total cost after the applicable deductible is met.
Tier 1 (T1) - Includes low-cost preferred generic drugs.
Tier 2 (T2) - Includes higher-cost generic drugs.
Tier 3 (T3) - Includes preferred brand-name drugs and some higher-cost generic drugs.
Tier 4 (T4) - Includes higher-cost non-preferred brand-name drugs and generic drugs (some plans may be limited to a 30-day supply).
Tier 5 (T5 SP) - Includes higher-cost biologics or prescription drugs that require close monitoring for safety and efficacy. These medications must be obtained from Health First Family Pharmacy when possible and are limited to a 30-day supply.
Preventive Care (NCS) - Includes some select preventive products, prescription medications and specific over-the-counter (OTC) medications available to you at no cost-sharing ($0) when applicable conditions are met.
Generic drugs are prescription drugs that have the same active ingredients as brand drugs and are prescribed for the same reasons. When the patent expires on a brand name drug, the FDA permits new manufacturers to produce an equivalent of the brand name drug and make it available to the public. Generally, more than one manufacturer will produce generic versions, although often the same pharmaceutical firm that produces the brand name drug also makes the generic version. This prompts competitive pricing of the generic version and usually results in a less expensive drug that is as safe and effective as the brand name drug.
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 2
What will my expenses be?
Every plan is different, and your financial obligation will vary based on your specific plan. You are responsible for any cost sharing your plan requires.
What is a deductible?
A deductible is a set dollar amount that you must pay each calendar year before your health plan starts paying. If your plan includes an integrated pharmacy deductible, it will accumulate with your in-network medical deductible. Refer to your plan documents to see when your deductible starts over for your plan.
What is the difference between a copayment and coinsurance?
Copayments and coinsurance are types of member cost sharing, and they represent the portion of covered prescription expenses members must pay. A copayment is a flat dollar amount while coinsurance is a percentage of the total allowable charges.
What does out-of-pocket maximum mean? The out-of-pocket maximum protects you from catastrophic medical and prescription drug expenses by limiting how much you have to pay during the benefit year. Your cost sharing for covered prescription drugs (deductible, coinsurance and copayment) all accumulate with your in-network medical out-of-pocket maximum. Refer to your plan documents to see when your out-of-pocket maximum starts over for your plan and to verify the specific cost sharing you have for specific tiers.
The Drug List is subject to change In order to continue to offer a safe and cost effective selection of prescription drugs, FHCA periodically makes changes to the Drug List. These changes may include removing medications, adding restrictions, and/or covering a drug at a higher tier. Updated formularies are posted to the website as changes are made. The following list represents some of the most common scenarios in which changes to drug coverage will occur:
Throughout the year, new medications are approved by the FDA. It is the policy of FHCA that new drugs will be excluded for 6 months from the date of FDA approval, during which time the Health First P&T Committee can review the drug for safety and efficacy.
When a medication is withdrawn from the market due to safety reasons or if it becomes available over-the-counter (OTC). At the time that a medication on the HFP Drug List becomes available OTC, it may be excluded from coverage from that point forward.
When a brand-name prescription drug loses its patent and the equivalent generic form is added to the Drug List, the brand-name drug may be moved to Tier 4 or removed from the formulary.
This formulary is current as of November 01, 2018. To get updated information about covered drugs, please visit our Web site at myFHCA.org or call Customer Service toll-free at 1.844.522.5279 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 5 p.m.
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: The Plan requires you and/or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. In order for the plan to pay for these drugs, the physician ordering the prescription is required to submit all medical information to FHCA documenting the medical necessity. These drugs are identified in the Drug List.
Step Therapy: In some cases, The Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. A complete list of drugs which require step therapy is listed in the reference table on page 6.
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Quantity Limits: For some covered drugs, there is a maximum amount that will be covered by FHCA over a certain period of time. For example, FHCA covers 30 tablets every 30 days or 90 tablets every 90 days for TRADJENTA.
How can I make the most of my prescription drug benefit? Prescription drug costs continue to rise every year and can represent a significant part of your healthcare expenses. FHCA helps you pay for your medications by sharing the cost with you and providing substantial discounts for covered medications. To help you manage your drug costs, here are some money-saving tips to consider:
Use generic medications whenever possible. Generic drugs are the chemical equivalent of brand name drugs and are just as effective in most cases. If you take generic drugs you will generally pay less. Talk to your doctor to see if switching to a generic equivalent of any brand-name drug you are taking is appropriate. Please see the list of drugs below to determine which generic drugs are included in lower cost-sharing tiers.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that FHCA does not cover your drug, you have two options:
You can ask Customer Service for a list of similar drugs that are covered by FHCA. When you receive the list, show it to your doctor and ask if switching to a covered medication is appropriate.
You can ask your physician to send FHCA information requesting we make an exception and cover your drug.
If FHCA approves the request for an exception to the formulary, the approved drug will be covered at the Tier 4 cost share unless the cost of the medication is greater than $500 per month, then it will be covered at the Tier 5 cost share.
Excluded drugs FHCA does not provide coverage for all drugs. In addition to the drugs marked “excluded” in this drug list, newly FDA approved drugs are not covered unless the Health First P&T Committee in its sole discretion approves these drugs for coverage. FHCA will automatically exclude a particular drug if a generic version becomes available and an entire class of drugs if a particular drug within that class becomes available over the counter.
The following are NOT covered by FHCA:
Compounded drugs Cosmetics or any drugs used for cosmetic purposes Diabetic supplies, blood glucose monitors and test strips other than those manufactured by Abbott under
the product name Freestyle, Precision, and test strips® Erectile dysfunction drugs (such as Viagra) Infertility drugs (such as Clomid) Some injectables (except insulin, Imitrex, and those requiring prior authorization) Most multivitamins and nutritional supplements (except prescription pre-natal vitamins and products
covered under the Preventive Care benefit) Nonprescription supplies or substances Over-the-counter (OTC) medications (except products covered under the Preventive Care benefit), or any
drug for which a similar over-the-counter version is available All new drugs approved by the FDA will be excluded from the preferred drug list/formulary unless the
Health First P&T Committee, in its sole discretion, decides to waive this exclusion for a particular drug. Support garments Syringes, needles, or other disposable supplies (except those used with insulin).
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 4
Preventive Care Medications: $0 Cost-share Medications and Products
The Affordable Care Act (ACA), commonly known as health care reform, was signed into federal law in 2010. The ACA requires private insurers to cover certain preventive services without any patient cost-sharing (i.e., copayments, coinsurance and deductible) when they are delivered by a network provider.
The Department of Health and Human Services (HHS) has recognized several recommending bodies (e.g., United States Preventive Services Task Force [USPSTF], Advisory Committee on Immunization Practices [ACIP], and Health Resources and Services Administration [HRSA]) who have identified several medication categories that fall within the preventive health mandate.
The following products, prescription medications and specific over-the-counter (OTC) medications (notated in Tier NCS throughout this formulary) are available to our members at no ($0) cost-sharing when:
Prescribed by a health care professional (all prescription and OTC medications will require a prescription)
Age and/or gender appropriate
This list will be reviewed periodically and is subject to change.
Medicine/Product Category and Who is Covered Examples of the Medicine/Product Covered
Aspirin Individuals < 60 years
Aspirin products < 325 MG
Fluoride Children age 6 months through 5 years
Fluoride Chewable Tablet 0.25 MG and 0.5 MG; Fluoride Drops 0.125 MG, 0.25 MG and 0.5 MG; Multivitamin W/ Fluoride Chewable 0.25 MG
and 0.5 MG; Multivitamin W/ Fluoride Drops 0.25 MG and 0.5
MG; Multivitamin W/ Fluoride Suspension 0.25 MG
and 0.5 MG
Folic Acid Women only through age 50 years
Folic Acid Tablet 0.4 MG and 0.8 MG; Prenatal Multivitamins W/ Folic Acid (0.4 MG
and 0.8 MG)
Vitamin D Supplements Adults > 65 years of age
Vitamin D 1,000 Units Or Less Per Dose Unit; Calcium With Vitamin D (1,000 Units Or Less
Per Dose Unit)
Immunizations The age of coverage varies based on the
vaccine product prescribed and recommendations by the U.S. Centers for Disease Control and Prevention
Covered immunizations include those that are routine vaccines recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and that meet the US Food and Drug Administration approved indications for age and/or gender limitations. Coverage also includes non-routine immunizations used to prevent other illnesses such as typhoid, yellow fever, and Japanese encephalitis.
Contraceptive Methods Women only, through age 50 years
Covered products include one or more Food and Drug Administration (FDA) approved 16 contraceptive methods available through the prescription drug benefit, including: Generic OTC spermicide and legend
diaphragms; Today® contraceptive sponge; Female condom;
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 5
Medicine/Product Category and Who is Covered Examples of the Medicine/Product Covered
Femcap®; Generic oral, transdermal and intramuscular
hormonal methods; Nuvaring®; Generic, OTC emergency contraceptives and
Ella®; The intrauterine systems Mirena® and
Paragard®; The intradermal agent, Nexplanon®
Primary Prevention of Breast Cancer For women > 35 years of age who meet
criteria Raloxifene is covered for only those who are
postmenopausal If you are 35 years of age or older and have
not had breast cancer, talk to your doctor about your risk. If appropriate, your doctor may offer to prescribe one of these risk-reducing medications.
You or your doctor can then submit a Prior Authorization request to get the medication approved at $0 cost-share if coverage criteria are met.
Tamoxifen Raloxifene Soltamox (Liquid Tamoxifen)
Tobacco Cessation Adults 18 and older Must receive counseling and have prescription
from a health care provider Up to two, 3-month treatment courses are
covered at no cost each year (any additional treatment may be subject to a cost-share)
Zyban (Generic); Chantix; Nicotine Replacement Products
Medications used to prepare for Colonoscopy Adults > 50 and < 75 years of age Limit of 2 prescriptions per year
Generic products such as: Bisacodyl; Magnesium Citrate; Milk Of Magnesia; PEG 3350-Electrolyte
If you have any questions regarding your eligibility for preventive care medications and preventive contraceptive coverage, please contact your employer or call Customer Service toll-free at 1.844.522.5279 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 5 p.m.
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Step Therapy Reference Table
Drug Name Drug that must be tried first
ALMOTRIPTAN, FROVATRIPTAN, NARATRIPTAN, RELPAX,
ZOLMITRIPTAN, ZOLMITRIPTAN ODT, ZOMIG NASAL
Sumatriptan, rizatriptan in the last 180 days
FOSRENAL, RENAGEL, RENVELA calcium acetate 667 mg in the last 180 days
OXICONAXOLE ketoconazole AND clotrimazole topical products in
the last 180 days
ULORIC Allopurinol in the last 180 days
VIIBRYD
Trial of any two (2) of the following drugs: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, trazodone,
venlafaxine in the last year
WELCHOL cholestyramine or colestipol in the last 180 days
SYMBICORT Advair in the last 180 days
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 7
Florida Hospital Care Advantage Formulary
The formulary provides coverage information about some of the drugs covered by FHCA. If you have trouble finding your drug in the list, turn to the Index that begins on page 102. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PRADAXA) and generic drugs are listed in lower-case italics (e.g., lisinopril).
The information in the Notes column tells you if FHCA has any special requirements for coverage of your drug.
Specialty Pharmacy (SP): Must be obtained from Health First Family Pharmacy and are limited to a 30-day supply. For members who reside outside the state of Florida, an exception will be considered to allow the medication to be filled at another pharmacy. Please contact Customer Service Department to initiate this process.
Prior Authorization (PA): FHCA requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from FHCA before you fill your prescriptions. If you don't get approval, the drug will not be covered.
Quantity Limit (QL): Quantity Limits may also be listed. For example, “30 EA per 30 days” would mean your coverage of this drug is limited to 30 pills every 30 days. Prescriptions written for more than the suggested Quantity Limits will only be honored up to the listed amount unless an exception is requested by your physician and approved by FHCA.
Step Therapy (ST): In some cases, FHCA requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. A complete list of drugs which require step therapy is listed in the reference table on page 6.
Maintenance Drug (MD): You may be taking these drugs on a long-term basis. Maintenance medications are generally those used to treat chronic conditions and long-term conditions. **Some exceptions may apply (i.e. certain medications used for ADHD, asthma/COPD rescue, acute pain, and acute infections).
No Cost-Share (NCS): Select preventive products, prescription medications and specific over-the-counter (OTC) medications available to our members at no cost-sharing ($0) when applicable conditions are met.
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2018 Commercial/TPA 5 Tier Formulary Version 5 Page 9
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
ANALGESICS
acetaminophen-codeine oral solution 120 mg-12
mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg
/10 ml (10 ml), 300 mg-30 mg /12.5 ml
T3 QL (2700 ML per 30 days)
acetaminophen-codeine oral tablet 300-15 mg,
300-30 mg T3 QL (240 EA per 30 days)
acetaminophen-codeine oral tablet 300-60 mg T3 QL (180 EA per 30 days)
almotriptan malate oral tablet 12.5 mg, 6.25 mg T4 ST; QL (18 EA per 30 days)
ASCOMP WITH CODEINE ORAL CAPSULE
30-50-325-40 MG T3
aspirin oral tablet 325 mg NCS MD
aspirin oral tablet,delayed release (dr/ec) 325 mg NCS MD
BAYER ASPIRIN ORAL TABLET 325 MG NCS
BUTALBITAL COMPOUND W/CODEINE
ORAL CAPSULE 30-50-325-40 MG T4 QL (180 EA per 30 days)
BUTALBITAL COMPOUND-CODEINE ORAL
CAPSULE 30-50-325-40 MG T4 QL (180 EA per 30 days)
butalbital-acetaminop-caf-cod oral capsule 50-
300-40-30 mg, 50-325-40-30 mg T4 QL (180 EA per 30 days)
butalbital-acetaminophen oral tablet 50-325 mg T4 QL (180 EA per 30 days)
butalbital-acetaminophen-caff oral capsule 50-
300-40 mg, 50-325-40 mg T4 QL (180 EA per 30 days)
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg T4 QL (180 EA per 30 days)
butalbital-aspirin-caffeine oral capsule 50-325-
40 mg T4 QL (180 EA per 30 days)
butorphanol tartrate injection solution 1 mg/ml, 2
mg/ml T3
BUTRANS TRANSDERMAL PATCH
WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20
MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR
T3 QL (4 EA per 28 days)
codeine sulfate oral tablet 15 mg, 30 mg, 60 mg T3 QL (180 EA per 30 days)
codeine-butalbital-asa-caff oral capsule 30-50-
325-40 mg T4 QL (180 EA per 30 days)
diclofenac potassium oral tablet 50 mg T2
dihydroergotamine injection solution 1 mg/ml T3
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 10
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
dihydroergotamine nasal spray,non-aerosol 0.5
mg/pump act. (4 mg/ml) T4
ELMIRON ORAL CAPSULE 100 MG T4
ENDOCET ORAL TABLET 10-325 MG T3 QL (180 EA per 30 days)
ENDOCET ORAL TABLET 2.5-325 MG, 5-325
MG, 7.5-325 MG T3 QL (240 EA per 30 days)
ERGOMAR SUBLINGUAL TABLET 2 MG T4
fentanyl citrate buccal lozenge on a handle 1,200
mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800
mcg
T5 (SP) PA; QL (120 EA per 30 days)
fentanyl transdermal patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr T3 QL (15 EA per 30 days)
frovatriptan oral tablet 2.5 mg T4 ST; QL (18 EA per 30 days)
hydrocodone-acetaminophen oral solution 7.5-
325 mg/15 ml T4 QL (2700 ML per 30 days)
hydrocodone-acetaminophen oral tablet 10-300
mg, 10-325 mg T3 QL (180 EA per 30 days)
hydrocodone-acetaminophen oral tablet 2.5-325
mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg T3 QL (240 EA per 30 days)
hydrocodone-acetaminophen oral tablet 7.5-325
mg T3 QL (84 EA per 30 days)
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-
200 mg, 7.5-200 mg T3 QL (50 EA per 30 days)
hydromorphone oral tablet 2 mg, 4 mg, 8 mg T3 QL (180 EA per 30 days)
ibuprofen-oxycodone oral tablet 400-5 mg T3 QL (28 EA per 30 days)
ketorolac oral tablet 10 mg T2
levorphanol tartrate oral tablet 2 mg T4 QL (180 EA per 30 days)
LITE COAT ASPIRIN ORAL TABLET 325 MG NCS
mefenamic acid oral capsule 250 mg T4
meperidine oral tablet 100 mg, 50 mg T3 QL (180 EA per 30 days)
methadone oral tablet 10 mg, 5 mg T3 QL (240 EA per 30 days)
MIGERGOT RECTAL SUPPOSITORY 2-100
MG T4 QL (20 EA per 28 days)
morphine concentrate oral solution 100 mg/5 ml
(20 mg/ml) T3 QL (600 ML per 30 days)
morphine concentrate oral syringe 20 mg/ml T3 QL (600 EA per 30 days)
morphine oral solution 10 mg/5 ml T3 QL (2700 ML per 30 days)
morphine oral solution 20 mg/5 ml (4 mg/ml) T3 QL (1350 ML per 30 days)
morphine oral tablet 15 mg, 30 mg T3 QL (180 EA per 30 days)
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You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
morphine oral tablet extended release 100 mg, 15
mg, 30 mg, 60 mg T3 QL (90 EA per 30 days)
morphine oral tablet extended release 200 mg T3 QL (60 EA per 30 days)
naratriptan oral tablet 1 mg, 2.5 mg T3 ST; QL (18 EA per 30 days)
NUCYNTA ER ORAL TABLET EXTENDED
RELEASE 12 HR 100 MG, 150 MG, 200 MG,
250 MG, 50 MG
T4 PA; QL (60 EA per 30 days)
NUCYNTA ORAL TABLET 100 MG, 50 MG,
75 MG T4 PA; QL (180 EA per 30 days)
OPANA ER ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG,
30 MG, 40 MG, 5 MG, 7.5 MG
T4 QL (60 EA per 30 days)
oxycodone oral solution 5 mg/5 ml T4 QL (5400 ML per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg T3 QL (180 EA per 30 days)
oxycodone oral tablet 30 mg T3 QL (120 EA per 30 days)
oxycodone oral tablet 5 mg T3 QL (240 EA per 30 days)
oxycodone-acetaminophen oral tablet 10-325 mg T3 QL (180 EA per 30 days)
oxycodone-acetaminophen oral tablet 2.5-325
mg, 5-325 mg, 7.5-325 mg T3 QL (240 EA per 30 days)
oxycodone-aspirin oral tablet 4.8355-325 mg T3 QL (360 EA per 30 days)
oxymorphone oral tablet 10 mg, 5 mg T4 QL (120 EA per 30 days)
oxymorphone oral tablet extended release 12 hr
10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg T4 QL (60 EA per 30 days)
pentazocine-naloxone oral tablet 50-0.5 mg T3
RELPAX ORAL TABLET 20 MG, 40 MG T4 ST; QL (18 EA per 30 days)
rizatriptan oral tablet 10 mg, 5 mg T2 QL (18 EA per 30 days)
rizatriptan oral tablet,disintegrating 10 mg, 5 mg T2 QL (18 EA per 30 days)
sumatriptan succinate oral tablet 100 mg, 25 mg,
50 mg T2 QL (18 EA per 30 days)
sumatriptan succinate subcutaneous pen injector
6 mg/0.5 ml T4 QL (8 ML per 30 days)
sumatriptan succinate subcutaneous solution 6
mg/0.5 ml T4 QL (8 ML per 30 days)
tramadol oral tablet 50 mg T3 QL (240 EA per 30 days)
tramadol oral tablet extended release 24 hr 100
mg, 200 mg, 300 mg T4 QL (30 EA per 30 days)
tramadol oral tablet, er multiphase 24 hr 100 mg,
200 mg, 300 mg T4 QL (30 EA per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 12
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
tramadol-acetaminophen oral tablet 37.5-325 mg T3 QL (240 EA per 30 days)
XTAMPZA ER ORAL
CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5
MG, 18 MG, 27 MG, 36 MG, 9 MG
T4 QL (60 EA per 30 days)
ZOHYDRO ER ORAL CAPSULE, ORAL
ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30
MG, 40 MG, 50 MG
T4 QL (60 EA per 30 days)
zolmitriptan oral tablet 2.5 mg, 5 mg T4 ST; QL (18 EA per 30 days)
zolmitriptan oral tablet,disintegrating 2.5 mg, 5
mg T4 ST; QL (18 EA per 30 days)
ZOMIG NASAL SPRAY,NON-AEROSOL 2.5
MG, 5 MG T4 ST; QL (12 EA per 30 days)
ANESTHETICS
lidocaine hcl laryngotracheal solution 4 % T2
lidocaine hcl mucous membrane jelly 2 % T2
lidocaine hcl mucous membrane solution 2 %, 4
% (40 mg/ml) T2
lidocaine hcl topical cream 3 % T2
lidocaine hcl topical lotion 3 % T2
lidocaine topical adhesive patch,medicated 5 % T4 PA; QL (90 EA per 30 days)
lidocaine topical ointment 5 % T4 PA; QL (150 GM per 30 days)
LIDOCAINE VISCOUS MUCOUS
MEMBRANE SOLUTION 2 % T2
lidocaine-prilocaine topical cream 2.5-2.5 % T2
lidocaine-prilocaine topical kit 2.5-2.5 % T2
phenazopyridine oral tablet 100 mg, 200 mg T2
SYNERA TOPICAL PATCH, MEDICATED
SELF-HEATING 70-70 MG T4 PA
ANTIALLERGY
cromolyn oral concentrate 100 mg/5 ml T2
ANTIARTHRITICS
allopurinol oral tablet 100 mg, 300 mg T2 MD
celecoxib oral capsule 100 mg, 200 mg, 400 mg,
50 mg T3 MD; QL (60 EA per 30 days)
colchicine oral capsule 0.6 mg T3 MD
colchicine oral tablet 0.6 mg T3 MD
DEPEN TITRATABS ORAL TABLET 250 MG T5 (SP) MD
diclofenac sodium oral tablet extended release 24
hr 100 mg T2
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You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
diclofenac sodium oral tablet,delayed release
(dr/ec) 25 mg, 50 mg, 75 mg T2
etodolac oral capsule 200 mg, 300 mg T3 MD
etodolac oral tablet 400 mg, 500 mg T3 MD
etodolac oral tablet extended release 24 hr 400
mg, 500 mg, 600 mg T4 MD
fenoprofen oral tablet 600 mg T4
flurbiprofen oral tablet 100 mg T2
flurbiprofen oral tablet 50 mg T2 MD
ibuprofen oral tablet 400 mg, 600 mg, 800 mg T1 MD
indomethacin oral capsule 25 mg, 50 mg T2
ketoprofen oral capsule 50 mg, 75 mg T2
leflunomide oral tablet 10 mg, 20 mg T3 MD; QL (30 EA per 30 days)
meclofenamate oral capsule 100 mg T4
meclofenamate oral capsule 50 mg T4 MD
meloxicam oral suspension 7.5 mg/5 ml T2 MD
meloxicam oral tablet 15 mg, 7.5 mg T2 MD
nabumetone oral tablet 500 mg, 750 mg T2
naproxen oral tablet 250 mg, 375 mg, 500 mg T1 MD
naproxen oral tablet,delayed release (dr/ec) 375
mg, 500 mg T2 MD
OTEZLA ORAL TABLET 30 MG T5 (SP) PA; MD
OTEZLA STARTER ORAL TABLETS,DOSE
PACK 10 MG (4)-20 MG (4)-30 MG (47), 10
MG (4)-20 MG (4)-30 MG(19)
T5 (SP) PA
oxaprozin oral tablet 600 mg T3
piroxicam oral capsule 10 mg, 20 mg T3
probenecid oral tablet 500 mg T2 MD
probenecid-colchicine oral tablet 500-0.5 mg T2 MD
RIDAURA ORAL CAPSULE 3 MG T5 (SP) MD
sulindac oral tablet 150 mg, 200 mg T2
tolmetin oral capsule 400 mg T3
tolmetin oral tablet 200 mg, 600 mg T3 MD
ULORIC ORAL TABLET 40 MG, 80 MG T4 ST; MD
XELJANZ ORAL TABLET 10 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
XELJANZ ORAL TABLET 5 MG T5 (SP) PA; MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 14
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
XELJANZ XR ORAL TABLET EXTENDED
RELEASE 24 HR 11 MG T5 (SP) PA; MD
ANTIASTHMATICS
acetylcysteine solution 100 mg/ml (10 %), 200
mg/ml (20 %) T2
ADVAIR DISKUS INHALATION BLISTER
WITH DEVICE 100-50 MCG/DOSE, 250-50
MCG/DOSE, 500-50 MCG/DOSE
T3 MD; QL (60 EA per 30 days)
ADVAIR HFA INHALATION HFA AEROSOL
INHALER 115-21 MCG/ACTUATION, 230-21
MCG/ACTUATION, 45-21 MCG/ACTUATION
T3 MD; QL (12 GM per 30 days)
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg
/3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml
T2 MD
albuterol sulfate oral syrup 2 mg/5 ml T2 MD
albuterol sulfate oral tablet 2 mg, 4 mg T4 MD
aminophylline intravenous solution 250 mg/10 ml T2
ANORO ELLIPTA INHALATION BLISTER
WITH DEVICE 62.5-25 MCG/ACTUATION T3 MD
ARCAPTA NEOHALER INHALATION
CAPSULE, W/INHALATION DEVICE 75 MCG T4 MD
ARNUITY ELLIPTA INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 200
MCG/ACTUATION
T3 MD
ASMANEX HFA INHALATION HFA
AEROSOL INHALER 100 MCG/ACTUATION,
200 MCG/ACTUATION
T3 MD; QL (13 GM per 30 days)
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED
110 MCG (30 DOSES), 220 MCG (120 DOSES),
220 MCG (30 DOSES), 220 MCG (60 DOSES)
T3 MD; QL (1 EA per 30 days)
ATROVENT HFA INHALATION HFA
AEROSOL INHALER 17 MCG/ACTUATION T4 MD; QL (26 GM per 30 days)
BREO ELLIPTA INHALATION BLISTER
WITH DEVICE 100-25 MCG/DOSE, 200-25
MCG/DOSE
T3 MD
BROVANA INHALATION SOLUTION FOR
NEBULIZATION 15 MCG/2 ML T4 PA; MD
budesonide inhalation suspension for nebulization
0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml T4 MD
COMBIVENT RESPIMAT INHALATION
MIST 20-100 MCG/ACTUATION T3 MD; QL (8 GM per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 15
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
cromolyn inhalation solution for nebulization 20
mg/2 ml T2 MD
DULERA INHALATION HFA AEROSOL
INHALER 100-5 MCG/ACTUATION, 200-5
MCG/ACTUATION
T3 MD; QL (13 GM per 30 days)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 50
MCG/ACTUATION
T3 MD; QL (60 EA per 30 days)
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION T3 MD; QL (240 EA per 30 days)
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110 MCG/ACTUATION T3 MD; QL (12 GM per 30 days)
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 220 MCG/ACTUATION T3 MD; QL (24 GM per 30 days)
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 44 MCG/ACTUATION T3 MD; QL (10.6 GM per 30 days)
ipratropium bromide inhalation solution 0.02 % T2 MD
ipratropium-albuterol inhalation solution for
nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml T2 MD
levalbuterol hcl inhalation solution for
nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25
mg/0.5 ml, 1.25 mg/3 ml
T4 MD
metaproterenol oral syrup 10 mg/5 ml T2 MD
metaproterenol oral tablet 10 mg, 20 mg T3 MD
montelukast oral granules in packet 4 mg T2 MD
montelukast oral tablet 10 mg T2 MD; QL (30 EA per 30 days)
montelukast oral tablet,chewable 4 mg, 5 mg T2 MD; QL (30 EA per 30 days)
SEREVENT DISKUS INHALATION BLISTER
WITH DEVICE 50 MCG/DOSE T3 MD; QL (60 EA per 30 days)
SPIRIVA RESPIMAT INHALATION MIST
1.25 MCG/ACTUATION, 2.5
MCG/ACTUATION
T3 MD; QL (4 GM per 30 days)
SPIRIVA WITH HANDIHALER INHALATION
CAPSULE, W/INHALATION DEVICE 18 MCG T3 MD; QL (30 EA per 30 days)
STIOLTO RESPIMAT INHALATION MIST
2.5-2.5 MCG/ACTUATION T3 MD; QL (4 GM per 30 days)
STRIVERDI RESPIMAT INHALATION MIST
2.5 MCG/ACTUATION T3 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 16
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
SYMBICORT INHALATION HFA AEROSOL
INHALER 160-4.5 MCG/ACTUATION, 80-4.5
MCG/ACTUATION
T3 ST; MD; QL (10.2 GM per 30
days)
terbutaline oral tablet 2.5 mg, 5 mg T2 MD
theophylline oral tablet extended release 12 hr
100 mg, 200 mg, 300 mg, 450 mg T2 MD
theophylline oral tablet extended release 400 mg,
600 mg T3
TRELEGY ELLIPTA INHALATION BLISTER
WITH DEVICE 100-62.5-25 MCG T4 PA; MD
VENTOLIN HFA INHALATION HFA
AEROSOL INHALER 90 MCG/ACTUATION T3 MD; QL (36 GM per 30 days)
XOLAIR SUBCUTANEOUS RECON SOLN
150 MG T5 (SP) PA; MD
zafirlukast oral tablet 10 mg, 20 mg T3 MD; QL (60 EA per 30 days)
ZYFLO CR ORAL TABLET, ER
MULTIPHASE 12 HR 600 MG T5 (SP) PA; MD; QL (120 EA per 30 days)
ZYFLO ORAL TABLET 600 MG T5 (SP) PA; MD; QL (120 EA per 30 days)
ANTIBIOTICS
AK-POLY-BAC OPHTHALMIC (EYE)
OINTMENT 500-10,000 UNIT/GRAM T2
amoxicillin oral capsule 250 mg, 500 mg T1
amoxicillin oral suspension for reconstitution 125
mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml T1
amoxicillin oral tablet 500 mg, 875 mg T1
amoxicillin oral tablet,chewable 125 mg T2
amoxicillin oral tablet,chewable 250 mg T1
amoxicillin-pot clavulanate oral suspension for
reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml,
600-42.9 mg/5 ml
T2
amoxicillin-pot clavulanate oral suspension for
reconstitution 250-62.5 mg/5 ml T3
amoxicillin-pot clavulanate oral tablet 250-125
mg T3
amoxicillin-pot clavulanate oral tablet 500-125
mg, 875-125 mg T2
amoxicillin-pot clavulanate oral tablet extended
release 12 hr 1,000-62.5 mg T3
amoxicillin-pot clavulanate oral tablet,chewable
200-28.5 mg, 400-57 mg T2
ampicillin oral capsule 250 mg, 500 mg T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 17
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
ampicillin oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml T3
AVAR TOPICAL CLEANSER 10-5 % (W/W) T4
AVAR-E GREEN TOPICAL CREAM 10-5 %
(W/W) T4
AVAR-E TOPICAL CREAM 10-5 % (W/W) T4
AZASITE OPHTHALMIC (EYE) DROPS 1 % T4
azithromycin oral packet 1 gram T2
azithromycin oral suspension for reconstitution
100 mg/5 ml, 200 mg/5 ml T2
azithromycin oral tablet 250 mg, 500 mg, 600 mg T1
bacitracin ophthalmic (eye) ointment 500
unit/gram T3
bacitracin-polymyxin b ophthalmic (eye) ointment
500-10,000 unit/gram T2
BACTROBAN NASAL NASAL OINTMENT 2
% T4
BENZAMYCINPAK TOPICAL GEL 3-5 % T4
BESIVANCE OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.6 % T4
BLEPHAMIDE S.O.P. OPHTHALMIC (EYE)
OINTMENT 10-0.2 % T3
CAYSTON INHALATION SOLUTION FOR
NEBULIZATION 75 MG/ML T5 (SP) PA
cefaclor oral capsule 250 mg, 500 mg T3
cefadroxil oral capsule 500 mg T2
cefadroxil oral suspension for reconstitution 250
mg/5 ml, 500 mg/5 ml T3
cefadroxil oral tablet 1 gram T3
cefazolin injection recon soln 1 gram, 300 g, 500
mg T2
cefdinir oral capsule 300 mg T2
cefdinir oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml T3
cefixime oral suspension for reconstitution 100
mg/5 ml, 200 mg/5 ml T4
cefpodoxime oral suspension for reconstitution
100 mg/5 ml, 50 mg/5 ml T3
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 18
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
cefpodoxime oral tablet 100 mg, 200 mg T3
cefprozil oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml T3
cefprozil oral tablet 250 mg, 500 mg T2
CEFTIN ORAL SUSPENSION FOR
RECONSTITUTION 125 MG/5 ML, 250 MG/5
ML
T4
ceftriaxone injection recon soln 1 gram, 10 gram,
2 gram, 250 mg, 500 mg T2
cefuroxime axetil oral tablet 250 mg, 500 mg T3
cefuroxime sodium injection recon soln 1.5 gram,
750 mg T2
cephalexin oral capsule 250 mg, 500 mg T1
cephalexin oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml T2
CILOXAN OPHTHALMIC (EYE) OINTMENT
0.3 % T3
CIPRO HC OTIC (EAR) DROPS,SUSPENSION
0.2-1 % T4
CIPRODEX OTIC (EAR)
DROPS,SUSPENSION 0.3-0.1 % T3
ciprofloxacin (mixture) oral tablet, er multiphase
24 hr 1,000 mg, 500 mg T3
ciprofloxacin hcl ophthalmic (eye) drops 0.3 % T1
ciprofloxacin hcl oral tablet 100 mg T4
ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750
mg T1
ciprofloxacin hcl otic (ear) dropperette 0.2 % T2 QL (60 EA per 30 days)
ciprofloxacin oral suspension,microcapsule recon
250 mg/5 ml, 500 mg/5 ml T3
clarithromycin oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml T3
clarithromycin oral tablet 250 mg, 500 mg T3
clarithromycin oral tablet extended release 24 hr
500 mg T3
CLEOCIN VAGINAL SUPPOSITORY 100 MG T4
CLINDACIN ETZ TOPICAL SWAB 1 % T2
CLINDACIN P TOPICAL SWAB 1 % T2
clindamycin hcl oral capsule 150 mg, 300 mg T1
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 19
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Drug Name Tier Notes
clindamycin palmitate hcl oral recon soln 75
mg/5 ml T3
clindamycin phosphate topical gel 1 % T3
clindamycin phosphate topical lotion 1 % T3
clindamycin phosphate topical solution 1 % T3
clindamycin phosphate topical swab 1 % T2
clindamycin phosphate vaginal cream 2 % T3
COLY-MYCIN S OTIC (EAR)
DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML T3
CORTISPORIN TOPICAL CREAM 3.5-10,000-
0.5 MG/G-UNIT/G-% T4
CORTISPORIN TOPICAL OINTMENT 1 % T4
CORTISPORIN-TC OTIC (EAR)
DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML T3
cycloserine oral capsule 250 mg T4
dapsone oral tablet 100 mg, 25 mg T3 MD
demeclocycline oral tablet 150 mg, 300 mg T3
dicloxacillin oral capsule 250 mg, 500 mg T2
DIFICID ORAL TABLET 200 MG T5 (SP) PA
doxycycline hyclate oral capsule 100 mg, 50 mg T3
doxycycline hyclate oral tablet 100 mg T3
doxycycline monohydrate oral capsule 100 mg,
50 mg T2
doxycycline monohydrate oral tablet 100 mg, 50
mg, 75 mg T3
E.E.S. 200 ORAL SUSPENSION FOR
RECONSTITUTION 200 MG/5 ML T4
E.E.S. 400 ORAL TABLET 400 MG T2
E.E.S. GRANULES ORAL SUSPENSION FOR
RECONSTITUTION 200 MG/5 ML T4
ERY PADS TOPICAL SWAB 2 % T3
ERY-TAB ORAL TABLET,DELAYED
RELEASE (DR/EC) 250 MG, 333 MG, 500 MG T3
ERYTHROCIN (AS STEARATE) ORAL
TABLET 250 MG T4
erythromycin ethylsuccinate oral tablet 400 mg T4
erythromycin ophthalmic (eye) ointment 5
mg/gram (0.5 %) T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 20
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
erythromycin oral capsule,delayed release(dr/ec)
250 mg T4
erythromycin oral tablet 250 mg, 500 mg T4
erythromycin with ethanol topical gel 2 % T2
erythromycin with ethanol topical solution 2 % T2
erythromycin with ethanol topical swab 2 % T2
erythromycin-benzoyl peroxide topical gel 3-5 % T4
ethambutol oral tablet 100 mg, 400 mg T3 MD
FIRVANQ ORAL RECON SOLN 25 MG/ML,
50 MG/ML T3
gatifloxacin ophthalmic (eye) drops 0.5 % T3
GENTAK OPHTHALMIC (EYE) OINTMENT
0.3 % (3 MG/GRAM) T2
gentamicin ophthalmic (eye) drops 0.3 % T2
gentamicin ophthalmic (eye) ointment 0.3 % (3
mg/gram) T2
gentamicin topical cream 0.1 % T2
gentamicin topical ointment 0.1 % T2
isoniazid oral solution 50 mg/5 ml T2 MD
isoniazid oral tablet 100 mg, 300 mg T2
levofloxacin ophthalmic (eye) drops 0.5 % T2
levofloxacin oral solution 250 mg/10 ml T4
levofloxacin oral tablet 250 mg, 500 mg, 750 mg T2
linezolid oral suspension for reconstitution 100
mg/5 ml T5 (SP) PA
linezolid oral tablet 600 mg T5 (SP) PA
methenamine hippurate oral tablet 1 gram T2
metronidazole oral tablet 250 mg, 500 mg T2
metronidazole vaginal gel 0.75 % T2
minocycline oral capsule 100 mg, 50 mg, 75 mg T2
MONUROL ORAL PACKET 3 GRAM T4
MOXEZA OPHTHALMIC (EYE) DROPS,
VISCOUS 0.5 % T3
mupirocin topical ointment 2 % T2
neomycin oral tablet 500 mg T2
neomycin-bacitracin-poly-hc ophthalmic (eye)
ointment 3.5-400-10,000 mg-unit/g-1% T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 21
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
neomycin-bacitracin-polymyxin ophthalmic (eye)
ointment 3.5-400-10,000 mg-unit-unit/g T2
neomycin-polymyxin b-dexameth ophthalmic
(eye) drops,suspension 3.5mg/ml-10,000 unit/ml-
0.1 %
T2
neomycin-polymyxin b-dexameth ophthalmic
(eye) ointment 3.5 mg/g-10,000 unit/g-0.1 % T2
neomycin-polymyxin-gramicidin ophthalmic (eye)
drops 1.75 mg-10,000 unit-0.025mg/ml T2
neomycin-polymyxin-hc otic (ear)
drops,suspension 3.5-10,000-1 mg/ml-unit/ml-% T2
neomycin-polymyxin-hc otic (ear) solution 3.5-
10,000-1 mg/ml-unit/ml-% T2
nitrofurantoin macrocrystal oral capsule 100 mg,
50 mg T2
nitrofurantoin monohyd/m-cryst oral capsule 100
mg T2
nitrofurantoin oral suspension 25 mg/5 ml T2
ofloxacin ophthalmic (eye) drops 0.3 % T2
ofloxacin oral tablet 400 mg T2
ofloxacin otic (ear) drops 0.3 % T4
penicillin v potassium oral recon soln 125 mg/5
ml, 250 mg/5 ml T2
penicillin v potassium oral tablet 250 mg, 500 mg T2
polymyxin b sulfate injection recon soln 500,000
unit T2
polymyxin b sulf-trimethoprim ophthalmic (eye)
drops 10,000 unit- 1 mg/ml T2
PRIFTIN ORAL TABLET 150 MG T4
pyrazinamide oral tablet 500 mg T2
rifabutin oral capsule 150 mg T4
rifampin oral capsule 150 mg, 300 mg T2
ROSANIL TOPICAL CLEANSER 10-5 %
(W/W) T4
ROSULA CLEANSING CLOTHS TOPICAL
PADS, MEDICATED 10-5 % T4
silver sulfadiazine topical cream 1 % T2
SSD TOPICAL CREAM 1 % T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 22
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
SSS 10-5 TOPICAL CREAM 10-5 % (W/W) T4
SSS 10-5 TOPICAL FOAM 10-5 % T4
streptomycin intramuscular recon soln 1 gram T3
sulfacetamide sodium ophthalmic (eye) drops 10
% T2
sulfacetamide sodium ophthalmic (eye) ointment
10 % T2
sulfacetamide sodium-sulfur topical cleanser 10-2
%, 10-5 % (w/w), 9-4.5 %, 9.8-4.8 % T4
sulfacetamide sodium-sulfur topical cream 10-2
%, 10-5 % (w/w), 9.8-4.8 % T4
sulfacetamide sodium-sulfur topical foam 10-5 % T4
sulfacetamide sodium-sulfur topical lotion 10-5 %
(w/v) T4
sulfacetamide sodium-sulfur topical pads,
medicated 10-4 % T4
sulfacetamide sodium-sulfur topical suspension
10-5 % T4
sulfacetamide sod-sulfur-urea topical cleanser
10-5-10 % T4
sulfadiazine oral tablet 500 mg T3
sulfamethoxazole-trimethoprim intravenous
solution 400-80 mg/5 ml T3
sulfamethoxazole-trimethoprim oral suspension
200-40 mg/5 ml T2
sulfamethoxazole-trimethoprim oral tablet 400-80
mg, 800-160 mg T1
SULFAMYLON TOPICAL CREAM 85 MG/G T4
tetracycline oral capsule 250 mg, 500 mg T4
THALOMID ORAL CAPSULE 100 MG, 150
MG, 200 MG, 50 MG T5 (SP) PA; MD
THERMAZENE TOPICAL CREAM 1 % T2
TOBRADEX OPHTHALMIC (EYE)
OINTMENT 0.3-0.1 % T3
TOBRADEX ST OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.3-0.05 % T3
tobramycin in 0.225 % nacl inhalation solution
for nebulization 300 mg/5 ml T5 (SP) PA; MD
tobramycin ophthalmic (eye) drops 0.3 % T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 23
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Drug Name Tier Notes
tobramycin-dexamethasone ophthalmic (eye)
drops,suspension 0.3-0.1 % T3
TRECATOR ORAL TABLET 250 MG T4
trimethoprim oral tablet 100 mg T2
vancomycin intravenous recon soln 1,000 mg, 500
mg T2
vancomycin oral capsule 125 mg, 250 mg T5 (SP) PA
VIGAMOX OPHTHALMIC (EYE) DROPS 0.5
% T3
XIFAXAN ORAL TABLET 200 MG T5 (SP) PA; QL (9 EA per 30 days)
XIFAXAN ORAL TABLET 550 MG T5 (SP) PA; MD; QL (90 EA per 30 days)
ZYLET OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.3-0.5 % T4
ANTICOAGULANTS
ELIQUIS ORAL TABLET 2.5 MG, 5 MG T3 MD
ELIQUIS ORAL TABLETS,DOSE PACK 5 MG
(74 TABS) T3
enoxaparin subcutaneous solution 300 mg/3 ml T4 QL (24 ML per 30 days)
enoxaparin subcutaneous syringe 100 mg/ml, 150
mg/ml T4 QL (28 ML per 30 days)
enoxaparin subcutaneous syringe 120 mg/0.8 ml,
80 mg/0.8 ml T4 QL (22.4 ML per 30 days)
enoxaparin subcutaneous syringe 30 mg/0.3 ml T4 QL (8.4 ML per 30 days)
enoxaparin subcutaneous syringe 40 mg/0.4 ml T4 QL (11.2 ML per 30 days)
enoxaparin subcutaneous syringe 60 mg/0.6 ml T4 QL (16.8 ML per 30 days)
fondaparinux subcutaneous syringe 10 mg/0.8 ml T5 (SP) PA; QL (24 ML per 30 days)
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml T5 (SP) PA; QL (15 ML per 30 days)
fondaparinux subcutaneous syringe 5 mg/0.4 ml T5 (SP) PA; QL (12 ML per 30 days)
fondaparinux subcutaneous syringe 7.5 mg/0.6 ml T5 (SP) PA; QL (18 ML per 30 days)
heparin (porcine) injection solution 10,000
unit/ml, 20,000 unit/ml, 5,000 unit/ml T2
heparin, porcine (pf) injection solution 1,000
unit/ml T2
heparin, porcine (pf) injection syringe 5,000
unit/0.5 ml T2
JANTOVEN ORAL TABLET 1 MG, 10 MG, 2
MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5
MG
T1 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 24
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
PRADAXA ORAL CAPSULE 110 MG, 150
MG, 75 MG T3 MD
warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg, 7.5 mg T1 MD
XARELTO ORAL TABLET 10 MG T3
XARELTO ORAL TABLET 15 MG, 20 MG T3 MD
XARELTO ORAL TABLETS,DOSE PACK 15
MG (42)- 20 MG (9) T3
ANTIDOTES
MOVANTIK ORAL TABLET 12.5 MG, 25 MG T4 PA
naloxone injection syringe 1 mg/ml T2
naltrexone oral tablet 50 mg T2
ANTIFUNGALS
caspofungin intravenous recon soln 50 mg, 70 mg T5 (SP) PA
CICLODAN TOPICAL SOLUTION 8 % T2
ciclopirox topical cream 0.77 % T3
ciclopirox topical gel 0.77 % T3
ciclopirox topical shampoo 1 % T3
ciclopirox topical solution 8 % T2
ciclopirox topical suspension 0.77 % T3
clotrimazole mucous membrane troche 10 mg T2
clotrimazole topical cream 1 % T2
clotrimazole topical solution 1 % T2
clotrimazole-betamethasone topical cream 1-0.05
% T2
clotrimazole-betamethasone topical lotion 1-0.05
% T3
econazole topical cream 1 % T4
ERTACZO TOPICAL CREAM 2 % T5 (SP) PA
fluconazole oral tablet 100 mg, 150 mg, 200 mg,
50 mg T2
flucytosine oral capsule 250 mg, 500 mg T5 (SP)
griseofulvin microsize oral suspension 125 mg/5
ml T2
GYNAZOLE-1 VAGINAL CREAM 2 % T4
itraconazole oral capsule 100 mg T4 PA; QL (120 EA per 30 days)
ketoconazole oral tablet 200 mg T2
ketoconazole topical cream 2 % T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 25
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
ketoconazole topical shampoo 2 % T2
MENTAX TOPICAL CREAM 1 % T3
naftifine topical cream 1 %, 2 % T4
NAFTIN TOPICAL GEL 1 % T4
NATACYN OPHTHALMIC (EYE)
DROPS,SUSPENSION 5 % T3
NOXAFIL INTRAVENOUS SOLUTION 300
MG/16.7 ML T5 (SP) PA
NOXAFIL ORAL SUSPENSION 200 MG/5 ML
(40 MG/ML) T5 (SP) PA
NOXAFIL ORAL TABLET,DELAYED
RELEASE (DR/EC) 100 MG T5 (SP) PA
nystatin oral suspension 100,000 unit/ml T2
nystatin oral tablet 500,000 unit T2
nystatin topical cream 100,000 unit/gram T2
nystatin topical ointment 100,000 unit/gram T2
nystatin topical powder 100,000 unit/gram T2
nystatin-triamcinolone topical cream 100,000-0.1
unit/g-% T4
nystatin-triamcinolone topical ointment 100,000-
0.1 unit/gram-% T4
NYSTOP TOPICAL POWDER 100,000
UNIT/GRAM T2
oxiconazole topical cream 1 % T4 ST
terbinafine hcl oral tablet 250 mg T2 QL (30 EA per 30 days)
terconazole vaginal cream 0.4 %, 0.8 % T4
terconazole vaginal suppository 80 mg T4
voriconazole oral suspension for reconstitution
200 mg/5 ml (40 mg/ml) T5 (SP) PA
voriconazole oral tablet 200 mg, 50 mg T5 (SP) PA
VUSION TOPICAL OINTMENT 0.25-15-81.35
% T4
ANTIHISTAMINE AND
DECONGESTANT COMBINATION
PROMETHAZINE VC ORAL SYRUP 6.25-5
MG/5 ML T3
promethazine-phenylephrine oral syrup 6.25-5
mg/5 ml T3
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 26
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
ANTIHISTAMINES
azelastine ophthalmic (eye) drops 0.05 % T2
BEPREVE OPHTHALMIC (EYE) DROPS 1.5
% T4
carbinoxamine maleate oral tablet 4 mg T3
clemastine oral tablet 2.68 mg T3
cyproheptadine oral tablet 4 mg T2
desloratadine oral tablet 5 mg T2 MD; QL (30 EA per 30 days)
diphenhydramine hcl injection solution 50 mg/ml T2
diphenhydramine hcl injection syringe 50 mg/ml T2
EMADINE OPHTHALMIC (EYE) DROPS 0.05
% T4
epinastine ophthalmic (eye) drops 0.05 % T3
hydroxyzine hcl intramuscular solution 25 mg/ml,
50 mg/ml T2
hydroxyzine hcl oral solution 10 mg/5 ml T2
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg T2
hydroxyzine pamoate oral capsule 100 mg, 25
mg, 50 mg T2
LASTACAFT OPHTHALMIC (EYE) DROPS
0.25 % T4 QL (6 ML per 30 days)
levocetirizine oral solution 2.5 mg/5 ml T4 MD
levocetirizine oral tablet 5 mg T2 MD; QL (30 EA per 30 days)
olopatadine ophthalmic (eye) drops 0.1 % T3 QL (10 ML per 30 days)
PATADAY OPHTHALMIC (EYE) DROPS 0.2
% T3 QL (10 ML per 30 days)
PAZEO OPHTHALMIC (EYE) DROPS 0.7 % T3
promethazine injection solution 25 mg/ml, 50
mg/ml T3
promethazine injection syringe 25 mg/ml T3
promethazine oral syrup 6.25 mg/5 ml T3
promethazine oral tablet 12.5 mg, 25 mg, 50 mg T2
ANTIHYPERGLYCEMICS
acarbose oral tablet 100 mg, 25 mg, 50 mg T2 MD; QL (90 EA per 30 days)
BYDUREON BCISE SUBCUTANEOUS
AUTO-INJECTOR 2 MG/0.85 ML T3 MD; QL (3.4 ML per 28 days)
BYDUREON SUBCUTANEOUS PEN
INJECTOR 2 MG/0.65 ML T3 MD; QL (4 EA per 28 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 27
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Drug Name Tier Notes
BYDUREON SUBCUTANEOUS
SUSPENSION,EXTENDED REL RECON 2 MG T3 MD; QL (4 EA per 28 days)
BYETTA SUBCUTANEOUS PEN INJECTOR
10 MCG/DOSE(250 MCG/ML) 2.4 ML T3 MD; QL (2.4 ML per 28 days)
BYETTA SUBCUTANEOUS PEN INJECTOR 5
MCG/DOSE (250 MCG/ML) 1.2 ML T3 MD; QL (1.2 ML per 30 days)
chlorpropamide oral tablet 100 mg, 250 mg T2 MD
CYCLOSET ORAL TABLET 0.8 MG T4 PA; MD; QL (180 EA per 30 days)
FIASP FLEXTOUCH U-100 INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
T3 MD; QL (60 ML per 30 days)
FIASP U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML T3 MD; QL (60 ML per 30 days)
glimepiride oral tablet 1 mg T1 MD; QL (240 EA per 30 days)
glimepiride oral tablet 2 mg T1 MD; QL (120 EA per 30 days)
glimepiride oral tablet 4 mg T1 MD; QL (60 EA per 30 days)
glipizide oral tablet 10 mg T1 MD; QL (120 EA per 30 days)
glipizide oral tablet 5 mg T1 MD; QL (240 EA per 30 days)
glipizide oral tablet extended release 24hr 10 mg,
2.5 mg, 5 mg T1 MD; QL (60 EA per 30 days)
glipizide-metformin oral tablet 2.5-250 mg T2 MD; QL (240 EA per 30 days)
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg T2 MD; QL (120 EA per 30 days)
glyburide micronized oral tablet 1.5 mg, 3 mg T2 MD; QL (120 EA per 30 days)
glyburide micronized oral tablet 6 mg T2 MD; QL (60 EA per 30 days)
glyburide oral tablet 1.25 mg T2 MD; QL (480 EA per 30 days)
glyburide oral tablet 2.5 mg T2 MD; QL (240 EA per 30 days)
glyburide oral tablet 5 mg T2 MD; QL (60 EA per 30 days)
glyburide-metformin oral tablet 1.25-250 mg T2 MD; QL (240 EA per 30 days)
glyburide-metformin oral tablet 2.5-500 mg, 5-
500 mg T2 MD; QL (120 EA per 30 days)
GLYXAMBI ORAL TABLET 10-5 MG, 25-5
MG T3 MD
HUMULIN R U-500 (CONC) INSULIN
SUBCUTANEOUS SOLUTION 500 UNIT/ML T5 (SP) MD; QL (20 ML per 30 days)
JARDIANCE ORAL TABLET 10 MG, 25 MG T3 MD; QL (30 EA per 30 days)
JENTADUETO ORAL TABLET 2.5-1,000 MG,
2.5-500 MG, 2.5-850 MG T3 MD; QL (60 EA per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 28
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Drug Name Tier Notes
LANTUS SOLOSTAR U-100 INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
T3 MD; QL (60 ML per 30 days)
LANTUS U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML T3 MD; QL (60 ML per 30 days)
LEVEMIR FLEXTOUCH U-100 INSULN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
T3 MD; QL (60 ML per 30 days)
LEVEMIR U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML T3 MD; QL (60 ML per 30 days)
metformin oral tablet 1,000 mg T1 MD; QL (60 EA per 30 days)
metformin oral tablet 500 mg T1 MD; QL (150 EA per 30 days)
metformin oral tablet 850 mg T1 MD; QL (90 EA per 30 days)
metformin oral tablet extended release 24 hr 500
mg T1 MD; QL (120 EA per 30 days)
metformin oral tablet extended release 24 hr 750
mg T1 MD; QL (60 EA per 30 days)
miglitol oral tablet 100 mg, 25 mg, 50 mg T4 MD; QL (90 EA per 30 days)
nateglinide oral tablet 120 mg, 60 mg T3 MD; QL (90 EA per 30 days)
NOVOLIN 70/30 U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100
UNIT/ML (70-30)
T3 MD; QL (60 ML per 30 days)
NOVOLIN N NPH U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100
UNIT/ML
T3 MD; QL (60 ML per 30 days)
NOVOLIN R REGULAR U-100 INSULN
INJECTION SOLUTION 100 UNIT/ML T3 MD; QL (60 ML per 30 days)
NOVOLOG FLEXPEN U-100 INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML
T3 MD; QL (60 ML per 30 days)
NOVOLOG MIX 70-30 U-100 INSULN
SUBCUTANEOUS SOLUTION 100 UNIT/ML
(70-30)
T3 MD; QL (60 ML per 30 days)
NOVOLOG MIX 70-30FLEXPEN U-100
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (70-30)
T3 MD; QL (60 ML per 30 days)
NOVOLOG PENFILL U-100 INSULIN
SUBCUTANEOUS CARTRIDGE 100 UNIT/ML T3 MD; QL (60 ML per 30 days)
NOVOLOG U-100 INSULIN ASPART
SUBCUTANEOUS SOLUTION 100 UNIT/ML T3 MD; QL (60 ML per 30 days)
OZEMPIC SUBCUTANEOUS PEN INJECTOR
0.25 MG OR 0.5 MG(2 MG/1.5 ML) T3 MD; QL (1.5 ML per 28 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 29
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Drug Name Tier Notes
OZEMPIC SUBCUTANEOUS PEN INJECTOR
1 MG/0.75 ML (2 MG/1.5 ML) T3 MD; QL (3 ML per 28 days)
pioglitazone oral tablet 15 mg, 30 mg, 45 mg T2 MD; QL (30 EA per 30 days)
pioglitazone-glimepiride oral tablet 30-2 mg, 30-
4 mg T3 MD; QL (30 EA per 30 days)
pioglitazone-metformin oral tablet 15-500 mg,
15-850 mg T3 MD; QL (90 EA per 30 days)
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg T2 MD; QL (90 EA per 30 days)
SEGLUROMET ORAL TABLET 2.5-1,000 MG,
2.5-500 MG, 7.5-1,000 MG, 7.5-500 MG T3 MD; QL (60 EA per 30 days)
STEGLATRO ORAL TABLET 15 MG, 5 MG T3 MD; QL (30 EA per 30 days)
SYMLINPEN 120 SUBCUTANEOUS PEN
INJECTOR 2,700 MCG/2.7 ML T5 (SP) MD
SYMLINPEN 60 SUBCUTANEOUS PEN
INJECTOR 1,500 MCG/1.5 ML T5 (SP) MD
SYNJARDY ORAL TABLET 12.5-1,000 MG,
12.5-500 MG, 5-1,000 MG, 5-500 MG T3 MD
SYNJARDY XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG,
25-1,000 MG, 5-1,000 MG
T3 MD
TANZEUM SUBCUTANEOUS PEN
INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML T3 MD; QL (4 EA per 28 days)
TOUJEO SOLOSTAR U-300 INSULIN
SUBCUTANEOUS INSULIN PEN 300
UNIT/ML (1.5 ML)
T3 MD; QL (21 ML per 30 days)
TRADJENTA ORAL TABLET 5 MG T3 MD; QL (30 EA per 30 days)
TRESIBA FLEXTOUCH U-100
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
T3 MD; QL (60 ML per 30 days)
TRESIBA FLEXTOUCH U-200
SUBCUTANEOUS INSULIN PEN 200
UNIT/ML (3 ML)
T3 MD; QL (36 ML per 30 days)
VICTOZA 2-PAK SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) T3 MD; QL (9 ML per 30 days)
VICTOZA 3-PAK SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) T3 MD; QL (9 ML per 30 days)
ANTIINFECTIVES/MISCELLANEOU
S
ALBENZA ORAL TABLET 200 MG T5 (SP)
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Drug Name Tier Notes
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML T4 PA
ALINIA ORAL TABLET 500 MG T4 PA
atovaquone oral suspension 750 mg/5 ml T5 (SP)
atovaquone-proguanil oral tablet 250-100 mg,
62.5-25 mg T4
benznidazole oral tablet 100 mg, 12.5 mg T2 PA
BILTRICIDE ORAL TABLET 600 MG T4
chloroquine phosphate oral tablet 250 mg, 500
mg T2 MD
COARTEM ORAL TABLET 20-120 MG T4
DARAPRIM ORAL TABLET 25 MG T3
hydroxychloroquine oral tablet 200 mg T3 MD
ivermectin oral tablet 3 mg T2
mefloquine oral tablet 250 mg T2
paromomycin oral capsule 250 mg T3
PENTAM INJECTION RECON SOLN 300 MG T5 (SP) PA
primaquine oral tablet 26.3 mg T3 QL (30 EA per 30 days)
quinine sulfate oral capsule 324 mg T4
ANTIINFLAM.TUMOR NECROSIS
FACTOR INHIBITING AGENTS
ENBREL SUBCUTANEOUS RECON SOLN 25
MG (1 ML) T5 (SP) PA; MD; QL (8 EA per 28 days)
ENBREL SUBCUTANEOUS SYRINGE 25
MG/0.5ML (0.51) T5 (SP) PA; MD; QL (4 ML per 28 days)
ENBREL SUBCUTANEOUS SYRINGE 50
MG/ML (0.98 ML) T5 (SP) PA; MD; QL (8 ML per 28 days)
ENBREL SURECLICK SUBCUTANEOUS PEN
INJECTOR 50 MG/ML (0.98 ML) T5 (SP) PA; MD; QL (8 ML per 28 days)
HUMIRA PEDIATRIC CROHN'S START
SUBCUTANEOUS SYRINGE KIT 40 MG/0.8
ML
T5 (SP) PA; MD; QL (3 EA per 180 days)
HUMIRA PEN CROHN'S-UC-HS START
SUBCUTANEOUS PEN INJECTOR KIT 40
MG/0.8 ML
T5 (SP) PA; MD; QL (6 EA per 180 days)
HUMIRA PEN PSORIASIS-UVEITIS
SUBCUTANEOUS PEN INJECTOR KIT 40
MG/0.8 ML
T5 (SP) PA; MD; QL (4 EA per 180 days)
HUMIRA PEN SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML T5 (SP) PA; MD; QL (4 EA per 28 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 31
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Drug Name Tier Notes
HUMIRA SUBCUTANEOUS SYRINGE KIT 10
MG/0.2 ML, 20 MG/0.4 ML T5 (SP) PA; MD; QL (2 EA per 28 days)
HUMIRA SUBCUTANEOUS SYRINGE KIT 40
MG/0.8 ML T5 (SP) PA; MD; QL (4 EA per 28 days)
ANTINEOPLASTICS
ACTIMMUNE SUBCUTANEOUS SOLUTION
100 MCG/0.5 ML T5 (SP) PA
ADRUCIL INTRAVENOUS SOLUTION 500
MG/10 ML T3
AFINITOR ORAL TABLET 10 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5
MG T5 (SP) PA; MD
ALIQOPA INTRAVENOUS RECON SOLN 60
MG T5 (SP) PA; MD
anastrozole oral tablet 1 mg T2 MD; QL (30 EA per 30 days)
BAVENCIO INTRAVENOUS SOLUTION 20
MG/ML T5 (SP) PA; MD
bexarotene oral capsule 75 mg T5 (SP) PA; MD
bicalutamide oral tablet 50 mg T2 MD
BUSULFEX INTRAVENOUS SOLUTION 60
MG/10 ML T5 (SP) PA
CALQUENCE ORAL CAPSULE 100 MG T5 (SP) PA; MD
capecitabine oral tablet 150 mg, 500 mg T5 (SP) PA
CAPRELSA ORAL TABLET 100 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
CAPRELSA ORAL TABLET 300 MG T5 (SP) PA; MD; QL (30 EA per 30 days)
cyclophosphamide oral capsule 25 mg, 50 mg T4
diclofenac sodium topical gel 3 % T5 (SP) PA
EMCYT ORAL CAPSULE 140 MG T5 (SP) PA
ERLEADA ORAL TABLET 60 MG T5 (SP) PA; MD
exemestane oral tablet 25 mg T4 MD
FARESTON ORAL TABLET 60 MG T5 (SP) MD; QL (30 EA per 30 days)
fluorouracil intravenous solution 1 gram/20 ml,
2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml T3
fluorouracil topical cream 5 % T3
fluorouracil topical solution 2 %, 5 % T3
flutamide oral capsule 125 mg T3 MD
GLEEVEC ORAL TABLET 100 MG, 400 MG T5 (SP) PA; MD
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Drug Name Tier Notes
HEXALEN ORAL CAPSULE 50 MG T5 (SP) PA
hydroxyurea oral capsule 500 mg T2 MD
IBRANCE ORAL CAPSULE 100 MG, 125 MG,
75 MG T5 (SP) PA; MD; QL (21 EA per 28 days)
IDHIFA ORAL TABLET 100 MG, 50 MG T5 (SP) PA; MD
imatinib oral tablet 100 mg T5 (SP) PA; MD; QL (180 EA per 30 days)
imatinib oral tablet 400 mg T5 (SP) PA; MD; QL (60 EA per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG T5 (SP) PA; QL (120 EA per 30 days)
IMBRUVICA ORAL CAPSULE 70 MG T5 (SP) PA; MD; QL (30 EA per 30 days)
IMBRUVICA ORAL TABLET 140 MG, 280
MG, 420 MG, 560 MG T5 (SP) PA; MD; QL (30 EA per 30 days)
INTRON A INJECTION RECON SOLN 10
MILLION UNIT (1 ML), 18 MILLION UNIT (1
ML), 50 MILLION UNIT (1 ML)
T5 (SP) PA
INTRON A INJECTION SOLUTION 10
MILLION UNIT/ML, 6 MILLION UNIT/ML T5 (SP) PA
JAKAFI ORAL TABLET 10 MG, 15 MG, 20
MG, 5 MG T5 (SP) PA; MD
JAKAFI ORAL TABLET 25 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
KISQALI FEMARA CO-PACK ORAL TABLET
200 MG/DAY(200 MG X 1)-2.5 MG, 400
MG/DAY(200 MG X 2)-2.5 MG, 600
MG/DAY(200 MG X 3)-2.5 MG
T5 (SP) PA; MD
KISQALI ORAL TABLET 200 MG/DAY (200
MG X 1), 400 MG/DAY (200 MG X 2), 600
MG/DAY (200 MG X 3)
T5 (SP) PA; MD
LENVIMA ORAL CAPSULE 10 MG/DAY (10
MG X 1), 12 MG/DAY (4 MG X 3), 14
MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY
(10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X
2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8
MG/DAY (4 MG X 2)
T5 (SP) PA; MD
letrozole oral tablet 2.5 mg T2 MD
LEUKERAN ORAL TABLET 2 MG T4
leuprolide subcutaneous kit 1 mg/0.2 ml T5 (SP) PA
leuprolide subcutaneous solution 1 mg/0.2 ml T5 (SP) PA; MD
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 22.5 MG T5 (SP) PA; MD; QL (1 EA per 84 days)
LUPRON DEPOT (4 MONTH)
INTRAMUSCULAR SYRINGE KIT 30 MG T5 (SP) PA; QL (1 EA per 112 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 33
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Drug Name Tier Notes
LUPRON DEPOT (6 MONTH)
INTRAMUSCULAR SYRINGE KIT 45 MG T5 (SP) PA; QL (1 EA per 168 days)
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 7.5 MG T5 (SP) PA; QL (1 EA per 28 days)
LYNPARZA ORAL CAPSULE 50 MG T5 (SP) PA
LYNPARZA ORAL TABLET 100 MG, 150 MG T5 (SP) PA; MD
LYSODREN ORAL TABLET 500 MG T3
MATULANE ORAL CAPSULE 50 MG T5 (SP)
megestrol oral tablet 20 mg, 40 mg T2
melphalan hcl intravenous recon soln 50 mg T5 (SP)
mercaptopurine oral tablet 50 mg T3 MD
methotrexate sodium (pf) injection recon soln 1
gram T2
methotrexate sodium (pf) injection solution 25
mg/ml T2
methotrexate sodium injection solution 25 mg/ml T2
methotrexate sodium oral tablet 2.5 mg T2 MD
NERLYNX ORAL TABLET 40 MG T5 (SP) PA; MD
NEXAVAR ORAL TABLET 200 MG T5 (SP) PA; QL (120 EA per 30 days)
NILANDRON ORAL TABLET 150 MG T5 (SP) MD
PANRETIN TOPICAL GEL 0.1 % T5 (SP) PA
PICATO TOPICAL GEL 0.015 %, 0.05 % T5 (SP) PA
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3
MG, 4 MG T5 (SP) PA; MD
POTELIGEO INTRAVENOUS SOLUTION 4
MG/ML T5 (SP) PA; MD
REVLIMID ORAL CAPSULE 10 MG, 15 MG,
2.5 MG, 20 MG, 25 MG, 5 MG T5 (SP) PA; MD
SPRYCEL ORAL TABLET 100 MG, 140 MG,
20 MG, 50 MG, 70 MG, 80 MG T5 (SP) PA; MD; QL (30 EA per 30 days)
SUTENT ORAL CAPSULE 12.5 MG, 25 MG,
37.5 MG, 50 MG T5 (SP) PA; QL (30 EA per 30 days)
TABLOID ORAL TABLET 40 MG T5 (SP) PA
tamoxifen oral tablet 10 mg, 20 mg T2
PA; PA only applies to NCS
eligibility as part of Preventive
Services Coverage (Breast Cancer
Prevention); MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 34
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Drug Name Tier Notes
TARCEVA ORAL TABLET 100 MG, 150 MG,
25 MG T5 (SP) PA; MD; QL (30 EA per 30 days)
TARGRETIN TOPICAL GEL 1 % T5 (SP) PA
TASIGNA ORAL CAPSULE 150 MG, 200 MG T5 (SP) PA; MD; QL (120 EA per 30 days)
temozolomide oral capsule 100 mg, 140 mg, 180
mg, 20 mg, 250 mg, 5 mg T5 (SP) PA
tretinoin (chemotherapy) oral capsule 10 mg T5 (SP) PA
TYKERB ORAL TABLET 250 MG T5 (SP) PA; MD; QL (180 EA per 30 days)
VERZENIO ORAL TABLET 100 MG, 150 MG,
200 MG, 50 MG T5 (SP) PA; MD
VOTRIENT ORAL TABLET 200 MG T5 (SP) PA; MD; QL (120 EA per 30 days)
VYXEOS INTRAVENOUS RECON SOLN 44-
100 MG T5 (SP) PA
XALKORI ORAL CAPSULE 200 MG, 250 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
XTANDI ORAL CAPSULE 40 MG T5 (SP) PA; SP; MD; QL (120 EA per 30
days)
YONSA ORAL TABLET 125 MG T5 (SP) PA; MD; QL (120 EA per 30 days)
ZOLINZA ORAL CAPSULE 100 MG T5 (SP) PA; QL (120 EA per 30 days)
ZYTIGA ORAL TABLET 250 MG T5 (SP) PA; SP; MD; QL (120 EA per 30
days)
ZYTIGA ORAL TABLET 500 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
ANTI-OBESITY DRUGS
phentermine oral capsule 15 mg T2 QL (180 EA per 365 days)
phentermine oral capsule 30 mg, 37.5 mg T2 QL (90 EA per 365 days)
phentermine oral tablet 37.5 mg T2 QL (90 EA per 365 days)
ANTIPARKINSON DRUGS
amantadine hcl oral capsule 100 mg T3 MD
amantadine hcl oral tablet 100 mg T3 MD
AZILECT ORAL TABLET 0.5 MG, 1 MG T4 MD
benztropine oral tablet 0.5 mg, 1 mg, 2 mg T2 MD
bromocriptine oral capsule 5 mg T4 MD
bromocriptine oral tablet 2.5 mg T4 MD
carbidopa oral tablet 25 mg T4 MD
carbidopa-levodopa oral tablet 10-100 mg, 25-
100 mg, 25-250 mg T2 MD
carbidopa-levodopa oral tablet extended release
25-100 mg, 50-200 mg T2 MD
entacapone oral tablet 200 mg T4 MD; QL (240 EA per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 35
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Drug Name Tier Notes
pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5
mg, 0.75 mg, 1 mg, 1.5 mg T2 MD
pramipexole oral tablet extended release 24 hr
0.375 mg, 0.75 mg, 1.5 mg, 3 mg, 4.5 mg T5 (SP) PA; MD
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg, 5 mg T2 MD
ropinirole oral tablet extended release 24 hr 12
mg, 2 mg, 4 mg, 6 mg, 8 mg T4 MD
selegiline hcl oral capsule 5 mg T2 MD
selegiline hcl oral tablet 5 mg T2 MD
tolcapone oral tablet 100 mg T5 (SP) MD
trihexyphenidyl oral elixir 0.4 mg/ml T2 MD
trihexyphenidyl oral tablet 2 mg, 5 mg T2 MD
ANTIPLATELET DRUGS
anagrelide oral capsule 0.5 mg, 1 mg T3 MD
ASPIRIN LOW-STRENGTH ORAL
TABLET,CHEWABLE 81 MG NCS
aspirin oral tablet,chewable 81 mg NCS MD
aspirin oral tablet,delayed release (dr/ec) 81 mg NCS MD
aspirin-dipyridamole oral capsule, er multiphase
12 hr 25-200 mg T4 MD
BRILINTA ORAL TABLET 60 MG, 90 MG T3 MD
CHILD ASPIRIN ORAL TABLET,CHEWABLE
81 MG NCS
CHILDREN'S ASPIRIN ORAL
TABLET,CHEWABLE 81 MG NCS MD
cilostazol oral tablet 100 mg, 50 mg T2 MD
clopidogrel oral tablet 75 mg T2 MD; QL (30 EA per 30 days)
dipyridamole oral tablet 25 mg, 50 mg, 75 mg T2 MD
EFFIENT ORAL TABLET 10 MG, 5 MG T3 MD
ENTERIC COATED ASPIRIN ORAL
TABLET,DELAYED RELEASE (DR/EC) 81
MG
NCS MD
ticlopidine oral tablet 250 mg T2
ZONTIVITY ORAL TABLET 2.08 MG T3 MD
ANTIVIRALS
abacavir oral solution 20 mg/ml T5 (SP) MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 36
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Drug Name Tier Notes
abacavir oral tablet 300 mg T3 PA; MD
abacavir-lamivudine oral tablet 600-300 mg T5 (SP) PA; MD
abacavir-lamivudine-zidovudine oral tablet 300-
150-300 mg T5 (SP) PA; MD
acyclovir oral capsule 200 mg T2 MD
acyclovir oral suspension 200 mg/5 ml T3 MD
acyclovir oral tablet 400 mg, 800 mg T2 MD
acyclovir topical ointment 5 % T4 QL (60 GM per 30 days)
adefovir oral tablet 10 mg T5 (SP) PA
APTIVUS ORAL CAPSULE 250 MG T5 (SP) PA; MD
APTIVUS ORAL SOLUTION 100 MG/ML T5 (SP) PA; MD
atazanavir oral capsule 150 mg, 200 mg, 300 mg T3 MD
ATRIPLA ORAL TABLET 600-200-300 MG T5 (SP) PA; MD; QL (30 EA per 30 days)
BARACLUDE ORAL SOLUTION 0.05 MG/ML T5 (SP) PA; MD
BIKTARVY ORAL TABLET 50-200-25 MG T5 (SP) MD; QL (30 EA per 30 days)
CIMDUO ORAL TABLET 300-300 MG T5 (SP) MD; QL (30 EA per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG T5 (SP) MD
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG T3 PA; MD
DESCOVY ORAL TABLET 200-25 MG T5 (SP) PA; MD
didanosine oral capsule,delayed release(dr/ec)
125 mg, 200 mg, 250 mg, 400 mg T3 PA; MD
EDURANT ORAL TABLET 25 MG T5 (SP) PA; MD
efavirenz oral capsule 200 mg, 50 mg T4 MD
efavirenz oral tablet 600 mg T4 MD
EMTRIVA ORAL CAPSULE 200 MG T3 PA; MD
EMTRIVA ORAL SOLUTION 10 MG/ML T3 PA; MD
entecavir oral tablet 0.5 mg, 1 mg T5 (SP) PA; MD; QL (30 EA per 30 days)
EPCLUSA ORAL TABLET 400-100 MG T5 (SP) PA
EPIVIR HBV ORAL SOLUTION 25 MG/5 ML
(5 MG/ML) T4 PA; MD
EPZICOM ORAL TABLET 600-300 MG T5 (SP) PA; MD
EVOTAZ ORAL TABLET 300-150 MG T5 (SP) PA; MD
famciclovir oral tablet 125 mg, 250 mg, 500 mg T3 MD
fosamprenavir oral tablet 700 mg T5 (SP) PA; MD
FUZEON SUBCUTANEOUS RECON SOLN 90
MG T5 (SP) PA; MD
GENVOYA ORAL TABLET 150-150-200-10
MG T5 (SP) PA; MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 37
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Drug Name Tier Notes
HARVONI ORAL TABLET 90-400 MG T5 (SP) PA
INTELENCE ORAL TABLET 100 MG T5 (SP) PA; MD; QL (120 EA per 30 days)
INTELENCE ORAL TABLET 200 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
INTELENCE ORAL TABLET 25 MG T4 PA; MD
INVIRASE ORAL CAPSULE 200 MG T5 (SP) PA; MD
INVIRASE ORAL TABLET 500 MG T5 (SP) PA; MD
ISENTRESS HD ORAL TABLET 600 MG T5 (SP) PA; MD
ISENTRESS ORAL POWDER IN PACKET 100
MG T5 (SP) PA; MD; QL (180 EA per 30 days)
ISENTRESS ORAL TABLET 400 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
ISENTRESS ORAL TABLET,CHEWABLE 100
MG, 25 MG T5 (SP) PA; MD; QL (180 EA per 30 days)
JULUCA ORAL TABLET 50-25 MG T5 (SP) MD; QL (30 EA per 30 days)
KALETRA ORAL SOLUTION 400-100 MG/5
ML T4 PA; MD
KALETRA ORAL TABLET 100-25 MG T4 PA; MD
KALETRA ORAL TABLET 200-50 MG T5 (SP) PA; MD
lamivudine oral solution 10 mg/ml T3 PA; MD
lamivudine oral tablet 100 mg T4 PA; MD
lamivudine oral tablet 150 mg, 300 mg T3 PA; MD
lamivudine-zidovudine oral tablet 150-300 mg T4 MD
LEXIVA ORAL SUSPENSION 50 MG/ML T4 PA; MD
LEXIVA ORAL TABLET 700 MG T5 (SP) PA; MD
MAVYRET ORAL TABLET 100-40 MG T5 (SP) PA
MODERIBA ORAL TABLET 200 MG T4 PA
nevirapine oral suspension 50 mg/5 ml T3 PA; MD
nevirapine oral tablet 200 mg T3 PA; MD
nevirapine oral tablet extended release 24 hr 100
mg, 400 mg T4 PA; MD
NORVIR ORAL CAPSULE 100 MG T4 PA; MD
NORVIR ORAL POWDER IN PACKET 100
MG T4 MD
NORVIR ORAL SOLUTION 80 MG/ML T4 PA; MD
NORVIR ORAL TABLET 100 MG T4 PA; MD
ODEFSEY ORAL TABLET 200-25-25 MG T5 (SP) PA; MD
oseltamivir oral capsule 30 mg, 45 mg, 75 mg T3 QL (60 EA per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 38
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Drug Name Tier Notes
PEGINTRON REDIPEN SUBCUTANEOUS
PEN INJECTOR KIT 120 MCG/0.5 ML, 150
MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5
ML
T5 (SP) PA
PEGINTRON SUBCUTANEOUS KIT 120
MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5
ML, 80 MCG/0.5 ML
T5 (SP) PA
PREZCOBIX ORAL TABLET 800-150 MG-MG T5 (SP) PA; MD
PREZISTA ORAL SUSPENSION 100 MG/ML T4 PA; MD
PREZISTA ORAL TABLET 150 MG T4 PA; MD
PREZISTA ORAL TABLET 300 MG, 400 MG T5 (SP) PA
PREZISTA ORAL TABLET 600 MG, 800 MG T5 (SP) PA; MD
PREZISTA ORAL TABLET 75 MG T3 PA; MD
RELENZA DISKHALER INHALATION
BLISTER WITH DEVICE 5 MG/ACTUATION T5 (SP) PA; QL (60 EA per 180 days)
RESCRIPTOR ORAL TABLET 200 MG T3 PA; MD
RESCRIPTOR ORAL TABLET, DISPERSIBLE
100 MG T3 PA; MD
RETROVIR INTRAVENOUS SOLUTION 10
MG/ML T4 PA
REYATAZ ORAL CAPSULE 100 MG T5 (SP) PA
REYATAZ ORAL CAPSULE 150 MG, 200 MG,
300 MG T5 (SP) PA; MD
REYATAZ ORAL POWDER IN PACKET 50
MG T5 (SP) PA; MD
RIBASPHERE ORAL CAPSULE 200 MG T4 PA
RIBASPHERE ORAL TABLET 200 MG T4 PA
ribavirin oral capsule 200 mg T4 PA
ribavirin oral tablet 200 mg T4 PA
rimantadine oral tablet 100 mg T2
ritonavir oral tablet 100 mg T4 MD
SELZENTRY ORAL TABLET 150 MG, 25 MG,
300 MG, 75 MG T5 (SP) PA; MD; QL (120 EA per 30 days)
SOVALDI ORAL TABLET 400 MG T5 (SP) PA; MD
stavudine oral capsule 15 mg, 20 mg, 30 mg, 40
mg T3 PA; MD
stavudine oral recon soln 1 mg/ml T3 PA
STRIBILD ORAL TABLET 150-150-200-300
MG T5 (SP) PA; MD
SUSTIVA ORAL CAPSULE 200 MG, 50 MG T4 PA; MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 39
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Drug Name Tier Notes
SUSTIVA ORAL TABLET 600 MG T4 PA; MD
SYMFI LO ORAL TABLET 400-300-300 MG T5 (SP) MD; QL (30 EA per 30 days)
SYMFI ORAL TABLET 600-300-300 MG T5 (SP) MD; QL (30 EA per 30 days)
TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75
MG T4 QL (60 EA per 30 days)
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION 6 MG/ML T4
tenofovir disoproxil fumarate oral tablet 300 mg T5 (SP) PA; MD
TIVICAY ORAL TABLET 10 MG, 25 MG, 50
MG T5 (SP) PA; MD
trifluridine ophthalmic (eye) drops 1 % T3
TRIUMEQ ORAL TABLET 600-50-300 MG T5 (SP) PA; MD
TRUVADA ORAL TABLET 100-150 MG, 133-
200 MG, 167-250 MG, 200-300 MG T5 (SP) PA; MD
TYZEKA ORAL TABLET 600 MG T5 (SP) PA
valacyclovir oral tablet 1 gram, 500 mg T2 MD; QL (90 EA per 30 days)
VALCYTE ORAL RECON SOLN 50 MG/ML T5 (SP) PA; MD
valganciclovir oral tablet 450 mg T5 (SP) PA; MD
VEREGEN TOPICAL OINTMENT 15 % T3
VIDEX 2 GRAM PEDIATRIC ORAL RECON
SOLN 10 MG/ML (FINAL) T4 PA; MD
VIDEX 4 GRAM PEDIATRIC ORAL RECON
SOLN 10 MG/ML (FINAL) T4 PA; MD
VIRACEPT ORAL TABLET 250 MG T4 PA; MD
VIRACEPT ORAL TABLET 625 MG T5 (SP) PA; MD
VIREAD ORAL POWDER 40 MG/SCOOP (40
MG/GRAM) T5 (SP) PA; MD
VIREAD ORAL TABLET 150 MG, 200 MG,
250 MG, 300 MG T5 (SP) PA; MD
VITEKTA ORAL TABLET 150 MG, 85 MG T5 (SP) PA; QL (30 EA per 30 days)
ZIAGEN ORAL SOLUTION 20 MG/ML T3 PA; MD
zidovudine oral capsule 100 mg T3 PA; MD
zidovudine oral syrup 10 mg/ml T3 PA; MD
zidovudine oral tablet 300 mg T3 PA; MD
ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % T4
AUTONOMIC DRUGS
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 40
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Drug Name Tier Notes
ADDERALL XR ORAL
CAPSULE,EXTENDED RELEASE 24HR 10
MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG
T4 MD; QL (30 EA per 30 days)
bethanechol chloride oral tablet 10 mg, 25 mg, 5
mg, 50 mg T3
dextroamphetamine oral capsule, extended
release 10 mg T4 MD; QL (180 EA per 30 days)
dextroamphetamine oral capsule, extended
release 15 mg T4 MD; QL (120 EA per 30 days)
dextroamphetamine oral capsule, extended
release 5 mg T4 MD; QL (90 EA per 30 days)
dextroamphetamine oral tablet 10 mg, 5 mg T3 MD; QL (180 EA per 30 days)
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15 mg, 20
mg, 25 mg, 30 mg, 5 mg
T2 MD; QL (30 EA per 30 days)
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15 mg, 20
mg, 25 mg, 30 mg, 5 mg
T2 MD; QL (60 EA per 30 days)
dextroamphetamine-amphetamine oral tablet 10
mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg T2 MD; QL (90 EA per 30 days)
dextroamphetamine-amphetamine oral tablet 30
mg T2 MD; QL (60 EA per 30 days)
donepezil oral tablet 10 mg, 5 mg T2 MD; QL (30 EA per 30 days)
epinephrine injection solution 1 mg/ml T4
EPIPEN 2-PAK INJECTION AUTO-INJECTOR
0.3 MG/0.3 ML T3 QL (4 EA per 30 days)
EPIPEN INJECTION AUTO-INJECTOR 0.3
MG/0.3 ML T3 QL (4 EA per 30 days)
EPIPEN JR 2-PAK INJECTION AUTO-
INJECTOR 0.15 MG/0.3 ML T3 QL (4 EA per 30 days)
EPIPEN JR INJECTION AUTO-INJECTOR 0.15
MG/0.3 ML T3 QL (4 EA per 30 days)
galantamine oral capsule,ext rel. pellets 24 hr 16
mg, 24 mg, 8 mg T3 MD; QL (30 EA per 30 days)
galantamine oral solution 4 mg/ml T4 MD; QL (600 ML per 30 days)
galantamine oral tablet 12 mg, 4 mg, 8 mg T3 MD; QL (60 EA per 30 days)
guanidine oral tablet 125 mg T2
methamphetamine oral tablet 5 mg T3 MD; QL (90 EA per 30 days)
midodrine oral tablet 10 mg, 2.5 mg, 5 mg T3
pilocarpine hcl oral tablet 5 mg, 7.5 mg T3 MD
pyridostigmine bromide oral tablet 60 mg T3 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 41
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Drug Name Tier Notes
pyridostigmine bromide oral tablet extended
release 180 mg T4 MD
rivastigmine tartrate oral capsule 1.5 mg, 3 mg,
4.5 mg, 6 mg T3 MD; QL (60 EA per 30 days)
BIOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON
SOLN 10 MCG/0.5 ML NCS
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2 LF-(2.5-
5-3-5 MCG)-5LF/0.5 ML
NCS
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5
MCG)-5LF/0.5 ML
NCS
AFLURIA 2018-2019 (PF) INTRAMUSCULAR
SYRINGE 45 MCG (15 MCG X 3)/0.5 ML NCS
AFLURIA 2018-2019 INTRAMUSCULAR
SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML NCS
AFLURIA QUAD 2018-2019 (PF)
INTRAMUSCULAR SYRINGE 60 MCG/0.5
ML
NCS
AFLURIA QUAD 2018-2019
INTRAMUSCULAR SUSPENSION 60
MCG/0.5 ML
NCS
bcg vaccine, live (pf) percutaneous suspension for
reconstitution 50 mg NCS
BEXSERO INTRAMUSCULAR SYRINGE 50-
50-50-25 MCG/0.5 ML NCS
BIOTHRAX INTRAMUSCULAR
SUSPENSION 0.5 ML/DOSE NCS
BOOSTRIX TDAP INTRAMUSCULAR
SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML NCS
BOOSTRIX TDAP INTRAMUSCULAR
SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML NCS
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 12 GRAM, 6
GRAM
T5 (SP) PA; MD
CERVARIX VACCINE (PF)
INTRAMUSCULAR SYRINGE 20-20 MCG/0.5
ML
NCS
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 42
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Drug Name Tier Notes
COMVAX (PF) INTRAMUSCULAR
SUSPENSION 5-7.5-125 MCG/0.5 ML NCS
DAPTACEL (DTAP PEDIATRIC) (PF)
INTRAMUSCULAR SUSPENSION 15-10-5 LF-
MCG-LF/0.5ML
NCS
ENGERIX-B (PF) INTRAMUSCULAR
SUSPENSION 20 MCG/ML NCS
ENGERIX-B (PF) INTRAMUSCULAR
SYRINGE 20 MCG/ML NCS
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SUSPENSION 10
MCG/0.5 ML
NCS
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SYRINGE 10 MCG/0.5
ML
NCS
FLUAD 2018-2019 (65 YR UP)(PF)
INTRAMUSCULAR SYRINGE 45 MCG (15
MCG X 3)/0.5 ML
NCS
FLUARIX QUAD 2018-2019 (PF)
INTRAMUSCULAR SYRINGE 60 MCG (15
MCG X 4)/0.5 ML
NCS
FLUBLOK QUAD 2018-2019 (PF)
INTRAMUSCULAR SYRINGE 180 MCG (45
MCG X 4)/0.5 ML
NCS
FLUCELVAX QUAD 2018-2019 (PF)
INTRAMUSCULAR SYRINGE 60 MCG (15
MCG X 4)/0.5 ML
NCS
FLUCELVAX QUAD 2018-2019
INTRAMUSCULAR SUSPENSION 60 MCG
(15 MCG X 4)/0.5 ML
NCS
FLULAVAL QUAD 2018-2019 (PF)
INTRAMUSCULAR SYRINGE 60 MCG (15
MCG X 4)/0.5 ML
NCS
FLULAVAL QUAD 2018-2019
INTRAMUSCULAR SUSPENSION 60 MCG
(15 MCG X 4)/0.5 ML
NCS
FLUZONE HIGH-DOSE 2018-19 (PF)
INTRAMUSCULAR SYRINGE 180 MCG/0.5
ML
NCS
FLUZONE QUAD 2018-2019 (PF)
INTRAMUSCULAR SUSPENSION 60 MCG
(15 MCG X 4)/0.5 ML
NCS
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 43
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Drug Name Tier Notes
FLUZONE QUAD 2018-2019 (PF)
INTRAMUSCULAR SYRINGE 60 MCG (15
MCG X 4)/0.5 ML
NCS
FLUZONE QUAD 2018-2019
INTRAMUSCULAR SUSPENSION 60 MCG
(15 MCG X 4)/0.5 ML
NCS
FLUZONE QUAD PEDI 2018-19 (PF)
INTRAMUSCULAR SYRINGE 30 MCG (7.5
MCG X 4)/0.25 ML
NCS
GAMMAGARD LIQUID INJECTION
SOLUTION 10 % T5 (SP) PA; MD
GARDASIL (PF) INTRAMUSCULAR
SUSPENSION 20-40-40-20 MCG/0.5 ML NCS
GARDASIL (PF) INTRAMUSCULAR
SYRINGE 20-40-40-20 MCG/0.5 ML NCS
GARDASIL 9 (PF) INTRAMUSCULAR
SUSPENSION 0.5 ML NCS
GARDASIL 9 (PF) INTRAMUSCULAR
SYRINGE 0.5 ML NCS
GRASTEK SUBLINGUAL TABLET 2,800
BAU T3 MD
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML, 720
ELISA UNIT/0.5 ML
NCS
HAVRIX (PF) INTRAMUSCULAR SYRINGE
1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5
ML
NCS
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN 2.5 UNIT NCS
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SUSPENSION 25-58-10 LF-MCG-LF/0.5ML NCS
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SYRINGE 25-58-10 LF-MCG-LF/0.5ML NCS
IPOL INJECTION SUSPENSION 40-8-32
UNIT/0.5 ML NCS
IXIARO (PF) INTRAMUSCULAR SYRINGE 6
MCG/0.5 ML NCS
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML NCS
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 44
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Drug Name Tier Notes
KINRIX (PF) INTRAMUSCULAR SYRINGE
25 LF-58 MCG-10 LF/0.5 ML NCS
MENACTRA (PF) INTRAMUSCULAR
SOLUTION 4 MCG/0.5 ML NCS
MENHIBRIX (PF) INTRAMUSCULAR
RECON SOLN 5-2.5 MCG/0.5 ML NCS
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN 50 MCG NCS
MENOMUNE - A/C/Y/W-135
SUBCUTANEOUS RECON SOLN 50 MCG NCS
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5 MCG/0.5 ML NCS
MENVEO MENA COMPONENT (PF)
INTRAMUSCULAR RECON SOLN 10 MCG
/0.5 ML (FINAL)
NCS
MENVEO MENCYW-135 COMPNT (PF)
INTRAMUSCULAR RECON SOLN 5 MCG X
3/ 0.5 ML (FINAL)
NCS
M-M-R II (PF) SUBCUTANEOUS RECON
SOLN 1,000-12,500 TCID50/0.5 ML NCS
PALYNZIQ SUBCUTANEOUS SYRINGE 10
MG/0.5 ML, 20 MG/ML T5 (SP) PA; MD
PALYNZIQ SUBCUTANEOUS SYRINGE 2.5
MG/0.5 ML T5 (SP) PA
PEDIARIX (PF) INTRAMUSCULAR SYRINGE
10 MCG-25LF-25 MCG-10LF/0.5 ML NCS
PEDVAX HIB (PF) INTRAMUSCULAR
SOLUTION 7.5 MCG/0.5 ML NCS
PENTACEL (PF) INTRAMUSCULAR KIT 15
LF UNIT-20 MCG-5 LF/0.5 ML NCS
PENTACEL ACTHIB COMPONENT (PF)
INTRAMUSCULAR RECON SOLN 10
MCG/0.5 ML
NCS
PENTACEL DTAP-IPV COMPNT (PF)
INTRAMUSCULAR SUSPENSION 15 LF-48
MCG- 5 LF UNIT/0.5ML
NCS
PNEUMOVAX 23 INJECTION SOLUTION 25
MCG/0.5 ML NCS
PNEUMOVAX 23 INJECTION SYRINGE 25
MCG/0.5 ML NCS
PREVNAR 13 (PF) INTRAMUSCULAR
SYRINGE 0.5 ML NCS
QL (0.5 ML Max Qty Per Fill
Retail)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 45
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Drug Name Tier Notes
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION
10EXP3-4.3-3- 3.99 TCID50/0.5
NCS
QUADRACEL (PF) INTRAMUSCULAR
SUSPENSION 15 LF-48 MCG- 5 LF
UNIT/0.5ML
NCS
RABAVERT (PF) INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 2.5
UNIT
NCS
RAGWITEK SUBLINGUAL TABLET 12 AMB
A 1 UNIT T3 MD
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION 10 MCG/ML, 40 MCG/ML, 5
MCG/0.5 ML
NCS
RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 10 MCG/ML, 5 MCG/0.5 ML NCS
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION 10EXP6 CCID50/ML NCS
ROTATEQ VACCINE ORAL SOLUTION 2 ML NCS
SHINGRIX (PF) INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 50
MCG/0.5 ML
NCS
SHINGRIX GE ANTIGEN COMPONENT
INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION 50 MCG
NCS
TAKHZYRO SUBCUTANEOUS SOLUTION
300 MG/2 ML (150 MG/ML) T5 (SP) PA; MD
TENIVAC (PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML NCS
TENIVAC (PF) INTRAMUSCULAR SYRINGE
5-2 LF UNIT/0.5 ML NCS
tetanus toxoid adsorbed intramuscular solution 5
lf unit/0.5 ml NCS
tetanus toxoid fluid injection solution 5 lf unit NCS
tetanus toxoid fluid injection syringe 5 lf unit NCS
tetanus toxoid,adsorbed (pf) intramuscular
suspension 5 lf unit/0.5 ml NCS
tetanus,diphtheria tox ped(pf) intramuscular
suspension 5-25 lf unit/0.5 ml NCS
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 46
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Drug Name Tier Notes
tetanus-diphtheria toxoids-td intramuscular
suspension 2-2 lf unit/0.5 ml NCS
THYMOGLOBULIN INTRAVENOUS RECON
SOLN 25 MG T5 (SP) PA
TRIHIBIT (PF) INTRAMUSCULAR KIT 6.7-
46.8-5-10 LF-MCG-LF-MCG NCS
TRIPEDIA (PF) INTRAMUSCULAR
SUSPENSION 6.7-46.8-5 LF-MCG-LF/0.5ML NCS
TRUMENBA INTRAMUSCULAR SYRINGE
120 MCG/0.5 ML NCS
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT- 20 MCG/ML NCS
TWINRIX (PF) INTRAMUSCULAR SYRINGE
720 ELISA UNIT- 20 MCG/ML NCS
TYPHIM VI INTRAMUSCULAR SOLUTION
25 MCG/0.5 ML NCS
TYPHIM VI INTRAMUSCULAR SYRINGE 25
MCG/0.5 ML NCS
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML NCS
VAQTA (PF) INTRAMUSCULAR SYRINGE
25 UNIT/0.5 ML, 50 UNIT/ML NCS
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION 1,350
UNIT/0.5 ML
NCS
VARIZIG INTRAMUSCULAR RECON SOLN
125 UNIT NCS
VARIZIG INTRAMUSCULAR SOLUTION 125
UNIT/1.2 ML NCS
VIVOTIF BERNA VACCINE ORAL
CAPSULE,DELAYED RELEASE(DR/EC) 2
BILLION UNIT
NCS
VIVOTIF ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 2 BILLION UNIT NCS
YF-VAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION 10
EXP4.74 UNIT/0.5 ML
NCS
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION 19,400
UNIT/0.65 ML
NCS
BLOOD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 47
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Drug Name Tier Notes
DROXIA ORAL CAPSULE 200 MG, 300 MG,
400 MG T4 MD
ENDARI ORAL POWDER IN PACKET 5
GRAM T5 (SP) PA
pentoxifylline oral tablet extended release 400 mg T2 MD
tranexamic acid intravenous solution 1,000 mg/10
ml (100 mg/ml) T3 PA
tranexamic acid oral tablet 650 mg T2 MD
CARDIAC DRUGS
AFEDITAB CR ORAL TABLET EXTENDED
RELEASE 30 MG, 60 MG T2 MD
amiodarone oral tablet 200 mg T2 MD
amlodipine oral tablet 10 mg, 2.5 mg, 5 mg T1 MD
CARTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24HR 120 MG, 180 MG, 240 MG,
300 MG
T2 MD
DIGITEK ORAL TABLET 125 MCG, 250 MCG T2 MD
DIGOX ORAL TABLET 125 MCG, 250 MCG T2 MD
digoxin oral solution 0.25 mg/5 ml (5 ml) T3
digoxin oral solution 50 mcg/ml T3 MD
digoxin oral tablet 125 mcg, 250 mcg T2 MD
diltiazem hcl oral capsule,ext.rel 24h degradable
120 mg, 180 mg, 240 mg T2 MD
diltiazem hcl oral capsule,extended release 12 hr
120 mg, 60 mg, 90 mg T2 MD
diltiazem hcl oral capsule,extended release 24 hr
120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420
mg
T2 MD
diltiazem hcl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg T2 MD
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg,
90 mg T2 MD
diltiazem hcl oral tablet extended release 24 hr
180 mg, 240 mg, 300 mg, 360 mg, 420 mg T3 MD
DILT-XR ORAL CAPSULE,EXT.REL 24H
DEGRADABLE 120 MG, 180 MG, 240 MG T2 MD
disopyramide phosphate oral capsule 100 mg,
150 mg T2 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 48
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Drug Name Tier Notes
dofetilide oral capsule 125 mcg, 250 mcg, 500
mcg T4 MD
felodipine oral tablet extended release 24 hr 10
mg, 2.5 mg, 5 mg T2 MD
flecainide oral tablet 100 mg, 150 mg, 50 mg T2 MD
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30
mg, 5 mg T3 MD
isosorbide dinitrate oral tablet extended release
40 mg T3 MD
isosorbide mononitrate oral tablet 10 mg, 20 mg T2 MD
isosorbide mononitrate oral tablet extended
release 24 hr 120 mg, 30 mg, 60 mg T2 MD
isradipine oral capsule 2.5 mg, 5 mg T3 MD
MATZIM LA ORAL TABLET EXTENDED
RELEASE 24 HR 180 MG, 240 MG, 300 MG,
360 MG, 420 MG
T3 MD
mexiletine oral capsule 150 mg, 200 mg, 250 mg T2 MD
MINITRAN TRANSDERMAL PATCH 24
HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR,
0.6 MG/HR
T2 MD
MULTAQ ORAL TABLET 400 MG T3 MD
nicardipine oral capsule 20 mg, 30 mg T3 MD
NIFEDICAL XL ORAL TABLET EXTENDED
RELEASE 24HR 30 MG, 60 MG T2
nifedipine oral capsule 10 mg, 20 mg T2 MD
nifedipine oral tablet extended release 24hr 30
mg, 60 mg, 90 mg T2 MD
nifedipine oral tablet extended release 30 mg, 60
mg, 90 mg T2 MD
nimodipine oral capsule 30 mg T2
nisoldipine oral tablet extended release 24 hr 17
mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg T3 MD
NITRO-BID TRANSDERMAL OINTMENT 2 % T4 MD
nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6
mg T2 MD
nitroglycerin transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr T2 MD
NITROSTAT SUBLINGUAL TABLET 0.3 MG,
0.4 MG, 0.6 MG T3 MD
NORPACE CR ORAL CAPSULE, EXTENDED
RELEASE 100 MG, 150 MG T5 (SP) PA; MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 49
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Drug Name Tier Notes
procainamide injection solution 100 mg/ml, 500
mg/ml T3
propafenone oral capsule,extended release 12 hr
225 mg, 325 mg, 425 mg T3 MD
propafenone oral tablet 150 mg, 225 mg, 300 mg T2 MD
quinidine gluconate oral tablet extended release
324 mg T4 MD
quinidine sulfate oral tablet 200 mg, 300 mg T2 MD
quinidine sulfate oral tablet extended release 300
mg T3
RANEXA ORAL TABLET EXTENDED
RELEASE 12 HR 1,000 MG, 500 MG T4 MD
TAZTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 180 MG, 240 MG,
300 MG, 360 MG
T2 MD
verapamil oral capsule, 24 hr er pellet ct 100 mg,
200 mg, 300 mg T2 MD
verapamil oral capsule,ext rel. pellets 24 hr 120
mg, 180 mg, 240 mg, 360 mg T2 MD
verapamil oral tablet 120 mg, 40 mg, 80 mg T2 MD
verapamil oral tablet extended release 120 mg,
180 mg, 240 mg T2 MD
CARDIOVASCULAR
acebutolol oral capsule 200 mg, 400 mg T2 MD
ADCIRCA ORAL TABLET 20 MG T5 (SP) PA; MD
ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5
MG, 2 MG, 2.5 MG T5 (SP) PA; MD
amlodipine-benazepril oral capsule 10-20 mg, 10-
40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg T2 MD; QL (30 EA per 30 days)
amlodipine-olmesartan oral tablet 10-20 mg, 10-
40 mg, 5-20 mg, 5-40 mg T3 MD
amlodipine-valsartan oral tablet 10-160 mg, 10-
320 mg, 5-160 mg, 5-320 mg T2 MD; QL (30 EA per 30 days)
amlodipine-valsartan-hcthiazid oral tablet 10-
160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-
160-12.5 mg, 5-160-25 mg
T3 MD; QL (30 EA per 30 days)
AMTURNIDE ORAL TABLET 150-5-12.5 MG,
300-10-12.5 MG, 300-10-25 MG, 300-5-12.5
MG, 300-5-25 MG
T3
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Drug Name Tier Notes
atenolol oral tablet 100 mg, 25 mg, 50 mg T1 MD
atenolol-chlorthalidone oral tablet 100-25 mg,
50-25 mg T2 MD
atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80
mg T2 MD; QL (30 EA per 30 days)
AZOR ORAL TABLET 10-20 MG, 10-40 MG,
5-20 MG, 5-40 MG T3 MD
benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg T1 MD
benazepril-hydrochlorothiazide oral tablet 10-
12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg T2 MD
BENICAR HCT ORAL TABLET 20-12.5 MG,
40-12.5 MG, 40-25 MG T3 MD
BENICAR ORAL TABLET 20 MG, 40 MG, 5
MG T3 MD
betaxolol oral tablet 10 mg, 20 mg T2 MD
bisoprolol fumarate oral tablet 10 mg, 5 mg T2 MD
bisoprolol-hydrochlorothiazide oral tablet 10-
6.25 mg, 2.5-6.25 mg, 5-6.25 mg T2 MD
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20
MG, 5 MG T3 MD
candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg T3 MD; QL (30 EA per 30 days)
candesartan-hydrochlorothiazid oral tablet 16-
12.5 mg, 32-12.5 mg, 32-25 mg T3 MD; QL (30 EA per 30 days)
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50
mg T2 MD
captopril-hydrochlorothiazide oral tablet 25-15
mg, 25-25 mg, 50-15 mg, 50-25 mg T2 MD
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg,
6.25 mg T1 MD
cholestyramine (with sugar) oral powder 4 gram T3 MD
cholestyramine (with sugar) oral powder in
packet 4 gram T3 MD
CHOLESTYRAMINE LIGHT ORAL POWDER
4 GRAM T3 MD
CHOLESTYRAMINE LIGHT ORAL POWDER
IN PACKET 4 GRAM T3 MD
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg T1 MD
clonidine transdermal patch weekly 0.1 mg/24 hr,
0.2 mg/24 hr, 0.3 mg/24 hr T3 MD; QL (4 EA per 28 days)
colesevelam oral tablet 625 mg T3 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 51
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Drug Name Tier Notes
colestipol oral granules 5 gram T3 MD
colestipol oral tablet 1 gram T3 MD
COREG CR ORAL CAPSULE, ER
MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG,
80 MG
T3 MD
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg T2 MD; QL (60 EA per 30 days)
enalapril maleate oral tablet 10 mg, 2.5 mg, 20
mg, 5 mg T1 MD
enalapril-hydrochlorothiazide oral tablet 10-25
mg, 5-12.5 mg T1 MD
ENTRESTO ORAL TABLET 24-26 MG, 49-51
MG, 97-103 MG T4 PA; MD; QL (60 EA per 30 days)
ergoloid oral tablet 1 mg T3 MD
ezetimibe oral tablet 10 mg T3 MD; QL (30 EA per 30 days)
fenofibrate micronized oral capsule 134 mg, 200
mg, 67 mg T2 MD
fenofibrate nanocrystallized oral tablet 145 mg,
48 mg T2 MD
fenofibrate oral tablet 160 mg, 54 mg T2 MD
fenofibric acid (choline) oral capsule,delayed
release(dr/ec) 135 mg T3 MD
fenofibric acid (choline) oral capsule,delayed
release(dr/ec) 45 mg T2 MD
fluvastatin oral capsule 20 mg, 40 mg T3 MD
fosinopril oral tablet 10 mg, 20 mg, 40 mg T2 MD
fosinopril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg T2 MD
gemfibrozil oral tablet 600 mg T2 MD
guanfacine oral tablet 1 mg, 2 mg T2 MD
hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50
mg T2 MD
irbesartan oral tablet 150 mg, 300 mg, 75 mg T1 MD
irbesartan-hydrochlorothiazide oral tablet 150-
12.5 mg, 300-12.5 mg T1 MD
labetalol oral tablet 100 mg, 200 mg, 300 mg T2 MD
LETAIRIS ORAL TABLET 10 MG, 5 MG T5 (SP) PA; MD
LEVATOL ORAL TABLET 20 MG T4 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 52
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Drug Name Tier Notes
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30
mg, 40 mg, 5 mg T1 MD
lisinopril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg T1 MD
losartan oral tablet 100 mg T1 MD; QL (30 EA per 30 days)
losartan oral tablet 25 mg, 50 mg T1 MD; QL (60 EA per 30 days)
losartan-hydrochlorothiazide oral tablet 100-12.5
mg, 100-25 mg T1 MD; QL (30 EA per 30 days)
losartan-hydrochlorothiazide oral tablet 50-12.5
mg T1 MD; QL (60 EA per 30 days)
lovastatin oral tablet 10 mg T1 MD; QL (30 EA per 30 days)
lovastatin oral tablet 20 mg, 40 mg T1 MD; QL (60 EA per 30 days)
methyldopa oral tablet 250 mg, 500 mg T2 MD
methyldopa-hydrochlorothiazide oral tablet 250-
15 mg, 250-25 mg T2 MD
metoprolol succinate oral tablet extended release
24 hr 100 mg, 200 mg, 25 mg, 50 mg T2 MD; QL (60 EA per 30 days)
metoprolol ta-hydrochlorothiaz oral tablet 100-25
mg, 100-50 mg, 50-25 mg T2 MD
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg T1 MD
minoxidil oral tablet 10 mg, 2.5 mg T2 MD
moexipril oral tablet 15 mg, 7.5 mg T3 MD
moexipril-hydrochlorothiazide oral tablet 15-12.5
mg, 15-25 mg, 7.5-12.5 mg T3 MD
nadolol oral tablet 20 mg, 40 mg, 80 mg T2 MD; QL (30 EA per 30 days)
niacin oral tablet extended release 24 hr 1,000
mg, 500 mg, 750 mg T3 MD
NIACOR ORAL TABLET 500 MG T2 MD
olmesartan oral tablet 20 mg, 40 mg, 5 mg T3 MD
olmesartan-amlodipin-hcthiazid oral tablet 20-5-
12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5
mg, 40-5-25 mg
T3 MD
olmesartan-hydrochlorothiazide oral tablet 20-
12.5 mg, 40-12.5 mg, 40-25 mg T3 MD
perindopril erbumine oral tablet 2 mg, 4 mg, 8
mg T3 MD
pindolol oral tablet 10 mg, 5 mg T3 MD
PRALUENT PEN SUBCUTANEOUS PEN
INJECTOR 150 MG/ML, 75 MG/ML T5 (SP) PA; MD; QL (2 ML per 28 days)
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Drug Name Tier Notes
PRALUENT SYRINGE SUBCUTANEOUS
SYRINGE 150 MG/ML, 75 MG/ML T5 (SP) PA; QL (2 ML per 28 days)
pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80
mg T2 MD; QL (30 EA per 30 days)
prazosin oral capsule 1 mg, 2 mg, 5 mg T2 MD
PREVALITE ORAL POWDER 4 GRAM T3 MD
PREVALITE ORAL POWDER IN PACKET 4
GRAM T3 MD
propranolol oral capsule,extended release 24 hr
120 mg, 160 mg, 60 mg, 80 mg T2 MD
propranolol oral solution 20 mg/5 ml (4 mg/ml),
40 mg/5 ml (8 mg/ml) T3 MD
propranolol oral tablet 10 mg, 20 mg, 40 mg, 60
mg, 80 mg T2 MD
propranolol-hydrochlorothiazid oral tablet 40-25
mg, 80-25 mg T2 MD
quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg T1 MD
quinapril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg T2 MD
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5
mg T1 MD
REMODULIN INJECTION SOLUTION 1
MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML T5 (SP) PA
REPATHA PUSHTRONEX SUBCUTANEOUS
WEARABLE INJECTOR 420 MG/3.5 ML T5 (SP) PA; MD; QL (3.5 ML per 28 days)
REPATHA SURECLICK SUBCUTANEOUS
PEN INJECTOR 140 MG/ML T5 (SP) PA; MD; QL (3 ML per 28 days)
REPATHA SYRINGE SUBCUTANEOUS
SYRINGE 140 MG/ML T5 (SP) PA; MD; QL (3 ML per 28 days)
rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5
mg T2 MD; QL (30 EA per 30 days)
sildenafil (antihypertensive) oral tablet 20 mg T4 PA; MD; QL (90 EA per 30 days)
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5
mg, 80 mg T1 MD; QL (30 EA per 30 days)
SORINE ORAL TABLET 120 MG, 160 MG, 240
MG, 80 MG T2 MD
SOTALOL AF ORAL TABLET 120 MG, 160
MG, 80 MG T2 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 54
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Drug Name Tier Notes
sotalol oral tablet 120 mg, 160 mg, 240 mg, 80
mg T2 MD
tadalafil (antihypertensive) oral tablet 20 mg T5 (SP) PA; MD
TEKAMLO ORAL TABLET 150-10 MG, 150-5
MG, 300-10 MG, 300-5 MG T3
TEKTURNA HCT ORAL TABLET 150-12.5
MG, 150-25 MG, 300-12.5 MG, 300-25 MG T3 MD
TEKTURNA ORAL TABLET 150 MG, 300 MG T3 MD
telmisartan oral tablet 20 mg, 40 mg, 80 mg T2 MD
terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg T2 MD; QL (60 EA per 30 days)
timolol maleate oral tablet 10 mg, 20 mg, 5 mg T2 MD
TRACLEER ORAL TABLET 125 MG, 62.5 MG T5 (SP) PA; MD
TRACLEER ORAL TABLET FOR
SUSPENSION 32 MG T5 (SP) PA; MD
trandolapril oral tablet 1 mg, 2 mg, 4 mg T2 MD
TRIBENZOR ORAL TABLET 20-5-12.5 MG,
40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG,
40-5-25 MG
T3 MD
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80
mg T2 MD
valsartan-hydrochlorothiazide oral tablet 160-
12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg,
80-12.5 mg
T2 MD
VENTAVIS INHALATION SOLUTION FOR
NEBULIZATION 10 MCG/ML, 20 MCG/ML T5 (SP) PA; MD
VYTORIN 10-10 ORAL TABLET 10-10 MG T4 MD; QL (30 EA per 30 days)
VYTORIN 10-20 ORAL TABLET 10-20 MG T4 MD; QL (30 EA per 30 days)
VYTORIN 10-40 ORAL TABLET 10-40 MG T4 MD; QL (30 EA per 30 days)
VYTORIN 10-80 ORAL TABLET 10-80 MG T4 MD; QL (30 EA per 30 days)
WELCHOL ORAL POWDER IN PACKET 3.75
GRAM T4 ST; MD
WELCHOL ORAL TABLET 625 MG T4 ST; MD
ZETIA ORAL TABLET 10 MG T3 MD; QL (30 EA per 30 days)
CNS DRUGS
APTIOM ORAL TABLET 200 MG, 400 MG,
600 MG, 800 MG T4 PA; MD
AUSTEDO ORAL TABLET 12 MG T5 (SP) PA; MD; QL (120 EA per 30 days)
AUSTEDO ORAL TABLET 6 MG, 9 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT 30 MCG T5 (SP) PA; MD; QL (4 EA per 28 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 55
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Drug Name Tier Notes
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT 30 MCG/0.5 ML T5 (SP) PA; MD; QL (4 EA per 28 days)
AVONEX INTRAMUSCULAR SYRINGE KIT
30 MCG/0.5 ML T5 (SP) PA; MD; QL (1 EA per 28 days)
BANZEL ORAL SUSPENSION 40 MG/ML T5 (SP) PA; MD; QL (2400 ML per 30
days)
BANZEL ORAL TABLET 200 MG T5 (SP) PA; MD; QL (90 EA per 30 days)
BANZEL ORAL TABLET 400 MG T5 (SP) PA; MD; QL (240 EA per 30 days)
BETASERON SUBCUTANEOUS KIT 0.3 MG T5 (SP) PA; MD; QL (14 EA per 28 days)
carbamazepine oral capsule, er multiphase 12 hr
100 mg, 200 mg, 300 mg T3 MD
carbamazepine oral suspension 100 mg/5 ml, 100
mg/5 ml (5 ml), 200 mg/10 ml T3 MD
carbamazepine oral tablet 200 mg T2 MD
carbamazepine oral tablet extended release 12 hr
100 mg, 200 mg, 400 mg T3 MD
carbamazepine oral tablet,chewable 100 mg T2 MD
CELONTIN ORAL CAPSULE 300 MG T4 MD
clonazepam oral tablet 0.5 mg, 1 mg T2 MD; QL (90 EA per 30 days)
clonazepam oral tablet 2 mg T2 MD; QL (300 EA per 30 days)
COPAXONE SUBCUTANEOUS SYRINGE 20
MG/ML T5 (SP) PA; MD
COPAXONE SUBCUTANEOUS SYRINGE 40
MG/ML T5 (SP) PA; MD; QL (12 ML per 30 days)
diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg,
5-7.5-10 mg T4
divalproex oral capsule, delayed rel sprinkle 125
mg T2 MD
divalproex oral tablet extended release 24 hr 250
mg, 500 mg T2 MD
divalproex oral tablet,delayed release (dr/ec) 125
mg, 250 mg, 500 mg T2 MD
ethosuximide oral capsule 250 mg T3 MD
ethosuximide oral solution 250 mg/5 ml T3 MD
felbamate oral suspension 600 mg/5 ml T5 (SP) MD
felbamate oral tablet 400 mg, 600 mg T5 (SP) MD
FYCOMPA ORAL SUSPENSION 0.5 MG/ML T4 PA; MD
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Drug Name Tier Notes
FYCOMPA ORAL TABLET 10 MG, 12 MG, 4
MG, 6 MG, 8 MG T4 PA; MD; QL (30 EA per 30 days)
FYCOMPA ORAL TABLET 2 MG T4 PA; MD; QL (60 EA per 30 days)
FYCOMPA ORAL TABLETS,DOSE PACK 2
MG (7)- 4 MG (7) T4 PA
gabapentin oral capsule 100 mg, 300 mg, 400 mg T2 MD; QL (270 EA per 30 days)
gabapentin oral solution 250 mg/5 ml, 250 mg/5
ml (5 ml), 300 mg/6 ml (6 ml) T2 MD; QL (2160 ML per 30 days)
gabapentin oral tablet 600 mg T2 MD; QL (180 EA per 30 days)
gabapentin oral tablet 800 mg T2 MD; QL (120 EA per 30 days)
GABITRIL ORAL TABLET 12 MG, 16 MG T5 (SP) MD
GILENYA ORAL CAPSULE 0.5 MG T5 (SP) PA; MD; QL (30 EA per 30 days)
HORIZANT ORAL TABLET EXTENDED
RELEASE 300 MG, 600 MG T4 PA; MD; QL (60 EA per 30 days)
lamotrigine oral tablet 100 mg, 150 mg, 200 mg,
25 mg T2 MD
lamotrigine oral tablet disintegrating, dose pk 25
mg (21) -50 mg (7), 25 mg(14)-50 mg (14)-100
mg (7), 50 mg (42) -100 mg (14)
T3
lamotrigine oral tablet, chewable dispersible 25
mg, 5 mg T2 MD
lamotrigine oral tablet,disintegrating 100 mg,
200 mg, 25 mg, 50 mg T3 MD; QL (90 EA per 30 days)
lamotrigine oral tablets,dose pack 25 mg (35), 25
mg (42) -100 mg (7), 25 mg (84) -100 mg (14) T3
levetiracetam oral solution 100 mg/ml, 500 mg/5
ml (5 ml) T2 MD
levetiracetam oral tablet 1,000 mg, 250 mg, 500
mg, 750 mg T2 MD
levetiracetam oral tablet extended release 24 hr
500 mg T2 MD; QL (180 EA per 30 days)
levetiracetam oral tablet extended release 24 hr
750 mg T2 MD; QL (120 EA per 30 days)
LYRICA ORAL CAPSULE 100 MG, 150 MG,
200 MG, 25 MG, 50 MG, 75 MG T4 MD; QL (90 EA per 30 days)
LYRICA ORAL CAPSULE 225 MG, 300 MG T4 MD; QL (60 EA per 30 days)
memantine oral capsule,sprinkle,er 24hr 14 mg,
21 mg, 28 mg, 7 mg T3 MD; QL (30 EA per 30 days)
memantine oral solution 2 mg/ml T4 MD; QL (300 ML per 30 days)
memantine oral tablet 10 mg, 5 mg T2 MD; QL (60 EA per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 57
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Drug Name Tier Notes
memantine oral tablets,dose pack 5-10 mg T2
oxcarbazepine oral suspension 300 mg/5 ml (60
mg/ml) T2 MD
oxcarbazepine oral tablet 150 mg, 300 mg, 600
mg T2 MD
PEGANONE ORAL TABLET 250 MG T4 MD
phenytoin oral suspension 100 mg/4 ml, 125 mg/5
ml T2 MD
phenytoin sodium extended oral capsule 100 mg,
200 mg, 300 mg T2 MD
POTIGA ORAL TABLET 200 MG, 300 MG,
400 MG T5 (SP) PA; QL (90 EA per 30 days)
POTIGA ORAL TABLET 50 MG T5 (SP) PA; QL (270 EA per 30 days)
primidone oral tablet 250 mg, 50 mg T2 MD
SABRIL ORAL TABLET 500 MG T5 (SP) PA
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG T5 (SP) PA; MD; QL (14 EA per 365 days)
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240 MG (46) T5 (SP) PA; QL (60 EA per 365 days)
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 240 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
tiagabine oral tablet 12 mg, 16 mg T4 MD
tiagabine oral tablet 2 mg, 4 mg T5 (SP) MD
topiramate oral capsule, sprinkle 15 mg, 25 mg T3 MD
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50
mg T2 MD
valproic acid (as sodium salt) oral solution 250
mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml (10
ml)
T2 MD
valproic acid (as sodium salt) oral syringe 250
mg/5 ml T2
valproic acid oral capsule 250 mg T2 MD
vigabatrin oral powder in packet 500 mg T5 (SP) PA; MD
VIMPAT ORAL SOLUTION 10 MG/ML T5 (SP) PA; MD; QL (1200 ML per 30
days)
VIMPAT ORAL TABLET 100 MG, 150 MG,
200 MG, 50 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
VIMPAT ORAL TABLETS,DOSE PACK 50
MG (14)- 100 MG (14) T5 (SP) PA
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 58
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Drug Name Tier Notes
zonisamide oral capsule 100 mg, 25 mg, 50 mg T2 MD
COLONY STIMULATING FACTORS
DOPTELET ORAL TABLET 20 MG T5 (SP) PA; QL (15 EA per 90 days)
LEUKINE INJECTION RECON SOLN 250
MCG T5 (SP) PA
MULPLETA ORAL TABLET 3 MG T5 (SP) PA; QL (7 EA per 90 days)
NEULASTA SUBCUTANEOUS SYRINGE 6
MG/0.6ML T5 (SP) PA
NEULASTA SUBCUTANEOUS SYRINGE, W/
WEARABLE INJECTOR 6 MG/0.6 ML T5 (SP) PA
NEUPOGEN INJECTION SOLUTION 300
MCG/ML, 480 MCG/1.6 ML T5 (SP) PA
NEUPOGEN INJECTION SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML T5 (SP) PA
PROCRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML,
3,000 UNIT/ML, 4,000 UNIT/ML, 40,000
UNIT/ML
T5 (SP) PA; MD; QL (14 ML per 30 days)
PROMACTA ORAL TABLET 12.5 MG, 25 MG,
50 MG, 75 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
CONTRACEPTIVES
AFTERA ORAL TABLET 1.5 MG NCS
ALTAVERA (28) ORAL TABLET 0.15-0.03
MG NCS MD
alyacen 1/35 (28) oral tablet 1-35 mg-mcg NCS MD
ALYACEN 7/7/7 (28) ORAL TABLET
0.5/0.75/1 MG- 35 MCG NCS MD
AMETHIA LO ORAL TABLETS,DOSE
PACK,3 MONTH 0.10 MG-20 MCG (84)/10
MCG (7)
NCS MD
AMETHIA ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG (84)/10 MCG (7) NCS MD
AMETHYST ORAL TABLET 90-20 MCG NCS MD
APRI ORAL TABLET 0.15-0.03 MG NCS MD
ARANELLE (28) ORAL TABLET 0.5/1/0.5-35
MG-MCG NCS MD
ASHLYNA ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG (84)/10 MCG (7) NCS MD
AUBRA ORAL TABLET 0.1-20 MG-MCG NCS MD
AVIANE ORAL TABLET 0.1-20 MG-MCG NCS MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 59
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Drug Name Tier Notes
AZURETTE (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5 NCS MD
BALZIVA (28) ORAL TABLET 0.4-35 MG-
MCG NCS MD
BEKYREE (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5 NCS MD
BEYAZ ORAL TABLET 3-0.02-0.451 MG (24)
(4) T4 MD
BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG
(24)/75 MG (4) NCS MD
BLISOVI FE 1/20 (28) ORAL TABLET 1 MG-
20 MCG (21)/75 MG (7) NCS MD
BRIELLYN ORAL TABLET 0.4-35 MG-MCG NCS MD
CAMILA ORAL TABLET 0.35 MG NCS MD
CAMRESE LO ORAL TABLETS,DOSE
PACK,3 MONTH 0.10 MG-20 MCG (84)/10
MCG (7)
NCS MD
CAMRESE ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG (84)/10 MCG (7) NCS MD
CAYA CONTOURED VAGINAL
DIAPHRAGM 60-85 MM NCS
CAZIANT (28) ORAL TABLET 0.1/.125/.15-25
MG-MCG NCS MD
CHATEAL ORAL TABLET 0.15-0.03 MG NCS MD
CONCEPTROL VAGINAL GEL 4 % NCS
CRYSELLE (28) ORAL TABLET 0.3-30 MG-
MCG NCS MD
CYCLAFEM 1/35 (28) ORAL TABLET 1-35
MG-MCG NCS MD
CYCLAFEM 7/7/7 (28) ORAL TABLET
0.5/0.75/1 MG- 35 MCG NCS MD
CYRED ORAL TABLET 0.15-0.03 MG NCS MD
DASETTA 1/35 (28) ORAL TABLET 1-35 MG-
MCG NCS MD
DASETTA 7/7/7 (28) ORAL TABLET 0.5/0.75/1
MG- 35 MCG NCS MD
DAYSEE ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG (84)/10 MCG (7) NCS MD
DEBLITANE ORAL TABLET 0.35 MG NCS MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 60
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Drug Name Tier Notes
DELYLA (28) ORAL TABLET 0.1-20 MG-
MCG NCS MD
desog-e.estradiol/e.estradiol oral tablet 0.15-0.02
mgx21 /0.01 mg x 5 NCS MD
desogestrel-ethinyl estradiol oral tablet 0.15-0.03
mg NCS MD
drospirenone-ethinyl estradiol oral tablet 3-0.02
mg, 3-0.03 mg NCS MD
ECONTRA EZ ORAL TABLET 1.5 MG NCS
ELINEST ORAL TABLET 0.3-30 MG-MCG NCS MD
ELLA ORAL TABLET 30 MG NCS
EMOQUETTE ORAL TABLET 0.15-0.03 MG NCS MD
ENPRESSE ORAL TABLET 50-30 (6)/75-40
(5)/125-30(10) NCS MD
ENSKYCE ORAL TABLET 0.15-0.03 MG NCS MD
ERRIN ORAL TABLET 0.35 MG NCS MD
ESTARYLLA ORAL TABLET 0.25-35 MG-
MCG NCS MD
FALLBACK SOLO ORAL TABLET 1.5 MG NCS
FALMINA (28) ORAL TABLET 0.1-20 MG-
MCG NCS MD
FC2 FEMALE CONDOM NCS
FEMCAP VAGINAL DEVICE 22 MM, 26 MM,
30 MM NCS
GENERESS FE ORAL TABLET,CHEWABLE
0.8MG-25MCG(24) AND 75 MG (4) T4 MD
GIANVI (28) ORAL TABLET 3-0.02 MG NCS MD
GILDAGIA ORAL TABLET 0.4-35 MG-MCG NCS
GILDESS 1.5/30 (21) ORAL TABLET 1.5-30
MG-MCG NCS
GILDESS 1/20 (21) ORAL TABLET 1-20 MG-
MCG NCS
GILDESS 24 FE ORAL TABLET 1 MG-20
MCG (24)/75 MG (4) NCS
GILDESS FE 1.5/30 (28) ORAL TABLET 1.5
MG-30 MCG (21)/75 MG (7) NCS
GILDESS FE 1/20 (28) ORAL TABLET 1 MG-
20 MCG (21)/75 MG (7) NCS
GYNOL II VAGINAL GEL 3 % NCS
HEATHER ORAL TABLET 0.35 MG NCS MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 61
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Drug Name Tier Notes
INTROVALE ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG NCS MD
JENCYCLA ORAL TABLET 0.35 MG NCS MD
JOLESSA ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG NCS MD
JOLIVETTE ORAL TABLET 0.35 MG NCS MD
JULEBER ORAL TABLET 0.15-0.03 MG NCS MD
JUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-
MCG NCS MD
JUNEL 1/20 (21) ORAL TABLET 1-20 MG-
MCG NCS MD
JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-
30 MCG (21)/75 MG (7) NCS MD
JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20
MCG (21)/75 MG (7) NCS MD
JUNEL FE 24 ORAL TABLET 1 MG-20 MCG
(24)/75 MG (4) NCS MD
KARIVA (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5 NCS MD
KELNOR 1/35 (28) ORAL TABLET 1-35 MG-
MCG NCS MD
KIMIDESS (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5 NCS
KURVELO ORAL TABLET 0.15-0.03 MG NCS MD
l norgest/e.estradiol-e.estrad oral tablets,dose
pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7),
0.15 mg-30 mcg (84)/10 mcg (7)
NCS MD
LARIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-
MCG NCS MD
LARIN 1/20 (21) ORAL TABLET 1-20 MG-
MCG NCS MD
LARIN 24 FE ORAL TABLET 1 MG-20 MCG
(24)/75 MG (4) NCS MD
LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-
30 MCG (21)/75 MG (7) NCS MD
LARIN FE 1/20 (28) ORAL TABLET 1 MG-20
MCG (21)/75 MG (7) NCS MD
LAYOLIS FE ORAL TABLET,CHEWABLE
0.8MG-25MCG(24) AND 75 MG (4) NCS MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 62
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Drug Name Tier Notes
LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-
MCG NCS MD
LESSINA ORAL TABLET 0.1-20 MG-MCG NCS MD
LEVONEST (28) ORAL TABLET 50-30 (6)/75-
40 (5)/125-30(10) NCS MD
levonorgestrel-ethinyl estrad oral tablet 0.1-20
mg-mcg, 0.15-0.03 mg, 90-20 mcg NCS MD
levonorgestrel-ethinyl estrad oral tablets,dose
pack,3 month 0.15 mg-30 mcg NCS MD
levonorg-eth estrad triphasic oral tablet 50-30
(6)/75-40 (5)/125-30(10) NCS MD
LEVORA-28 ORAL TABLET 0.15-0.03 MG NCS MD
LO LOESTRIN FE ORAL TABLET 1 MG-10
MCG (24)/10 MCG (2) T4 MD
LOMEDIA 24 FE ORAL TABLET 1 MG-20
MCG (24)/75 MG (4) NCS
LORYNA (28) ORAL TABLET 3-0.02 MG NCS MD
LOW-OGESTREL (28) ORAL TABLET 0.3-30
MG-MCG NCS MD
LUTERA (28) ORAL TABLET 0.1-20 MG-
MCG NCS MD
LYZA ORAL TABLET 0.35 MG NCS MD
MARLISSA ORAL TABLET 0.15-0.03 MG NCS MD
medroxyprogesterone intramuscular suspension
150 mg/ml NCS MD
medroxyprogesterone intramuscular syringe 150
mg/ml NCS MD
MICROGESTIN 1.5/30 (21) ORAL TABLET
1.5-30 MG-MCG NCS MD
MICROGESTIN 1/20 (21) ORAL TABLET 1-20
MG-MCG NCS MD
MICROGESTIN FE 1.5/30 (28) ORAL TABLET
1.5 MG-30 MCG (21)/75 MG (7) NCS MD
MICROGESTIN FE 1/20 (28) ORAL TABLET 1
MG-20 MCG (21)/75 MG (7) NCS MD
MINASTRIN 24 FE ORAL
TABLET,CHEWABLE 1 MG-20 MCG(24) /75
MG (4)
T4 MD
MIRENA INTRAUTERINE INTRAUTERINE
DEVICE 20 MCG/24 HR (5 YEARS) NCS MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 63
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Drug Name Tier Notes
MONO-LINYAH ORAL TABLET 0.25-35 MG-
MCG NCS MD
MONONESSA (28) ORAL TABLET 0.25-35
MG-MCG NCS MD
MY WAY ORAL TABLET 1.5 MG NCS
MYZILRA ORAL TABLET 50-30 (6)/75-40
(5)/125-30(10) NCS MD
NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/
2 MG-3 MG/1 MG T3 MD
NECON 0.5/35 (28) ORAL TABLET 0.5-35
MG-MCG NCS MD
NECON 1/35 (28) ORAL TABLET 1-35 MG-
MCG NCS
NECON 1/50 (28) ORAL TABLET 1-50 MG-
MCG NCS
NECON 10/11 (28) ORAL TABLET 0.5-35/1-35
MG-MCG/MG-MCG NCS
NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1
MG- 35 MCG NCS
NEXPLANON SUBDERMAL IMPLANT 68
MG NCS
NEXT CHOICE ONE DOSE ORAL TABLET
1.5 MG NCS
NIKKI (28) ORAL TABLET 3-0.02 MG NCS MD
NORA-BE ORAL TABLET 0.35 MG NCS MD
noreth-ethinyl estradiol-iron oral tablet,chewable
0.8mg-25mcg(24) and 75 mg (4) NCS MD
norethindrone (contraceptive) oral tablet 0.35 mg NCS MD
norethindrone ac-eth estradiol oral tablet 1-20
mg-mcg NCS MD
norethindrone-e.estradiol-iron oral tablet 1 mg-
20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg
(4)
NCS MD
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-
35 mcg (28), 0.25-35 mg-mcg
NCS MD
NORINYL 1+50 (28) ORAL TABLET 1-50 MG-
MCG T3
NORLYROC ORAL TABLET 0.35 MG NCS MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 64
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Drug Name Tier Notes
NORTREL 0.5/35 (28) ORAL TABLET 0.5-35
MG-MCG NCS MD
NORTREL 1/35 (21) ORAL TABLET 1-35 MG-
MCG NCS MD
NORTREL 1/35 (28) ORAL TABLET 1-35 MG-
MCG NCS MD
NORTREL 7/7/7 (28) ORAL TABLET
0.5/0.75/1 MG- 35 MCG NCS MD
NUVARING VAGINAL RING 0.12-0.015
MG/24 HR NCS MD
OCELLA ORAL TABLET 3-0.03 MG NCS MD
OGESTREL (28) ORAL TABLET 0.5-50 MG-
MCG NCS MD
OPCICON ONE-STEP ORAL TABLET 1.5 MG NCS
ORSYTHIA ORAL TABLET 0.1-20 MG-MCG NCS MD
PARAGARD T 380A INTRAUTERINE
INTRAUTERINE DEVICE 380 SQUARE MM NCS MD
PHILITH ORAL TABLET 0.4-35 MG-MCG NCS MD
PIMTREA (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5 NCS MD
PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35
MCG, 1-35 MG-MCG NCS MD
PLAN B ONE-STEP ORAL TABLET 1.5 MG NCS
PORTIA ORAL TABLET 0.15-0.03 MG NCS MD
PREVIFEM ORAL TABLET 0.25-35 MG-MCG NCS MD
QUASENSE ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG NCS MD
RECLIPSEN (28) ORAL TABLET 0.15-0.03
MG NCS MD
SAFYRAL ORAL TABLET 3-0.03-0.451 MG
(21) (7) T3 MD
SETLAKIN ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG NCS MD
SHAROBEL ORAL TABLET 0.35 MG NCS MD
SKYLA INTRAUTERINE INTRAUTERINE
DEVICE 14 MCG/24 HOUR (3 YEARS) T3 MD
SPRINTEC (28) ORAL TABLET 0.25-35 MG-
MCG NCS MD
SRONYX ORAL TABLET 0.1-20 MG-MCG NCS MD
SYEDA ORAL TABLET 3-0.03 MG NCS MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 65
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Drug Name Tier Notes
TAKE ACTION ORAL TABLET 1.5 MG NCS
TARINA FE 1/20 (28) ORAL TABLET 1 MG-20
MCG (21)/75 MG (7) NCS MD
TILIA FE ORAL TABLET 1-20(5)/1-30(7)
/1MG-35MCG (9) NCS MD
TODAY CONTRACEPTIVE SPONGE
VAGINAL CONTRACEPTIVE SPONGE 1,000
MG
NCS
TRI-ESTARYLLA ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28) NCS MD
TRI-LEGEST FE ORAL TABLET 1-20(5)/1-
30(7) /1MG-35MCG (9) NCS MD
TRI-LINYAH ORAL TABLET 0.18/0.215/0.25
MG-35 MCG (28) NCS MD
TRI-LO-SPRINTEC ORAL TABLET
0.18/0.215/0.25 MG-25 MCG NCS MD
TRINESSA (28) ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28) NCS MD
TRI-PREVIFEM (28) ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28) NCS MD
TRI-SPRINTEC (28) ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28) NCS MD
TRIVORA (28) ORAL TABLET 50-30 (6)/75-40
(5)/125-30(10) NCS MD
VELIVET TRIPHASIC REGIMEN (28) ORAL
TABLET 0.1/.125/.15-25 MG-MCG NCS MD
VESTURA (28) ORAL TABLET 3-0.02 MG NCS
VIORELE (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5 NCS MD
VYFEMLA (28) ORAL TABLET 0.4-35 MG-
MCG NCS MD
WERA (28) ORAL TABLET 0.5-35 MG-MCG NCS MD
WIDE-SEAL DIAPHRAGM 60 VAGINAL
DIAPHRAGM 60 MM NCS
WIDE-SEAL DIAPHRAGM 65 VAGINAL
DIAPHRAGM 65 MM NCS
WIDE-SEAL DIAPHRAGM 70 VAGINAL
DIAPHRAGM 70 MM NCS
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 66
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Drug Name Tier Notes
WIDE-SEAL DIAPHRAGM 75 VAGINAL
DIAPHRAGM 75 MM NCS
WIDE-SEAL DIAPHRAGM 80 VAGINAL
DIAPHRAGM 80 MM NCS
WIDE-SEAL DIAPHRAGM 85 VAGINAL
DIAPHRAGM 85 MM NCS
WIDE-SEAL DIAPHRAGM 90 VAGINAL
DIAPHRAGM 90 MM NCS
WIDE-SEAL DIAPHRAGM 95 VAGINAL
DIAPHRAGM 95 MM NCS
WYMZYA FE ORAL TABLET,CHEWABLE
0.4MG-35MCG(21) AND 75 MG (7) NCS MD
XULANE TRANSDERMAL PATCH WEEKLY
150-35 MCG/24 HR NCS MD
YASMIN (28) ORAL TABLET 3-0.03 MG T4 MD
YAZ (28) ORAL TABLET 3-0.02 MG T4 MD
ZARAH ORAL TABLET 3-0.03 MG NCS MD
ZENCHENT (28) ORAL TABLET 0.4-35 MG-
MCG NCS MD
ZENCHENT FE ORAL TABLET,CHEWABLE
0.4MG-35MCG(21) AND 75 MG (7) NCS
ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-
MCG NCS MD
ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-
MCG NCS
COUGH/COLD PREPARATIONS
benzonatate oral capsule 100 mg, 150 mg, 200
mg T2
BROMFED DM ORAL SYRUP 2-30-10 MG/5
ML T3
brompheniramine-pseudoeph-dm oral syrup 2-30-
10 mg/5 ml T3 QL (1200 ML per 30 days)
hydrocodone-homatropine oral syrup 5-1.5 mg/5
ml (5 ml) T2
hydrocodone-homatropine oral tablet 5-1.5 mg T2
HYDROMET ORAL SYRUP 5-1.5 MG/5 ML T2
PROMETHAZINE VC-CODEINE ORAL
SYRUP 6.25-5-10 MG/5 ML T3
promethazine-codeine oral syrup 6.25-10 mg/5 ml T3
promethazine-dm oral syrup 6.25-15 mg/5 ml T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 67
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Drug Name Tier Notes
promethazine-phenyleph-codeine oral syrup 6.25-
5-10 mg/5 ml T3
DIAGNOSTIC
FREESTYLE INSULINX TEST STRIPS STRIP T3 MD; QL (200 EA per 30 days)
FREESTYLE LITE STRIPS STRIP T3 MD; QL (200 EA per 30 days)
FREESTYLE TEST STRIP T3 MD; QL (200 EA per 30 days)
GLUCAGEN DIAGNOSTIC KIT INJECTION
RECON SOLN 1 MG/ML T3 QL (4 EA per 30 days)
PRECISION XTRA TEST STRIP T3 MD; QL (200 EA per 30 days)
DIURETICS
acetazolamide oral tablet 125 mg, 250 mg T3 MD
acetazolamide sodium injection recon soln 500
mg T3
amiloride oral tablet 5 mg T2 MD
amiloride-hydrochlorothiazide oral tablet 5-50
mg T2 MD
ammonium chloride intravenous solution 5
meq/ml T2
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg T2 MD
chlorothiazide oral tablet 250 mg, 500 mg T2 MD
chlorthalidone oral tablet 25 mg, 50 mg T2 MD
DYRENIUM ORAL CAPSULE 100 MG, 50 MG T4 MD
EDECRIN ORAL TABLET 25 MG T5 (SP) PA; MD
eplerenone oral tablet 25 mg, 50 mg T3 MD
furosemide oral solution 10 mg/ml T2 MD
furosemide oral solution 40 mg/4 ml, 40 mg/5 ml
(8 mg/ml) T1 MD
furosemide oral tablet 20 mg, 40 mg, 80 mg T1 MD
hydrochlorothiazide oral capsule 12.5 mg T1 MD
hydrochlorothiazide oral tablet 12.5 mg, 25 mg,
50 mg T1 MD
indapamide oral tablet 1.25 mg, 2.5 mg T2 MD
JYNARQUE ORAL TABLETS, SEQUENTIAL
45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30
MG (PM), 90 MG (AM)/ 30 MG (PM)
T5 (SP) PA; MD; QL (60 EA per 30 days)
methazolamide oral tablet 25 mg, 50 mg T4 MD
methyclothiazide oral tablet 5 mg T3 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 68
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Drug Name Tier Notes
metolazone oral tablet 10 mg, 2.5 mg, 5 mg T2 MD
SAMSCA ORAL TABLET 15 MG, 30 MG T5 (SP) PA
spironolactone oral tablet 100 mg, 25 mg, 50 mg T2 MD
spironolacton-hydrochlorothiaz oral tablet 25-25
mg T2 MD
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg T2 MD
triamterene-hydrochlorothiazid oral capsule
37.5-25 mg T2 MD
triamterene-hydrochlorothiazid oral tablet 37.5-
25 mg, 75-50 mg T2 MD
EENT PREPS
ACETASOL HC OTIC (EAR) DROPS 1-2 % T3
acetic acid otic (ear) solution 2 % T2
ALOCRIL OPHTHALMIC (EYE) DROPS 2 % T4
ALOMIDE OPHTHALMIC (EYE) DROPS 0.1
% T4
ALPHAGAN P OPHTHALMIC (EYE) DROPS
0.1 % T4 MD; QL (15 ML per 30 days)
ALREX OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.2 % T3
antipyrine-benzocaine otic (ear) drops 5.4-1.4 % T2
apraclonidine ophthalmic (eye) drops 0.5 % T2
atropine ophthalmic (eye) drops 1 % T2 MD
atropine sulfate (pf) ophthalmic (eye) drops 1 % T2
azelastine nasal aerosol,spray 137 mcg (0.1 %) T3 MD; QL (60 ML per 30 days)
azelastine nasal spray,non-aerosol 0.15 % (205.5
mcg) T3 MD; QL (60 ML per 30 days)
AZOPT OPHTHALMIC (EYE)
DROPS,SUSPENSION 1 % T3 MD; QL (15 ML per 30 days)
betaxolol ophthalmic (eye) drops 0.5 % T3 MD
BETIMOL OPHTHALMIC (EYE) DROPS 0.25
%, 0.5 % T3 MD
BETOPTIC S OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.25 % T4 MD
brimonidine ophthalmic (eye) drops 0.15 % T3 MD
brimonidine ophthalmic (eye) drops 0.2 % T1 MD
bromfenac ophthalmic (eye) drops 0.09 % T3
carteolol ophthalmic (eye) drops 1 % T2 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 69
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Drug Name Tier Notes
COMBIGAN OPHTHALMIC (EYE) DROPS
0.2-0.5 % T3 MD; QL (10 ML per 30 days)
CORTANE-B TOPICAL LOTION 1-1-0.1 % T4
COSOPT (PF) OPHTHALMIC (EYE)
DROPPERETTE 2-0.5 % T3 MD; QL (60 EA per 30 days)
cromolyn ophthalmic (eye) drops 4 % T2
cyclopentolate ophthalmic (eye) drops 1 %, 2 % T2
dexamethasone sodium phosphate ophthalmic
(eye) drops 0.1 % T2
diclofenac sodium ophthalmic (eye) drops 0.1 % T2
dorzolamide ophthalmic (eye) drops 2 % T2 MD
dorzolamide-timolol ophthalmic (eye) drops 22.3-
6.8 mg/ml T2 MD
DUREZOL OPHTHALMIC (EYE) DROPS 0.05
% T4
flunisolide nasal spray,non-aerosol 25 mcg
(0.025 %) T3 MD; QL (50 ML per 30 days)
fluocinolone acetonide oil otic (ear) drops 0.01 % T3
fluorometholone ophthalmic (eye)
drops,suspension 0.1 % T2
flurbiprofen sodium ophthalmic (eye) drops 0.03
% T2
fluticasone nasal spray,suspension 50
mcg/actuation T2 MD; QL (16 GM per 30 days)
FML S.O.P. OPHTHALMIC (EYE) OINTMENT
0.1 % T4
HOMATROPAIRE OPHTHALMIC (EYE)
DROPS 5 % T3 MD
homatropine hbr ophthalmic (eye) drops 5 % T3 MD
hydrocortisone-acetic acid otic (ear) drops 1-2 % T3
ILEVRO OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.3 % T3
ipratropium bromide nasal spray,non-aerosol
0.03 % T2 MD; QL (30 ML per 30 days)
ipratropium bromide nasal spray,non-aerosol 42
mcg (0.06 %) T2 QL (30 ML per 30 days)
ISTALOL OPHTHALMIC (EYE) DROPS,
ONCE DAILY 0.5 % T4 MD
ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 70
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Drug Name Tier Notes
latanoprost ophthalmic (eye) drops 0.005 % T1 MD
levobunolol ophthalmic (eye) drops 0.5 % T2 MD
LOTEMAX OPHTHALMIC (EYE)
DROPS,GEL 0.5 % T4
LOTEMAX OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.5 % T4
LOTEMAX OPHTHALMIC (EYE) OINTMENT
0.5 % T4
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01
% T3 MD; QL (5 ML per 30 days)
metipranolol ophthalmic (eye) drops 0.3 % T2 MD
mometasone nasal spray,non-aerosol 50
mcg/actuation T4 MD
naphazoline ophthalmic (eye) drops 0.1 % T2
NEVANAC OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.1 % T3
olopatadine nasal spray,non-aerosol 0.6 % T4
PHOSPHOLINE IODIDE OPHTHALMIC
(EYE) DROPS 0.125 % T3 MD
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,
4 % T3 MD
prednisolone acetate ophthalmic (eye)
drops,suspension 1 % T2
prednisolone sodium phosphate ophthalmic (eye)
drops 1 % T2
proparacaine ophthalmic (eye) drops 0.5 % T3
RESTASIS OPHTHALMIC (EYE)
DROPPERETTE 0.05 % T3 MD; QL (60 EA per 30 days)
SIMBRINZA OPHTHALMIC (EYE)
DROPS,SUSPENSION 1-0.2 % T3 MD
timolol maleate ophthalmic (eye) drops 0.25 %,
0.5 % T2 MD
TRAVATAN Z OPHTHALMIC (EYE) DROPS
0.004 % T3 MD; QL (5 ML per 30 days)
tropicamide ophthalmic (eye) drops 0.5 %, 1 % T3
TYZINE NASAL DROPS 0.05 % T3
VERAMYST NASAL SPRAY,SUSPENSION
27.5 MCG/ACTUATION T3 QL (10 GM per 30 days)
VEXOL OPHTHALMIC (EYE)
DROPS,SUSPENSION 1 % T4
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 71
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Drug Name Tier Notes
ZIOPTAN (PF) OPHTHALMIC (EYE)
DROPPERETTE 0.0015 % T4 MD
ELECT/CALORIC/H2O
calcium acetate oral capsule 667 mg T2 MD
CYTRA-2 ORAL SOLUTION 500-334 MG/5
ML T2
CYTRA-3 ORAL SOLUTION 550-500-334
MG/5 ML T4
DENTA 5000 PLUS DENTAL CREAM 1.1 % T2 MD
DENTAGEL DENTAL GEL 1.1 % T2 MD
fluoride (sodium) dental solution 0.2 % T2
fluoride (sodium) oral drops 0.5 mg (1.1 mg
sod.fluorid)/ml NCS MD
fluoride (sodium) oral tablet 1 mg (2.2 mg sod.
fluoride) NCS
fluoride (sodium) oral tablet,chewable 0.25
mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium
fluorid), 1 mg (2.2 mg sod. fluoride)
NCS MD
FLUORITAB ORAL TABLET,CHEWABLE 0.5
MG (1.1 MG SODIUM FLUORID), 1 MG (2.2
MG SOD. FLUORIDE)
NCS MD
FOSRENOL ORAL TABLET,CHEWABLE
1,000 MG, 500 MG, 750 MG T3 ST; MD
GLUCAGEN HYPOKIT INJECTION RECON
SOLN 1 MG T3 QL (4 EA per 30 days)
GLUCAGEN INJECTION RECON SOLN 1 MG T3 QL (4 EA per 30 days)
GLUCAGON EMERGENCY KIT (HUMAN)
INJECTION RECON SOLN 1 MG T3
ISOLYTE S PH 7.4 INTRAVENOUS
PARENTERAL SOLUTION T2
KALEXATE ORAL POWDER IN PACKET 15
GRAM T3
KIONEX (WITH SORBITOL) ORAL
SUSPENSION 15-19.3 GRAM/60 ML T2
KIONEX ORAL POWDER T3
KLOR-CON 10 ORAL TABLET EXTENDED
RELEASE 10 MEQ T2 MD
KLOR-CON 8 ORAL TABLET EXTENDED
RELEASE 8 MEQ T2 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 72
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Drug Name Tier Notes
KLOR-CON M10 ORAL TABLET,ER
PARTICLES/CRYSTALS 10 MEQ T2 MD
KLOR-CON M15 ORAL TABLET,ER
PARTICLES/CRYSTALS 15 MEQ T2 MD
KLOR-CON M20 ORAL TABLET,ER
PARTICLES/CRYSTALS 20 MEQ T2 MD
KLOR-CON ORAL PACKET 20 MEQ T2 MD
KLOR-CON SPRINKLE ORAL CAPSULE,
EXTENDED RELEASE 10 MEQ T2
KLOR-CON SPRINKLE ORAL CAPSULE,
EXTENDED RELEASE 8 MEQ T2 MD
KLOR-CON/25 ORAL PACKET 25 MEQ T2
LUDENT FLUORIDE ORAL
TABLET,CHEWABLE 0.25 MG(0.55 MG SOD.
FLUORIDE), 0.5 MG (1.1 MG SODIUM
FLUORID), 1 MG (2.2 MG SOD. FLUORIDE)
NCS MD
NORMAL SALINE FLUSH INJECTION
SYRINGE T2
phospha 250 neutral oral tablet 250 mg T2
potassium chloride oral capsule, extended release
10 meq, 8 meq T2 MD
potassium chloride oral liquid 20 meq/15 ml, 40
meq/15 ml T2 MD
potassium chloride oral packet 20 meq T2 MD
potassium chloride oral tablet extended release
10 meq, 20 meq, 8 meq T2 MD
potassium chloride oral tablet,er
particles/crystals 10 meq, 20 meq T2 MD
potassium citrate oral tablet extended release 10
meq (1,080 mg), 15 meq, 5 meq (540 mg) T3 MD
PREVIDENT 5000 BOOSTER PLUS DENTAL
PASTE 1.1 % T4 MD
PREVIDENT 5000 DRY MOUTH DENTAL
GEL 1.1 % T4 MD
PREVIDENT 5000 ENAMEL PROTECT
DENTAL PASTE 1.1-5 % T4 MD
PREVIDENT 5000 PLUS DENTAL CREAM 1.1
% T4 MD
PREVIDENT 5000 SENSITIVE DENTAL
PASTE 1.1-5 % T4 MD
PREVIDENT DENTAL GEL 1.1 % T4 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 73
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Drug Name Tier Notes
PREVIDENT DENTAL SOLUTION 0.2 % T4 MD
PROGLYCEM ORAL SUSPENSION 50
MG/ML T4 MD
RENAGEL ORAL TABLET 400 MG T3 ST
RENAGEL ORAL TABLET 800 MG T3 ST; MD
RENVELA ORAL POWDER IN PACKET 0.8
GRAM, 2.4 GRAM T5 (SP) ST; MD
RENVELA ORAL TABLET 800 MG T5 (SP) ST; MD
SF 5000 PLUS DENTAL CREAM 1.1 % T2 MD
SF DENTAL GEL 1.1 % T2 MD
sodium chloride 0.9 % injection solution T2
sodium chloride 0.9 % injection syringe T2
sodium chloride 0.9 % intravenous parenteral
solution T2
SODIUM POLYSTYRENE (SORB FREE)
ORAL SUSPENSION 15 GRAM/60 ML T3
sodium polystyrene sulfonate oral powder T3
sodium polystyrene sulfonate oral suspension 15
gram/60 ml T2
SPS (WITH SORBITOL) ORAL SUSPENSION
15-20 GRAM/60 ML T2
TRICITRATES ORAL SOLUTION 550-500-334
MG/5 ML T4
GASTROINTESTINAL
ALOPHEN ORAL TABLET,DELAYED
RELEASE (DR/EC) 5 MG NCS
alosetron oral tablet 0.5 mg, 1 mg T5 (SP) PA; QL (60 EA per 30 days)
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG T3 MD; QL (60 EA per 30 days)
ANALPRAM ADVANCED KIT 2.5 %-1 %/ 630
MG/1 %-1 % T4 QL (4 EA per 30 days)
ANUCORT-HC RECTAL SUPPOSITORY 25
MG T3
ANZEMET ORAL TABLET 100 MG, 50 MG T5 (SP) PA
aprepitant oral capsule 125 mg, 40 mg, 80 mg T4 QL (60 EA per 30 days)
aprepitant oral capsule,dose pack 125 mg (1)- 80
mg (2) T4 QL (60 EA per 30 days)
APRISO ORAL CAPSULE,EXTENDED
RELEASE 24HR 0.375 GRAM T3 MD; QL (120 EA per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 74
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Drug Name Tier Notes
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml T4
balsalazide oral capsule 750 mg T3
bisacodyl oral tablet,delayed release (dr/ec) 5 mg NCS
BISA-LAX ORAL TABLET,DELAYED
RELEASE (DR/EC) 5 MG NCS
BUPHENYL ORAL TABLET 500 MG T5 (SP) PA; MD
CANASA RECTAL SUPPOSITORY 1,000 MG T5 (SP) MD
CANTIL ORAL TABLET 25 MG T4
CARAFATE ORAL SUSPENSION 100 MG/ML T4 MD
CESAMET ORAL CAPSULE 1 MG T5 (SP) PA
chlordiazepoxide-clidinium oral capsule 5-2.5 mg T3
cimetidine hcl oral solution 300 mg/5 ml T2 MD
cimetidine oral tablet 200 mg, 300 mg, 400 mg,
800 mg T2 MD
CITRATE OF MAGNESIA ORAL SOLUTION NCS
CITROMA ORAL SOLUTION NCS
CLEARLAX ORAL POWDER 17
GRAM/DOSE NCS
CLENPIQ ORAL SOLUTION 10 MG-3.5
GRAM -12 GRAM/160 ML T3
COMPRO RECTAL SUPPOSITORY 25 MG T4
CONSTULOSE ORAL SOLUTION 10
GRAM/15 ML T2 MD
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 -60,000
UNIT, 24,000-76,000 -120,000 UNIT, 3,000-
9,500- 15,000 UNIT, 36,000-114,000- 180,000
UNIT, 6,000-19,000 -30,000 UNIT
T3 MD
dicyclomine oral capsule 10 mg T1 MD
dicyclomine oral solution 10 mg/5 ml T2
dicyclomine oral tablet 20 mg T1 MD
DIPENTUM ORAL CAPSULE 250 MG T5 (SP) MD
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5
ml T2
diphenoxylate-atropine oral tablet 2.5-0.025 mg T2
DONNATAL ORAL TABLET 16.2-0.1037 -
0.0194 MG T4
dronabinol oral capsule 10 mg T5 (SP) PA
dronabinol oral capsule 2.5 mg, 5 mg T4 PA
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 75
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Drug Name Tier Notes
DUCODYL ORAL TABLET,DELAYED
RELEASE (DR/EC) 5 MG NCS
EMEND ORAL CAPSULE 125 MG, 40 MG, 80
MG T4 PA; QL (60 EA per 30 days)
EMEND ORAL CAPSULE,DOSE PACK 125
MG (1)- 80 MG (2) T4 PA; QL (60 EA per 30 days)
ENULOSE ORAL SOLUTION 10 GRAM/15
ML T2 MD
famotidine oral suspension 40 mg/5 ml (8 mg/ml) T3 MD
famotidine oral tablet 10 mg, 20 mg, 40 mg T2 MD
FLEET LAXATIVE ORAL
TABLET,DELAYED RELEASE (DR/EC) 5 MG NCS
GAVILAX ORAL POWDER 17 GRAM/DOSE NCS
GAVILYTE-C ORAL RECON SOLN 240-
22.72-6.72 -5.84 GRAM NCS
GAVILYTE-G ORAL RECON SOLN 236-
22.74-6.74 -5.86 GRAM NCS
GAVILYTE-H AND BISACODYL ORAL KIT
5-210 MG-GRAM NCS
GAVILYTE-N ORAL RECON SOLN 420
GRAM NCS
GENERLAC ORAL SOLUTION 10 GRAM/15
ML T2 MD
GENTLE LAXATIVE ORAL
TABLET,DELAYED RELEASE (DR/EC) 5 MG NCS
GENTLELAX ORAL POWDER 17
GRAM/DOSE NCS
GLYCOLAX ORAL POWDER 17
GRAM/DOSE NCS
glycopyrrolate oral tablet 1 mg, 2 mg T2 MD
granisetron hcl oral tablet 1 mg T3
HEALTHYLAX ORAL POWDER IN PACKET
17 GRAM NCS
hydrocortisone acetate rectal suppository 25 mg,
30 mg T3
hydrocortisone-pramoxine rectal cream 1-1 %,
2.5-1 % T3
hyoscyamine sulfate oral drops 0.125 mg/ml T2 MD
hyoscyamine sulfate oral elixir 0.125 mg/5 ml T2 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 76
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Drug Name Tier Notes
hyoscyamine sulfate oral tablet 0.125 mg T2 MD
hyoscyamine sulfate oral tablet extended release
12 hr 0.375 mg T2 MD
hyoscyamine sulfate oral tablet,disintegrating
0.125 mg T2 MD
hyoscyamine sulfate sublingual tablet 0.125 mg T2 MD
HYOSYNE ORAL DROPS 0.125 MG/ML T2 MD
KEPIVANCE INTRAVENOUS RECON SOLN
6.25 MG T5 (SP)
KRISTALOSE ORAL PACKET 10 GRAM, 20
GRAM T3 MD
lactulose oral solution 10 gram/15 ml, 10
gram/15 ml (15 ml), 20 gram/30 ml T2 MD
lansoprazole oral capsule,delayed release(dr/ec)
15 mg, 30 mg T2 MD; QL (30 EA per 30 days)
LAXACLEAR ORAL POWDER 17
GRAM/DOSE NCS
LAXATIVE (BISACODYL) ORAL TABLET 5
MG NCS
LAXATIVE (BISACODYL) ORAL
TABLET,DELAYED RELEASE (DR/EC) 5 MG NCS
LAXATIVE FEMININE ORAL TABLET 5 MG NCS
LAXATIVE PEG 3350 ORAL POWDER 17
GRAM/DOSE NCS
LIALDA ORAL TABLET,DELAYED
RELEASE (DR/EC) 1.2 GRAM T3 MD; QL (120 EA per 30 days)
lidocaine hcl-hydrocortison ac rectal cream 3-0.5
% T2
lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %,
3-1 % (7 gram) T4 QL (4 EA per 30 days)
lidocaine-hydrocortisone-aloe rectal gel 2.8-0.55
% T2
lidocaine-hydrocortisone-aloe rectal kit 2-2 %, 3-
2.5 % (7 gram) T4 QL (4 EA per 30 days)
LINZESS ORAL CAPSULE 145 MCG, 290
MCG T3 MD
LINZESS ORAL CAPSULE 72 MCG T3 MD; QL (30 EA per 30 days)
loperamide oral capsule 2 mg T2 MD
magnesium citrate oral solution NCS
meclizine oral tablet 12.5 mg, 25 mg T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 77
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Drug Name Tier Notes
mesalamine rectal enema 4 gram/60 ml T4 MD
mesalamine with cleansing wipe rectal enema kit
4 gram/60 ml T4
methscopolamine oral tablet 2.5 mg, 5 mg T2
metoclopramide hcl oral solution 5 mg/5 ml T2
metoclopramide hcl oral tablet 10 mg, 5 mg T2
MILK OF MAGNESIA CONCENTRATED
ORAL SUSPENSION 2,400 MG/10 ML NCS
MILK OF MAGNESIA ORAL SUSPENSION
400 MG/5 ML NCS
MIRALAX ORAL POWDER IN PACKET 17
GRAM NCS
misoprostol oral tablet 100 mcg, 200 mcg T2 MD
MOTOFEN ORAL TABLET 1-0.025 MG T4
MOVIPREP ORAL POWDER IN PACKET 100-
7.5-2.691 GRAM T4
nizatidine oral capsule 150 mg, 300 mg T2 MD
nizatidine oral solution 150 mg/10 ml T2 MD
omega-3 acid ethyl esters oral capsule 1 gram T3 MD
omeprazole oral capsule,delayed release(dr/ec)
10 mg, 20 mg, 40 mg T2 MD
omeprazole oral tablet,delayed release (dr/ec) 20
mg T2 MD
ondansetron hcl oral solution 4 mg/5 ml T2
ondansetron hcl oral tablet 24 mg T2 QL (30 EA per 30 days)
ondansetron hcl oral tablet 4 mg, 8 mg T2 QL (60 EA per 30 days)
ondansetron oral tablet,disintegrating 4 mg, 8 mg T3
ORAL SALINE LAXATIVE ORAL LIQUID
7.2-2.7 GRAM/15 ML NCS
ORAL SALINE LAXATIVE ORAL SOLUTION NCS
OSCIMIN SR ORAL TABLET EXTENDED
RELEASE 12 HR 0.375 MG T2 MD
OSMOPREP ORAL TABLET 1.5 GRAM T4
pantoprazole oral tablet,delayed release (dr/ec)
20 mg, 40 mg T2 MD; QL (60 EA per 30 days)
peg 3350-electrolytes oral recon soln 236-22.74-
6.74 -5.86 gram, 240-22.72-6.72 -5.84 gram NCS
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 78
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Drug Name Tier Notes
PEG-3350 WITH FLAVOR PACKS ORAL
RECON SOLN 420 GRAM NCS
peg-electrolyte soln oral recon soln 420 gram NCS
PEG-PREP ORAL KIT 5-210 MG-GRAM NCS
PHENADOZ RECTAL SUPPOSITORY 12.5
MG, 25 MG T3
PHENERGAN RECTAL SUPPOSITORY 12.5
MG, 25 MG, 50 MG T3
PHOSPHATE LAXATIVE ORAL LIQUID 7.2-
2.7 GRAM/15 ML NCS
polyethylene glycol 3350 oral powder 17
gram/dose NCS
polyethylene glycol 3350 oral powder in packet
17 gram NCS
POWDERLAX ORAL POWDER 17
GRAM/DOSE NCS
PREPARATION CLEANSING ORAL LIQUID
7.2-2.7 GRAM/15 ML NCS
prochlorperazine edisylate injection solution 10
mg/2 ml (5 mg/ml) T4
prochlorperazine maleate oral tablet 10 mg, 5 mg T2
prochlorperazine rectal suppository 25 mg T4
PROCORT RECTAL CREAM 1.85-1.15 % T3
PROCTOFOAM HC RECTAL FOAM 1-1 % T4
PROCTOSOL HC RECTAL CREAM WITH
APPLICATOR 2.5 % T2
promethazine rectal suppository 12.5 mg, 25 mg,
50 mg T3
PROMETHEGAN RECTAL SUPPOSITORY
12.5 MG, 25 MG, 50 MG T3
propantheline oral tablet 15 mg T3
PURELAX ORAL POWDER 17 GRAM/DOSE NCS
PURELAX ORAL POWDER IN PACKET 17
GRAM NCS
rabeprazole oral tablet,delayed release (dr/ec) 20
mg T4 MD; QL (30 EA per 30 days)
ranitidine hcl oral syrup 15 mg/ml T2 MD
ranitidine hcl oral tablet 150 mg, 300 mg, 75 mg T2 MD
RECTIV RECTAL OINTMENT 0.4 % (W/W) T4
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 79
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Drug Name Tier Notes
scopolamine base transdermal patch 3 day 1 mg
over 3 days T4
SMOOTHLAX ORAL POWDER 17
GRAM/DOSE NCS
SMOOTHLAX ORAL POWDER IN PACKET
17 GRAM NCS
sodium phenylbutyrate oral tablet 500 mg T5 (SP) PA; MD
sucralfate oral suspension 100 mg/ml T3 MD
sucralfate oral tablet 1 gram T2 MD
sulfasalazine oral tablet 500 mg T2 MD
SULFAZINE ORAL TABLET 500 MG T2
SUPREP BOWEL PREP KIT ORAL RECON
SOLN 17.5-3.13-1.6 GRAM T3
TIGAN INTRAMUSCULAR SOLUTION 100
MG/ML T4 PA
TRILYTE WITH FLAVOR PACKETS ORAL
RECON SOLN 420 GRAM NCS
trimethobenzamide oral capsule 300 mg T2
ursodiol oral capsule 300 mg T4 MD
ursodiol oral tablet 250 mg, 500 mg T4 MD
VASCEPA ORAL CAPSULE 1 GRAM T3 MD
WOMAN'S LAXATIVE ORAL TABLET 5 MG NCS
WOMAN'S LAXATIVE ORAL
TABLET,DELAYED RELEASE (DR/EC) 5 MG NCS
WOMEN'S GENTLE LAXATIVE(BISAC)
ORAL TABLET,DELAYED RELEASE
(DR/EC) 5 MG
NCS
WOMEN'S LAXATIVE (BISACODYL) ORAL
TABLET 5 MG NCS
WOMEN'S LAXATIVE (BISACODYL) ORAL
TABLET,DELAYED RELEASE (DR/EC) 5 MG NCS
HORMONES
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25
GRAM (1.62 %)
T3 PA; MD; QL (150 GM per 30
days)
ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62
% (40.5 MG/2.5 GRAM)
T3 PA; MD; QL (60 GM per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 80
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Drug Name Tier Notes
budesonide oral capsule,delayed,extend.release 3
mg T5 (SP)
budesonide oral tablet,delayed and ext.release 9
mg T4 QL (30 EA per 30 days)
cabergoline oral tablet 0.5 mg T3 MD; QL (16 EA per 28 days)
calcitonin (salmon) nasal spray,non-aerosol 200
unit/actuation T3 MD; QL (3.7 ML per 30 days)
CLIMARA PRO TRANSDERMAL PATCH
WEEKLY 0.045-0.015 MG/24 HR T4 MD
COMBIPATCH TRANSDERMAL PATCH
SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25
MG/24 HR
T3 MD
cortisone oral tablet 25 mg T2
danazol oral capsule 100 mg, 200 mg, 50 mg T4
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5
MG/ML T3
desmopressin nasal spray with pump 10
mcg/spray (0.1 ml) T3 MD
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 ml) T3 MD
desmopressin oral tablet 0.1 mg, 0.2 mg T3 MD
dexamethasone oral solution 0.5 mg/5 ml T3
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg,
1.5 mg, 2 mg, 4 mg, 6 mg T2
dexamethasone sodium phosphate injection
solution 10 mg/ml, 4 mg/ml T2
dexamethasone sodium phosphate injection
syringe 4 mg/ml T3
DIVIGEL TRANSDERMAL GEL IN PACKET
0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5
GRAM (0.1 %), 1 MG/GRAM (0.1 %)
T4 MD
DUAVEE ORAL TABLET 0.45-20 MG T3 MD
ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25 MG T3
ESTRACE VAGINAL CREAM 0.01 % (0.1
MG/GRAM) T3 MD
estradiol oral tablet 0.5 mg, 1 mg, 2 mg T2 MD
estradiol transdermal patch semiweekly 0.025
mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24 hr
T4 MD; QL (8 EA per 28 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 81
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Drug Name Tier Notes
estradiol transdermal patch weekly 0.025 mg/24
hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24
hr, 0.075 mg/24 hr, 0.1 mg/24 hr
T3 MD; QL (4 EA per 28 days)
estradiol vaginal tablet 10 mcg T3 MD
estradiol-norethindrone acet oral tablet 0.5-0.1
mg, 1-0.5 mg T2 MD
ESTROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 1.25
GRAM/ACTUATION
T4 MD
estrogens-methyltestosterone oral tablet 0.625-
1.25 mg, 1.25-2.5 mg T3 MD
estropipate oral tablet 0.75 mg T2 MD
estropipate oral tablet 1.5 mg, 3 mg T2
fludrocortisone oral tablet 0.1 mg T2 MD
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg T2 MD
hydrocortisone rectal enema 100 mg/60 ml T4
INCRELEX SUBCUTANEOUS SOLUTION 10
MG/ML T5 (SP) PA
JINTELI ORAL TABLET 1-5 MG-MCG T3 MD
LOPREEZA ORAL TABLET 0.5-0.1 MG, 1-0.5
MG T3 MD
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 11.25 MG T5 (SP) PA; QL (1 EA per 84 days)
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 3.75 MG T5 (SP) PA; QL (1 EA per 28 days)
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 11.25 MG,
30 MG
T5 (SP) PA; QL (1 EA per 84 days)
LUPRON DEPOT-PED INTRAMUSCULAR
KIT 11.25 MG, 15 MG, 7.5 MG (PED) T5 (SP) PA; QL (1 EA per 28 days)
medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5
mg T2 MD
MENEST ORAL TABLET 0.3 MG, 0.625 MG,
1.25 MG, 2.5 MG T4 PA; MD
methylergonovine oral tablet 0.2 mg T3
methylprednisolone acetate injection suspension
40 mg/ml, 80 mg/ml T2
methylprednisolone oral tablet 16 mg, 32 mg, 4
mg, 8 mg T2
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 82
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Drug Name Tier Notes
methylprednisolone oral tablets,dose pack 4 mg T2
MILLIPRED DP ORAL TABLETS,DOSE
PACK 5 MG (21 TABS) T3
MIMVEY LO ORAL TABLET 0.5-0.1 MG T3 MD
MIMVEY ORAL TABLET 1-0.5 MG T3 MD
norethindrone acetate oral tablet 5 mg T2 MD
norethindrone ac-eth estradiol oral tablet 0.5-2.5
mg-mcg, 1-5 mg-mcg T3 MD
octreotide acetate injection solution 1,000
mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500
mcg/ml
T5 (SP) PA; MD
OMNITROPE SUBCUTANEOUS CARTRIDGE
10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
T5 (SP) PA; MD
OMNITROPE SUBCUTANEOUS RECON
SOLN 5.8 MG T5 (SP) PA; MD
oxandrolone oral tablet 10 mg T5 (SP) PA; MD; QL (120 EA per 30 days)
oxandrolone oral tablet 2.5 mg T5 (SP) PA; MD; QL (60 EA per 30 days)
prednisolone oral solution 15 mg/5 ml T2
prednisolone sodium phosphate oral solution 15
mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml
(5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
T2
prednisolone sodium phosphate oral
tablet,disintegrating 10 mg, 15 mg, 30 mg T4
PREDNISONE INTENSOL ORAL
CONCENTRATE 5 MG/ML T2
prednisone oral solution 5 mg/5 ml T2
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20
mg, 5 mg, 50 mg T1
prednisone oral tablets,dose pack 10 mg, 5 mg T2
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25 MG T3 MD
PREMARIN VAGINAL CREAM 0.625
MG/GRAM T3 MD
PREMPHASE ORAL TABLET 0.625 MG (14)/
0.625MG-5MG(14) T3 MD
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-
1.5 MG, 0.625-2.5 MG, 0.625-5 MG T3 MD
progesterone intramuscular oil 50 mg/ml T2
progesterone micronized oral capsule 100 mg,
200 mg T2 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 83
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Drug Name Tier Notes
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON 10
MG, 20 MG, 30 MG
T5 (SP) PA; MD
SIGNIFOR LAR INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 10
MG, 20 MG, 30 MG, 40 MG, 60 MG
T5 (SP) PA; MD
SOMATULINE DEPOT SUBCUTANEOUS
SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
T5 (SP) PA; MD
SYNAREL NASAL SPRAY,NON-AEROSOL 2
MG/ML T5 (SP)
testosterone cypionate intramuscular oil 100
mg/ml T3 MD; QL (10 ML per 28 days)
testosterone cypionate intramuscular oil 200
mg/ml T3 MD; QL (4 ML per 28 days)
testosterone enanthate intramuscular oil 200
mg/ml T3 QL (5 ML per 28 days)
testosterone transdermal gel 50 mg/5 gram (1 %) T3 MD; QL (60 GM per 30 days)
testosterone transdermal gel in metered-dose
pump 12.5 mg/ 1.25 gram (1 %) T3 MD; QL (75 GM per 30 days)
testosterone transdermal gel in packet 1 % (25
mg/2.5gram) T3 MD; QL (150 GM per 30 days)
testosterone transdermal gel in packet 1 % (50
mg/5 gram) T3 MD; QL (60 GM per 30 days)
triamcinolone acetonide injection suspension 40
mg/ml T4
TYMLOS SUBCUTANEOUS PEN INJECTOR
80 MCG (3,120 MCG/1.56 ML) T5 (SP) PA; MD
VAGIFEM VAGINAL TABLET 10 MCG T3 MD
IMMUNOSUPPRESSANTS
azathioprine oral tablet 50 mg T2 MD
cyclosporine modified oral capsule 100 mg, 25
mg, 50 mg T3 MD
cyclosporine modified oral solution 100 mg/ml T3 MD
cyclosporine oral capsule 100 mg, 25 mg T3 MD
ELIDEL TOPICAL CREAM 1 % T4
GENGRAF ORAL CAPSULE 100 MG, 25 MG T3 MD
GENGRAF ORAL CAPSULE 50 MG T3
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 84
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Drug Name Tier Notes
GENGRAF ORAL SOLUTION 100 MG/ML T3 MD
mycophenolate mofetil oral capsule 250 mg T3 MD
mycophenolate mofetil oral suspension for
reconstitution 200 mg/ml T4 MD
mycophenolate mofetil oral tablet 500 mg T3 MD
mycophenolate sodium oral tablet,delayed release
(dr/ec) 180 mg, 360 mg T4 MD
NULOJIX INTRAVENOUS RECON SOLN 250
MG T5 (SP) PA; MD
PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5
MG T4 MD
RAPAMUNE ORAL SOLUTION 1 MG/ML T5 (SP) MD
sirolimus oral tablet 0.5 mg, 1 mg, 2 mg T4 MD
tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg T3 MD
tacrolimus topical ointment 0.03 %, 0.1 % T4 PA
ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG,
0.75 MG T5 (SP) PA; MD
MISCELLANEOUS MEDICAL
SUPPLIES, DEVICES, NON-DRUG
ASSURE ID INSULIN SAFETY SYRINGE 1
ML 29 GAUGE X 1/2" T3 MD; QL (200 EA per 30 days)
BD LANCET DEVICE T3
CURITY GAUZE TOPICAL BANDAGE 2 X 2 " T3
FREESTYLE FREEDOM LITE KIT T3 MD
FREESTYLE INSULINX T3 MD
FREESTYLE LANCETS 28 GAUGE T3 MD; QL (200 EA per 30 days)
FREESTYLE LITE METER KIT T3 MD
insulin syringe-needle u-100 syringe 0.3 ml 29
gauge, 1 ml 29 gauge x 1/2", 1/2 ml 28 gauge T3 MD; QL (200 EA per 30 days)
lancets T3 MD; QL (200 EA per 30 days)
PEN NEEDLE NEEDLE 31 GAUGE X 5/16" T3 MD; QL (200 EA per 30 days)
PENTIPS NEEDLE 31 GAUGE X 5/16" T3 MD; QL (200 EA per 30 days)
PRECISION XTRA MONITOR T3 MD
MUSCLE RELAXANTS
baclofen oral tablet 10 mg, 20 mg T2 MD
carisoprodol oral tablet 350 mg T2 QL (30 EA per 30 days)
chlorzoxazone oral tablet 500 mg T2 QL (120 EA per 30 days)
cyclobenzaprine oral tablet 10 mg, 5 mg T2 QL (90 EA per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 85
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Drug Name Tier Notes
dantrolene oral capsule 100 mg, 25 mg, 50 mg T3 MD
metaxalone oral tablet 800 mg T4 QL (120 EA per 30 days)
methocarbamol oral tablet 500 mg, 750 mg T2
orphenadrine citrate oral tablet extended release
100 mg T2 QL (60 EA per 30 days)
tizanidine oral tablet 2 mg, 4 mg T2 MD
PRE-NATAL VITAMINS
PNV 29-1 ORAL TABLET 29 MG IRON- 1 MG T3 MD
PRENATABS FA ORAL TABLET 29-1 MG T2 MD
PRENATABS RX ORAL TABLET 29 MG
IRON- 1 MG T4 MD
PRETAB ORAL TABLET 29-1 MG T2 MD
VITAFOL-OB+DHA ORAL COMBO PACK 65-
1-250 MG T3 MD
PSYCHOTHERAPEUTIC DRUGS
alprazolam oral tablet 0.25 mg, 0.5 mg T2 QL (120 EA per 30 days)
alprazolam oral tablet 1 mg T2 QL (240 EA per 30 days)
alprazolam oral tablet 2 mg T2 QL (150 EA per 30 days)
alprazolam oral tablet extended release 24 hr 0.5
mg T3 QL (90 EA per 30 days)
alprazolam oral tablet extended release 24 hr 1
mg, 2 mg, 3 mg T3 QL (60 EA per 30 days)
amitriptyline oral tablet 10 mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg T2 MD
amitriptyline-chlordiazepoxide oral tablet 12.5-5
mg, 25-10 mg T2 MD
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50
mg T2 MD
aripiprazole oral solution 1 mg/ml T4 MD
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20
mg, 30 mg, 5 mg T4 MD; QL (30 EA per 30 days)
aripiprazole oral tablet,disintegrating 10 mg, 15
mg T4 MD; QL (60 EA per 30 days)
armodafinil oral tablet 150 mg, 200 mg, 250 mg,
50 mg T4 PA; MD; QL (30 EA per 30 days)
BRINTELLIX ORAL TABLET 10 MG, 20 MG,
5 MG T3 QL (30 EA per 30 days)
bupropion hcl oral tablet 100 mg, 75 mg T2 MD
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Drug Name Tier Notes
bupropion hcl oral tablet extended release 24 hr
150 mg T2 MD; QL (90 EA per 30 days)
bupropion hcl oral tablet extended release 24 hr
300 mg T2 MD; QL (30 EA per 30 days)
bupropion hcl oral tablet sustained-release 12 hr
100 mg, 200 mg T2 MD; QL (60 EA per 30 days)
bupropion hcl oral tablet sustained-release 12 hr
150 mg T2 MD; QL (90 EA per 30 days)
buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg,
7.5 mg T2 MD
chlordiazepoxide hcl oral capsule 10 mg, 25 mg,
5 mg T2
chlorpromazine oral tablet 10 mg, 100 mg, 200
mg, 25 mg, 50 mg T3 MD
citalopram oral solution 10 mg/5 ml T2 MD; QL (600 ML per 30 days)
citalopram oral tablet 10 mg, 40 mg T1 MD; QL (30 EA per 30 days)
citalopram oral tablet 20 mg T1 MD; QL (60 EA per 30 days)
clomipramine oral capsule 25 mg, 50 mg, 75 mg T4 MD
clorazepate dipotassium oral tablet 15 mg T2 QL (180 EA per 30 days)
clorazepate dipotassium oral tablet 3.75 mg, 7.5
mg T2 QL (90 EA per 30 days)
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50
mg T2 MD
clozapine oral tablet,disintegrating 100 mg, 12.5
mg, 150 mg, 200 mg, 25 mg T4 PA; MD
DAYTRANA TRANSDERMAL PATCH 24
HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9
HR, 30 MG/9 HR
T4 MD; QL (30 EA per 30 days)
desipramine oral tablet 10 mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg T2 MD
desvenlafaxine oral tablet extended release 24 hr
100 mg, 50 mg T4 MD
desvenlafaxine oral tablet extended release 24hr
100 mg, 50 mg T4 MD
desvenlafaxine succinate oral tablet extended
release 24 hr 100 mg, 25 mg, 50 mg T4 MD
dexmethylphenidate oral capsule,er biphasic 50-
50 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg T3 MD; QL (30 EA per 30 days)
dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5
mg T3 MD; QL (60 EA per 30 days)
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Drug Name Tier Notes
DIAZEPAM INTENSOL ORAL
CONCENTRATE 5 MG/ML T4 PA
diazepam oral concentrate 5 mg/ml T4 PA
diazepam oral solution 5 mg/5 ml (1 mg/ml) T4
diazepam oral tablet 10 mg T2 QL (120 EA per 30 days)
diazepam oral tablet 2 mg, 5 mg T2 QL (90 EA per 30 days)
doxepin oral capsule 10 mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg T2 MD
doxepin oral concentrate 10 mg/ml T2 MD
duloxetine oral capsule,delayed release(dr/ec) 20
mg, 40 mg, 60 mg T3 MD; QL (60 EA per 30 days)
duloxetine oral capsule,delayed release(dr/ec) 30
mg T3 MD; QL (90 EA per 30 days)
EMSAM TRANSDERMAL PATCH 24 HOUR
12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR T5 (SP) PA; MD; QL (30 EA per 30 days)
escitalopram oxalate oral solution 5 mg/5 ml T3 MD; QL (600 ML per 30 days)
escitalopram oxalate oral tablet 10 mg, 20 mg, 5
mg T2 MD; QL (30 EA per 30 days)
FANAPT ORAL TABLET 1 MG, 10 MG, 12
MG, 2 MG, 4 MG, 6 MG, 8 MG T4 PA; MD; QL (60 EA per 30 days)
FANAPT ORAL TABLETS,DOSE PACK
1MG(2)-2MG(2)- 4MG(2)-6MG(2) T4 PA; QL (8 EA per 28 days)
fluoxetine oral capsule 10 mg, 20 mg T2 MD; QL (90 EA per 30 days)
fluoxetine oral capsule 40 mg T2 MD; QL (60 EA per 30 days)
fluoxetine oral solution 20 mg/5 ml (4 mg/ml) T2 MD; QL (600 ML per 30 days)
fluoxetine oral tablet 10 mg T3 MD; QL (240 EA per 30 days)
fluoxetine oral tablet 20 mg T3 MD; QL (120 EA per 30 days)
fluphenazine hcl oral concentrate 5 mg/ml T3
fluphenazine hcl oral elixir 2.5 mg/5 ml T3 MD
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg,
5 mg T2 MD
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg T2 MD; QL (90 EA per 30 days)
FOCALIN XR ORAL CAPSULE,ER BIPHASIC
50-50 25 MG, 35 MG T4 MD; QL (30 EA per 30 days)
guanfacine oral tablet extended release 24 hr 1
mg, 2 mg, 3 mg, 4 mg T3 MD; QL (30 EA per 30 days)
haloperidol decanoate intramuscular solution 100
mg/ml, 50 mg/ml T2 MD
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Drug Name Tier Notes
haloperidol lactate injection solution 5 mg/ml T2
haloperidol lactate oral concentrate 2 mg/ml T2 MD
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2
mg, 20 mg, 5 mg T2 MD
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg T2 MD
imipramine pamoate oral capsule 100 mg, 125
mg, 150 mg, 75 mg T4 MD
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234
MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML
T5 (SP) PA; MD
LATUDA ORAL TABLET 120 MG, 20 MG, 40
MG, 60 MG T4 MD; QL (30 EA per 30 days)
LATUDA ORAL TABLET 80 MG T4 MD; QL (60 EA per 30 days)
lithium carbonate oral capsule 150 mg, 300 mg,
600 mg T1 MD
lithium carbonate oral tablet 300 mg T2 MD
lithium carbonate oral tablet extended release
300 mg, 450 mg T2 MD
lithium citrate oral solution 8 meq/5 ml T2 MD
lorazepam oral concentrate 2 mg/ml T2
lorazepam oral tablet 0.5 mg, 1 mg T2 QL (180 EA per 30 days)
lorazepam oral tablet 2 mg T2 QL (150 EA per 30 days)
loxapine succinate oral capsule 10 mg, 25 mg, 5
mg, 50 mg T2 MD
maprotiline oral tablet 25 mg, 50 mg, 75 mg T3 MD
MARPLAN ORAL TABLET 10 MG T4 MD
meprobamate oral tablet 200 mg, 400 mg T3
methylphenidate hcl oral capsule,er biphasic 50-
50 20 mg, 30 mg T3 MD; QL (60 EA per 30 days)
methylphenidate hcl oral capsule,er biphasic 50-
50 40 mg T3 MD; QL (30 EA per 30 days)
methylphenidate hcl oral solution 10 mg/5 ml, 5
mg/5 ml T2 MD
methylphenidate hcl oral tablet 10 mg, 20 mg, 5
mg T2 MD; QL (90 EA per 30 days)
methylphenidate hcl oral tablet extended release
10 mg T3 MD; QL (180 EA per 30 days)
methylphenidate hcl oral tablet extended release
20 mg T4 MD; QL (90 EA per 30 days)
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Drug Name Tier Notes
methylphenidate hcl oral tablet extended release
24hr 18 mg, 27 mg, 36 mg, 54 mg T3 MD; QL (30 EA per 30 days)
mirtazapine oral tablet 15 mg, 7.5 mg T2 MD; QL (90 EA per 30 days)
mirtazapine oral tablet 30 mg, 45 mg T2 MD; QL (30 EA per 30 days)
mirtazapine oral tablet,disintegrating 15 mg, 30
mg, 45 mg T2 MD; QL (30 EA per 30 days)
modafinil oral tablet 100 mg, 200 mg T4 PA; MD; QL (30 EA per 30 days)
nefazodone oral tablet 100 mg, 150 mg, 250 mg,
50 mg T2 MD; QL (60 EA per 30 days)
nefazodone oral tablet 200 mg T2 MD; QL (90 EA per 30 days)
nortriptyline oral capsule 10 mg, 25 mg, 50 mg,
75 mg T1 MD
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20
mg, 5 mg, 7.5 mg T2 MD; QL (30 EA per 30 days)
olanzapine oral tablet,disintegrating 10 mg, 15
mg, 20 mg, 5 mg T3 MD; QL (30 EA per 30 days)
olanzapine-fluoxetine oral capsule 12-25 mg, 12-
50 mg, 3-25 mg, 6-25 mg, 6-50 mg T4 MD
paliperidone oral tablet extended release 24hr 1.5
mg, 3 mg, 9 mg T5 (SP) PA; MD; QL (30 EA per 30 days)
paliperidone oral tablet extended release 24hr 6
mg T5 (SP) PA; MD; QL (60 EA per 30 days)
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg,
40 mg T2 MD; QL (90 EA per 30 days)
paroxetine hcl oral tablet extended release 24 hr
12.5 mg T3 MD; QL (30 EA per 30 days)
paroxetine hcl oral tablet extended release 24 hr
25 mg, 37.5 mg T3 MD; QL (60 EA per 30 days)
PAXIL ORAL SUSPENSION 10 MG/5 ML T4 MD; QL (900 ML per 30 days)
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg T2 MD
perphenazine-amitriptyline oral tablet 2-10 mg,
2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg T2 MD
PEXEVA ORAL TABLET 10 MG, 20 MG, 30
MG, 40 MG T4 MD
phenelzine oral tablet 15 mg T3 MD
pimozide oral tablet 1 mg, 2 mg T3 MD
PRISTIQ ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG, 25 MG, 50 MG T3 MD; QL (30 EA per 30 days)
protriptyline oral tablet 10 mg, 5 mg T3 MD
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Drug Name Tier Notes
quetiapine oral tablet 100 mg, 200 mg, 25 mg,
300 mg, 400 mg, 50 mg T2 MD; QL (90 EA per 30 days)
quetiapine oral tablet extended release 24 hr 150
mg, 200 mg, 300 mg, 400 mg, 50 mg T4 PA; MD
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5
MG/2 ML, 50 MG/2 ML
T4 PA; MD; QL (4 EA per 28 days)
risperidone oral solution 1 mg/ml T2 MD
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg T2 MD; QL (120 EA per 30 days)
risperidone oral tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg, 4 mg T3 MD; QL (120 EA per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 10 MG, 5 MG T4 PA
SAPHRIS SUBLINGUAL TABLET 10 MG, 2.5
MG, 5 MG T4 PA; MD
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 150 MG, 200 MG, 300 MG,
400 MG, 50 MG
T4 PA; MD
sertraline oral concentrate 20 mg/ml T2 MD; QL (300 ML per 30 days)
sertraline oral tablet 100 mg, 25 mg, 50 mg T2 MD; QL (60 EA per 30 days)
STRATTERA ORAL CAPSULE 10 MG, 18
MG, 25 MG, 40 MG T3 MD; QL (60 EA per 30 days)
STRATTERA ORAL CAPSULE 100 MG, 60
MG, 80 MG T3 MD; QL (30 EA per 30 days)
thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50
mg T2 MD
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg T2 MD
tranylcypromine oral tablet 10 mg T3 MD
trazodone oral tablet 100 mg, 150 mg, 50 mg T2 MD
trazodone oral tablet 300 mg T4 MD
trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5
mg T2 MD
trimipramine oral capsule 100 mg, 25 mg, 50 mg T4 MD
TRINTELLIX ORAL TABLET 10 MG, 20 MG,
5 MG T3 MD; QL (30 EA per 30 days)
venlafaxine oral capsule,extended release 24hr
150 mg T2 MD; QL (60 EA per 30 days)
venlafaxine oral capsule,extended release 24hr
37.5 mg, 75 mg T2 MD; QL (90 EA per 30 days)
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Drug Name Tier Notes
venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg,
50 mg, 75 mg T2 MD; QL (90 EA per 30 days)
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40
MG T4 ST; MD; QL (30 EA per 30 days)
VIIBRYD ORAL TABLETS,DOSE PACK 10
MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40
MG (16)
T4 ST; QL (30 EA per 30 days)
VYVANSE ORAL CAPSULE 10 MG, 20 MG,
30 MG, 40 MG, 50 MG, 60 MG, 70 MG T3 MD; QL (30 EA per 30 days)
ziprasidone hcl oral capsule 20 mg, 40 mg, 60
mg, 80 mg T2 MD; QL (60 EA per 30 days)
SEDATIVE/HYPNOTICS
BELSOMRA ORAL TABLET 10 MG, 15 MG,
20 MG, 5 MG T4 PA
estazolam oral tablet 1 mg, 2 mg T2
eszopiclone oral tablet 1 mg, 2 mg, 3 mg T2 QL (30 EA per 30 days)
flurazepam oral capsule 15 mg, 30 mg T2
phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) T2 MD
phenobarbital oral tablet 100 mg, 15 mg, 16.2
mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg T2 MD
SILENOR ORAL TABLET 3 MG, 6 MG T4
temazepam oral capsule 15 mg, 30 mg T2 QL (30 EA per 30 days)
triazolam oral tablet 0.125 mg, 0.25 mg T2
XYREM ORAL SOLUTION 500 MG/ML T5 (SP) PA
zaleplon oral capsule 10 mg, 5 mg T2 QL (30 EA per 30 days)
zolpidem oral tablet 10 mg, 5 mg T2 QL (30 EA per 30 days)
SKIN PREPS
8-MOP ORAL CAPSULE 10 MG T5 (SP)
ACANYA TOPICAL GEL 1.2-2.5 % T4
acitretin oral capsule 10 mg, 17.5 mg, 25 mg T5 (SP) PA
adapalene topical cream 0.1 % T3
adapalene topical gel 0.1 % T3
alclometasone topical cream 0.05 % T3
alclometasone topical ointment 0.05 % T3
ALTABAX TOPICAL OINTMENT 1 % T4
aluminum chloride topical solution 20 % T2
amcinonide topical cream 0.1 % T4
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Drug Name Tier Notes
ammonium lactate topical cream 12 % T2
ammonium lactate topical lotion 12 % T2
AMNESTEEM ORAL CAPSULE 10 MG, 20
MG, 40 MG T5 (SP)
benzoyl peroxide topical cleanser 6 % T2
benzoyl peroxide topical cleanser 7 % T3
benzoyl peroxide topical foam 5.3 %, 9.8 % T2
benzoyl peroxide topical gel 10 %, 2.5 % T2
betamethasone dipropionate topical cream 0.05
% T3
betamethasone dipropionate topical lotion 0.05 % T2
betamethasone dipropionate topical ointment
0.05 % T3
betamethasone valerate topical cream 0.1 % T2
betamethasone valerate topical lotion 0.1 % T3
betamethasone valerate topical ointment 0.1 % T2
betamethasone, augmented topical cream 0.05 % T2
betamethasone, augmented topical gel 0.05 % T2
betamethasone, augmented topical lotion 0.05 % T3
betamethasone, augmented topical ointment 0.05
% T2
calcipotriene scalp solution 0.005 % T4
calcipotriene topical cream 0.005 % T4
calcipotriene topical ointment 0.005 % T4
calcipotriene-betamethasone topical ointment
0.005-0.064 % T4
calcitriol topical ointment 3 mcg/gram T5 (SP) PA
CAPEX TOPICAL SHAMPOO 0.01 % T3
CLARAVIS ORAL CAPSULE 10 MG, 20 MG,
30 MG, 40 MG T4
clindamycin-benzoyl peroxide topical gel 1-5 %,
1.2 %(1 % base) -5 % T4
clobetasol scalp solution 0.05 % T3
clobetasol topical cream 0.05 % T4
clobetasol topical gel 0.05 % T4
clobetasol topical lotion 0.05 % T4
clobetasol topical ointment 0.05 % T4
clobetasol topical shampoo 0.05 % T4
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Drug Name Tier Notes
clobetasol-emollient topical cream 0.05 % T4
clocortolone pivalate topical cream 0.1 % T4
CLODAN TOPICAL SHAMPOO 0.05 % T4
CONDYLOX TOPICAL GEL 0.5 % T4
CORDRAN TAPE LARGE ROLL TOPICAL
TAPE 4 MCG/CM2 T4
CORDRAN TAPE SMALL ROLL TOPICAL
TAPE 4 MCG/CM2 T4
CORDRAN TOPICAL LOTION 0.05 % T4
COSENTYX (2 SYRINGES) SUBCUTANEOUS
SYRINGE 150 MG/ML T5 (SP) PA; MD
COSENTYX PEN (2 PENS) SUBCUTANEOUS
PEN INJECTOR 150 MG/ML T5 (SP) PA; MD
COSENTYX PEN SUBCUTANEOUS PEN
INJECTOR 150 MG/ML T5 (SP) PA; MD
COSENTYX SUBCUTANEOUS SYRINGE 150
MG/ML T5 (SP) PA; MD
desonide topical cream 0.05 % T4
desonide topical lotion 0.05 % T4
desonide topical ointment 0.05 % T4
desoximetasone topical cream 0.05 %, 0.25 % T3
desoximetasone topical gel 0.05 % T3
desoximetasone topical ointment 0.05 %, 0.25 % T3
diclofenac sodium topical gel 1 % T3 MD
diflorasone topical cream 0.05 % T4
DUPIXENT SUBCUTANEOUS SYRINGE 300
MG/2 ML T5 (SP) PA; MD
ELETONE TOPICAL CREAM T4
EPICERAM TOPICAL EMULSION,
EXTENDED RELEASE T4
EPIDUO TOPICAL GEL 0.1-2.5 % T4
EPIDUO TOPICAL GEL WITH PUMP 0.1-2.5
% T4
EPIFOAM TOPICAL FOAM 1-1 % T4
EUCRISA TOPICAL OINTMENT 2 % T4
FINACEA TOPICAL GEL 15 % T4
fluocinolone and shower cap scalp oil 0.01 % T3
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Drug Name Tier Notes
fluocinolone topical cream 0.01 %, 0.025 % T3
fluocinolone topical oil 0.01 % T3
fluocinolone topical ointment 0.025 % T3
fluocinolone topical solution 0.01 % T3
fluocinonide topical cream 0.05 % T3
fluocinonide topical gel 0.05 % T3
fluocinonide topical ointment 0.05 % T3
fluocinonide topical solution 0.05 % T3
FLUOCINONIDE-E TOPICAL CREAM 0.05 % T3
fluticasone topical cream 0.05 % T2
fluticasone topical lotion 0.05 % T3
fluticasone topical ointment 0.005 % T2
halobetasol propionate topical cream 0.05 % T4
halobetasol propionate topical ointment 0.05 % T4
HALOG TOPICAL OINTMENT 0.1 % T4
HPR PLUS TOPICAL CREAM T4
HPR PLUS TOPICAL FOAM T4
HPR TOPICAL FOAM T4
hydrocortisone acetate topical cream 1 % T2
hydrocortisone butyrate topical cream 0.1 % T2
hydrocortisone butyrate topical ointment 0.1 % T4
hydrocortisone butyrate topical solution 0.1 % T4
hydrocortisone butyr-emollient topical cream 0.1
% T4
hydrocortisone topical cream 0.5 %, 1 %, 2.5 % T2
hydrocortisone topical cream with perineal
applicator 1 %, 2.5 % T2
hydrocortisone topical lotion 1 % T1
hydrocortisone topical lotion 2.5 % T3
hydrocortisone topical ointment 0.5 %, 1 %, 2.5
% T2
hydrocortisone valerate topical cream 0.2 % T4
hydrocortisone valerate topical ointment 0.2 % T2
HYLATOPIC TOPICAL FOAM T4
HYLATOPICPLUS TOPICAL CREAM T4
HYLATOPICPLUS TOPICAL FOAM T4
imiquimod topical cream in packet 5 % T4 QL (20 EA per 28 days)
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Drug Name Tier Notes
iodoquinol-hc topical cream 1-1 % T3
isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40
mg T4
lindane topical lotion 1 % T3
lindane topical shampoo 1 % T3
LOCOID TOPICAL LOTION 0.1 % T4
malathion topical lotion 0.5 % T3
methoxsalen oral capsule,liqd-filled,rapid rel 10
mg T5 (SP)
metronidazole topical cream 0.75 % T3
metronidazole topical gel 0.75 % T3
metronidazole topical gel 1 % T4
metronidazole topical gel with pump 1 % T4
metronidazole topical lotion 0.75 % T4
mometasone topical cream 0.1 % T2
mometasone topical ointment 0.1 % T2
mometasone topical solution 0.1 % T2
MYORISAN ORAL CAPSULE 10 MG, 20 MG,
30 MG, 40 MG T4
NEOSALUS TOPICAL FOAM T4
OXSORALEN TOPICAL LOTION 1 % T3
permethrin topical cream 5 % T4
PHYSIOLYTE IRRIGATION SOLUTION 140-
5-3-98 MEQ/L T4
podofilox topical solution 0.5 % T3
PRAMOSONE TOPICAL LOTION 1-1 %, 2.5-1
% T4
prednicarbate topical cream 0.1 % T3
prednicarbate topical ointment 0.1 % T3
PROCTO-PAK TOPICAL CREAM WITH
PERINEAL APPLICATOR 1 % T2
PROCTOZONE-HC TOPICAL CREAM WITH
PERINEAL APPLICATOR 2.5 % T2
PROMISEB TOPICAL CREAM T4
PRUTECT TOPICAL EMULSION T3
REGRANEX TOPICAL GEL 0.01 % T4 PA
REMEVEN TOPICAL CREAM 50 % T2
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Drug Name Tier Notes
ringer's irrigation solution T2
salicylic acid topical cream,extended release 6 % T2
salicylic acid topical foam 6 % T2
salicylic acid topical gel 6 % T2
salicylic acid topical lotion,extended release 6 % T2
salicylic acid topical shampoo 6 % T2
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM T4
selenium sulfide topical lotion 2.5 % T2
selenium sulfide topical shampoo 2.25 % T4
SKLICE TOPICAL LOTION 0.5 % T4
sodium chloride irrigation solution 0.9 % T2
sulfacetamide sodium (acne) topical suspension
10 % T2
sulfacetamide sodium topical cleanser 10 % T4
sulfacetamide sodium topical cleanser, gel 10 % T4
sulfacetamide sodium topical shampoo 10 % T4
tazarotene topical cream 0.1 % T4
TAZORAC TOPICAL CREAM 0.05 %, 0.1 % T4
TAZORAC TOPICAL GEL 0.05 %, 0.1 % T4
tretinoin (emollient) topical cream 0.05 % T3
tretinoin microspheres topical gel 0.04 %, 0.1 % T3
tretinoin microspheres topical gel with pump 0.04
%, 0.1 % T3
tretinoin topical cream 0.025 %, 0.05 %, 0.1 % T3
tretinoin topical gel 0.01 %, 0.025 %, 0.05 % T3
triamcinolone acetonide topical aerosol 0.147
mg/gram T4
triamcinolone acetonide topical cream 0.025 %,
0.1 %, 0.5 % T2
triamcinolone acetonide topical lotion 0.025 %,
0.1 % T2
triamcinolone acetonide topical ointment 0.025
%, 0.1 %, 0.5 % T2
ULESFIA TOPICAL LOTION 5 % T4
urea topical cream 10 %, 20 %, 39 %, 40 %, 45
%, 47 %, 50 % T2
urea topical foam 35 % T2
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Drug Name Tier Notes
urea topical gel 40 %, 45 % T2
urea topical lotion 10 %, 40 %, 45 % T2
urea topical nail film suspension 40 % T2
VELTIN TOPICAL GEL 1.2-0.025 % T5 (SP)
water for irrigation, sterile irrigation solution T2
ZENATANE ORAL CAPSULE 10 MG, 20 MG,
30 MG, 40 MG T4
ZIANA TOPICAL GEL 1.2-0.025 % T5 (SP)
ZONALON TOPICAL CREAM 5 % T4
SMOKING DETERRENTS
bupropion hcl (smoking deter) oral tablet
extended release 12 hr 150 mg NCS QL (336 EA per 365 days)
CHANTIX CONTINUING MONTH BOX
ORAL TABLET 1 MG NCS QL (340 EA per 365 days)
CHANTIX CONTINUING MONTH PAK ORAL
TABLET 1 MG NCS QL (340 EA per 365 days)
CHANTIX ORAL TABLET 0.5 MG, 1 MG NCS QL (340 EA per 365 days)
CHANTIX STARTING MONTH BOX ORAL
TABLETS,DOSE PACK 0.5 MG (11)- 1 MG
(42)
NCS QL (106 EA per 365 days)
CHANTIX STARTING MONTH PAK ORAL
TABLETS,DOSE PACK 0.5 MG (11)- 1 MG
(42)
NCS QL (106 EA per 365 days)
nicotine (polacrilex) buccal gum 2 mg, 4 mg NCS QL (2800 EA per 365 days)
nicotine (polacrilex) buccal lozenge 2 mg, 4 mg NCS QL (2448 EA per 365 days)
nicotine transdermal patch 24 hour 14 mg/24 hr,
21 mg/24 hr NCS QL (84 EA per 365 days)
nicotine transdermal patch 24 hour 7 mg/24 hr NCS QL (28 EA per 365 days)
NICOTROL INHALATION CARTRIDGE 10
MG NCS QL (2688 EA per 365 days)
NICOTROL NS NASAL SPRAY,NON-
AEROSOL 10 MG/ML NCS QL (6720 ML per 365 days)
THYROID PREPS
ARMOUR THYROID ORAL TABLET 120 MG,
15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60
MG, 90 MG
T3 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 98
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
levothyroxine oral tablet 100 mcg, 112 mcg, 125
mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25
mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
T2 MD
LEVOXYL ORAL TABLET 100 MCG, 112
MCG, 125 MCG, 137 MCG, 150 MCG, 175
MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG,
88 MCG
T2 MD
liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg T2 MD
methimazole oral tablet 10 mg, 5 mg T1 MD
NATURE-THROID ORAL TABLET 113.75
MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG,
195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG,
65 MG, 81.25 MG, 97.5 MG
T2 MD
NP THYROID ORAL TABLET 30 MG, 60 MG,
90 MG T2 MD
propylthiouracil oral tablet 50 mg T3 MD
SYNTHROID ORAL TABLET 100 MCG, 112
MCG, 125 MCG, 137 MCG, 150 MCG, 175
MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG,
75 MCG, 88 MCG
T3 MD
UNITHROID ORAL TABLET 100 MCG, 112
MCG, 125 MCG, 137 MCG, 150 MCG, 175
MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG,
75 MCG, 88 MCG
T2 MD
UNCLASSIFIED DRUG PRODUCTS
acamprosate oral tablet,delayed release (dr/ec)
333 mg T4 MD
ADAGEN INTRAMUSCULAR SOLUTION 250
UNIT/ML T5 (SP) PA
alendronate oral tablet 10 mg, 40 mg, 5 mg T2 MD; QL (30 EA per 30 days)
alendronate oral tablet 35 mg, 70 mg T1 MD; QL (4 EA per 28 days)
alfuzosin oral tablet extended release 24 hr 10 mg T2 MD; QL (30 EA per 30 days)
ARCALYST SUBCUTANEOUS RECON SOLN
220 MG T5 (SP) PA; MD
buprenorphine hcl sublingual tablet 2 mg, 8 mg T3 PA; QL (90 EA per 30 days)
CHEMET ORAL CAPSULE 100 MG T4
chlorhexidine gluconate mucous membrane
mouthwash 0.12 % T2
CYSTAGON ORAL CAPSULE 150 MG, 50 MG T4 PA; MD
disulfiram oral tablet 250 mg, 500 mg T2 MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 99
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5
mcg T3 PA; MD
doxycycline hyclate oral tablet 20 mg T2
dutasteride oral capsule 0.5 mg T3 MD; QL (30 EA per 30 days)
dutasteride-tamsulosin oral capsule, er
multiphase 24 hr 0.5-0.4 mg T3 MD; QL (30 EA per 30 days)
ESBRIET ORAL CAPSULE 267 MG T5 (SP) PA; MD
ESBRIET ORAL TABLET 267 MG, 801 MG T5 (SP) PA; MD
etidronate disodium oral tablet 200 mg, 400 mg T3 MD
EXJADE ORAL TABLET, DISPERSIBLE 125
MG, 250 MG, 500 MG T5 (SP) PA; MD
FERRIPROX ORAL TABLET 500 MG T5 (SP) PA
finasteride oral tablet 5 mg T2 MD
flavoxate oral tablet 100 mg T2 MD
FORTEO SUBCUTANEOUS PEN INJECTOR
20 MCG/DOSE - 600 MCG/2.4 ML T5 (SP) PA; MD; QL (2.4 ML per 28 days)
ibandronate oral tablet 150 mg T2 MD; QL (1 EA per 28 days)
KALYDECO ORAL GRANULES IN PACKET
50 MG, 75 MG T5 (SP) PA; MD; QL (56 EA per 28 days)
KALYDECO ORAL TABLET 150 MG T5 (SP) PA; MD; QL (60 EA per 30 days)
KUVAN ORAL TABLET,SOLUBLE 100 MG T5 (SP) PA; MD
leucovorin calcium oral tablet 10 mg, 15 mg, 25
mg, 5 mg T4
levocarnitine (with sugar) oral solution 100
mg/ml T3 MD
levocarnitine oral tablet 330 mg T3 MD
megestrol oral suspension 400 mg/10 ml (10 ml),
400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml) T2 MD
megestrol oral suspension 625 mg/5 ml T4 MD
miglustat oral capsule 100 mg T5 (SP) PA; MD
NAGLAZYME INTRAVENOUS SOLUTION 5
MG/5 ML T5 (SP) PA; MD
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5
MG T5 (SP) PA; MD
ORKAMBI ORAL GRANULES IN PACKET
100-125 MG, 150-188 MG T5 (SP) PA; MD
ORKAMBI ORAL TABLET 100-125 MG, 200-
125 MG T5 (SP) PA; MD
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 100
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
oxybutynin chloride oral tablet 5 mg T2 MD; QL (120 EA per 30 days)
oxybutynin chloride oral tablet extended release
24hr 10 mg, 5 mg T2 MD; QL (30 EA per 30 days)
oxybutynin chloride oral tablet extended release
24hr 15 mg T2 MD; QL (60 EA per 30 days)
pamidronate intravenous recon soln 30 mg, 90
mg T5 (SP) PA
pamidronate intravenous solution 30 mg/10 ml (3
mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9
mg/ml)
T5 (SP) PA
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg T4 PA; MD
PAROEX ORAL RINSE MUCOUS
MEMBRANE MOUTHWASH 0.12 % T2
polyethylene glycol 3350(bulk) powder T2
prolia subcutaneous syringe 60 mg/ml T5 (SP) MD; QL (1 ML per 180 days)
PULMOZYME INHALATION SOLUTION 1
MG/ML T5 (SP)
PA; MD; QL (150 ML per 30
days)
raloxifene oral tablet 60 mg T3
PA; PA only applies to NCS
eligibility as part of Preventive
Services Coverage (Breast Cancer
Prevention); MD; QL (30 EA per
30 days)
risedronate oral tablet 150 mg T4 MD; QL (1 EA per 30 days)
risedronate oral tablet 30 mg T4 QL (30 EA per 30 days)
risedronate oral tablet 35 mg T4 MD; QL (4 EA per 28 days)
risedronate oral tablet 5 mg T4 MD; QL (30 EA per 30 days)
SAVELLA ORAL TABLET 100 MG, 12.5 MG,
25 MG, 50 MG T4 MD; QL (60 EA per 30 days)
SAVELLA ORAL TABLETS,DOSE PACK 12.5
MG (5)-25 MG(8)-50 MG(42) T4 QL (55 EA per 30 days)
SENSIPAR ORAL TABLET 30 MG, 60 MG T5 (SP) MD; QL (60 EA per 30 days)
SENSIPAR ORAL TABLET 90 MG T5 (SP) MD; QL (120 EA per 30 days)
sodium chloride inhalation solution for
nebulization 0.9 %, 10 %, 3 %, 7 % T2
somavert subcutaneous recon soln 10 mg T5 (SP) PA; MD
SOMAVERT SUBCUTANEOUS RECON
SOLN 15 MG, 20 MG, 25 MG, 30 MG T5 (SP) PA; MD
SUBOXONE SUBLINGUAL FILM 12-3 MG T3 PA; MD; QL (60 EA per 30 days)
SUBOXONE SUBLINGUAL FILM 2-0.5 MG,
4-1 MG, 8-2 MG T3 PA; MD; QL (90 EA per 30 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 101
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
Drug Name Tier Notes
SYPRINE ORAL CAPSULE 250 MG T5 (SP)
tamsulosin oral capsule 0.4 mg T2 MD
TAVALISSE ORAL TABLET 100 MG, 150 MG T5 (SP) PA; QL (60 EA per 30 days)
tolterodine oral tablet 1 mg, 2 mg T3 MD; QL (60 EA per 30 days)
TOVIAZ ORAL TABLET EXTENDED
RELEASE 24 HR 4 MG, 8 MG T4 MD; QL (30 EA per 30 days)
triamcinolone acetonide dental paste 0.1 % T3
trientine oral capsule 250 mg T5 (SP)
trospium oral capsule,extended release 24hr 60
mg T2 MD; QL (30 EA per 30 days)
trospium oral tablet 20 mg T4 MD
TYBOST ORAL TABLET 150 MG T3 MD; QL (30 EA per 30 days)
VESICARE ORAL TABLET 10 MG, 5 MG T3 MD; QL (30 EA per 30 days)
ZAVESCA ORAL CAPSULE 100 MG T5 (SP) PA; MD
ZEMAIRA INTRAVENOUS RECON SOLN
1,000 MG T5 (SP) PA; MD
zoledronic acid-mannitol-water intravenous
piggyback 5 mg/100 ml T5 (SP) PA
VITAMINS
calcitriol oral capsule 0.25 mcg, 0.5 mcg T2 MD
calcitriol oral solution 1 mcg/ml T2 MD
ergocalciferol (vitamin d2) oral capsule 50,000
unit NCS MD; QL (4 EA per 28 days)
folic acid oral tablet 1 mg, 400 mcg, 800 mcg NCS MD
MULTI-VITAMIN WITH FLUORIDE ORAL
DROPS 0.25 MG/ML, 0.5 MG/ML NCS
MULTIVITAMINS WITH FLUORIDE ORAL
TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG NCS
niacin oral tablet 500 mg T2
niacin oral tablet extended release 750 mg T3
VITAMIN D2 ORAL CAPSULE 50,000 UNIT NCS MD; QL (4 EA per 28 days)
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 102
Index
8 8-MOP .................................... 92
A abacavir .................................. 36
abacavir-lamivudine ............... 36
abacavir-lamivudine-zidovudine
............................................ 36
acamprosate ............................ 99
ACANYA ............................... 92
acarbose .................................. 26
acebutolol ............................... 49
acetaminophen-codeine ............ 9
ACETASOL HC .................... 68
acetazolamide ......................... 67
acetazolamide sodium ............ 67
acetic acid ............................... 68
acetylcysteine ......................... 14
acitretin ................................... 92
ACTHIB (PF) ......................... 41
ACTIMMUNE ....................... 31
acyclovir ................................. 36
ADACEL(TDAP
ADOLESN/ADULT)(PF) .. 41
ADAGEN ............................... 99
adapalene ................................ 92
ADCIRCA .............................. 49
ADDERALL XR .................... 40
adefovir................................... 36
ADEMPAS ............................. 49
ADRUCIL .............................. 31
ADVAIR DISKUS ................. 14
ADVAIR HFA ....................... 14
AFEDITAB CR ...................... 47
AFINITOR ............................. 31
AFLURIA 2018-2019 ............ 41
AFLURIA 2018-2019 (PF) .... 41
AFLURIA QUAD 2018-2019 41
AFLURIA QUAD 2018-2019
(PF) ..................................... 41
AFTERA ................................ 58
AK-POLY-BAC ..................... 16
ALBENZA ............................. 30
albuterol sulfate ...................... 14
alclometasone ......................... 92
alendronate ............................. 99
alfuzosin ................................. 99
ALINIA .................................. 30
ALIQOPA .............................. 31
allopurinol .............................. 12
almotriptan malate .................... 9
ALOCRIL ............................... 68
ALOMIDE.............................. 68
ALOPHEN ............................. 74
alosetron ................................. 74
ALPHAGAN P ....................... 68
alprazolam ........................ 85, 86
ALREX ................................... 68
ALTABAX ............................. 92
ALTAVERA (28) ................... 58
aluminum chloride .................. 92
alyacen 1/35 (28) .................... 58
ALYACEN 7/7/7 (28) ............ 58
amantadine hcl ........................ 34
amcinonide ............................. 92
AMETHIA.............................. 59
AMETHIA LO ....................... 59
AMETHYST .......................... 59
amiloride ................................. 67
amiloride-hydrochlorothiazide67
aminophylline ......................... 14
amiodarone ............................. 47
AMITIZA ............................... 74
amitriptyline ........................... 86
amitriptyline-chlordiazepoxide
............................................ 86
amlodipine .............................. 47
amlodipine-benazepril ............ 50
amlodipine-olmesartan ........... 50
amlodipine-valsartan .............. 50
amlodipine-valsartan-hcthiazid
............................................ 50
ammonium chloride ................ 67
ammonium lactate .................. 92
AMNESTEEM ....................... 92
amoxapine .............................. 86
amoxicillin .............................. 16
amoxicillin-pot clavulanate .... 16
ampicillin ................................ 17
AMTURNIDE ........................ 50
anagrelide ............................... 35
ANALPRAM ADVANCED .. 74
anastrozole .............................. 31
ANDROGEL .......................... 80
ANORO ELLIPTA................. 14
antipyrine-benzocaine ............ 68
ANUCORT-HC ...................... 74
ANZEMET ............................. 74
apraclonidine .......................... 68
aprepitant ................................ 74
APRI ....................................... 59
APRISO .................................. 74
APTIOM ................................. 55
APTIVUS ............................... 36
ARANELLE (28) ................... 59
ARCALYST ........................... 99
ARCAPTA NEOHALER ....... 14
aripiprazole ............................. 86
armodafinil ............................. 86
ARMOUR THYROID............ 98
ARNUITY ELLIPTA ............. 14
ASCOMP WITH CODEINE .... 9
ASHLYNA ............................. 59
ASMANEX HFA ................... 14
ASMANEX TWISTHALER .. 14
aspirin ................................. 9, 35
ASPIRIN LOW-STRENGTH 35
aspirin-dipyridamole............... 35
ASSURE ID INSULIN
SAFETY ............................. 84
atazanavir ................................ 36
atenolol ................................... 50
atenolol-chlorthalidone ........... 50
atorvastatin ............................. 50
atovaquone .............................. 30
atovaquone-proguanil ............. 30
ATRIPLA ............................... 36
atropine ............................. 68, 74
atropine sulfate (pf) ................ 68
ATROVENT HFA.................. 14
AUBRA .................................. 59
AUSTEDO ............................. 55
AVAR ..................................... 17
AVAR-E ................................. 17
AVAR-E GREEN ................... 17
AVIANE ................................. 59
AVONEX ............................... 55
AVONEX (WITH ALBUMIN)
............................................ 55
AZASITE ............................... 17
azathioprine ............................ 84
azelastine .................... 26, 68, 69
AZILECT ............................... 34
azithromycin ........................... 17
AZOPT ................................... 69
AZOR ..................................... 50
AZURETTE (28) .................... 59
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 103
B bacitracin ................................ 17
bacitracin-polymyxin b .......... 17
baclofen .................................. 85
BACTROBAN NASAL ......... 17
balsalazide .............................. 74
BALZIVA (28) ....................... 59
BANZEL ................................ 55
BARACLUDE ....................... 36
BAVENCIO ........................... 31
BAYER ASPIRIN .................... 9
bcg vaccine, live (pf) .............. 41
BD LANCET DEVICE .......... 85
BEKYREE (28) ...................... 59
BELSOMRA .......................... 91
benazepril ............................... 50
benazepril-hydrochlorothiazide
............................................ 50
BENICAR .............................. 50
BENICAR HCT ..................... 50
BENZAMYCINPAK ............. 17
benznidazole ........................... 30
benzonatate ............................. 67
benzoyl peroxide .................... 92
benztropine ............................. 34
BEPREVE .............................. 26
BESIVANCE ......................... 17
betamethasone dipropionate ... 92
betamethasone valerate .......... 92
betamethasone, augmented.... 92,
93
BETASERON ........................ 55
betaxolol ........................... 50, 69
bethanechol chloride .............. 40
BETIMOL .............................. 69
BETOPTIC S.......................... 69
bexarotene .............................. 31
BEXSERO .............................. 41
BEYAZ................................... 59
bicalutamide ........................... 31
BIKTARVY ........................... 36
BILTRICIDE .......................... 30
BIOTHRAX ........................... 42
bisacodyl................................. 74
BISA-LAX ............................. 74
bisoprolol fumarate ................ 50
bisoprolol-hydrochlorothiazide
............................................ 50
BLEPHAMIDE S.O.P. ........... 17
BLISOVI 24 FE...................... 59
BLISOVI FE 1/20 (28) ........... 59
BOOSTRIX TDAP................. 42
BREO ELLIPTA .................... 14
BRIELLYN ............................ 59
BRILINTA ............................. 35
brimonidine ............................ 69
BRINTELLIX ........................ 86
BROMFED DM ..................... 67
bromfenac ............................... 69
bromocriptine ......................... 34
brompheniramine-pseudoeph-
dm ....................................... 67
BROVANA ............................ 14
budesonide ........................ 14, 80
bumetanide ............................. 67
BUPHENYL ........................... 74
buprenorphine hcl ................... 99
bupropion hcl .......................... 86
bupropion hcl (smoking deter)97
buspirone ................................ 86
BUSULFEX ........................... 31
BUTALBITAL COMPOUND
W/CODEINE........................ 9
BUTALBITAL COMPOUND-
CODEINE ............................ 9
butalbital-acetaminop-caf-cod .. 9
butalbital-acetaminophen ......... 9
butalbital-acetaminophen-caff .. 9
butalbital-aspirin-caffeine ........ 9
butorphanol tartrate .................. 9
BUTRANS ............................... 9
BYDUREON .......................... 27
BYDUREON BCISE ............. 27
BYETTA ................................ 27
BYSTOLIC ............................ 50
C cabergoline ............................. 80
calcipotriene ........................... 93
calcipotriene-betamethasone .. 93
calcitonin (salmon) ................. 80
calcitriol .......................... 93, 102
calcium acetate ....................... 71
CALQUENCE ........................ 31
CAMILA ................................ 59
CAMRESE ............................. 59
CAMRESE LO ....................... 59
CANASA................................ 74
candesartan ............................. 50
candesartan-hydrochlorothiazid
............................................ 50
CANTIL ................................. 74
capecitabine ............................ 31
CAPEX ................................... 93
CAPRELSA ............................ 31
captopril .................................. 50
captopril-hydrochlorothiazide 50
CARAFATE ........................... 74
carbamazepine ........................ 55
carbidopa ................................ 35
carbidopa-levodopa ................ 35
carbinoxamine maleate ........... 26
CARIMUNE NF
NANOFILTERED .............. 42
carisoprodol ............................ 85
carteolol .................................. 69
CARTIA XT ........................... 47
carvedilol ................................ 50
caspofungin............................. 24
CAYA CONTOURED ........... 59
CAYSTON ............................. 17
CAZIANT (28) ....................... 59
cefaclor ................................... 17
cefadroxil ................................ 17
cefazolin ................................. 17
cefdinir .................................... 17
cefixime .................................. 17
cefpodoxime ........................... 18
cefprozil .................................. 18
CEFTIN .................................. 18
ceftriaxone .............................. 18
cefuroxime axetil .................... 18
cefuroxime sodium ................. 18
celecoxib ................................. 12
CELONTIN ............................ 55
cephalexin ............................... 18
CERVARIX VACCINE (PF) . 42
CESAMET ............................. 74
CHANTIX .............................. 98
CHANTIX CONTINUING
MONTH BOX .................... 97
CHANTIX CONTINUING
MONTH PAK .................... 97
CHANTIX STARTING
MONTH BOX .................... 98
CHANTIX STARTING
MONTH PAK .................... 98
CHATEAL ............................. 59
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 104
CHEMET ............................... 99
CHILD ASPIRIN ................... 35
CHILDREN'S ASPIRIN ........ 35
chlordiazepoxide hcl .............. 86
chlordiazepoxide-clidinium .... 74
chlorhexidine gluconate ......... 99
chloroquine phosphate............ 30
chlorothiazide ......................... 67
chlorpromazine ....................... 86
chlorpropamide....................... 27
chlorthalidone ......................... 67
chlorzoxazone......................... 85
cholestyramine (with sugar) ... 51
CHOLESTYRAMINE LIGHT
............................................ 51
CICLODAN ........................... 24
ciclopirox ................................ 24
cilostazol................................. 35
CILOXAN .............................. 18
CIMDUO ................................ 36
cimetidine ............................... 74
cimetidine hcl ......................... 74
CIPRO HC.............................. 18
CIPRODEX ............................ 18
ciprofloxacin........................... 18
ciprofloxacin (mixture) .......... 18
ciprofloxacin hcl ..................... 18
citalopram ............................... 86
CITRATE OF MAGNESIA ... 74
CITROMA ............................. 74
CLARAVIS ............................ 93
clarithromycin ........................ 18
CLEARLAX........................... 74
clemastine ............................... 26
CLENPIQ ............................... 74
CLEOCIN............................... 18
CLIMARA PRO ..................... 80
CLINDACIN ETZ.................. 18
CLINDACIN P ....................... 18
clindamycin hcl ...................... 19
clindamycin palmitate hcl ...... 19
clindamycin phosphate ........... 19
clindamycin-benzoyl peroxide93
clobetasol ................................ 93
clobetasol-emollient ............... 93
clocortolone pivalate .............. 93
CLODAN ............................... 93
clomipramine .......................... 86
clonazepam ............................. 55
clonidine ................................. 51
clonidine hcl ........................... 51
clopidogrel .............................. 35
clorazepate dipotassium ......... 86
clotrimazole ............................ 24
clotrimazole-betamethasone ... 24
clozapine ................................. 87
COARTEM ............................ 30
codeine sulfate .......................... 9
codeine-butalbital-asa-caff ....... 9
colchicine................................ 12
colesevelam ............................ 51
colestipol ................................ 51
COLY-MYCIN S ................... 19
COMBIGAN .......................... 69
COMBIPATCH ...................... 80
COMBIVENT RESPIMAT ... 14
COMPLERA .......................... 36
COMPRO ............................... 74
COMVAX (PF) ...................... 42
CONCEPTROL ...................... 59
CONDYLOX.......................... 93
CONSTULOSE ...................... 75
COPAXONE .......................... 55
CORDRAN ............................ 93
CORDRAN TAPE LARGE
ROLL.................................. 93
CORDRAN TAPE SMALL
ROLL.................................. 93
COREG CR ............................ 51
CORTANE-B ......................... 69
cortisone ................................. 80
CORTISPORIN ...................... 19
CORTISPORIN-TC ............... 19
COSENTYX ........................... 93
COSENTYX (2 SYRINGES) 93
COSENTYX PEN .................. 93
COSENTYX PEN (2 PENS) .. 93
COSOPT (PF)......................... 69
CREON .................................. 75
CRIXIVAN ............................ 36
cromolyn ..................... 12, 15, 69
CRYSELLE (28) .................... 60
CURITY GAUZE................... 85
CYCLAFEM 1/35 (28) .......... 60
CYCLAFEM 7/7/7 (28) ......... 60
cyclobenzaprine ...................... 85
cyclopentolate ......................... 69
cyclophosphamide .................. 31
cycloserine .............................. 19
CYCLOSET ........................... 27
cyclosporine............................ 84
cyclosporine modified ............ 84
cyproheptadine ....................... 26
CYRED................................... 60
CYSTAGON .......................... 99
CYTRA-2 ............................... 71
CYTRA-3 ............................... 71
D danazol .................................... 80
dantrolene ............................... 85
dapsone ................................... 19
DAPTACEL (DTAP
PEDIATRIC) (PF) .............. 42
DARAPRIM ........................... 30
DASETTA 1/35 (28) .............. 60
DASETTA 7/7/7 (28) ............. 60
DAYSEE ................................ 60
DAYTRANA .......................... 87
DEBLITANE .......................... 60
DELYLA (28) ........................ 60
demeclocycline ....................... 19
DENTA 5000 PLUS ............... 71
DENTAGEL ........................... 71
DEPEN TITRATABS ............ 12
DEPO-ESTRADIOL .............. 80
DESCOVY ............................. 36
desipramine............................. 87
desloratadine ........................... 26
desmopressin .......................... 80
desog-e.estradiol/e.estradiol ... 60
desogestrel-ethinyl estradiol ... 60
desonide .................................. 94
desoximetasone....................... 94
desvenlafaxine ........................ 87
desvenlafaxine succinate ........ 87
dexamethasone ................. 80, 81
dexamethasone sodium
phosphate ...................... 69, 81
dexmethylphenidate ................ 87
dextroamphetamine ................ 40
dextroamphetamine-
amphetamine....................... 40
diazepam ........................... 55, 87
DIAZEPAM INTENSOL ....... 87
diclofenac potassium ................ 9
diclofenac sodium 12, 13, 31, 69,
94
dicloxacillin ............................ 19
dicyclomine ............................ 75
didanosine ............................... 36
DIFICID ................................. 19
diflorasone .............................. 94
DIGITEK ................................ 47
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 105
DIGOX ................................... 47
digoxin .................................... 47
dihydroergotamine ............. 9, 10
diltiazem hcl ..................... 47, 48
DILT-XR ................................ 48
DIPENTUM ........................... 75
diphenhydramine hcl .............. 26
diphenoxylate-atropine ........... 75
dipyridamole........................... 35
disopyramide phosphate ......... 48
disulfiram ............................... 99
divalproex ............................... 56
DIVIGEL ................................ 81
dofetilide................................. 48
donepezil ................................ 40
DONNATAL .......................... 75
DOPTELET ............................ 58
dorzolamide ............................ 69
dorzolamide-timolol ............... 69
doxazosin ................................ 51
doxepin ................................... 87
doxercalciferol ........................ 99
doxycycline hyclate .......... 19, 99
doxycycline monohydrate ...... 19
dronabinol............................... 75
drospirenone-ethinyl estradiol 60
DROXIA ................................ 47
DUAVEE ............................... 81
DUCODYL ............................ 75
DULERA ................................ 15
duloxetine ............................... 87
DUPIXENT ............................ 94
DUREZOL ............................. 69
dutasteride .............................. 99
dutasteride-tamsulosin ............ 99
DYRENIUM .......................... 67
E E.E.S. 200 ............................... 19
E.E.S. 400 ............................... 19
E.E.S. GRANULES ............... 19
econazole ................................ 24
ECONTRA EZ ....................... 60
EDECRIN............................... 67
EDURANT ............................. 36
efavirenz ................................. 36
EFFIENT ................................ 35
ELETONE .............................. 94
ELIDEL .................................. 84
ELINEST ................................ 60
ELIQUIS ................................ 23
ELLA ...................................... 60
ELMIRON .............................. 10
EMADINE.............................. 26
EMCYT .................................. 31
EMEND .................................. 75
EMOQUETTE........................ 60
EMSAM ................................. 87
EMTRIVA .............................. 36
enalapril maleate..................... 51
enalapril-hydrochlorothiazide 51
ENBREL ................................ 30
ENBREL SURECLICK ......... 30
ENDARI ................................. 47
ENDOCET ............................. 10
ENGERIX-B (PF) .................. 42
ENGERIX-B PEDIATRIC (PF)
............................................ 42
ENJUVIA ............................... 81
enoxaparin .............................. 23
ENPRESSE ............................ 60
ENSKYCE.............................. 60
entacapone .............................. 35
entecavir ................................. 36
ENTERIC COATED ASPIRIN
............................................ 36
ENTRESTO............................ 51
ENULOSE .............................. 75
EPCLUSA .............................. 36
EPICERAM ............................ 94
EPIDUO ................................. 94
EPIFOAM .............................. 94
epinastine ................................ 26
epinephrine ............................. 40
EPIPEN .................................. 40
EPIPEN 2-PAK ...................... 40
EPIPEN JR ............................. 41
EPIPEN JR 2-PAK ................. 40
EPIVIR HBV .......................... 36
eplerenone .............................. 68
EPZICOM .............................. 36
ergocalciferol (vitamin d2) ... 102
ergoloid ................................... 51
ERGOMAR ............................ 10
ERLEADA ............................. 31
ERRIN .................................... 60
ERTACZO.............................. 24
ERY PADS ............................. 19
ERY-TAB ............................... 19
ERYTHROCIN (AS
STEARATE) ...................... 19
erythromycin........................... 20
erythromycin ethylsuccinate ... 19
erythromycin with ethanol ...... 20
erythromycin-benzoyl peroxide
............................................ 20
ESBRIET ................................ 99
escitalopram oxalate ............... 87
ESTARYLLA ......................... 60
estazolam ................................ 91
ESTRACE .............................. 81
estradiol .................................. 81
estradiol-norethindrone acet ... 81
ESTROGEL ............................ 81
estrogens-methyltestosterone . 81
estropipate............................... 81
eszopiclone ............................. 91
ethambutol .............................. 20
ethosuximide........................... 56
etidronate disodium ................ 99
etodolac................................... 13
EUCRISA ............................... 94
EVOTAZ ................................ 37
exemestane ............................. 31
EXJADE ................................. 99
ezetimibe................................. 51
F FALLBACK SOLO................ 60
FALMINA (28) ...................... 60
famciclovir .............................. 37
famotidine ............................... 75
FANAPT........................... 87, 88
FARESTON ........................... 32
FC2 FEMALE CONDOM ..... 60
felbamate ................................ 56
felodipine ................................ 48
FEMCAP ................................ 60
fenofibrate............................... 51
fenofibrate micronized ............ 51
fenofibrate nanocrystallized ... 51
fenofibric acid (choline) ......... 51
fenoprofen............................... 13
fentanyl ................................... 10
fentanyl citrate ........................ 10
FERRIPROX .......................... 99
FIASP FLEXTOUCH U-100
INSULIN ............................ 27
FIASP U-100 INSULIN ......... 27
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 106
FINACEA............................... 94
finasteride ............................... 99
FIRVANQ .............................. 20
flavoxate ................................. 99
flecainide ................................ 48
FLEET LAXATIVE ............... 75
FLOVENT DISKUS .............. 15
FLOVENT HFA ..................... 15
FLUAD 2018-2019 (65 YR
UP)(PF) .............................. 42
FLUARIX QUAD 2018-2019
(PF) ..................................... 42
FLUBLOK QUAD 2018-2019
(PF) ..................................... 42
FLUCELVAX QUAD 2018-
2019 .................................... 42
FLUCELVAX QUAD 2018-
2019 (PF) ............................ 42
fluconazole ............................. 24
flucytosine .............................. 24
fludrocortisone ....................... 81
FLULAVAL QUAD 2018-2019
............................................ 43
FLULAVAL QUAD 2018-2019
(PF) ..................................... 43
flunisolide ............................... 69
fluocinolone ............................ 94
fluocinolone acetonide oil ...... 69
fluocinolone and shower cap .. 94
fluocinonide ............................ 94
FLUOCINONIDE-E .............. 94
fluoride (sodium) .................... 71
FLUORITAB ......................... 71
fluorometholone ..................... 69
fluorouracil ............................. 32
fluoxetine ................................ 88
fluphenazine hcl ..................... 88
flurazepam .............................. 91
flurbiprofen............................. 13
flurbiprofen sodium ................ 69
flutamide................................. 32
fluticasone ........................ 69, 94
fluvastatin ............................... 51
fluvoxamine ............................ 88
FLUZONE HIGH-DOSE 2018-
19 (PF) ................................ 43
FLUZONE QUAD 2018-2019
............................................ 43
FLUZONE QUAD 2018-2019
(PF) ..................................... 43
FLUZONE QUAD PEDI 2018-
19 (PF) ................................ 43
FML S.O.P. ............................ 70
FOCALIN XR ........................ 88
folic acid ............................... 102
fondaparinux ........................... 23
FORTEO ................................ 99
fosamprenavir ......................... 37
fosinopril ................................ 51
fosinopril-hydrochlorothiazide
............................................ 51
FOSRENOL ........................... 71
FREESTYLE FREEDOM LITE
............................................ 85
FREESTYLE INSULINX ...... 85
FREESTYLE INSULINX TEST
STRIPS ............................... 67
FREESTYLE LANCETS ....... 85
FREESTYLE LITE METER.. 85
FREESTYLE LITE STRIPS .. 67
FREESTYLE TEST ............... 67
frovatriptan ............................. 10
furosemide .............................. 68
FUZEON ................................ 37
FYCOMPA ............................. 56
G gabapentin .............................. 56
GABITRIL ............................. 56
galantamine ............................ 41
GAMMAGARD LIQUID ...... 43
GARDASIL (PF) .................... 43
GARDASIL 9 (PF) ................. 43
gatifloxacin ............................. 20
GAVILAX .............................. 75
GAVILYTE-C ........................ 75
GAVILYTE-G........................ 75
GAVILYTE-H AND
BISACODYL ..................... 75
GAVILYTE-N........................ 75
gemfibrozil ............................. 52
GENERESS FE ...................... 60
GENERLAC ........................... 76
GENGRAF ............................. 84
GENTAK................................ 20
gentamicin .............................. 20
GENTLE LAXATIVE ........... 76
GENTLELAX ........................ 76
GENVOYA ............................ 37
GIANVI (28) .......................... 61
GILDAGIA ............................ 61
GILDESS 1.5/30 (21) ............. 61
GILDESS 1/20 (21) ................ 61
GILDESS 24 FE ..................... 61
GILDESS FE 1.5/30 (28) ....... 61
GILDESS FE 1/20 (28) .......... 61
GILENYA .............................. 56
GLEEVEC .............................. 32
glimepiride .............................. 27
glipizide .................................. 27
glipizide-metformin ................ 27
GLUCAGEN .......................... 72
GLUCAGEN DIAGNOSTIC
KIT ..................................... 67
GLUCAGEN HYPOKIT........ 72
GLUCAGON EMERGENCY
KIT (HUMAN) ................... 72
glyburide ................................. 27
glyburide micronized .............. 27
glyburide-metformin............... 27
GLYCOLAX .......................... 76
glycopyrrolate ......................... 76
GLYXAMBI........................... 27
granisetron hcl ........................ 76
GRASTEK .............................. 43
griseofulvin microsize ............ 24
guanfacine......................... 52, 88
guanidine ................................ 41
GYNAZOLE-1 ....................... 24
GYNOL II .............................. 61
H halobetasol propionate ............ 94
HALOG .................................. 94
haloperidol .............................. 88
haloperidol decanoate ............. 88
haloperidol lactate .................. 88
HARVONI .............................. 37
HAVRIX (PF) ........................ 43
HEALTHYLAX ..................... 76
HEATHER ............................. 61
heparin (porcine) .................... 23
heparin, porcine (pf) ............... 23
HEXALEN ............................. 32
HOMATROPAIRE ................ 70
homatropine hbr...................... 70
HORIZANT ............................ 56
HPR ........................................ 95
HPR PLUS.............................. 94
HUMIRA ................................ 31
HUMIRA PEDIATRIC
CROHN'S START ............. 30
HUMIRA PEN ....................... 31
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 107
HUMIRA PEN CROHN'S-UC-
HS START ......................... 31
HUMIRA PEN PSORIASIS-
UVEITIS ............................ 31
HUMULIN R U-500 (CONC)
INSULIN ............................ 28
hydralazine ............................. 52
hydrochlorothiazide ................ 68
hydrocodone-acetaminophen . 10
hydrocodone-homatropine ..... 67
hydrocodone-ibuprofen .......... 10
hydrocortisone .................. 81, 95
hydrocortisone acetate ...... 76, 95
hydrocortisone butyrate .......... 95
hydrocortisone butyr-emollient
............................................ 95
hydrocortisone valerate .......... 95
hydrocortisone-acetic acid...... 70
hydrocortisone-pramoxine ..... 76
HYDROMET ......................... 67
hydromorphone ...................... 10
hydroxychloroquine ............... 30
hydroxyurea ............................ 32
hydroxyzine hcl ...................... 26
hydroxyzine pamoate ............. 26
HYLATOPIC ......................... 95
HYLATOPICPLUS ............... 95
hyoscyamine sulfate ............... 76
HYOSYNE ............................. 76
I ibandronate ............................. 99
IBRANCE .............................. 32
ibuprofen ................................ 13
ibuprofen-oxycodone ............. 10
IDHIFA .................................. 32
ILEVRO ................................. 70
imatinib................................... 32
IMBRUVICA ......................... 32
imipramine hcl........................ 88
imipramine pamoate ............... 88
imiquimod .............................. 95
IMOVAX RABIES VACCINE
(PF) ..................................... 43
INCRELEX ............................ 81
indapamide ............................. 68
indomethacin .......................... 13
INFANRIX (DTAP) (PF)....... 44
insulin syringe-needle u-100 .. 85
INTELENCE .......................... 37
INTRON A ............................. 32
INTROVALE ......................... 61
INVEGA SUSTENNA ........... 88
INVIRASE ............................. 37
iodoquinol-hc.......................... 95
IPOL ....................................... 44
ipratropium bromide ......... 15, 70
ipratropium-albuterol.............. 15
irbesartan ................................ 52
irbesartan-hydrochlorothiazide
............................................ 52
ISENTRESS ........................... 37
ISENTRESS HD .................... 37
ISOLYTE S PH 7.4 ................ 72
isoniazid.................................. 20
isosorbide dinitrate ................. 48
isosorbide mononitrate ........... 48
isotretinoin .............................. 95
isradipine ................................ 48
ISTALOL ............................... 70
itraconazole ............................ 25
ivermectin ............................... 30
IXIARO (PF) .......................... 44
J JAKAFI .................................. 32
JANTOVEN ........................... 24
JARDIANCE .......................... 28
JENCYCLA............................ 61
JENTADUETO ...................... 28
JINTELI.................................. 81
JOLESSA ............................... 61
JOLIVETTE ........................... 61
JULEBER ............................... 61
JULUCA ................................. 37
JUNEL 1.5/30 (21) ................. 61
JUNEL 1/20 (21) .................... 61
JUNEL FE 1.5/30 (28) ........... 61
JUNEL FE 1/20 (28) .............. 61
JUNEL FE 24 ......................... 61
JYNARQUE ........................... 68
K KALETRA ............................. 37
KALEXATE ........................... 72
KALYDECO ........................ 100
KARIVA (28) ......................... 61
KELNOR 1/35 (28) ................ 61
KEPIVANCE ......................... 76
ketoconazole ........................... 25
ketoprofen ............................... 13
ketorolac ........................... 10, 70
KIMIDESS (28)...................... 61
KINRIX (PF) .......................... 44
KIONEX ................................. 72
KIONEX (WITH SORBITOL)
............................................ 72
KISQALI ................................ 32
KISQALI FEMARA CO-PACK
............................................ 32
KLOR-CON ........................... 72
KLOR-CON 10 ...................... 72
KLOR-CON 8 ........................ 72
KLOR-CON M10 ................... 72
KLOR-CON M15 ................... 72
KLOR-CON M20 ................... 72
KLOR-CON SPRINKLE ....... 72
KLOR-CON/25 ...................... 72
KRISTALOSE ........................ 76
KURVELO ............................. 61
KUVAN ................................ 100
L l norgest/e.estradiol-e.estrad ... 62
labetalol .................................. 52
lactulose .................................. 76
lamivudine .............................. 37
lamivudine-zidovudine ........... 37
lamotrigine .............................. 56
lancets ..................................... 85
lansoprazole ............................ 76
LANTUS SOLOSTAR U-100
INSULIN ............................ 28
LANTUS U-100 INSULIN .... 28
LARIN 1.5/30 (21) ................. 62
LARIN 1/20 (21) .................... 62
LARIN 24 FE ......................... 62
LARIN FE 1.5/30 (28) ........... 62
LARIN FE 1/20 (28) .............. 62
LASTACAFT ......................... 26
latanoprost .............................. 70
LATUDA ................................ 88
LAXACLEAR ........................ 76
LAXATIVE (BISACODYL) . 76
LAXATIVE FEMININE ........ 76
LAXATIVE PEG 3350 .......... 77
LAYOLIS FE ......................... 62
LEENA 28 .............................. 62
leflunomide ............................. 13
LENVIMA .............................. 32
LESSINA ................................ 62
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 108
LETAIRIS .............................. 52
letrozole .................................. 32
leucovorin calcium ............... 100
LEUKERAN .......................... 32
LEUKINE............................... 58
leuprolide ................................ 33
levalbuterol hcl ....................... 15
LEVATOL ............................. 52
LEVEMIR FLEXTOUCH U-
100 INSULN ...................... 28
LEVEMIR U-100 INSULIN .. 28
levetiracetam .................... 56, 57
levobunolol ............................. 70
levocarnitine ......................... 100
levocarnitine (with sugar)..... 100
levocetirizine .......................... 26
levofloxacin ............................ 20
LEVONEST (28).................... 62
levonorgestrel-ethinyl estrad .. 62
levonorg-eth estrad triphasic .. 62
LEVORA-28 .......................... 62
levorphanol tartrate ................ 10
levothyroxine .......................... 98
LEVOXYL ............................. 98
LEXIVA ................................. 37
LIALDA ................................. 77
lidocaine ................................. 12
lidocaine hcl ........................... 12
lidocaine hcl-hydrocortison ac 77
LIDOCAINE VISCOUS ........ 12
lidocaine-hydrocortisone-aloe 77
lidocaine-prilocaine ................ 12
lindane .................................... 95
linezolid .................................. 20
LINZESS ................................ 77
liothyronine ............................ 98
lisinopril ................................. 52
lisinopril-hydrochlorothiazide 52
LITE COAT ASPIRIN ........... 10
lithium carbonate .................... 88
lithium citrate ......................... 88
LO LOESTRIN FE................. 62
LOCOID ................................. 95
LOMEDIA 24 FE ................... 62
loperamide .............................. 77
LOPREEZA ........................... 81
lorazepam ......................... 88, 89
LORYNA (28)........................ 62
losartan ................................... 52
losartan-hydrochlorothiazide .. 52
LOTEMAX ............................ 70
lovastatin ................................ 52
LOW-OGESTREL (28) ......... 62
loxapine succinate .................. 89
LUDENT FLUORIDE ........... 72
LUMIGAN ............................. 70
LUPRON DEPOT ............ 33, 82
LUPRON DEPOT (3 MONTH)
...................................... 33, 82
LUPRON DEPOT (4 MONTH)
............................................ 33
LUPRON DEPOT (6 MONTH)
............................................ 33
LUPRON DEPOT-PED ......... 82
LUPRON DEPOT-PED (3
MONTH) ............................ 82
LUTERA (28)......................... 62
LYNPARZA ........................... 33
LYRICA ................................. 57
LYSODREN ........................... 33
LYZA ..................................... 62
M magnesium citrate................... 77
malathion ................................ 95
maprotiline.............................. 89
MARLISSA ............................ 62
MARPLAN ............................ 89
MATULANE.......................... 33
MATZIM LA ......................... 48
MAVYRET ............................ 37
meclizine ................................ 77
meclofenamate........................ 13
medroxyprogesterone . 62, 63, 82
mefenamic acid....................... 10
mefloquine .............................. 30
megestrol ........................ 33, 100
meloxicam .............................. 13
melphalan hcl ......................... 33
memantine .............................. 57
MENACTRA (PF) ................. 44
MENEST ................................ 82
MENHIBRIX (PF) ................. 44
MENOMUNE - A/C/Y/W-135
............................................ 44
MENOMUNE - A/C/Y/W-135
(PF) ..................................... 44
MENTAX ............................... 25
MENVEO A-C-Y-W-135-DIP
(PF) ..................................... 44
MENVEO MENA
COMPONENT (PF) ........... 44
MENVEO MENCYW-135
COMPNT (PF) ................... 44
meperidine .............................. 10
meprobamate .......................... 89
mercaptopurine ....................... 33
mesalamine ............................. 77
mesalamine with cleansing wipe
............................................ 77
metaproterenol ........................ 15
metaxalone .............................. 85
metformin ............................... 28
methadone............................... 10
methamphetamine................... 41
methazolamide ........................ 68
methenamine hippurate .......... 20
methimazole ........................... 98
methocarbamol ....................... 85
methotrexate sodium .............. 33
methotrexate sodium (pf) ....... 33
methoxsalen ............................ 95
methscopolamine .................... 77
methyclothiazide..................... 68
methyldopa ............................. 52
methyldopa-hydrochlorothiazide
............................................ 52
methylergonovine ................... 82
methylphenidate hcl................ 89
methylprednisolone ................ 82
methylprednisolone acetate .... 82
metipranolol ............................ 70
metoclopramide hcl ................ 77
metolazone .............................. 68
metoprolol succinate ............... 52
metoprolol ta-hydrochlorothiaz
............................................ 52
metoprolol tartrate .................. 52
metronidazole ................... 20, 95
mexiletine ............................... 48
MICROGESTIN 1.5/30 (21) .. 63
MICROGESTIN 1/20 (21) ..... 63
MICROGESTIN FE 1.5/30 (28)
............................................ 63
MICROGESTIN FE 1/20 (28)63
midodrine ................................ 41
MIGERGOT ........................... 10
miglitol ................................... 28
miglustat ............................... 100
MILK OF MAGNESIA .......... 77
MILK OF MAGNESIA
CONCENTRATED ............ 77
MILLIPRED DP ..................... 82
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 109
MIMVEY ............................... 82
MIMVEY LO ......................... 82
MINASTRIN 24 FE ............... 63
MINITRAN ............................ 48
minocycline ............................ 20
minoxidil ................................ 52
MIRALAX ............................. 77
MIRENA ................................ 63
mirtazapine ............................. 89
misoprostol ............................. 77
M-M-R II (PF) ........................ 44
modafinil ................................ 89
MODERIBA........................... 37
moexipril ................................ 52
moexipril-hydrochlorothiazide
............................................ 52
mometasone ................ 70, 95, 96
MONO-LINYAH ................... 63
MONONESSA (28) ............... 63
montelukast ............................ 15
MONUROL ............................ 20
morphine........................... 10, 11
morphine concentrate ............. 10
MOTOFEN............................. 77
MOVANTIK .......................... 24
MOVIPREP ............................ 77
MOXEZA ............................... 20
MULPLETA........................... 58
MULTAQ ............................... 48
MULTI-VITAMIN WITH
FLUORIDE ...................... 102
MULTIVITAMINS WITH
FLUORIDE ...................... 102
mupirocin ............................... 20
MY WAY ............................... 63
mycophenolate mofetil ........... 84
mycophenolate sodium ........... 84
MYORISAN........................... 96
MYZILRA .............................. 63
N nabumetone ............................ 13
nadolol .................................... 52
naftifine .................................. 25
NAFTIN ................................. 25
NAGLAZYME..................... 100
naloxone ................................. 24
naltrexone ............................... 24
naphazoline............................. 70
naproxen ................................. 13
naratriptan ............................... 11
NATACYN ............................ 25
NATAZIA .............................. 63
nateglinide .............................. 28
NATURE-THROID ............... 98
NECON 0.5/35 (28) ............... 63
NECON 1/35 (28) .................. 63
NECON 1/50 (28) .................. 63
NECON 10/11 (28) ................ 63
NECON 7/7/7 (28) ................. 63
nefazodone.............................. 89
neomycin ................................ 20
neomycin-bacitracin-poly-hc.. 21
neomycin-bacitracin-polymyxin
............................................ 21
neomycin-polymyxin b-
dexameth ............................ 21
neomycin-polymyxin-
gramicidin ........................... 21
neomycin-polymyxin-hc ........ 21
NEOSALUS ........................... 96
NERLYNX ............................. 33
NEULASTA ........................... 58
NEUPOGEN .......................... 58
NEVANAC ............................ 70
nevirapine ............................... 37
NEXAVAR ............................ 33
NEXPLANON........................ 63
NEXT CHOICE ONE DOSE . 63
niacin .............................. 52, 102
NIACOR ................................. 52
nicardipine .............................. 48
nicotine ................................... 98
nicotine (polacrilex) ............... 98
NICOTROL ............................ 98
NICOTROL NS ...................... 98
NIFEDICAL XL..................... 48
nifedipine ................................ 48
NIKKI (28) ............................. 63
NILANDRON ........................ 33
nimodipine .............................. 48
nisoldipine .............................. 49
NITRO-BID............................ 49
nitrofurantoin .......................... 21
nitrofurantoin macrocrystal .... 21
nitrofurantoin monohyd/m-cryst
............................................ 21
nitroglycerin ........................... 49
NITROSTAT .......................... 49
nizatidine ................................ 77
NORA-BE .............................. 64
noreth-ethinyl estradiol-iron ... 64
norethindrone (contraceptive) 64
norethindrone acetate .............. 82
norethindrone ac-eth estradiol
...................................... 64, 82
norethindrone-e.estradiol-iron 64
norgestimate-ethinyl estradiol 64
NORINYL 1+50 (28) ............. 64
NORLYROC .......................... 64
NORMAL SALINE FLUSH .. 72
NORPACE CR ....................... 49
NORTREL 0.5/35 (28) ........... 64
NORTREL 1/35 (21) .............. 64
NORTREL 1/35 (28) .............. 64
NORTREL 7/7/7 (28) ............. 64
nortriptyline ............................ 89
NORVIR ................................. 38
NOVOLIN 70/30 U-100
INSULIN ............................ 28
NOVOLIN N NPH U-100
INSULIN ............................ 28
NOVOLIN R REGULAR U-
100 INSULN ...................... 28
NOVOLOG FLEXPEN U-100
INSULIN ............................ 28
NOVOLOG MIX 70-30 U-100
INSULN ............................. 28
NOVOLOG MIX 70-
30FLEXPEN U-100 ........... 28
NOVOLOG PENFILL U-100
INSULIN ............................ 29
NOVOLOG U-100 INSULIN
ASPART ............................. 29
NOXAFIL............................... 25
NP THYROID ........................ 98
NUCYNTA............................. 11
NUCYNTA ER ...................... 11
NULOJIX ............................... 84
NUVARING ........................... 64
nystatin ................................... 25
nystatin-triamcinolone ............ 25
NYSTOP................................. 25
O OCELLA ................................ 64
octreotide acetate .................... 82
ODEFSEY .............................. 38
ofloxacin ................................. 21
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 110
OGESTREL (28) .................... 64
olanzapine............................... 89
olanzapine-fluoxetine ............. 89
olmesartan .............................. 53
olmesartan-amlodipin-hcthiazid
............................................ 53
olmesartan-hydrochlorothiazide
............................................ 53
olopatadine ....................... 26, 70
omega-3 acid ethyl esters ....... 77
omeprazole ............................. 78
OMNITROPE......................... 82
ondansetron ............................ 78
ondansetron hcl ...................... 78
OPANA ER ............................ 11
OPCICON ONE-STEP .......... 64
ORAL SALINE LAXATIVE 78
ORFADIN ............................ 100
ORKAMBI ........................... 100
orphenadrine citrate ................ 85
ORSYTHIA ............................ 64
OSCIMIN SR ......................... 78
oseltamivir .............................. 38
OSMOPREP ........................... 78
OTEZLA ................................ 13
OTEZLA STARTER.............. 13
oxandrolone ............................ 82
oxaprozin ................................ 13
oxcarbazepine ......................... 57
oxiconazole............................. 25
OXSORALEN ........................ 96
oxybutynin chloride.............. 100
oxycodone .............................. 11
oxycodone-acetaminophen ..... 11
oxycodone-aspirin .................. 11
oxymorphone .......................... 11
OZEMPIC .............................. 29
P paliperidone ...................... 89, 90
PALYNZIQ ............................ 44
pamidronate .......................... 100
PANRETIN ............................ 33
pantoprazole ........................... 78
PARAGARD T 380A............. 64
paricalcitol ............................ 100
PAROEX ORAL RINSE ..... 100
paromomycin .......................... 30
paroxetine hcl ......................... 90
PATADAY ............................. 26
PAXIL .................................... 90
PAZEO ................................... 26
PEDIARIX (PF) ..................... 44
PEDVAX HIB (PF) ................ 44
peg 3350-electrolytes ............. 78
PEG-3350 WITH FLAVOR
PACKS ............................... 78
PEGANONE .......................... 57
peg-electrolyte soln ................ 78
PEGINTRON ......................... 38
PEGINTRON REDIPEN ....... 38
PEG-PREP.............................. 78
PEN NEEDLE ........................ 85
penicillin v potassium ............. 21
PENTACEL (PF) ................... 44
PENTACEL ACTHIB
COMPONENT (PF) ........... 45
PENTACEL DTAP-IPV
COMPNT (PF) ................... 45
PENTAM................................ 30
pentazocine-naloxone ............. 11
PENTIPS ................................ 85
pentoxifylline.......................... 47
perindopril erbumine .............. 53
permethrin .............................. 96
perphenazine ........................... 90
perphenazine-amitriptyline ..... 90
PEXEVA ................................ 90
PHENADOZ .......................... 78
phenazopyridine ..................... 12
phenelzine ............................... 90
PHENERGAN ........................ 78
phenobarbital .................... 91, 92
phentermine ............................ 34
phenytoin ................................ 57
phenytoin sodium extended .... 57
PHILITH ................................ 64
phospha 250 neutral................ 72
PHOSPHATE LAXATIVE .... 78
PHOSPHOLINE IODIDE ...... 70
PHYSIOLYTE ....................... 96
PICATO.................................. 33
pilocarpine hcl .................. 41, 70
pimozide ................................. 90
PIMTREA (28) ....................... 64
pindolol ................................... 53
pioglitazone ............................ 29
pioglitazone-glimepiride ........ 29
pioglitazone-metformin .......... 29
PIRMELLA ............................ 64
piroxicam ................................ 13
PLAN B ONE-STEP .............. 64
PNEUMOVAX 23 ................. 45
PNV 29-1 ................................ 85
podofilox................................. 96
polyethylene glycol 3350 ....... 78
polyethylene glycol 3350(bulk)
.......................................... 100
polymyxin b sulfate ................ 21
polymyxin b sulf-trimethoprim
............................................ 21
POMALYST........................... 33
PORTIA .................................. 64
potassium chloride ............ 72, 73
potassium citrate ..................... 73
POTELIGEO .......................... 33
POTIGA ................................. 57
POWDERLAX ....................... 78
PRADAXA ............................. 24
PRALUENT PEN ................... 53
PRALUENT SYRINGE ......... 53
pramipexole ............................ 35
PRAMOSONE ....................... 96
pravastatin............................... 53
prazosin................................... 53
PRECISION XTRA MONITOR
............................................ 85
PRECISION XTRA TEST ..... 67
prednicarbate .......................... 96
prednisolone ........................... 82
prednisolone acetate ............... 70
prednisolone sodium phosphate
................................ 70, 82, 83
prednisone............................... 83
PREDNISONE INTENSOL ... 83
PREMARIN ........................... 83
PREMPHASE......................... 83
PREMPRO ............................. 83
PRENATABS FA ................... 85
PRENATABS RX .................. 85
PREPARATION CLEANSING
............................................ 78
PRETAB ................................. 85
PREVALITE .......................... 53
PREVIDENT .......................... 73
PREVIDENT 5000 BOOSTER
PLUS .................................. 73
PREVIDENT 5000 DRY
MOUTH ............................. 73
PREVIDENT 5000 ENAMEL
PROTECT .......................... 73
PREVIDENT 5000 PLUS ...... 73
PREVIDENT 5000 SENSITIVE
............................................ 73
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 111
PREVIFEM ............................ 64
PREVNAR 13 (PF) ................ 45
PREZCOBIX .......................... 38
PREZISTA ............................. 38
PRIFTIN ................................. 21
primaquine .............................. 30
primidone ............................... 57
PRISTIQ ................................. 90
probenecid .............................. 13
probenecid-colchicine ............ 13
procainamide .......................... 49
prochlorperazine ..................... 78
prochlorperazine edisylate...... 78
prochlorperazine maleate ....... 78
PROCORT ............................. 79
PROCRIT ............................... 58
PROCTOFOAM HC .............. 79
PROCTO-PAK ....................... 96
PROCTOSOL HC .................. 79
PROCTOZONE-HC............... 96
progesterone ........................... 83
progesterone micronized ........ 83
PROGLYCEM ....................... 73
PROGRAF ............................. 84
prolia..................................... 100
PROMACTA .......................... 58
promethazine .................... 26, 79
PROMETHAZINE VC .......... 26
PROMETHAZINE VC-
CODEINE .......................... 67
promethazine-codeine ............ 67
promethazine-dm .................... 67
promethazine-phenyleph-
codeine ............................... 67
promethazine-phenylephrine .. 26
PROMETHEGAN .................. 79
PROMISEB ............................ 96
propafenone ............................ 49
propantheline .......................... 79
proparacaine ........................... 71
propranolol ............................. 53
propranolol-hydrochlorothiazid
............................................ 53
propylthiouracil ...................... 98
PROQUAD (PF) .................... 45
protriptyline ............................ 90
PRUTECT .............................. 96
PULMOZYME..................... 100
PURELAX ............................. 79
pyrazinamide .......................... 21
pyridostigmine bromide ......... 41
Q QUADRACEL (PF) ............... 45
QUASENSE ........................... 65
quetiapine ............................... 90
quinapril.................................. 53
quinapril-hydrochlorothiazide 53
quinidine gluconate ................ 49
quinidine sulfate ..................... 49
quinine sulfate ........................ 30
R RABAVERT (PF) .................. 45
rabeprazole ............................. 79
RAGWITEK ........................... 45
raloxifene .............................. 101
ramipril ................................... 53
RANEXA ............................... 49
ranitidine hcl ........................... 79
RAPAMUNE.......................... 84
RECLIPSEN (28) ................... 65
RECOMBIVAX HB (PF) ...... 45
RECTIV.................................. 79
REGRANEX .......................... 96
RELENZA DISKHALER ...... 38
RELPAX ................................ 11
REMEVEN ............................. 96
REMODULIN ........................ 53
RENAGEL ............................. 73
RENVELA ............................. 73
repaglinide .............................. 29
REPATHA PUSHTRONEX .. 53
REPATHA SURECLICK ...... 53
REPATHA SYRINGE ........... 54
RESCRIPTOR ........................ 38
RESTASIS.............................. 71
RETROVIR ............................ 38
REVLIMID ............................ 33
REYATAZ ............................. 38
RIBASPHERE........................ 38
ribavirin .................................. 38
RIDAURA .............................. 13
rifabutin .................................. 21
rifampin .................................. 21
rimantadine ............................. 38
ringer's .................................... 96
risedronate ............................ 101
RISPERDAL CONSTA ......... 90
risperidone .............................. 90
ritonavir .................................. 38
rivastigmine tartrate ................ 41
rizatriptan ................................ 11
ropinirole ................................ 35
ROSANIL ............................... 21
ROSULA CLEANSING
CLOTHS............................. 21
rosuvastatin ............................. 54
ROTARIX .............................. 45
ROTATEQ VACCINE ........... 45
S SABRIL .................................. 57
SAFYRAL .............................. 65
salicylic acid ........................... 96
SAMSCA ................................ 68
SANDOSTATIN LAR DEPOT
............................................ 83
SANTYL ................................ 96
SAPHRIS ................................ 90
SAPHRIS (BLACK CHERRY)
............................................ 90
SAVELLA ............................ 101
scopolamine base .................... 79
SEGLUROMET ..................... 29
selegiline hcl ........................... 35
selenium sulfide ...................... 96
SELZENTRY ......................... 39
SENSIPAR ........................... 101
SEREVENT DISKUS ............ 15
SEROQUEL XR ..................... 90
sertraline ................................. 90
SETLAKIN............................. 65
SF ............................................ 73
SF 5000 PLUS ........................ 73
SHAROBEL ........................... 65
SHINGRIX (PF) ..................... 45
SHINGRIX GE ANTIGEN
COMPONENT ................... 45
SIGNIFOR LAR ..................... 83
sildenafil (antihypertensive) ... 54
SILENOR ............................... 92
silver sulfadiazine ................... 22
SIMBRINZA .......................... 71
simvastatin .............................. 54
sirolimus ................................. 84
SKLICE .................................. 96
SKYLA ................................... 65
SMOOTHLAX ....................... 79
sodium chloride .............. 96, 101
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 112
sodium chloride 0.9 % ............ 73
sodium phenylbutyrate ........... 79
SODIUM POLYSTYRENE
(SORB FREE) .................... 73
sodium polystyrene sulfonate . 73
SOMATULINE DEPOT ........ 83
somavert ............................... 101
SOMAVERT ........................ 101
SORINE ................................. 54
sotalol ..................................... 54
SOTALOL AF........................ 54
SOVALDI .............................. 39
SPIRIVA RESPIMAT ........... 15
SPIRIVA WITH
HANDIHALER .................. 15
spironolactone ........................ 68
spironolacton-hydrochlorothiaz
............................................ 68
SPRINTEC (28) ..................... 65
SPRYCEL .............................. 33
SPS (WITH SORBITOL)....... 73
SRONYX ............................... 65
SSD......................................... 22
SSS 10-5 ................................. 22
stavudine................................. 39
STEGLATRO......................... 29
STIOLTO RESPIMAT .......... 15
STRATTERA ......................... 91
streptomycin ........................... 22
STRIBILD .............................. 39
STRIVERDI RESPIMAT ...... 15
SUBOXONE ........................ 101
sucralfate ................................ 79
sulfacetamide sodium ....... 22, 96
sulfacetamide sodium (acne) .. 96
sulfacetamide sodium-sulfur .. 22
sulfacetamide sod-sulfur-urea 22
sulfadiazine............................. 22
sulfamethoxazole-trimethoprim
............................................ 22
SULFAMYLON..................... 22
sulfasalazine ........................... 79
SULFAZINE .......................... 79
sulindac................................... 13
sumatriptan succinate ............. 11
SUPREP BOWEL PREP KIT 79
SUSTIVA ............................... 39
SUTENT................................. 34
SYEDA................................... 65
SYMBICORT......................... 16
SYMFI .................................... 39
SYMFI LO ............................. 39
SYMLINPEN 120 .................. 29
SYMLINPEN 60 .................... 29
SYNAREL.............................. 83
SYNERA ................................ 12
SYNJARDY ........................... 29
SYNJARDY XR..................... 29
SYNTHROID ......................... 98
SYPRINE ............................. 101
T TABLOID .............................. 34
tacrolimus ............................... 84
tadalafil (antihypertensive) ..... 54
TAKE ACTION ..................... 65
TAKHZYRO .......................... 45
TAMIFLU .............................. 39
tamoxifen ................................ 34
tamsulosin ............................. 101
TANZEUM ............................ 29
TARCEVA ............................. 34
TARGRETIN ......................... 34
TARINA FE 1/20 (28) ........... 65
TASIGNA .............................. 34
TAVALISSE ........................ 101
tazarotene................................ 97
TAZORAC ............................. 97
TAZTIA XT ........................... 49
TECFIDERA .......................... 57
TEKAMLO ............................ 54
TEKTURNA .......................... 54
TEKTURNA HCT ................. 54
telmisartan .............................. 54
temazepam .............................. 92
temozolomide ......................... 34
TENIVAC (PF) ................ 45, 46
tenofovir disoproxil fumarate . 39
terazosin.................................. 54
terbinafine hcl ......................... 25
terbutaline ............................... 16
terconazole.............................. 25
testosterone ....................... 83, 84
testosterone cypionate ............ 83
testosterone enanthate............. 83
tetanus toxoid adsorbed .......... 46
tetanus toxoid fluid ................. 46
tetanus toxoid,adsorbed (pf) ... 46
tetanus,diphtheria tox ped(pf). 46
tetanus-diphtheria toxoids-td .. 46
tetracycline ............................. 22
THALOMID ........................... 22
theophylline ............................ 16
THERMAZENE ..................... 22
thioridazine ............................. 91
thiothixene .............................. 91
THYMOGLOBULIN ............. 46
tiagabine ................................. 57
ticlopidine ............................... 36
TIGAN .................................... 79
TILIA FE ................................ 65
timolol maleate ................. 54, 71
TIVICAY ................................ 39
tizanidine ................................ 85
TOBRADEX .......................... 22
TOBRADEX ST ..................... 22
tobramycin .............................. 23
tobramycin in 0.225 % nacl .... 22
tobramycin-dexamethasone .... 23
TODAY CONTRACEPTIVE
SPONGE............................. 65
tolcapone................................. 35
tolmetin ................................... 13
tolterodine ............................. 101
topiramate ............................... 57
torsemide ................................ 68
TOUJEO SOLOSTAR U-300
INSULIN ............................ 29
TOVIAZ ............................... 101
TRACLEER ........................... 54
TRADJENTA ......................... 29
tramadol .................................. 11
tramadol-acetaminophen ........ 12
trandolapril ............................. 54
tranexamic acid ....................... 47
tranylcypromine ...................... 91
TRAVATAN Z ....................... 71
trazodone ................................ 91
TRECATOR ........................... 23
TRELEGY ELLIPTA ............. 16
TRESIBA FLEXTOUCH U-100
............................................ 29
TRESIBA FLEXTOUCH U-200
............................................ 29
tretinoin................................... 97
tretinoin (chemotherapy) ........ 34
tretinoin (emollient) ................ 97
tretinoin microspheres ............ 97
triamcinolone acetonide... 84, 97,
101
triamterene-hydrochlorothiazid
............................................ 68
triazolam ................................. 92
TRIBENZOR .......................... 54
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 113
TRICITRATES ...................... 74
trientine................................. 101
TRI-ESTARYLLA ................. 65
trifluoperazine ........................ 91
trifluridine............................... 39
trihexyphenidyl....................... 35
TRIHIBIT (PF) ....................... 46
TRI-LEGEST FE.................... 65
TRI-LINYAH ......................... 65
TRI-LO-SPRINTEC............... 65
TRILYTE WITH FLAVOR
PACKETS .......................... 79
trimethobenzamide ................. 79
trimethoprim ........................... 23
trimipramine ........................... 91
TRINESSA (28) ..................... 65
TRINTELLIX......................... 91
TRIPEDIA (PF)...................... 46
TRI-PREVIFEM (28) ............. 65
TRI-SPRINTEC (28).............. 65
TRIUMEQ .............................. 39
TRIVORA (28) ...................... 65
tropicamide ............................. 71
trospium ................................ 101
TRUMENBA ......................... 46
TRUVADA ............................ 39
TWINRIX (PF) ...................... 46
TYBOST .............................. 101
TYKERB ................................ 34
TYMLOS ............................... 84
TYPHIM VI ........................... 46
TYZEKA ................................ 39
TYZINE ................................. 71
U ULESFIA ............................... 97
ULORIC ................................. 13
UNITHROID .......................... 99
urea ......................................... 97
ursodiol ................................... 79
V VAGIFEM .............................. 84
valacyclovir ............................ 39
VALCYTE ............................. 39
valganciclovir ......................... 39
valproic acid ........................... 58
valproic acid (as sodium salt) . 58
valsartan ................................. 54
valsartan-hydrochlorothiazide 54
vancomycin ............................ 23
VAQTA (PF) .......................... 46
VARIVAX (PF) ..................... 46
VARIZIG................................ 46
VASCEPA .............................. 80
VELIVET TRIPHASIC
REGIMEN (28) .................. 66
VELTIN.................................. 97
venlafaxine ............................. 91
VENTAVIS ............................ 54
VENTOLIN HFA ................... 16
VERAMYST .......................... 71
verapamil ................................ 49
VEREGEN ............................. 39
VERZENIO ............................ 34
VESICARE .......................... 101
VESTURA (28) ...................... 66
VEXOL .................................. 71
VICTOZA 2-PAK .................. 29
VICTOZA 3-PAK .................. 30
VIDEX 2 GRAM PEDIATRIC
............................................ 39
VIDEX 4 GRAM PEDIATRIC
............................................ 39
vigabatrin ................................ 58
VIGAMOX ............................. 23
VIIBRYD ............................... 91
VIMPAT ................................. 58
VIORELE (28) ....................... 66
VIRACEPT ............................ 39
VIREAD ........................... 39, 40
VITAFOL-OB+DHA ............. 85
VITAMIN D2 ....................... 102
VITEKTA ............................... 40
VIVOTIF ................................ 47
VIVOTIF BERNA VACCINE
............................................ 46
voriconazole ........................... 25
VOTRIENT ............................ 34
VUSION ................................. 25
VYFEMLA (28) ..................... 66
VYTORIN 10-10 .................... 54
VYTORIN 10-20 .................... 54
VYTORIN 10-40 .................... 54
VYTORIN 10-80 .................... 54
VYVANSE ............................. 91
VYXEOS ................................ 34
W warfarin .................................. 24
water for irrigation, sterile ...... 97
WELCHOL............................. 55
WERA (28) ............................. 66
WIDE-SEAL DIAPHRAGM 60
............................................ 66
WIDE-SEAL DIAPHRAGM 65
............................................ 66
WIDE-SEAL DIAPHRAGM 70
............................................ 66
WIDE-SEAL DIAPHRAGM 75
............................................ 66
WIDE-SEAL DIAPHRAGM 80
............................................ 66
WIDE-SEAL DIAPHRAGM 85
............................................ 66
WIDE-SEAL DIAPHRAGM 90
............................................ 66
WIDE-SEAL DIAPHRAGM 95
............................................ 66
WOMAN'S LAXATIVE ........ 80
WOMEN'S GENTLE
LAXATIVE(BISAC) ......... 80
WOMEN'S LAXATIVE
(BISACODYL)................... 80
WYMZYA FE ........................ 66
X XALKORI .............................. 34
XARELTO ............................. 24
XELJANZ............................... 13
XELJANZ XR ........................ 14
XIFAXAN .............................. 23
XOLAIR ................................. 16
XTAMPZA ER ....................... 12
XTANDI ................................. 34
XULANE ................................ 66
XYREM .................................. 92
Y YASMIN (28) ......................... 66
YAZ (28) ................................ 66
YF-VAX (PF) ......................... 47
YONSA .................................. 34
Z zafirlukast ............................... 16
zaleplon................................... 92
ZARAH .................................. 66
ZAVESCA ............................ 101
ZEMAIRA ............................ 102
ZENATANE ........................... 97
ZENCHENT (28) ................... 66
ZENCHENT FE ..................... 66
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 114
ZETIA .................................... 55
ZIAGEN ................................. 40
ZIANA ................................... 97
zidovudine .............................. 40
ZIOPTAN (PF) ....................... 71
ziprasidone hcl........................ 91
ZIRGAN ................................. 40
ZOHYDRO ER ...................... 12
zoledronic acid-mannitol-water
.......................................... 102
ZOLINZA ............................... 34
zolmitriptan ............................ 12
zolpidem ................................. 92
ZOMIG ................................... 12
ZONALON ............................. 97
zonisamide .............................. 58
ZONTIVITY .......................... 36
ZORTRESS ............................ 84
ZOSTAVAX (PF) .................. 47
ZOVIA 1/35E (28) ................. 66
ZOVIA 1/50E (28) ................. 66
ZYFLO ................................... 16
ZYFLO CR ............................. 16
ZYLET ................................... 23
ZYTIGA ................................. 34
2018 Commercial/TPA 5 Tier Formulary Version 5 Page 115
This formulary was updated on 11/01/2018. For more recent information or other questions, please call Customer Service toll-free at 1.844.522.5279 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 5 p.m. or visit myFHCA.org.
Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
Nondiscrimination Notice
Florida Hospital Care Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Hospital Care Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Florida Hospital Care Advantage:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, accessible electronic formats)
Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If you need these services, please contact Civil Rights Coordinator.
If you believe that Florida Hospital Care Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, 6450 US Highway 1, Rockledge, FL 32955, 321-434-4521, 1-800-955-8771 (TTY), Fax: 321-434-4362, civilrightscoordinator@health-first.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance our Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
36194_MPINFO324FH (08/2017)
English:
If you, or someone you’re helping, has questions about Florida Hospital Care Advantage, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 844-522-5279.
Spanish:
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Haitian Creole:
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Vietnamese:
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Portuguese:
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Chinese:
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您的母語免費取得幫助和資訊。請致電 844-522-5279 與翻譯員洽談。
French:
Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Florida Hospital Care Advantage, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 844-522-5279.
Tagalog:
Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Florida Hospital Care Advantage, may karapatan ka na humingi ng tulong at impormasyon sa iyong wika nang libre. Upang makausap ang isang tagasalin, tumawag sa 844-522-5279.
Russian:
Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Florida Hospital Care Advantage, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 844-522-5279.
Arabic:
، فلديك الحق في الحصول على Florida Hospital Care Advantageإن كان لديك أو لدى شخص تساعده أسئلة بخصوص 5279-522-844المساعدةوالمعلومات الضرورية بلغتك من دون أية تكلفة. للتحدث مع مترجم اتصل بالرقم
Italian:
Se lei o qualcuno che sta aiutando avete domande su Florida Hospital Care Advantage, ha il diritto di ottenere aiuto e informazioni nella sua lingua gratuitamente. Per parlare con un interprete, può chiamare il numero 844-522-5279.
German:
Falls Sie oder jemand, dem Sie helfen, Fragen zum Florida Hospital Care Advantage haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 844-522-5279 an.
Korean:
만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Florida Hospital Care Advantage에 관해서 질문이
있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가
있습니다. 그렇게 통역사와 얘기하기 위해서는 844-522-5279로 전화하십시오.
Polish:
Jeśli Ty lub osoba, której pomagasz, macie pytania na temat Florida Hospital Care Advantage, macie Państwo prawo do bezpłatnego uzyskania informacji i pomocy w języku ojczystym. Aby porozmawiać z tłumaczem, prosimy zadzwonić pod numer 844-522-5279.
Gujarati:
જો તમે અથવા તમ ેકોઇને મદદ કરી રહ્યા હો તેમાાંથી કોઇન ેફ્લોરિડા હોસ્પિટલ કેિ એડવાાંટેજ વવશે પ્રશ્નો હોય
તો તમને તમારી ભાષામાાં વવના મલૂ્યે મદદ અન ેમાહહતી મેળવવાનો અવિકાર છે. દુભાવષયા સાથ ેવાત કરવા માટે 844-522-5279 પર કૉલ કરો. Thai:
หากคณุหรอืคนทีค่ณุก าลงัชว่ยเหลอืมคี าถามเกีย่วกบั Florida Hospital Care Advantage
คุณมสีทิธทิีจ่ะไดร้บัความชว่ยเหลอืและขอ้มลูในภาษาของคณุไดโ้ดยไมม่คี่าใชจ้า่ย หากตอ้งการพูดคุยกบัล่าม โปรดโทร 844-522-5279.
Health First Commercial Plans, Inc. is doing business under the name of Florida Hospital Care Advantage. Florida Hospital Care Advantage does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
36194_MPINFO109FH (10/2016)