2018 Select Formulary - Southern Scripts, LLC Rx Select Formulary... · 2018 Select Formulary...
Transcript of 2018 Select Formulary - Southern Scripts, LLC Rx Select Formulary... · 2018 Select Formulary...
2018 Select Formulary
Effective 01/01/2018
The Formulary List is a guide providing tier designation for common medicines within select therapeutic categories. The Formulary List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing.
For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available. It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider.
Tier Definitions 1 Generics 2 Preferred Brands 3 Non-Preferred Brands 4 Excluded Drugs - 100% Patient Liability (ST) Step Therapy (PA) Prior Authorization (SP) Specialty Drugs
Major Drug Class Overview Non-Preferred and Excluded* Drugs With Preferred Options
2018
Preferred Non-Preferred / Excluded * Drug Class
ANALGESICS
EUFLEXXA*, GEL-ONE*, HYALGAN*, MONOVISC*, ORTHOVISC*
GELSYN-3, SUPARTZ FX, SYNVISC, SYNVISC-ONE
ANTIARTHRITICS
ABSTRAL*, EMBEDA, FENTORA*, KADIAN, ZOHYDRO ER
fentanyl, fentanyl citrate, morphine sulfate er, oxycodone hcl, HYSINGLA ER, NUCYNTA ER, OXYCONTIN
NARCOTICS
ANTI-INFECTIVES
REBETOL moderiba, ribapak, ribavirin, ribavirin ANTIVIRALS
DAKLINZA*, EPCLUSA*, HARVONI*, SOVALDI*, TECHNIVIE*, VIEKIRA PAK*
MAVYRET, ZEPATIER HEPATITIS C
DOXYCYCLINE IR-DR* ORACEA TETRACYCLINES
CARDIAC
BENICAR HCT, EDARBI*, EDARBYCLOR* candesartan-hydrochlorothiazid, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide
ANGIOTENSIN RECEPTOR BLOCKER
PRADAXA clopidogrel, ELIQUIS, XARELTO ANTICOAGULANTS
LIVALO, VYTORIN atorvastatin calcium, rosuvastatin calcium, simvastatin
STATINS
CNS
ADDERALL XR dextroamphetamine-amphet er, dextroamphetamine-amphetamine
ADHD
PEXEVA, SARAFEM citalopram hbr, escitalopram oxalate, escitalopram oxalate, fluoxetine hcl, fluvoxamine maleate, paroxetine er, paroxetine hcl, sertraline hcl, trazodone hcl, VIIBRYD
ANTIDEPRESSANTS
FANAPT, INVEGA, REXULTI aripiprazole, olanzapine, olanzapine odt, quetiapine fumarate, quetiapine fumarate er, LATUDA, SAPHRIS
ANTI-PSYCHOTIC
ZOLPIMIST eszopiclone, zaleplon, zolpidem tartrate er, BELSOMRA, ROZEREM
SLEEP
DIABETES
ALOGLIPTIN*, KAZANO*, KOMBIGLYZE XR*, NESINA*, ONGLYZA*, OSENI*
JANUMET XR, JANUVIA, JENTADUETO, TRADJENTA
DPP-4
BYDUREON PEN*, BYETTA*, TANZEUM* TRULICITY, VICTOZA INCRETINS
AFREZZA, APIDRA*, HUMALOG*, HUMALOG MIX 50-50*, HUMALOG MIX 75-25*, HUMULIN 70-30*, HUMULIN N*, HUMULIN R*
NOVOLIN 70-30, NOVOLIN N, NOVOLIN R, NOVOLOG, NOVOLOG FLEXPEN, NOVOLOG MIX 70-30
INSULIN
BASAGLAR KWIKPEN U-100* LANTUS, LANTUS SOLOSTAR, LEVEMIR, TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH U-200
INSULIN: LONG ACTING
GLUMETZA*, RIOMET metformin hcl OTHER
INVOKAMET*, INVOKANA* FARXIGA, JARDIANCE, SYNJARDY, XIGDUO XR
SGLT-2
Preferred Non-Preferred / Excluded * Drug Class
DIABETES
ACCU-CHEK AVIVA CONNECT*, ACCU-CHEK AVIVA PLUS*, ADVOCATE BLOOD GLUCOSE MONITOR*, ASCENSIA BREEZE 2*, CONTOUR*, EMBRACE*, FREESTYLE TEST STRIPS*, PRODIGY*, TRUETEST TEST STRIPS*, TRUETRACK SMART SYSTEM*, UNISTRIP1*
ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO
TESTING
ENDOCRINE
ESTRING estradiol, DIVIGEL, PREMARIN ESTROGENS
GANIRELIX ACETATE*, PREGNYL CETROTIDE, NOVAREL GONADOTROPIN
BRAVELLE*, FOLLISTIM AQ*, FOLLISTIM AQ* clomiphene citrate, GONAL-F, MENOPUR OVULATORY STIMULANTS
ENDOMETRIN* CRINONE PROGESTINS
AXIRON*, FORTESTA*, NATESTO*, STRIANT*, TESTIM*, VOGELXO*
ANDROGEL TESTOSTERONE
GASTROINTESTINAL
PANCREAZE*, PERTZYE* CREON, VIOKACE, ZENPEP DIGESTIVE ENZYMES
ASACOL HD*, DELZICOL*, DIPENTUM*, LIALDA balsalazide disodium, AMITIZA, APRISO, LINZESS, PENTASA
OTHER
DEXILANT, ZEGERID RX lansoprazole, omeprazole, pantoprazole sodium
PROTON PUMP INHIBITORS
GROWTH HORMONES
GENOTROPIN*, HUMATROPE*, NUTROPIN AQ NUSPIN*, OMNITROPE*, SAIZEN*, ZOMACTON*, ZORBTIVE*
NORDITROPIN FLEXPRO
HEMATOLOGY
ARANESP*, EPOGEN*, MIRCERA* PROCRIT
MUSCULOSKELETAL
ACTEMRA, CIMZIA, OTEZLA, REMICADE, SIMPONI, STELARA, TALTZ AUTOINJECTOR, TALTZ SYRINGE, XELJANZ
COSENTYX 150MG, COSENTYX 300MG, ENBREL, ENTYVIO, HUMIRA, ORENCIA, SILIQ
ANTI-INFLAMMATORY **
** Trial of ONE First Line Product and ONE Second Line Product is Required before any Non-Preferred Products.
Required Second Line Required First Line Indication
HUMIRA or ORENCIA HUMIRA or ORENCIA Rheumatoid Arthritis
Juvenille Idiopathic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA
COSENTYX or HUMIRA or ORENCIA HUMIRA or ORENCIA Ankylosing Spondylitis
Psoriatic Arthritis HUMIRA or ORENCIA HUMIRA or ORENCIA
COSENTYX or SILIQ COSENTYX or HUMIRA Plaque Psoriasis
ENBREL Pediatric Plaque Psoriasis
ENTYVIO HUMIRA Crohn's Disease
HUMIRA Pediatric Crohn's
ENTYVIO HUMIRA Ulcerative Colitis
HUMIRA Hidradentis Supperativa
HUMIRA Uvelitis
OPHTHALMIC
AZOPT, COSOPT PF, SIMBRINZA dorzolamide hcl, latanoprost, COMBIGAN, TRAVATAN Z, ZIOPTAN
GLAUCOMA
ACUVAIL* bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, NEVANAC, PROLENSA
NSAIDS
Preferred Non-Preferred / Excluded * Drug Class
OTIC
CETRAXAL* ciprofloxacin hcl MISCELLANEOUS
RESPIRATORY
DULERA*, INCRUSE ELLIPTA*, TUDORZA PRESSAIR*
ADVAIR DISKUS, ANORO ELLIPTA, BREO ELLIPTA, SPIRIVA, STIOLTO RESPIMAT, SYMBICORT
ARCAPTA NEOHALER*, FORADIL, PROVENTIL HFA*, XOPENEX HFA*
PERFOROMIST, PROAIR HFA, SEREVENT DISKUS, VENTOLIN HFA
BETA AGONISTS
ALVESCO*, ASMANEX* ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR
INHALED STEROIDS
BECONASE AQ*, NASONEX, OMNARIS*, ZETONNA*
flunisolide, DYMISTA, QNASL NASAL STEROIDS
TOPICAL
ATRALIN, AVAGE, AZELEX, BENZACLIN, VELTIN*
adapalene, clindamycin phos-tretinoin, clindamycin-benzoyl peroxide, erythromycin, metronidazole, tretinoin, ACANYA, EPIDUO, FINACEA, TAZORAC
ACNE
ALDARA, FLUOROURACIL*, ZYCLARA* fluorouracil, imiquimod, PICATO MISCELLANEOUS
UROLOGICAL
ENABLEX, GELNIQUE, TOVIAZ* oxybutynin chloride, tolterodine tartrate, MYRBETRIQ, VESICARE
ANTISPASMODICS
CIALIS*, LEVITRA*, STAXYN*, STENDRA*, VIAGRA
sildenafil citrate ERECTILE DYSFUNCTION
Please Note: Drugs Marked with * are Excluded
CARDIAC
ACE INHIBITORS
CAPSULE
amlodipine besylate-benazepril 1
TABLET
benazepril hcl 1
TABLET
benazepril hcl-hctz 1
TABLET
captopril 1
TABLET
captopril/hydrochlorothiazide 1
TABLET
enalapril maleate 1
TABLET
fosinopril sodium 1
TABLET
fosinopril-hydrochlorothiazide 1
TABLET
lisinopril 1
TABLET
lisinopril-hctz 1
TABLET
moexipril hcl 1
TABLET
moexipril-hydrochlorothiazide 1
TABLET
perindopril erbumine 1
TABLET
quinapril 1
TABLET
quinapril-hydrochlorothiazide 1
CAPSULE
ramipril 1
TABLET
trandolapril 1
TABLET
ACCUPRIL 3
CAPSULE
ALTACE 3
SOLUTION, ORAL
EPANED 3
TABLET
LOTENSIN 3
TABLET
MAVIK 3
TABLET
PRINIVIL 3
SOLUTION, ORAL
QBRELIS 3
TABLET,IMMED AND EXTEND REL BIPHASE 24HR
TARKA 3
TABLET
VASOTEC 3
TABLET
ZESTRIL 3
ANTICOAGULANTS
TABLET
cilostazol 1
TABLET
clopidogrel 1
TABLET
dipyridamole 1
SYRINGE (ML)
enoxaparin sodium SP 1
SYRINGE (ML)
fondaparinux sodium SP 1
VIAL (ML)
heparin sodium 1
TABLET
jantoven 1
TABLET, EXTENDED RELEASE
pentoxifylline 1
TABLET
ticlopidine hcl 1
TABLET
warfarin sodium 1
TABLET
BRILINTA 2
TABLET
COUMADIN 2
TABLET
EFFIENT 2
TABLET
ELIQUIS 2
SYRINGE (ML)
FRAGMIN SP 2
TABLET
MEPHYTON 2
TABLET
XARELTO SP 2
CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR
AGGRENOX 3
CAPSULE
PRADAXA 3
ANTIARRHYTHMIC
TABLET
amiodarone hcl 1
SOLUTION, ORAL
digoxin 1
TABLET
digoxin 1
CAPSULE
disopyramide phosphate 1
TABLET
flecainide acetate 1
CAPSULE
mexiletine hcl 1
TABLET
pacerone 1
VIAL (ML)
procainamide hcl 1
TABLET
propafenone hcl 1
Printed Date:11/1/2017
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B4G Participant: N
CARDIAC
ANTIARRHYTHMIC
VIAL (ML)
quinidine gluconate 1
TABLET, EXTENDED RELEASE
quinidine sulfate 1
TABLET
quinidine sulfate 1
TABLET
sorine 1
TABLET
sotalol 1
TABLET
sotalol af 1
TABLET
MULTAQ 3
CAPSULE, EXTENDED RELEASE
NORPACE CR 3
CAPSULE
TIKOSYN SP 3
OTHER
TABLET
ENTRESTO 2
TABLET, EXTENDED RELEASE 12 HR
RANEXA 2
TABLET
VECAMYL 3
ANGIOTENSIN RECEPTOR BLOCKER
TABLET
candesartan cilexetil 1
TABLET
candesartan-hydrochlorothiazid 1
TABLET
eprosartan mesylate 1
TABLET
irbesartan 1
TABLET
irbesartan-hydrochlorothiazide 1
TABLET
losartan potassium 1
TABLET
losartan-hydrochlorothiazide 1
TABLET
olmesartan medoxomil 1
TABLET
olmesartan medoxomil 1
TABLET
telmisartan 1
TABLET
telmisartan-amlodipine 1
TABLET
telmisartan-hydrochlorothiazid 1
TABLET
valsartan 1
TABLET
valsartan-hydrochlorothiazide 1
TABLET
TEKAMLO 2
TABLET
TEKTURNA 2
TABLET
TEKTURNA HCT 2
TABLET
ATACAND HCT 3
TABLET
AZOR 3
TABLET
BENICAR 3
TABLET
BENICAR HCT 3
TABLET
DIOVAN HCT 3
TABLET
EXFORGE 3
TABLET
EXFORGE HCT 3
TABLET
TRIBENZOR 3
TABLET
EDARBI 4
TABLET
EDARBYCLOR 4
BETA BLOCKERS
CAPSULE
acebutolol hcl 1
TABLET
atenolol 1
TABLET
atenolol w/chlorthalidone 1
TABLET
betaxolol hcl 1
TABLET
bisoprolol fumarate 1
TABLET
bisoprolol fumarate/hctz 1
TABLET
carvedilol 1
TABLET
labetalol hcl 1
TABLET
metoprolol tartrate 1
TABLET
nadolol 1
TABLET
nadolol-bendroflumethiazide 1
TABLET
pindolol 1
TABLET
propranolol hcl 1
SOLUTION, ORAL
propranolol hcl 1
TABLET
propranolol hcl-hctz 1
Printed Date:11/1/2017
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B4G Participant: N
CARDIAC
BETA BLOCKERS
TABLET
timolol maleate 1
TABLET
BYSTOLIC 2
CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR
COREG CR 2
TABLET
LEVATOL 3
CALCIUM CHANNEL BLOCKERS
TABLET, EXTENDED RELEASE
afeditab cr 1
TABLET
amlodipine besylate 1
CAPSULE, EXT RELEASE 24 HR
cartia xt 1
CAPSULE, EXT RELEASE 24 HR
diltiazem 24hr cd 1
CAPSULE, EXT RELEASE 24 HR
diltiazem er 1
TABLET
diltiazem hcl 1
TABLET, EXTENDED RELEASE 24 HR
felodipine er 1
CAPSULE
isradipine 1
CAPSULE
nifedipine 1
TABLET, EXTENDED RELEASE
nifedipine er 1
CAPSULE
nimodipine 1
TABLET, EXTENDED RELEASE 24 HR
nisoldipine 1
CAPSULE, EXTENDED RELEASE 24HR
taztia xt 1
CAPSULE,24HR EXTENDED RELEASE PELLET CT
verapamil er pm 1
TABLET
verapamil hcl 1
DIURETICS
TABLET
acetazolamide 1
TABLET
amiloride hcl 1
TABLET
amiloride hcl w/hctz 1
TABLET
bumetanide 1
TABLET
chlorothiazide 1
TABLET
eplerenone 1
SOLUTION, ORAL
furosemide 1
TABLET
hydrochlorothiazide 1
TABLET
indapamide 1
TABLET
methazolamide 1
TABLET
methyclothiazide 1
TABLET
metolazone 1
TABLET
spironolactone 1
TABLET
spironolactone w/hctz 1
TABLET
torsemide 1
TABLET
triamterene w/hctz 1
CAPSULE
DYRENIUM 3
OTHER ANTI-HYPERTENSIVES
TABLET
clonidine hcl 1
TABLET
clorpres 1
TABLET
doxazosin mesylate 1
TABLET
guanfacine hcl 1
TABLET
hydralazine hcl 1
TABLET
methyldopa 1
TABLET
methyldopa/hydrochlorothiazide 1
TABLET
minoxidil 1
CAPSULE
prazosin hcl 1
TABLET
reserpine 1
CAPSULE
terazosin hcl 1
TABLET
BIDIL 3
TABLET, EXTENDED RELEASE 24 HR
CARDURA XL 3
STATINS
TABLET
amlodipine-atorvastatin 1
TABLET
atorvastatin calcium 1
POWDER IN PACKET (EA)
cholestyramine 1
TABLET
colestipol hcl 1
Printed Date:11/1/2017
Page 7 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
CARDIAC
STATINS
TABLET
fenofibrate 1
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
fenofibric acid 1
CAPSULE
fluvastatin sodium 1
TABLET
gemfibrozil 1
TABLET
lovastatin 1
TABLET, EXTENDED RELEASE 24 HR
niacin er 1
TABLET
pravastatin sodium 1
POWDER IN PACKET (EA)
prevalite 1
TABLET
rosuvastatin calcium 1
TABLET
simvastatin 1
CAPSULE
JUXTAPID SP 2
CAPSULE
LIPOFEN 2
PEN INJECTOR (ML)
PRALUENT PEN SP 2
SYRINGE (ML)
PRALUENT SYRINGE SP 2
PEN INJECTOR (ML)
REPATHA SURECLICK SP 2
SYRINGE (ML)
REPATHA SYRINGE SP 2
CAPSULE
VASCEPA 2
TABLET
WELCHOL 2
POWDER IN PACKET (EA)
WELCHOL 2
TABLET, EXTENDED RELEASE 24 HR
ALTOPREV 3
CAPSULE
ANTARA 3
TABLET
CRESTOR 3
TABLET
FENOGLIDE 3
TABLET, EXTENDED RELEASE 24 HR
LESCOL XL 3
TABLET
LIVALO 3
CAPSULE
LOVAZA 3
TABLET
NIACOR 3
TABLET
TRIGLIDE 3
TABLET
VYTORIN 3
TABLET
ZETIA 3
NITRATES
TABLET
isosorbide dinitrate 1
TABLET
isosorbide mononitrate 1
OINTMENT (GRAM)
nitro-bid 1
PATCH, TRANSDERMAL 24 HOURS
nitroglycerin 1
AEROSOL, SPRAY (GRAM)
nitroglycerin 1
CAPSULE, EXTENDED RELEASE
DILATRATE-SR 2
PATCH, TRANSDERMAL 24 HOURS
MINITRAN 3
PATCH, TRANSDERMAL 24 HOURS
NITRO-DUR 3
TABLET, SUBLINGUAL
NITROSTAT 3
ANALGESICS
ANTIARTHRITICS
SYRINGE (ML)
GELSYN-3 SP 2
SYRINGE (ML)
SUPARTZ FX SP 2
SYRINGE (ML)
SYNVISC SP 2
SYRINGE (ML)
SYNVISC-ONE SP 2
SYRINGE (ML)
EUFLEXXA SP 4
SYRINGE (ML)
GEL-ONE SP 4
SYRINGE (ML)
GENVISC 850 SP 4
SYRINGE (ML)
HYALGAN SP 4
SYRINGE (ML)
HYMOVIS SP 4
SYRINGE (ML)
MONOVISC SP 4
SYRINGE (ML)
ORTHOVISC SP 4
HEADACHE
CAPSULE
apap/dichlphen/isometheptene 1
AEROSOL, SPRAY WITH PUMP (ML)
dihydroergotamine mesylate SP 1
TABLET
naratriptan hcl 1
Printed Date:11/1/2017
Page 8 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
ANALGESICS
HEADACHE
TABLET
rizatriptan 1
TABLET
sumatriptan succinate 1
PEN INJECTOR (ML)
sumatriptan succinate SP 1
SPRAY, NON-AEROSOL (EA)
sumatriptan succinate SP 1
TABLET
zolmitriptan 1
TABLET,DISINTEGRATING
zolmitriptan odt 1
TABLET
TREXIMET 2
SPRAY, NON-AEROSOL (EA)
ZOMIG 2
TABLET
AXERT 3
TABLET
CAFERGOT 3
TABLET, SUBLINGUAL
ERGOMAR 3
TABLET
FROVA 3
TABLET
RELPAX 3
NEEDLE-FREE INJECTOR (ML)
SUMAVEL DOSEPRO 4
NARCOTIC ANTAGONISTS
TABLET, SUBLINGUAL
buprenorphine-naloxone 1
TABLET
naltrexone hydrochloride 1
SPRAY, NON-AEROSOL (EA)
NARCAN 2
FILM, MEDICATED (EA)
SUBOXONE 2
SUSPENSION, EXTENDED RELEASE, RECONST.
VIVITROL 2
TABLET, SUBLINGUAL
ZUBSOLV 2
NARCOTICS
SOLUTION, ORAL
acetaminophen w/codeine 1
TABLET
acetaminophen w/codeine 1
TABLET, SUBLINGUAL
buprenorphine hydrochloride 1
CAPSULE
butalbital compound 1
CAPSULE
butalbital compound w/codeine 1
TABLET
butalbital/apap/caffeine 1
CAPSULE
butalbital/caff/apap/codeine 1
TABLET
codeine sulfate 1
TABLET, SOLUBLE
diskets 1
PATCH, TRANSDERMAL 72 HOURS
fentanyl 1
LOZENGE ON A HANDLE
fentanyl citrate 1
TABLET
hydrocodone bit-ibuprofen 1
TABLET
hydrocodone w/acetaminophen 1
SOLUTION, ORAL
hydrocodone w/acetaminophen 1
TABLET
hydromorphone hcl 1
SOLUTION, ORAL
meperidine hcl 1
SOLUTION, ORAL
methadone hcl 1
SUPPOSITORY, RECTAL
morphine sulfate 1
TABLET, EXTENDED RELEASE
morphine sulfate er 1
SOLUTION, ORAL
oxycodone hcl 1
TABLET
oxycodone hcl-ibuprofen 1
TABLET
oxycodone w/acetaminophen 1
TABLET
oxycodone w/aspirin 1
TABLET
oxymorphone hcl 1
TABLET,ORAL ONLY,EXTENDED RELEASE 24 HR
HYSINGLA ER 2
TABLET
NUCYNTA 2
TABLET, EXTENDED RELEASE 12 HR
NUCYNTA ER 2
TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR
OXYCONTIN 2
SUSPENSION, ORAL (FINAL DOSE FORM)
CAPITAL W/CODEINE 3
CAPSULE,ORAL ONLY, EXT. RELEASE PELLETS
EMBEDA 3
CAPSULE, EXTENDED RELEASE PELLETS
KADIAN 3
TABLET
PRIMLEV 3
CAPSULE,ORAL ONLY, EXTENDED RELEASE 12HR
ZOHYDRO ER 3
TABLET, SUBLINGUAL
ABSTRAL 4
Printed Date:11/1/2017
Page 9 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
ANALGESICS
NARCOTICS
PATCH, TRANSDERMAL WEEKLY
BUTRANS 4
TABLET, EFFERVESCENT
FENTORA 4
SPRAY, NON-AEROSOL (EA)
SUBSYS 4
NSAIDS
CAPSULE
celecoxib 1
TABLET
diclofenac potassium 1
TABLET, EXTENDED RELEASE 24 HR
diclofenac sodium 1
TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE
diclofenac sodium-misoprostol 1
TABLET
etodolac 1
TABLET
fenoprofen calcium 1
TABLET
flurbiprofen 1
CAPSULE
indomethacin 1
CAPSULE
ketoprofen 1
TABLET
ketorolac tromethamine 1
CAPSULE
meclofenamate sodium 1
CAPSULE
mefenamic acid 1
TABLET
meloxicam 1
SUSPENSION, ORAL (FINAL DOSE FORM)
meloxicam 1
TABLET
nabumetone 1
TABLET
naproxen 1
TABLET
naproxen sodium 1
TABLET
oxaprozin 1
CAPSULE
piroxicam 1
TABLET
sulindac 1
CAPSULE
tolmetin sodium 1
PATCH, TRANSDERMAL 12 HOURS
FLECTOR 2
CAPSULE
ZORVOLEX 2
CAPSULE
CELEBREX 3
TABLET
DUEXIS 3
SUPPOSITORY, RECTAL
INDOCIN 3
CAPSULE
NALFON 3
SPRAY, NON-AEROSOL (EA)
SPRIX SP 3
TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE
VIMOVO 3
GEL (GRAM)
VOLTAREN 3
CAPSULE
ZIPSOR 3
MISCELLANEOUS
TABLET
diflunisal 1
TABLET
salsalate 1
TABLET
tramadol hcl 1
TABLET, EXTENDED RELEASE 24 HR
tramadol hcl er 1
TABLET
tramadol hcl-acetaminophen 1
CAPSULE,EXT.RELEASE 24 HR BIPHASIC 25-75
CONZIP 3
GROWTH HORMONES
PEN INJECTOR (ML)
NORDITROPIN FLEXPRO SP 2
VIAL (EA)
EGRIFTA SP 4
CARTRIDGE (EA)
GENOTROPIN SP 4
CARTRIDGE (EA)
HUMATROPE SP 4
PEN INJECTOR (ML)
NUTROPIN AQ NUSPIN SP 4
CARTRIDGE (ML)
OMNITROPE SP 4
CARTRIDGE (EA)
SAIZEN SP 4
VIAL (EA)
SEROSTIM SP 4
VIAL (EA)
ZOMACTON SP 4
VIAL (EA)
ZORBTIVE SP 4
HEMATOLOGY
SYRINGE (ML)
NEULASTA SP 2
VIAL (ML)
PROCRIT SP 2
SYRINGE (ML)
ZARXIO SP 2
Printed Date:11/1/2017
Page 10 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
HEMATOLOGY
VIAL (ML)
ARANESP SP 4
* ST: Must try and fail Procrit.
SYRINGE (ML)
ARANESP SP 4
* ST: Must try and fail Procrit.
VIAL (ML)
EPOGEN SP 4
SYRINGE (ML)
MIRCERA SP 4
SYRINGE (ML)
NEUPOGEN SP 4
ONCOLOGY
TABLET
anastrozole SP 1
TABLET
bicalutamide SP 1
VIAL (ML)
cytarabine SP 1
TABLET
exemestane SP 1
CAPSULE
flutamide SP 1
CAPSULE
hydroxyurea 1
TABLET
imatinib mesylate 1
TABLET
letrozole SP 1
TABLET
leucovorin calcium 1
SUSPENSION, ORAL (FINAL DOSE FORM)
megestrol acetate 1
TABLET
megestrol acetate 1
TABLET
mercaptopurine 1
TABLET
methotrexate 1
TABLET
tamoxifen citrate 1
CAPSULE
temozolomide SP 1
TABLET
AFINITOR SP 2
TABLET FOR SUSPENSION
AFINITOR DISPERZ SP 2
CAPSULE
ALECENSA SP 2
TABLET
BOSULIF SP 2
TABLET
CAPRELSA SP 2
CAPSULE
DROXIA 2
SYRINGE (EA)
ELIGARD SP 2
CAPSULE
EMCYT SP 2
TABLET
FARESTON SP 2
TABLET
GILOTRIF SP 2
CAPSULE
HYCAMTIN SP 2
TABLET
ICLUSIG SP 2
CAPSULE
IMBRUVICA SP 2
TABLET
INLYTA SP 2
TABLET
JAKAFI SP 2
TABLET
LEUKERAN SP
hh 2
TABLET
LYSODREN SP 2
CAPSULE
MATULANE SP 2
TABLET
MEKINIST SP 2
TABLET
MESNEX SP 2
TABLET
NEXAVAR SP 2
CAPSULE
POMALYST SP 2
CAPSULE
REVLIMID SP 2
TABLET
SPRYCEL SP 2
TABLET
STIVARGA SP 2
CAPSULE
SUTENT SP 2
TABLET
TABLOID 2
CAPSULE
TAFINLAR SP 2
TABLET
TARCEVA SP 2
CAPSULE
TASIGNA SP 2
CAPSULE
THALOMID SP 2
TABLET
TREXALL 2
TABLET
TYKERB SP 2
Printed Date:11/1/2017
Page 11 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
ONCOLOGY
TABLET
VOTRIENT SP 2
CAPSULE
XALKORI SP 2
TABLET
ZELBORAF SP 2
CAPSULE
ZOLINZA SP 2
TABLET
ZYTIGA SP 2
CAPSULE
COMETRIQ SP 3
TABLET
GLEEVEC SP 3
SUSPENSION, ORAL (FINAL DOSE FORM)
MEGACE ES 3
SOLUTION, ORAL
SOLTAMOX 3
CAPSULE
TEMODAR SP 3
VIAL (EA)
VIDAZA SP 3
CAPSULE
XTANDI SP 4
* ST: Must try and fail Zytiga.
IMMUNOSUPPRESSANTS
TABLET
azathioprine 1
CAPSULE
cyclosporine SP 1
SOLUTION, ORAL
cyclosporine SP 1
CAPSULE
gengraf SP 1
SOLUTION, ORAL
gengraf SP 1
CAPSULE
mycophenolate mofetil SP 1
TABLET
sirolimus SP 1
CAPSULE
tacrolimus SP 1
TABLET
AZASAN SP 2
CAPSULE
NEORAL SP 2
SOLUTION, ORAL
NEORAL SP 2
SOLUTION, ORAL
RAPAMUNE 2
SOLUTION, ORAL
SANDIMMUNE 2
CAPSULE
SANDIMMUNE 2
TABLET
ZORTRESS SP 2
CAPSULE, EXT RELEASE 24 HR
ASTAGRAF XL SP 3
SUSPENSION, RECONSTITUTED, ORAL (ML)
CELLCEPT SP 3
TABLET
RAPAMUNE 3
INTERFERONS
VIAL (ML)
ACTIMMUNE SP 2
VIAL (ML)
ALFERON N SP 2
KIT
AVONEX ADMINISTRATION PACK 2
KIT
BETASERON SP 2
KIT
EXTAVIA SP 2
VIAL (EA)
INTRON A SP 2
SYRINGE (ML)
PEGASYS SP 2
SYRINGE (ML)
REBIF SP 2
KIT
SYLATRON SP 2
KIT
PEG-INTRON SP
3
PEN INJECTOR KIT (EA)
PEG-INTRON REDIPEN SP 3
OPHTHALMIC
ANTIBIOTICS
OINTMENT (GRAM)
bacitracin 1
OINTMENT (GRAM)
bacitracin 1
OINTMENT (GRAM)
bacitracin/polymyxin 1
DROPS
ciprofloxacin hcl 1
OINTMENT (GRAM)
erythromycin 1
DROPS
gatifloxacin 1
OINTMENT (GRAM)
gentamicin sulfate 1
DROPS
gentamicin sulfate 1
DROPS
levofloxacin hemihydrate 1
OINTMENT (GRAM)
neo/polymyxin/dexamethasone 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
neo/polymyxin/dexamethasone 1
Printed Date:11/1/2017
Page 12 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
OPHTHALMIC
ANTIBIOTICS
OINTMENT (GRAM)
neomycin/bacitracin/poly/hc 1
OINTMENT (GRAM)
neomycin/bacitracin/polymyxin 1
DROPS
neomycin/polymyxin/gramicidin 1
SOLUTION, NON-ORAL
neomycin/polymyxin/hc 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
neomycin/polymyxin/hc 1
DROPS
ofloxacin 1
DROPS
polymyxin b sul-trimethoprim 1
DROPS
sulfacetamide sodium 1
DROPS
sulfacetamide w/prednisolone 1
DROPS
tobramycin sulfate 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
tobramycin-dexamethasone 1
DROPS
AZASITE 2
DROPS
AZASITE 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
CIPRODEX 2
DROPS, VISCOUS (ML)
MOXEZA 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
NATACYN 2
OINTMENT (GRAM)
TOBRADEX 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
TOBRADEX ST 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
ZYLET 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
BESIVANCE 3
DROPS
BLEPH-10 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
BLEPHAMIDE 3
OINTMENT (GRAM)
BLEPHAMIDE S.O.P. 3
OINTMENT (GRAM)
CILOXAN 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
CIPRO HC 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
COLY-MYCIN S 3
OINTMENT (GRAM)
PRED-G 3
OINTMENT (GRAM)
TOBREX 3
BETA BLOCKERS
DROPS
betaxolol hcl 1
DROPS
carteolol hcl 1
DROPS
levobunolol hcl 1
DROPS
metipranolol 1
DROPS
timolol maleate 1
DROPS
BETIMOL 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
BETOPTIC S 3
DROPPERETTE, SINGLE-USE DROP DISPENSER
TIMOPTIC 3
DROPS, ONCE DAILY
ISTALOL 4
GLAUCOMA
DROPS
dorzolamide hcl 1
DROPS
dorzolamide-timolol 1
DROPS
latanoprost 1
DROPS
pilocarpine hcl 1
DROPS
COMBIGAN 2
DROPS
TRAVATAN Z 2
DROPPERETTE, SINGLE-USE DROP DISPENSER
ZIOPTAN 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
AZOPT 3
DROPPERETTE, SINGLE-USE DROP DISPENSER
COSOPT PF 3
KIT
MITOSOL 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
SIMBRINZA 3
DROPS
LUMIGAN 4
NSAIDS
DROPS
bromfenac sodium 1
DROPS
diclofenac sodium 1
DROPS
flurbiprofen sodium 1
DROPS
ketorolac tromethamine 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
ILEVRO 2
Printed Date:11/1/2017
Page 13 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
OPHTHALMIC
NSAIDS
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
NEVANAC 2
DROPS
PROLENSA 2
DROPPERETTE, SINGLE-USE DROP DISPENSER
ACUVAIL 4
STEROIDS
DROPS
dexamethasone sodium phosphate 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
fluorometholone 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
prednisolone acetate 1
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
ALREX 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
LOTEMAX 2
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
PRED MILD 2
DROPS
DUREZOL 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
FLAREX 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
FML FORTE 3
SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
MAXIDEX 3
MYDRIATICS
DROPS
atropine sulfate 1
DROPS
cyclopentolate hcl 1
DROPS
homatropine hydrobromide 1
DROPS
tropicamide 1
DROPS
CYCLOGYL 3
DROPS
PAREMYD 3
VASOCONSTRICTOR
DROPS
CYCLOMYDRIL 3
MISCELLANEOUS
DROPS
apraclonidine hcl 1
DROPS
azelastine hcl 1
DROPS
brimonidine tartrate 1
DROPS
cromolyn sodium 1
DROPS
epinastine hcl 1
DROPS
flucaine 1
DROPS
fluorescein-benoxinate 1
DROPS
proparacaine hcl 1
DROPS
tetracaine hcl 1
DROPS
trifluridine 1
DROPS
ALPHAGAN P 2
DROPS
BEPREVE 2
DROPS
CYSTARAN SP 2
DROPPERETTE, SINGLE-USE DROP DISPENSER
RESTASIS 2
DROPS
ALOCRIL 3
DROPS
EMADINE 3
DROPPERETTE, SINGLE-USE DROP DISPENSER
IOPIDINE 3
DROPS
LASTACAFT 3
DROPS
PATADAY 3
DROPS
PATANOL 3
DROPPERETTE, VISCOUS
TETRAVISC 3
GEL (GRAM)
ZIRGAN 3
OTIC
MISCELLANEOUS
DROPS
acetasol hc 1
SOLUTION, NON-ORAL
acetic acid 1
DROPS
acetic acid/hydrocortisone 1
DROPPERETTE, SINGLE-USE DROP DISPENSER
ciprofloxacin hcl 1
DROPPERETTE, SINGLE-USE DROP DISPENSER
CETRAXAL 4
TOPICAL
CORTICOSTEROIDS VERY HIGH POTENCY
CREAM (GRAM)
clobetasol e 1
SHAMPOO
clobetasol propionate 1
OINTMENT (GRAM)
clobetasol propionate 1
SOLUTION, NON-ORAL
clobetasol propionate 1
OINTMENT (GRAM)
halobetasol propionate 1
Printed Date:11/1/2017
Page 14 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
TOPICAL
CORTICOSTEROIDS VERY HIGH POTENCY
SPRAY, NON-AEROSOL (ML)
CLOBEX 3
ANESTHETICS
OINTMENT (GRAM)
lidocaine 1
CREAM (GRAM)
lidocaine-hc 1
CREAM (GRAM)
lidocaine-prilocaine 1
GEL (GRAM)
NOVACORT 3
CREAM (GRAM)
PLIAGLIS 3
MISCELLANEOUS
CREAM (GRAM)
fluorouracil 1
CREAM IN PACKET (EA)
imiquimod 1
SHAMPOO
lindane 1
LOTION (ML)
malathion 1
CREAM (GRAM)
permethrin 1
SOLUTION, NON-ORAL
podofilox 1
CREAM (GRAM)
silver sulfadiazine 1
CREAM (GRAM)
thermazene 1
CREAM (GRAM)
CARAC 2
CREAM (GRAM)
ELIDEL 2
GEL (EA)
PICATO SP 2
GEL (GRAM)
REGRANEX 2
OINTMENT (GRAM)
SANTYL 2
CREAM IN PACKET (EA)
ALDARA 3
CREAM (GRAM)
BIONECT 3
GEL (GRAM)
BIONECT 3
CREAM (GRAM)
EURAX 3
OINTMENT (GRAM)
PROTOPIC 3
CREAM (GRAM)
FLUOROURACIL 4
CREAM IN PACKET (EA)
ZYCLARA 4
CREAM IN METERED-DOSE PUMP
ZYCLARA 4
CORTICOSTEROIDS HIGH POTENCY
CREAM (GRAM)
amcinonide 1
OINTMENT (GRAM)
amcinonide 1
LOTION (ML)
amcinonide 1
CREAM (GRAM)
apexicon e 1
CREAM (GRAM)
betamethasone dipropionate 1
OINTMENT (GRAM)
betamethasone dipropionate 1
LOTION (ML)
betamethasone dipropionate 1
OINTMENT (GRAM)
betamethasone valerate 1
GEL (GRAM)
desoximetasone 1
CREAM (GRAM)
desoximetasone 1
OINTMENT (GRAM)
desoximetasone 1
CREAM (GRAM)
diflorasone diacetate 1
CREAM (GRAM)
fluocinonide 1
CREAM (GRAM)
fluocinonide 1
OINTMENT (GRAM)
fluocinonide 1
CREAM (GRAM)
fluocinonide-e 1
CREAM (GRAM)
triamcinolone acetonide 1
CREAM (GRAM)
HALOG 3
OINTMENT (GRAM)
HALOG 3
SPRAY, NON-AEROSOL (ML)
TOPICORT 3
TOPICAL CORTICOSTEROIDS MEDIUM POTENCY
CREAM (GRAM)
betamethasone valerate 1
LOTION (ML)
betamethasone valerate 1
CREAM (GRAM)
fluticasone propionate 1
LOTION (ML)
fluticasone propionate 1
CREAM (GRAM)
hydrocortisone butyrate 1
SOLUTION, NON-ORAL
hydrocortisone butyrate 1
Printed Date:11/1/2017
Page 15 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
TOPICAL
TOPICAL CORTICOSTEROIDS MEDIUM POTENCY
OINTMENT (GRAM)
mometasone furoate 1
SOLUTION, NON-ORAL
mometasone furoate 1
OINTMENT (GRAM)
prednicarbate 1
OINTMENT (GRAM)
trianex 1
CREAM (GRAM)
triderm 1
CREAM (GRAM)
CLODERM 3
CREAM (GRAM)
CORDRAN 3
AEROSOL (GRAM)
KENALOG 3
LOTION (ML)
LOCOID 3
OINTMENT (GRAM)
TOPICORT 3
TOPICAL CORTICOSTEROIDS LOW POTENCY
CREAM (GRAM)
alclometasone dipropionate 1
OINTMENT (GRAM)
alclometasone dipropionate 1
OINTMENT (GRAM)
desonide 1
LOTION (ML)
desonide 1
CREAM (GRAM)
fluocinolone acetonide 1
SOLUTION, NON-ORAL
fluocinolone acetonide 1
CREAM (GRAM)
hydrocortisone 1
SHAMPOO
CAPEX SHAMPOO 3
GEL (GRAM)
DESONATE 3
CREAM (GRAM)
SYNALAR 3
SOLUTION, NON-ORAL
TEXACORT 3
FOAM (GRAM)
VERDESO 3
ACNE
GEL (GRAM)
adapalene 1
CLEANSER (ML)
benzoyl peroxide 1
FOAM (GRAM)
benzoyl peroxide 1
CAPSULE
claravis SP 1
SWAB, MEDICATED
clindamycin phosphate 1
FOAM (GRAM)
clindamycin phosphate 1
SOLUTION, NON-ORAL
clindamycin phosphate 1
GEL (GRAM)
clindamycin phosphate 1
LOTION (ML)
clindamycin phosphate 1
GEL (GRAM)
clindamycin phos-tretinoin 1
GEL (GRAM)
clindamycin-benzoyl peroxide 1
GEL (GRAM)
erygel 1
GEL (GRAM)
erythromycin 1
SOLUTION, NON-ORAL
erythromycin 1
GEL (GRAM)
erythromycin-benzoyl peroxide 1
GEL (GRAM)
metronidazole 1
CREAM (GRAM)
metronidazole 1
LOTION (ML)
metronidazole 1
CAPSULE
myorisan SP 1
CREAM (GRAM)
rosadan 1
GEL (GRAM)
rosadan 1
LOTION (GRAM)
sodium sulfacetamide/sulfur 1
CLEANSER (ML)
sodium sulfacetamide/sulfur 1
CREAM (GRAM)
tretinoin 1
GEL (GRAM)
tretinoin 1
GEL (GRAM)
tretinoin microsphere 1
CAPSULE
ABSORICA SP 2
GEL WITH PUMP (GRAM)
ACANYA 2
GEL WITH PUMP (GRAM)
EPIDUO 2
FOAM (GRAM)
FINACEA 2
GEL (GRAM)
MIRVASO 2
GEL (GRAM)
TAZORAC 2
Printed Date:11/1/2017
Page 16 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
TOPICAL
ACNE
CREAM (GRAM)
TAZORAC 2
KIT
ACCUCAINE 3
GEL (GRAM)
ACZONE 3
GEL (GRAM)
ATRALIN 3
CREAM (GRAM)
AVAGE 3
PADS, MEDICATED (EA)
AVAR 3
CREAM (GRAM)
AZELEX 3
GEL WITH PUMP (GRAM)
BENZACLIN 3
FOAM (GRAM)
BENZEFOAM 3
GEL (ML)
CLINDAGEL 3
LOTION (ML)
DIFFERIN 3
FOAM (GRAM)
FABIOR 3
COMBINATION PACKAGE (EA)
INOVA 3
CREAM (GRAM)
NORITATE 3
GEL (GRAM)
NUOX 3
PADS, MEDICATED (EA)
PACNEX HP 3
GEL (GRAM)
VELTIN 4
ANTIPSORIATIC
CAPSULE
acitretin 1
OINTMENT (GRAM)
calcipotriene 1
CREAM (GRAM)
calcipotriene 1
SOLUTION, NON-ORAL
calcipotriene 1
OINTMENT (GRAM)
calcitrene 1
CREAM (GRAM)
drithocreme hp 1
SHAMPOO
selenium sulfide 1
LOTION (ML)
selenium sulfide 1
CLEANSER (ML)
sodium sulfacetamide 1
SHAMPOO
sodium sulfacetamide 1
SUSPENSION, TOPICAL (GRAM)
TACLONEX 2
FOAM (GRAM)
EPIFOAM 3
SHAMPOO
OVACE PLUS 3
CREAM (GRAM)
PRAMOSONE 3
LOTION (ML)
PRAMOSONE 3
CREAM (GRAM)
PRAMOSONE E 3
FOAM (GRAM)
SORILUX 3
FOAM (GRAM)
TERSI FOAM 3
CREAM, RAPID RELEASE (GRAM)
ZITHRANOL-RR 3
ANTIFUNGALS
SUSPENSION, TOPICAL (ML)
ciclopirox 1
SHAMPOO
ciclopirox 1
GEL (GRAM)
ciclopirox 1
SOLUTION, NON-ORAL
clotrimazole 1
CREAM (GRAM)
clotrimazole 1
CREAM (GRAM)
clotrimazole/betamethasone 1
LOTION (ML)
clotrimazole/betamethasone 1
CREAM (GRAM)
econazole nitrate 1
SHAMPOO
ketoconazole 1
CREAM (GRAM)
ketoconazole 1
OINTMENT (GRAM)
nystatin 1
CREAM (GRAM)
nystatin w/triamcinolone 1
FOAM (GRAM)
ECOZA 3
CREAM (GRAM)
ERTACZO 3
SOLUTION, NON-ORAL
EXELDERM 3
LOTION (ML)
EXODERM 3
CREAM (GRAM)
MENTAX 3
CREAM (GRAM)
NAFTIN 3
GEL (GRAM)
NAFTIN 3
Printed Date:11/1/2017
Page 17 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
TOPICAL
ANTIFUNGALS
CREAM (GRAM)
OXISTAT 3
LOTION (ML)
OXISTAT 3
ANTIBACTERIALS
OINTMENT (GRAM)
mupirocin 1
CREAM (GRAM)
SULFAMYLON 2
GEL IN PACKET (GRAM)
ALCORTIN A 3
OINTMENT (GRAM)
ALTABAX 3
OINTMENT (GRAM)
CENTANY 3
ANTIVIRALS
OINTMENT (GRAM)
acyclovir 1
CREAM (GRAM)
DENAVIR 3
CREAM (GRAM)
XERESE 3
UROLOGICAL
BPH
TABLET
finasteride 1
CAPSULE
RAPAFLO 2
CAPSULE
AVODART 3
CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR
JALYN 3
ANTISPASMODICS
TABLET
bethanechol chloride 1
TABLET
flavoxate hcl 1
TABLET
oxybutynin chloride 1
SYRUP
oxybutynin chloride 1
TABLET, EXTENDED RELEASE 24 HR
oxybutynin chloride er 1
TABLET
tolterodine tartrate 1
CAPSULE, EXT RELEASE 24 HR
tolterodine tartrate er 1
TABLET
trospium chloride 1
TABLET, EXTENDED RELEASE 24 HR
MYRBETRIQ 2
TABLET
VESICARE 2
TABLET, EXTENDED RELEASE 24 HR
ENABLEX 3
GEL IN PACKET (GRAM)
GELNIQUE 3
PATCH, TRANSDERMAL SEMIWEEKLY
OXYTROL 3
TABLET, EXTENDED RELEASE 24 HR
TOVIAZ 4
ERECTILE DYSFUNCTION
TABLET
sildenafil citrate 1
SUPPOSITORY, URETHRAL
MUSE 2
TABLET
VIAGRA 3
TABLET
CIALIS 4
TABLET
LEVITRA 4
TABLET,DISINTEGRATING
STAXYN 4
TABLET
STENDRA 4
DIABETES
INSULIN
VIAL (ML)
NOVOLIN 70-30 2
VIAL (ML)
NOVOLIN N 2
VIAL (ML)
NOVOLIN R 2
CARTRIDGE (ML)
NOVOLOG 2
INSULIN PEN (ML)
NOVOLOG FLEXPEN 2
VIAL (ML)
NOVOLOG MIX 70-30 2
CARTRIDGE WITH INHALER
AFREZZA 3
VIAL (ML)
APIDRA 4
INSULIN PEN (ML)
APIDRA SOLOSTAR 4
VIAL (ML)
HUMALOG 4
VIAL (ML)
HUMALOG MIX 50-50 4
VIAL (ML)
HUMALOG MIX 75-25 4
VIAL (ML)
HUMULIN 70-30 4
VIAL (ML)
HUMULIN N 4
VIAL (ML)
HUMULIN R 4
INSULIN: LONG ACTING
VIAL (ML)
LANTUS 2
Printed Date:11/1/2017
Page 18 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
DIABETES
INSULIN: LONG ACTING
INSULIN PEN (ML)
LANTUS SOLOSTAR 2
VIAL (ML)
LEVEMIR 2
INSULIN PEN (ML)
TOUJEO SOLOSTAR 2
INSULIN PEN (ML)
TRESIBA FLEXTOUCH U-200 2
INSULIN PEN (ML)
BASAGLAR KWIKPEN U-100 4
INCRETINS
PEN INJECTOR (ML)
TRULICITY 2
PEN INJECTOR (ML)
VICTOZA SP 2
VIAL (EA)
BYDUREON SP 4
PEN INJECTOR (EA)
BYDUREON PEN SP 4
PEN INJECTOR (ML)
BYETTA SP 4
PEN INJECTOR (EA)
TANZEUM 4
DPP-4
TABLET
GLYXAMBI 2
TABLET
JANUMET 2
TABLET,EXTENDED RELEASE MULTIPHASE 24 HR
JANUMET XR 2
TABLET
JANUVIA 2
TABLET
JENTADUETO 2
TABLET
TRADJENTA 2
TABLET
ALOGLIPTIN 4
TABLET
ALOGLIPTIN-METFORMIN 4
TABLET
KAZANO 4
TABLET,EXTENDED RELEASE MULTIPHASE 24 HR
KOMBIGLYZE XR 4
TABLET
NESINA 4
TABLET
ONGLYZA 4
TABLET
OSENI 4
SULFONYLUREAS
TABLET
glimepiride 1
TABLET, EXTENDED RELEASE 24 HR
glipizide er 1
TABLET
glipizide-metformin 1
TABLET
glyburide 1
TABLET
glyburide micronized 1
TABLET
glyburide-metformin hcl 1
TZD
TABLET
pioglitazone hcl 1
TABLET
pioglitazone-glimepiride 1
TABLET
pioglitazone-metformin 1
OTHER
TABLET
acarbose 1
TABLET
metformin hcl 1
TABLET, EXTENDED RELEASE 24 HR
metformin hcl er 1
TABLET
nateglinide 1
TABLET
repaglinide 1
VIAL (EA)
GLUCAGEN 2
KIT
GLUCAGON EMERGENCY KIT 2
PEN INJECTOR (ML)
SYMLINPEN 120 2
TABLET
CYCLOSET 3
TABLET
GLYSET 3
SOLUTION, ORAL
RIOMET 3
TABLET, ER GASTRIC RETENTION 24 HR
GLUMETZA SP 4
SGLT-2
TABLET
FARXIGA 2
TABLET
JARDIANCE 2
TABLET
SYNJARDY 2
TABLET,IMMED AND EXTEND REL BIPHASE 24HR
XIGDUO XR 2
TABLET
INVOKAMET 4
TABLET
INVOKANA 4
TESTING
EACH
ACCU-CHEK 2
Printed Date:11/1/2017
Page 19 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
DIABETES
TESTING
NEEDLE, DISPOSABLE
BD INSULIN PEN NEEDLE UF MINI 2
SYRINGE, EMPTY DISPOSABLE
B-D INSULIN SYRINGE 2
NEEDLE, DISPOSABLE
B-D NEEDLES 2
EACH
DEXCOM G4 2
EACH
DEXCOM G5 2
SYRINGE, EMPTY DISPOSABLE
INSULIN- SYRINGE 2
STRIP
ONE TOUCH ULTRA TEST STRIPS 2
STRIP
ONE TOUCH VERIO 2
EACH
ACCU-CHEK AVIVA CONNECT 4
STRIP
ACCU-CHEK AVIVA PLUS 4
STRIP
ACCU-CHEK COMPACT 4
EACH
ACCU-CHEK NANO SMARTVIEW 4
STRIP
ACCU-CHEK SMARTVIEW 4
STRIP
ACCUTREND GLUCOSE 4
EACH
ADVOCATE BLOOD GLUCOSE MONITOR 4
STRIP
ASCENSIA BREEZE 2 4
STRIP
CONTOUR 4
STRIP
CONTOUR NEXT EZ 4
STRIP
EMBRACE 4
STRIP
FREESTYLE INSULINX 4
STRIP
FREESTYLE INSULINX TEST STRIPS 4
STRIP
FREESTYLE LITE STRIPS 4
STRIP
FREESTYLE TEST STRIPS 4
STRIP
OPTIUM 4
STRIP
OPTIUM EZ 4
STRIP
PRECISION PCX PLUS 4
STRIP
PRECISION Q-I-D 4
STRIP
PRECISION XTRA 4
KIT
PRODIGY 4
STRIP
TRUETEST TEST STRIPS 4
KIT
TRUETRACK SMART SYSTEM 4
STRIP
UNISTRIP1 4
VACCINES
VIAL (ML)
BOOSTRIX 2
SYRINGE (ML)
CERVARIX 2
SYRINGE (ML)
ENGERIX-B 2
VIAL (ML)
GARDASIL 2
VIAL (ML)
HAVRIX 2
SYRINGE (ML)
INFANRIX 2
VIAL (ML)
PNEUMOVAX 23 2
SYRINGE (ML)
PREVNAR 13 2
VIAL (ML)
RECOMBIVAX HB 2
SOLUTION, ORAL
ROTATEQ 2
VIAL (ML)
TWINRIX 2
VIAL (EA)
ZOSTAVAX 2
VITAMINS/ELECTROLYTES
CAPSULE
calcium acetate 1
TABLET
dialyvite 1
TABLET
elite-ob 1
TABLET, CHEWABLE
fluoride 1
TABLET
folic acid 1
PACKET (EA)
klor-con 1
COMBINATION PACKAGE, TABLET AND DR CAP
obstetrix dha 1
LIQUID (ML)
potassium chloride 1
TABLET, EXTENDED RELEASE
potassium chloride 1
Printed Date:11/1/2017
Page 20 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
VITAMINS/ELECTROLYTES
TABLET
prenatabs rx 1
TABLET
prenatal plus 1
SPRAY, NON-AEROSOL (EA)
NASCOBAL 2
COMBINATION PACKAGE (EA)
DUET DHA 3
TABLET, EXTENDED RELEASE
K-TAB 3
TABLET
OB COMPLETE 3
SOLUTION, ORAL
PHOSLYRA 3
MISCELLANEOUS
TABLET, EXTENDED RELEASE 12 HR
bupropion sr 1
AEROSOL, SPRAY WITH PUMP (ML)
calcitonin-salmon 1
CAPSULE
cevimeline hcl 1
TABLET
disulfiram 1
TABLET
etidronate disodium 1
TABLET
midodrine hcl 1
TABLET
riluzole 1
TABLET, DISPERSIBLE
CARBAGLU SP 2
TABLET
CHANTIX 2
AUTO-INJECTOR (EA)
EPINEPHRINE 2
AUTO-INJECTOR (EA)
EPINEPHRINE 2
AUTO-INJECTOR (EA)
EPIPEN 2
AUTO-INJECTOR (EA)
EPIPEN JR. 2
TABLET, DISPERSIBLE
EXJADE SP 2
TABLET, CHEWABLE
FOSRENOL 2
AUTO-INJECTOR (EA)
ADRENACLICK 3
KIT
EPISNAP 3
GEL IN PACKET (ML)
GELCLAIR 3
TABLET
RENAGEL 3
POWDER IN PACKET (EA)
RENVELA 3
POWDER IN PACKET (EA)
SALIVAMAX 3
TABLET, CHEWABLE
VELPHORO 3
AUTO-INJECTOR (EA)
AUVI-Q 4
CNS
ANTIDEPRESSANTS
TABLET
amitriptyline hcl 1
TABLET
amitriptyline/chlordiazepoxide 1
TABLET
amitriptyline-perphenazine 1
TABLET
amoxapine 1
TABLET
bupropion hcl 1
TABLET, EXTENDED RELEASE 24 HR
bupropion hcl xl 1
SOLUTION, ORAL
citalopram hbr 1
TABLET
citalopram hbr 1
CAPSULE
clomipramine hcl 1
TABLET
desipramine hcl 1
CAPSULE
doxepin hcl 1
CONCENTRATE, ORAL
doxepin hcl 1
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
duloxetine hcl 1
SOLUTION, ORAL
escitalopram oxalate 1
TABLET
escitalopram oxalate 1
SOLUTION, ORAL
fluoxetine hcl 1
CAPSULE
fluoxetine hcl 1
TABLET
fluvoxamine maleate 1
TABLET
imipramine hcl 1
CAPSULE
imipramine pamoate 1
TABLET
maprotiline hcl 1
TABLET
mirtazapine 1
TABLET
nefazodone hcl 1
Printed Date:11/1/2017
Page 21 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
CNS
ANTIDEPRESSANTS
CAPSULE
nortriptyline hcl 1
SOLUTION, ORAL
nortriptyline hcl 1
TABLET, EXTENDED RELEASE 24 HR
paroxetine er 1
TABLET
paroxetine hcl 1
TABLET
phenelzine sulfate 1
TABLET
protriptyline hcl 1
TABLET
sertraline hcl 1
TABLET
tranylcypromine sulfate 1
TABLET
trazodone hcl 1
TABLET
venlafaxine hcl 1
CAPSULE, EXT RELEASE 24 HR
venlafaxine hcl er 1
CAPSULE
BRISDELLE 2
CAPSULE,EXTENDED RELEASE 24 HR DOSE PACK
FETZIMA 2
TABLET
VIIBRYD 2
TABLET, EXTENDED RELEASE 24 HR
APLENZIN SP 3
TABLET, EXTENDED RELEASE 24 HR
DESVENLAFAXINE ER 3
PATCH, TRANSDERMAL 24 HOURS
EMSAM 3
TABLET, EXTENDED RELEASE 24 HR
FORFIVO XL 3
TABLET, EXTENDED RELEASE 24 HR
KHEDEZLA 3
TABLET
MARPLAN 3
TABLET
PEXEVA 3
TABLET, EXTENDED RELEASE 24 HR
PRISTIQ 3
TABLET
SARAFEM 3
MISCELLANEOUS
TABLET
armodafinil 1
TABLET, EXTENDED RELEASE
lithium carbonate 1
CAPSULE
lithium carbonate 1
SOLUTION, ORAL
lithium citrate 1
TABLET
modafinil 1
TABLET
BELVIQ 2
CAPSULE
NUEDEXTA 2
PEN INJECTOR (ML)
SAXENDA 2
TABLET
OTREXUP SP
XENAZINE SP 3
CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR
QSYMIA 4
ANTICONVULSANTS
SUSPENSION, ORAL (FINAL DOSE FORM)
carbamazepine 1
TABLET
carbamazepine 1
TABLET, EXTENDED RELEASE 12 HR
carbamazepine er 1
TABLET, EXTENDED RELEASE 12 HR
carbamazepine er 1
TABLET,DISINTEGRATING
clonazepam 1
TABLET
clonazepam 1
KIT
diazepam 1
TABLET, ENTERIC COATED
divalproex sodium 1
TABLET, EXTENDED RELEASE 24 HR
divalproex sodium er 1
TABLET
epitol 1
CAPSULE
ethosuximide 1
CAPSULE
ethosuximide 1
SOLUTION, ORAL
ethosuximide 1
TABLET
felbamate 1
SUSPENSION, ORAL (FINAL DOSE FORM)
felbamate 1
VIAL (ML)
fosphenytoin sodium 1
CAPSULE
gabapentin 1
TABLET
gabapentin 1
TABLET
lamotrigine 1
TABLET
levetiracetam 1
SOLUTION, ORAL
levetiracetam 1
TABLET
oxcarbazepine 1
Printed Date:11/1/2017
Page 22 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
CNS
ANTICONVULSANTS
SUSPENSION, ORAL (FINAL DOSE FORM)
oxcarbazepine 1
ELIXIR
phenobarbital 1
TABLET
phenobarbital 1
SUSPENSION, ORAL (FINAL DOSE FORM)
phenytoin 1
CAPSULE
phenytoin sodium 1
TABLET
primidone 1
TABLET
tiagabine hcl 1
TABLET
topiramate 1
CAPSULE
valproic acid 1
SOLUTION, ORAL
valproic acid 1
CAPSULE
zonisamide 1
TABLET
BANZEL SP 2
TABLET
FYCOMPA 2
TABLET
GABITRIL 2
TABLET, EXTENDED RELEASE, DOSE PACK
LAMICTAL XR 2
CAPSULE
LYRICA 2
SUSPENSION, ORAL (FINAL DOSE FORM)
ONFI SP 2
TABLET, EXTENDED RELEASE 24 HR
OXTELLAR XR 2
TABLET
PEGANONE 2
TABLET
POTIGA 2
TABLET
SABRIL SP 2
CAPSULE, EXT RELEASE 24 HR
TROKENDI XR 2
TABLET
VIMPAT 2
SOLUTION, ORAL
VIMPAT 2
TABLET, EXTENDED RELEASE 24 HR
DEPAKOTE ER 3
CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR
EQUETRO 3
TABLET, EXTENDED RELEASE
HORIZANT 3
TABLET,DISINTEGRATING
LAMICTAL ODT 3
ADHD
TABLET
dexmethylphenidate hcl 1
CAPSULE,EXTENDED RELEASE BIPHASIC 50-50
dexmethylphenidate hcl er 1
SOLUTION, ORAL
dextroamphetamine sulfate 1
TABLET
dextroamphetamine sulfate 1
CAPSULE, EXT RELEASE 24 HR
dextroamphetamine-amphet er 1
TABLET
dextroamphetamine-amphetamine 1
TABLET
guanidine hcl 1
CAPSULE,EXTENDED RELEASE BIPHASIC 50-50
methylphenidate er 1
TABLET
methylphenidate hcl 1
SOLUTION, ORAL
methylphenidate hcl 1
CAPSULE,EXTENDED RELEASE BIPHASIC 30-70
methylphenidate hcl cd 1
PATCH, TRANSDERMAL 24 HOURS
DAYTRANA 2
TABLET,CHEW,IR AND ER BIPHASIC REL 24HR
QUILLICHEW ER 2
SUSPENSION,EXTENDED RELEASE,RECONST.24HR
QUILLIVANT XR 2
CAPSULE
VYVANSE 2
CAPSULE, EXT RELEASE 24 HR
ADDERALL XR 3
TABLET,DISINTEGRATING,ER BIPHASIC 24 HR
ADZENYS XR-ODT 3
CAPSULE,EXTENDED RELEASE BIPHASIC 50-50
FOCALIN XR 3
TABLET, EXTENDED RELEASE 24 HR
INTUNIV 3
CAPSULE
STRATTERA 3
ANTI-PSYCHOTIC
TABLET
aripiprazole 1
TABLET
chlorpromazine hcl 1
TABLET
clozapine 1
TABLET,DISINTEGRATING
clozapine odt 1
TABLET
fluphenazine hcl 1
CONCENTRATE, ORAL
fluphenazine hcl 1
Printed Date:11/1/2017
Page 23 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
CNS
ANTI-PSYCHOTIC
TABLET
haloperidol 1
VIAL (ML)
haloperidol decanoate 1
CONCENTRATE, ORAL
haloperidol lactate 1
CAPSULE
loxapine succinate 1
TABLET
olanzapine 1
TABLET,DISINTEGRATING
olanzapine odt 1
CAPSULE
olanzapine-fluoxetine hcl 1
TABLET
perphenazine 1
TABLET
quetiapine fumarate 1
TABLET, EXTENDED RELEASE 24 HR
quetiapine fumarate er 1
TABLET
risperidone 1
TABLET,DISINTEGRATING
risperidone odt 1
TABLET
thioridazine hcl 1
CAPSULE
thiothixene 1
TABLET
trifluoperazine hcl 1
CAPSULE
ziprasidone hcl 1
SUSPENSION,EXTENDED RELEASE SYRINGE (EA)
ABILIFY MAINTENA SP 2
TABLET
LATUDA 2
SYRINGE (EA)
RISPERDAL CONSTA SP 2
TABLET, SUBLINGUAL
SAPHRIS 2
TABLET
ABILIFY 3
TABLET
FANAPT 3
TABLET,DISINTEGRATING
FAZACLO 3
TABLET, EXTENDED RELEASE 24 HR
INVEGA SP 3
TABLET
ORAP 3
TABLET
REXULTI 3
TABLET, EXTENDED RELEASE 24 HR
SEROQUEL XR 3
SUSPENSION, ORAL (FINAL DOSE FORM)
VERSACLOZ 3
ANXIOLYTICS
TABLET
alprazolam 1
TABLET, EXTENDED RELEASE 24 HR
alprazolam er 1
CONCENTRATE, ORAL
alprazolam intensol 1
TABLET,DISINTEGRATING
alprazolam odt 1
TABLET, EXTENDED RELEASE 24 HR
alprazolam xr 1
TABLET
buspirone hcl 1
CAPSULE
chlordiazepoxide hcl 1
TABLET
clorazepate dipotassium 1
CONCENTRATE, ORAL
diazepam 1
TABLET
diazepam 1
TABLET
lorazepam 1
CONCENTRATE, ORAL
lorazepam intensol 1
SYRUP
midazolam hcl 1
CAPSULE
oxazepam 1
ALZHEIMER'S
CAPSULE, EXTENDED RELEASE PELLETS 24 HR
galantamine er 1
CAPSULE
rivastigmine 1
CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR
NAMENDA XR 2
PATCH, TRANSDERMAL 24 HOURS
EXELON 3
SOLUTION, ORAL
NAMENDA 3
ANTIPARKINSONISM
TABLET
benztropine mesylate 1
TABLET
bromocriptine mesylate 1
TABLET
carbidopa/levodopa 1
TABLET, EXTENDED RELEASE
carbidopa-levodopa er 1
TABLET
carbidopa-levodopa-entacapone 1
TABLET
entacapone 1
TABLET
ropinirole hcl 1
Printed Date:11/1/2017
Page 24 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
CNS
ANTIPARKINSONISM
TABLET
selegiline hcl 1
ELIXIR
trihexyphenidyl hcl 1
TABLET
trihexyphenidyl hcl 1
PATCH, TRANSDERMAL 24 HOURS
NEUPRO 2
TABLET,DISINTEGRATING
ZELAPAR 2
TABLET
AZILECT 3
TABLET, EXTENDED RELEASE 24 HR
MIRAPEX ER 3
TABLET
STALEVO 3
TABLET
TASMAR 3
MS
TABLET, EXTENDED RELEASE 12 HR
AMPYRA SP 2
TABLET
AUBAGIO SP 2
CAPSULE
GILENYA SP 2
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
TECFIDERA SP 2
SYRINGE (ML)
COPAXONE SP 3
SLEEP
TABLET
estazolam 1
TABLET
eszopiclone 1
CAPSULE
flurazepam hcl 1
TABLET
quazepam 1
CAPSULE
temazepam 1
CAPSULE
zaleplon 1
TABLET, EXTENDED RELEASE MULTIPHASE
zolpidem tartrate er 1
TABLET
BELSOMRA 2
TABLET
ROZEREM 2
TABLET
BUTISOL SODIUM 3
TABLET, SUBLINGUAL
INTERMEZZO 3
AEROSOL, SPRAY WITH PUMP (ML)
ZOLPIMIST 3
ENDOCRINE
CONTRACEPTIVES
TABLET
altavera 1
TABLET
alyacen 1
TABLET, DOSE PACK, 3 MONTHS
amethia 1
TABLET
amethyst 1
TABLET
apri 1
TABLET
aranelle 1
TABLET
aubra 1
TABLET
aviane 1
TABLET
azurette 1
TABLET
balziva 1
TABLET
briellyn 1
TABLET, DOSE PACK, 3 MONTHS
camrese 1
TABLET
caziant 1
TABLET
chateal 1
TABLET
cryselle 1
TABLET
cyclafem 1
TABLET
dasetta 1
TABLET, DOSE PACK, 3 MONTHS
daysee 1
TABLET
elinest 1
TABLET
emoquette 1
TABLET
enpresse 1
TABLET
enskyce 1
TABLET
estarylla 1
TABLET
falmina 1
TABLET
gianvi 1
TABLET
gildagia 1
TABLET, DOSE PACK, 3 MONTHS
introvale 1
TABLET, DOSE PACK, 3 MONTHS
jolessa 1
Printed Date:11/1/2017
Page 25 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
ENDOCRINE
CONTRACEPTIVES
TABLET
junel 1
TABLET
kariva 1
TABLET
kelnor 1-35 1
TABLET
kurvelo 1
TABLET
larin fe 1
TABLET
leena 1
TABLET
lessina 1
TABLET
levonest 1
TABLET
levora 1
TABLET
lomedia 24 fe 1
TABLET
loryna 1
TABLET
low-ogestrel 1
TABLET
lutera 1
TABLET
marlissa 1
TABLET
microgestin 1
TABLET
mono-linyah 1
TABLET
mononessa 1
TABLET
myzilra 1
TABLET
necon 1
TABLET
nortrel 1
TABLET
ocella 1
TABLET
ogestrel 1
TABLET
orsythia 1
TABLET
philith 1
TABLET
pimtrea 1
TABLET
pirmella 1
TABLET
portia 1
TABLET
previfem 1
TABLET, DOSE PACK, 3 MONTHS
quasense 1
TABLET
reclipsen 1
TABLET
sprintec 1
TABLET
sronyx 1
TABLET
syeda 1
TABLET
tilia fe 1
TABLET
tri-estarylla 1
TABLET
tri-linyah 1
TABLET
trinessa 1
TABLET
tri-previfem 1
TABLET
tri-sprintec 1
TABLET
trivora 1
TABLET
velivet 1
TABLET
vestura 1
TABLET
viorele 1
TABLET
wera 1
TABLET, CHEWABLE
wymzya fe 1
TABLET
zarah 1
TABLET
zenchent 1
TABLET
zovia 1
TABLET
LO LOESTRIN FE 2
TABLET
NATAZIA 2
RING, VAGINAL
NUVARING 2
TABLET
SAFYRAL 2
INTRAUTERINE DEVICE
SKYLA SP 2
TABLET
BEYAZ 3
TABLET, CHEWABLE
GENERESS FE 3
Printed Date:11/1/2017
Page 26 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
ENDOCRINE
CONTRACEPTIVES
TABLET
ORTHO TRI-CYCLEN LO 3
TABLET, DOSE PACK, 3 MONTHS
QUARTETTE 3
ESTROGENS
PATCH, TRANSDERMAL WEEKLY
estradiol 1
TABLET
estradiol-norethindrone acetat 1
TABLET
estrogen & methyltestosterone 1
TABLET
jinteli 1
PATCH, TRANSDERMAL SEMIWEEKLY
COMBIPATCH 2
GEL IN PACKET (EA)
DIVIGEL 2
TABLET
DUAVEE 2
CREAM WITH APPLICATOR
ESTRACE 2
PATCH, TRANSDERMAL SEMIWEEKLY
MINIVELLE 2
CREAM WITH APPLICATOR
PREMARIN 2
TABLET
PREMARIN 2
TABLET
PREMPHASE 2
TABLET
PREMPRO 2
PATCH, TRANSDERMAL SEMIWEEKLY
ALORA 3
TABLET
ANGELIQ 3
PATCH, TRANSDERMAL WEEKLY
CLIMARA PRO 3
RING, VAGINAL
ESTRING 3
TABLET
FEMHRT 3
TABLET
PREFEST 3
TABLET
VAGIFEM 3
GEL IN METERED-DOSE PUMP
ESTROGEL 4
PROGESTINS
TABLET
camila 1
TABLET
errin 1
TABLET
heather 1
TABLET
jencycla 1
TABLET
jolivette 1
TABLET
lyza 1
TABLET
nora-be 1
TABLET
norethindrone acetate 1
CAPSULE
progesterone 1
GEL WITH PREFILLED APPLICATOR (GRAM)
CRINONE 2
INSERT
ENDOMETRIN SP 4
OVULATORY STIMULANTS
TABLET
clomiphene citrate SP 1
VIAL (EA)
GONAL-F SP 2
VIAL (EA)
MENOPUR SP 2
VIAL (EA)
BRAVELLE SP 4
VIAL (ML)
FOLLISTIM AQ SP 4
CARTRIDGE (ML)
FOLLISTIM AQ SP 4
GONADOTROPIN
KIT
CETROTIDE SP 2
VIAL (EA)
NOVAREL SP 2
VIAL (EA)
PREGNYL SP 3
SYRINGE (ML)
GANIRELIX ACETATE SP 4
TESTOSTERONE
TABLET
androxy 1
CAPSULE
danazol 1
TABLET
oxandrolone 1
VIAL (ML)
testosterone cypionate 1
GEL IN PACKET (GRAM)
ANDROGEL 2
GEL IN METERED-DOSE PUMP
ANDROGEL 2
PATCH, TRANSDERMAL 24 HOURS
ANDRODERM 4
CAPSULE
ANDROID 4
SOLUTION IN METERED-DOSE PUMP WITH APPL.
AXIRON 4
Printed Date:11/1/2017
Page 27 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
ENDOCRINE
TESTOSTERONE
VIAL (ML)
DEPO-TESTOSTERONE 4
GEL IN METERED-DOSE PUMP
FORTESTA 4
GEL IN METERED-DOSE PUMP
NATESTO 4
MUCOADHESIVE SYSTEM,EXTEND.RELEASE 12 HR
STRIANT 4
GEL (GRAM)
TESTIM 4
PELLET (EA)
TESTOPEL SP 4
GEL IN PACKET (GRAM)
TESTOSTERONE 4
GEL (GRAM)
TESTOSTERONE 4
GEL IN METERED-DOSE PUMP
TESTOSTERONE 4
CAPSULE
TESTRED 4
GEL (GRAM)
VOGELXO 4
GEL IN PACKET (GRAM)
VOGELXO 4
GEL IN METERED-DOSE PUMP
VOGELXO 4
ADRENAL HORMONES
TABLET
dexamethasone 1
TABLET
fludrocortisone acetate 1
TABLET
hydrocortisone 1
TABLET, DOSE PACK
methylprednisolone 1
VIAL (ML)
methylprednisolone acetate 1
SOLUTION, ORAL
prednisolone 1
TABLET
prednisone 1
VIAL (EA)
SOLU-CORTEF 2
VIAL (ML)
ACTHAR H.P. 3
TABLET,DISINTEGRATING
ORAPRED ODT 3
TABLET, ENTERIC COATED
RAYOS 4
THYROID
TABLET
levothyroxine sodium 1
TABLET
levoxyl 1
TABLET
liothyronine sodium 1
TABLET
methimazole 1
TABLET
nature-throid 1
TABLET
unithroid 1
TABLET
ARMOUR THYROID 2
SOLUTION, ORAL
SSKI 3
TABLET
THYROLAR 3
CAPSULE
TIROSINT 3
MISCELLANEOUS
TABLET
cabergoline 1
CAPSULE
calcitriol 1
AEROSOL, SPRAY WITH PUMP (ML)
desmopressin acetate 1
TABLET
desmopressin acetate 1
TABLET
ADDYI 3
GASTROINTESTINAL
H2 ANTAGONISTS
SOLUTION, ORAL
cimetidine 1
TABLET
cimetidine 1
SUSPENSION, ORAL (FINAL DOSE FORM)
famotidine 1
TABLET
famotidine 1
TABLET
misoprostol 1
CAPSULE
nizatidine 1
SYRUP
ranitidine hcl 1
TABLET
ranitidine hcl 1
PROTON PUMP INHIBITORS
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
lansoprazole 1
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
omeprazole 1
CAPSULE
omeprazole-sodium bicarbonate 1
TABLET, ENTERIC COATED
pantoprazole sodium 1
TABLET, ENTERIC COATED
rabeprazole sodium 1
Printed Date:11/1/2017
Page 28 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
GASTROINTESTINAL
PROTON PUMP INHIBITORS
CAPSULE, DELAYED RELEASE, BIPHASIC
DEXILANT 3
PACKET (EA)
ZEGERID RX 3
SUSP FOR RECON,DELAYED REL. IN A PACKET
NEXIUM RX 4
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
NEXIUM RX 4
OTHER ULCER THERAPY
COMBINATION PACKAGE (EA)
lansoprazol-amoxicil-clarithro 1
TABLET
sucralfate 1
SUSPENSION, ORAL (FINAL DOSE FORM)
CARAFATE 2
CAPSULE
PYLERA 2
ANTIEMETIC
CAPSULE
dronabinol SP 1
TABLET
granisetron hcl SP 1
TABLET
meclizine hcl 1
SOLUTION, ORAL
ondansetron hcl 1
TABLET
ondansetron hcl 1
TABLET,DISINTEGRATING
ondansetron odt 1
SUPPOSITORY, RECTAL
prochlorperazine maleate 1
TABLET
prochlorperazine maleate 1
CAPSULE
trimethobenzamide hcl 1
PATCH, TRANSDERMAL WEEKLY
SANCUSO SP 2
TABLET
ANZEMET SP 3
CAPSULE
EMEND SP 3
PATCH,TRANSDERMAL 3 DAY
TRANSDERM-SCOP 3
FILM, MEDICATED (EA)
ZUPLENZ 3
ANTIDIARRHEALS
TABLET,DISINTEGRATING
anaspaz 1
CAPSULE
dicyclomine hcl 1
CAPSULE
dicyclomine hcl 1
TABLET
diphenoxylate w/atropine 1
LIQUID (ML)
diphenoxylate w/atropine 1
TABLET
glycopyrrolate 1
DROPS
hyoscyamine sulfate 1
CAPSULE
loperamide hcl 1
TABLET
methscopolamine bromide 1
SOLUTION, ORAL
CUVPOSA 3
TABLET
HOMAPIN 10 3
DIGESTIVE ENZYMES
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
CREON SP 2
SOLUTION, ORAL
SUCRAID SP 2
TABLET
VIOKACE SP 2
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
ZENPEP SP 2
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
PANCREAZE SP 4
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
PERTZYE 4
BOWEL EVACUANTS
SOLUTION, RECONSTITUTED, ORAL
SUPREP 2
SOLUTION, RECONSTITUTED, ORAL
COLYTE 3
POWDER IN PACKET (EA)
MOVIPREP 3
TABLET
OSMOPREP 3
RECTAL
SUPPOSITORY, RECTAL
anucort-hc 1
ENEMA (ML)
colocort 1
ENEMA (ML)
mesalamine 1
SUPPOSITORY, RECTAL
CANASA 2
AEROSOL, FOAM WITH APPLICATOR (GRAM)
CORTIFOAM 2
OTHER
CAPSULE
balsalazide disodium 1
CAPSULE, DELAYED, AND EXTENDED RELEASE
budesonide ec 1
CAPSULE
clidinium w/chlordiazepoxide 1
SOLUTION, ORAL
constulose 1
Printed Date:11/1/2017
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B4G Participant: N
GASTROINTESTINAL
OTHER
SOLUTION, ORAL
lactulose 1
TABLET
metoclopramide hcl 1
SOLUTION, ORAL
metoclopramide hcl 1
TABLET
sulfasalazine 1
TABLET, ENTERIC COATED
sulfasalazine dr 1
CAPSULE
ursodiol 1
CAPSULE
AMITIZA 2
CAPSULE, EXT RELEASE 24 HR
APRISO 2
LIQUID (ML)
BELLADONNA 2
TABLET
CHENODAL SP 2
VIAL (EA)
KINEVAC 2
CAPSULE
LINZESS 2
TABLET
MOVANTIK 2
CAPSULE, EXTENDED RELEASE
PENTASA 2
SYRINGE (ML)
RELISTOR SP 2
CAPSULE
ENTEREG 3
TABLET
GIAZO 3
PACKET (EA)
KRISTALOSE 3
TABLET, ENTERIC COATED
LIALDA SP 3
TABLET
LOTRONEX 3
TABLET, ENTERIC COATED
ASACOL HD SP 4
CAPSULE (WITH DELAYED RELEASE TABLETS)
DELZICOL 4
CAPSULE
DIPENTUM 4
MUSCULOSKELETAL
OSTEOPOROSIS
SOLUTION, ORAL
alendronate sodium 1
TABLET
alendronate sodium 1
TABLET
ibandronate sodium 1
PEN INJECTOR (ML)
FORTEO SP 2
TABLET
ACTONEL 3
TABLET, ENTERIC COATED
ATELVIA 3
TABLET, EFFERVESCENT
BINOSTO 3
TABLET
FOSAMAX PLUS D 3
SYRINGE (ML)
PROLIA SP 3
MUSCLE RELAXANTS
TABLET
baclofen 1
TABLET
carisoprodol 1
TABLET
carisoprodol compound 1
TABLET
carisoprodol compound/codeine 1
TABLET
carisoprodol-aspirin 1
TABLET
chlorzoxazone 1
TABLET
cyclobenzaprine hcl 1
CAPSULE
dantrolene sodium 1
TABLET
meprobamate 1
TABLET
metaxalone 1
TABLET
methocarbamol 1
TABLET, EXTENDED RELEASE
orphenadrine citrate 1
TABLET
tizanidine hcl 1
CAPSULE, EXT RELEASE 24 HR
AMRIX 3
TABLET
LORZONE 3
GOUT THERAPY
TABLET
allopurinol 1
CAPSULE
COLCHICINE 1
TABLET
probenecid 1
TABLET
probenecid w/colchicine 1
TABLET
COLCRYS 2
Printed Date:11/1/2017
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B4G Participant: N
OTREXUP SP
MUSCULOSKELETAL
GOUT THERAPY
CAPSULE
MITIGARE 2
TABLET
ULORIC 2
ANTI-INFLAMMATORY
PEN INJECTOR (ML)
COSENTYX 150MG SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
COSENTYX 300MG SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
PEN INJECTOR (ML)
ENBREL SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
VIAL (EA)
ENTYVIO SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
PEN INJECTOR KIT (EA)
HUMIRA SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
ORENCIA SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
AUTO-INJECTOR (ML)
ORENCIA CLICKJECT SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
AUTO-INJECTOR (ML)
2
AUTO-INJECTOR (ML)
RASUVO SP 2
TABLET
SAVELLA 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
SILIQ SP 2
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
ACTEMRA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
KIT
CIMZIA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE KIT (EA)
CIMZIA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
TABLET
OTEZLA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
VIAL (EA)
REMICADE SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
TABLET
SAVELLA 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
PEN INJECTOR (ML)
SIMPONI SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
STELARA SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
AUTO-INJECTOR (ML)
TALTZ AUTOINJECTOR SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
TALTZ SYRINGE SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
TABLET
XELJANZ SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
TABLET, EXTENDED RELEASE 24 HR
XELJANZ XR SP 3
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
SYRINGE (ML)
KINERET SP 4
* PA: Coverage based on indication. See details in Major Drug Class Overview chart.
RESPIRATORY
AMPUL FOR NEBULIZATION (ML)
ipratropium-albuterol 1
GRANULES IN PACKET (EA)
montelukast sodium 1
TABLET
montelukast sodium 1
TABLET
sildenafil citrate SP 1
TABLET
zafirlukast 1
TABLET
ADCIRCA SP 2
TABLET
ADEMPAS 2
BLISTER, WITH INHALATION DEVICE
ADVAIR DISKUS 2
Printed Date:11/1/2017
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B4G Participant: N
OTREXUP SP
RESPIRATORY
HFA AEROSOL WITH ADAPTER (GRAM)
ADVAIR HFA 2
BLISTER, WITH INHALATION DEVICE
ANORO ELLIPTA 2
HFA AEROSOL WITH ADAPTER (GRAM)
ATROVENT HFA 2
BLISTER, WITH INHALATION DEVICE
BREO ELLIPTA 2
MIST INHALER (GRAM)
COMBIVENT RESPIMAT 2
TABLET
DALIRESP 2
TABLET
KALYDECO SP 2
TABLET
LETAIRIS SP 2
SOLUTION, NON-ORAL
PULMOZYME SP 2
CAPSULE, WITH INHALATION DEVICE
SPIRIVA 2
MIST INHALER (GRAM)
SPIRIVA RESPIMAT 2
MIST INHALER (GRAM)
STIOLTO RESPIMAT 2
HFA AEROSOL WITH ADAPTER (GRAM)
SYMBICORT 2
TABLET
TRACLEER SP 2
VIAL (EA)
XOLAIR SP 2
TABLET
ZYFLO SP 3
HFA AEROSOL WITH ADAPTER (GRAM)
DULERA 4
BLISTER, WITH INHALATION DEVICE
INCRUSE ELLIPTA 4
AEROSOL POWDER, BREATH ACTIVATED (EA)
TUDORZA PRESSAIR 4
INHALED STEROIDS
AMPUL FOR NEBULIZATION (ML)
budesonide 1
BLISTER, WITH INHALATION DEVICE
ARNUITY ELLIPTA 2
BLISTER, WITH INHALATION DEVICE
FLOVENT DISKUS 2
AEROSOL WITH ADAPTER (GRAM)
FLOVENT HFA 2
AEROSOL POWDER, BREATH ACTIVATED (EA)
PULMICORT FLEXHALER 2
AEROSOL WITH ADAPTER (GRAM)
QVAR 2
HFA AEROSOL WITH ADAPTER (GRAM)
ALVESCO 4
AEROSOL POWDER, BREATH ACTIVATED (EA)
ASMANEX 4
NASAL STEROIDS
AEROSOL, SPRAY (ML)
flunisolide 1
SPRAY, SUSPENSION
fluticasone propionate 1
AEROSOL, SPRAY WITH PUMP (GRAM)
DYMISTA 2
HFA AEROSOL WITH ADAPTER (GRAM)
QNASL 2
AEROSOL, SPRAY WITH PUMP (GRAM)
NASONEX 3
AEROSOL, SPRAY (GRAM)
BECONASE AQ 4
AEROSOL, SPRAY WITH PUMP (GRAM)
OMNARIS 4
HFA AEROSOL WITH ADAPTER (GRAM)
ZETONNA 4
BETA AGONISTS
SOLUTION, NON-ORAL
albuterol sulfate 1
TABLET
albuterol sulfate 1
SYRUP
albuterol sulfate 1
VIAL, NEBULIZER (ML)
levalbuterol hcl 1
SYRUP
metaproterenol sulfate 1
TABLET
metaproterenol sulfate 1
TABLET
terbutaline sulfate 1
VIAL, NEBULIZER (ML)
PERFOROMIST 2
HFA AEROSOL WITH ADAPTER (GRAM)
PROAIR HFA 2
BLISTER, WITH INHALATION DEVICE
SEREVENT DISKUS 2
MIST INHALER (GRAM)
STRIVERDI RESPIMAT 2
HFA AEROSOL WITH ADAPTER (GRAM)
VENTOLIN HFA 2
CAPSULE, WITH INHALATION DEVICE
FORADIL 3
CAPSULE, WITH INHALATION DEVICE
ARCAPTA NEOHALER 4
HFA AEROSOL WITH ADAPTER (GRAM)
PROVENTIL HFA 4
HFA AEROSOL WITH ADAPTER (GRAM)
XOPENEX HFA 4
ANTIHISTAMINES
TABLET
arbinoxa 1
TABLET
carbinoxamine 1
LIQUID (ML)
carbinoxamine 1
Printed Date:11/1/2017
Page 32 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
RESPIRATORY
ANTIHISTAMINES
TABLET
clemastine fumarate 1
TABLET
cyproheptadine hcl 1
TABLET
desloratadine 1
ELIXIR
diphenhydramine hcl 1
SOLUTION, ORAL
hydroxyzine hcl 1
TABLET
hydroxyzine hcl 1
CAPSULE
hydroxyzine pamoate 1
CAPSULE
hydroxyzine pamoate 1
TABLET
levocetirizine dihydrochloride 1
TABLET
promethazine hcl 1
TABLET
r-tanna 1
SYRUP
CYPROHEPTADINE HCL 3
CAPSULE
SEMPREX-D 3
ANTITUSSIVE
CAPSULE
benzonatate 1
LIQUID (ML)
guaifenesin with codeine 1
TABLET
hydrocodone/homatropine 1
SUSPENSION, EXTENDED RELEASE 12 HR
hydrocodone-chlorpheniramine 1
SYRUP
promethazine vc w/codeine 1
SYRUP
promethazine w/dm 1
CAPSULE, EXTENDED RELEASE 12 HR
TUSSICAPS 2
SYRUP
BROMFED-DM 3
SUSPENSION, ORAL (FINAL DOSE FORM)
ZODRYL AC 35 3
OTHER
AEROSOL, SPRAY WITH PUMP (ML)
azelastine hcl 1
AEROSOL, SPRAY (ML)
ipratropium bromide 1
TABLET, EXTENDED RELEASE 12 HR
theophylline anhydrous 1
SOLUTION, ORAL
theophylline anhydrous 1
SPACER (EA)
AEROCHAMBER 2
SPACER (EA)
AEROCHAMBER PLUS 2
AEROSOL, SPRAY WITH PUMP (GRAM)
PATANASE 3
ANTI-INFECTIVES
PENICILLINS
TABLET
amoxicillin 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
amoxicillin 1
TABLET, EXTENDED RELEASE 12 HR
amoxicillin-clavulanate pot er 1
TABLET
amoxicillin-clavulanate potass 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
amoxicillin-clavulanate potass 1
CAPSULE
ampicillin trihydrate 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
ampicillin trihydrate 1
CAPSULE
dicloxacillin sodium 1
TABLET
penicillin v potassium 1
SOLUTION, RECONSTITUTED, ORAL
penicillin v potassium 1
HIV
TABLET
abacavir SP 1
TABLET
abacavir-lamivudine-zidovudine SP 1
CAPSULE,DELAYED RELEASE (ENTERIC COATED)
didanosine SP 1
TABLET
lamivudine-zidovudine SP 1
SUSPENSION, ORAL (FINAL DOSE FORM)
nevirapine SP 1
TABLET
nevirapine SP 1
CAPSULE
stavudine SP 1
SOLUTION, RECONSTITUTED, ORAL
stavudine SP 1
TABLET
zidovudine SP 1
CAPSULE
zidovudine SP 1
SYRUP
zidovudine SP 1
SOLUTION, ORAL
APTIVUS SP 2
CAPSULE
APTIVUS SP 2
TABLET
ATRIPLA SP 2
Printed Date:11/1/2017
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B4G Participant: N
ANTI-INFECTIVES
HIV
TABLET
COMPLERA SP 2
CAPSULE
CRIXIVAN SP 2
TABLET
DESCOVY SP 2
TABLET
EDURANT SP 2
CAPSULE
EMTRIVA SP 2
SOLUTION, ORAL
EMTRIVA SP 2
TABLET
GENVOYA SP 2
TABLET
INTELENCE SP 2
TABLET
INVIRASE 2
TABLET
ISENTRESS SP 2
TABLET
KALETRA SP 2
TABLET
LEXIVA SP 2
SUSPENSION, ORAL (FINAL DOSE FORM)
LEXIVA SP 2
SOLUTION, ORAL
NORVIR SP 2
TABLET
NORVIR SP 2
TABLET
ODEFSEY SP 2
TABLET
PREZISTA SP 2
SUSPENSION, ORAL (FINAL DOSE FORM)
PREZISTA SP 2
TABLET
RESCRIPTOR SP 2
CAPSULE
REYATAZ SP 2
TABLET
SELZENTRY SP 2
TABLET
STRIBILD SP 2
CAPSULE
SUSTIVA SP 2
TABLET
TIVICAY SP 2
TABLET
TRUVADA SP 2
SOLUTION, RECONSTITUTED, ORAL
VIDEX SP 2
TABLET
VIRACEPT SP 2
TABLET
VIREAD SP 2
SOLUTION, ORAL
ZIAGEN SP 2
SOLUTION, ORAL
EPIVIR SP 3
TABLET
EPZICOM SP 3
SOLUTION, ORAL
KALETRA SP 3
ANTIVIRALS
SUSPENSION, ORAL (FINAL DOSE FORM)
acyclovir 1
CAPSULE
acyclovir 1
TABLET
acyclovir 1
CAPSULE
amantadine hcl 1
SOLUTION, ORAL
amantadine hcl 1
TABLET
famciclovir 1
TABLET
lamivudine SP 1
TABLET
moderiba SP 1
TABLET, DOSE PACK
ribapak SP 1
CAPSULE
ribasphere SP 1
TABLET
ribavirin SP 1
CAPSULE
ribavirin SP 1
TABLET
rimantadine hcl 1
TABLET
valacyclovir 1
SOLUTION, ORAL
EPIVIR HBV SP 2
SUSPENSION, RECONSTITUTED, ORAL (ML)
TAMIFLU 2
TABLET
BARACLUDE SP 3
SOLUTION, ORAL
REBETOL SP 3
MUCO-ADHESIVE BUCCAL TABLET
SITAVIG SP 3
CAPSULE
TAMIFLU 3
TABLET
VALCYTE SP 3
SOLUTION, RECONSTITUTED, ORAL
VALCYTE SP 3
VAGINAL
Printed Date:11/1/2017
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B4G Participant: N
ANTI-INFECTIVES
VAGINAL
CREAM WITH APPLICATOR
clindamycin phosphate 1
GEL WITH APPLICATOR (GRAM)
metronidazole 1
SUPPOSITORY, VAGINAL
miconazole 3 1
CREAM WITH APPLICATOR
terconazole 1
SUPPOSITORY, VAGINAL
terconazole 1
CREAM WITH APPLICATOR
AVC 3
CREAM WITH PREFILLED APPLICATOR
GYNAZOLE-1 3
MISCELLANEOUS
CAPSULE
clindamycin hcl 1
SOLUTION, RECONSTITUTED, ORAL
clindamycin palmitate hcl 1
TABLET
dapsone 1
TABLET
linezolid SP 1
TABLET
methenamine hippurate 1
TABLET
methenamine mandelate 1
CAPSULE
nitrofurantoin 1
CAPSULE
nitrofurantoin macrocrystal 1
TABLET
sulfadiazine 1
TABLET
sulfamethoxazole/trimethoprim 1
SUSPENSION, ORAL (FINAL DOSE FORM)
sulfamethoxazole/trimethoprim 1
TABLET
trimethoprim 1
CAPSULE
vancomycin hcl 1
CAPSULE
TOBI PODHALER SP 2
TABLET
OTREXUP SP
XIFAXAN SP 2
PACKET (EA)
MONUROL 3
SOLUTION, ORAL
PRIMSOL 3
TABLET
SIVEXTRO 3
TABLET
ZYVOX 3
HEPATITIS C
TABLET
MAVYRET 2
TABLET
ZEPATIER SP 2
TABLET
DAKLINZA SP 4
TABLET
EPCLUSA SP 4
TABLET
HARVONI SP 4
CAPSULE
OLYSIO SP 4
TABLET
SOVALDI SP 4
TABLET
TECHNIVIE SP 4
TABLET, DOSE PACK
VIEKIRA PAK SP 4
CEPHALOSPORINS
SUSPENSION, RECONSTITUTED, ORAL (ML)
cefaclor 1
CAPSULE
cefaclor 1
CAPSULE
cefadroxil 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
cefadroxil 1
CAPSULE
cefdinir 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
cefdinir 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
cefprozil 1
TABLET
cefprozil 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
ceftibuten 1
CAPSULE
ceftibuten 1
TABLET
cephalexin 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
cephalexin 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
CEFTIN 3
SUSPENSION, RECONSTITUTED, ORAL (ML)
SUPRAX 3
ERYTHROMYCINS/MACROLIDS
SUSPENSION, RECONSTITUTED, ORAL (ML)
azithromycin 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
clarithromycin 1
TABLET
clarithromycin 1
TABLET, EXTENDED RELEASE 24 HR
clarithromycin er 1
Printed Date:11/1/2017
Page 35 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
ANTI-INFECTIVES
ERYTHROMYCINS/MACROLIDS
TABLET, ENTERIC COATED
ery-tab 1
TABLET
erythromycin 1
TABLET
erythromycin ethylsuccinate 1
TABLET
DIFICID SP 3
TABLET, PARTICLES/CRYSTALS IN
PCE 3
TETRACYCLINES
TABLET
demeclocycline hcl 1
TABLET
doxycycline hyclate 1
CAPSULE
doxycycline monohydrate 1
CAPSULE
minocycline hcl 1
CAPSULE
morgidox 1
CAPSULE
tetracycline hcl 1
CAPSULE,IMMEDIATE, DELAY RELEASE,BIPHASE
ORACEA 2
TABLET, EXTENDED RELEASE 24 HR
SOLODYN 2
TABLET, ENTERIC COATED
DORYX 3
SYRUP
VIBRAMYCIN 3
CAPSULE,IMMEDIATE, DELAY RELEASE,BIPHASE
DOXYCYCLINE IR-DR 4
QUINOLONES
TABLET,EXTENDED RELEASE MULTIPHASE 24 HR
ciprofloxacin er 1
TABLET
ciprofloxacin hcl 1
SOLUTION, ORAL
levofloxacin hemihydrate 1
TABLET
levofloxacin hemihydrate 1
ANTIFUNGAL
TROCHE
clotrimazole 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
fluconazole 1
TABLET
fluconazole 1
CAPSULE
flucytosine 1
TABLET
griseofulvin 1
SUSPENSION, ORAL (FINAL DOSE FORM)
griseofulvin 1
TABLET
griseofulvin ultramicrosize 1
CAPSULE
itraconazole 1
TABLET
ketoconazole 1
TABLET
nystatin 1
SUSPENSION, ORAL (FINAL DOSE FORM)
nystatin 1
TABLET
terbinafine 1
SUSPENSION, RECONSTITUTED, ORAL (ML)
voriconazole 1
TABLET
voriconazole 1
SUSPENSION, ORAL (FINAL DOSE FORM)
NOXAFIL SP 2
SOLUTION, ORAL
SPORANOX 2
TABLET
ONMEL SP 3
ANTIMALARIALS
TABLET
atovaquone-proguanil hcl 1
TABLET
chloroquine phosphate 1
TABLET
hydroxychloroquine sulfate 1
TABLET
mefloquine hcl 1
CAPSULE
quinine sulfate 1
TABLET
COARTEM 2
TABLET
DARAPRIM 2
TABLET
PRIMAQUINE 2
ANTIMYCOBACTERIALS
TABLET
ethambutol hcl 1
TABLET
isoniazid 1
TABLET
pyrazinamide 1
CAPSULE
rifampin 1
TABLET
SIRTURO 2
CAPSULE
CYCLOSERINE 3
GRANULES DELAYED RELEASE FOR SUSP PACKET
PASER 3
TABLET
RIFATER 3
Printed Date:11/1/2017
Page 36 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
ANTI-INFECTIVES
ANTIMYCOBACTERIALS
TABLET
TRECATOR 3
ANTIPARASITICS
TABLET
metronidazole 1
CAPSULE
paromomycin sulfate 1
TABLET
tinidazole 1
TABLET
ALBENZA SP 2
TABLET
ALINIA 2
SUSPENSION, RECONSTITUTED, ORAL (ML)
ALINIA 2
TABLET
BILTRICIDE 2
TABLET, EXTENDED RELEASE
FLAGYL ER 3
SUSPENSION, ORAL (FINAL DOSE FORM)
MEPRON 3
TABLET
STROMECTOL 3
Printed Date:11/1/2017
Page 37 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
Quick Reference Preferred Drug List
A
abacavir
abacavir-lamivudine-zidovudine ABILIFY MAINTENA
ABSORICA
ACANYA
acarbose
ACCU-CHEK
acebutolol hcl
acetaminophen w/codeine
acetasol hc
acetazolamide
acetic acid
acetic acid/hydrocortisone
acitretin
ACTIMMUNE
acyclovir
adapalene
ADCIRCA
ADEMPAS
ADVAIR DISKUS
ADVAIR HFA
AEROCHAMBER
AEROCHAMBER PLUS
afeditab cr
AFINITOR
AFINITOR DISPERZ
ALBENZA
albuterol sulfate
alclometasone dipropionate
ALECENSA
alendronate sodium
ALFERON N
ALINIA
allopurinol
ALPHAGAN P
alprazolam
alprazolam er
alprazolam intensol
alprazolam odt
alprazolam xr
ALREX
altavera
alyacen
amantadine hcl
amcinonide
amethia
amethyst
amiloride hcl
amiloride hcl w/hctz
amiodarone hcl
AMITIZA
amitriptyline hcl
amitriptyline/chlordiazepoxide
amitriptyline-perphenazine
amlodipine besylate
amlodipine besylate-benazepril amlodipine-atorvastatin
amoxapine
amoxicillin
amoxicillin-clavulanate pot er
amoxicillin-clavulanate potass
ampicillin trihydrate
AMPYRA
anaspaz
anastrozole
ANDROGEL
androxy
ANORO ELLIPTA
anucort-hc
apap/dichlphen/isometheptene apexicon e
apraclonidine hcl
apri
APRISO
APTIVUS
aranelle
arbinoxa
aripiprazole
armodafinil
ARMOUR THYROID
ARNUITY ELLIPTA
atenolol
atenolol w/chlorthalidone
atorvastatin calcium
atovaquone-proguanil hcl
ATRIPLA
atropine sulfate
ATROVENT HFA
AUBAGIO
aubra
aviane
AVONEX ADMINISTRATION PACK AZASAN
AZASITE
azathioprine
azelastine hcl
azithromycin
azurette
B
bacitracin
bacitracin/polymyxin
baclofen
balsalazide disodium
balziva
BANZEL
BD INSULIN PEN NEEDLE UF MINI B-D INSULIN SYRINGE
B-D NEEDLES
BELLADONNA
BELSOMRA
BELVIQ
benazepril hcl
benazepril hcl-hctz
benzonatate
benzoyl peroxide
benztropine mesylate
BEPREVE
betamethasone dipropionate
betamethasone valerate
BETASERON
betaxolol hcl
bethanechol chloride
bicalutamide
BILTRICIDE
bisoprolol fumarate
bisoprolol fumarate/hctz
BOOSTRIX
BOSULIF
BREO ELLIPTA
briellyn
BRILINTA
brimonidine tartrate
BRISDELLE
bromfenac sodium
bromocriptine mesylate
budesonide
budesonide ec
bumetanide
buprenorphine hydrochloride
buprenorphine-naloxone
bupropion hcl
bupropion hcl xl
bupropion sr
buspirone hcl
butalbital compound
butalbital compound w/codeine butalbital/apap/caffeine
butalbital/caff/apap/codeine
BYSTOLIC
C
cabergoline
calcipotriene
calcitonin-salmon
calcitrene
calcitriol
calcium acetate
camila
camrese
CANASA
candesartan cilexetil
candesartan-hydrochlorothiazid CAPRELSA
captopril
captopril/hydrochlorothiazide
CARAC
CARAFATE
CARBAGLU
carbamazepine
carbamazepine er
carbidopa/levodopa
carbidopa-levodopa er
carbidopa-levodopa-entacapone carbinoxamine
carisoprodol
carisoprodol compound
carisoprodol compound/codeine
Printed Date:11/1/2017
Page 38 | 2018 Select Formulary Data Last Updated:10/30/2017
B4G Participant: N
C
carisoprodol-aspirin
carteolol hcl
cartia xt
carvedilol
caziant
cefaclor
cefadroxil
cefdinir
cefprozil
ceftibuten
celecoxib
cephalexin
CERVARIX
CETROTIDE
cevimeline hcl
CHANTIX
chateal
CHENODAL
chlordiazepoxide hcl
chloroquine phosphate
chlorothiazide
chlorpromazine hcl
chlorzoxazone
cholestyramine
ciclopirox
cilostazol
cimetidine
CIPRODEX
ciprofloxacin er
ciprofloxacin hcl
citalopram hbr
claravis
clarithromycin
clarithromycin er
clemastine fumarate
clidinium w/chlordiazepoxide
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate
clindamycin phos-tretinoin
clindamycin-benzoyl peroxide
clobetasol e
clobetasol propionate
clomiphene citrate
clomipramine hcl
clonazepam
clonidine hcl
clopidogrel
clorazepate dipotassium
clorpres
clotrimazole
clotrimazole/betamethasone
clozapine
clozapine odt
COARTEM
codeine sulfate
COLCHICINE
COLCRYS
colestipol hcl
colocort
COMBIGAN
COMBIPATCH
COMBIVENT RESPIMAT
COMPLERA
constulose
COREG CR
CORTIFOAM
COSENTYX 150MG
COSENTYX 300MG
COUMADIN
CREON
CRINONE
CRIXIVAN
cromolyn sodium
cryselle
cyclafem
cyclobenzaprine hcl
cyclopentolate hcl
cyclosporine
cyproheptadine hcl
CYSTARAN
cytarabine
D
DALIRESP
danazol
dantrolene sodium
dapsone
DARAPRIM
dasetta
daysee
DAYTRANA
demeclocycline hcl
DESCOVY
desipramine hcl
desloratadine
desmopressin acetate
desonide
desoximetasone
dexamethasone
dexamethasone sodium phosphate DEXCOM G4
DEXCOM G5
dexmethylphenidate hcl
dexmethylphenidate hcl er
dextroamphetamine sulfate
dextroamphetamine-amphet er dextroamphetamine-amphetamine dialyvite
diazepam
diclofenac potassium
diclofenac sodium
diclofenac sodium-misoprostol
dicloxacillin sodium
dicyclomine hcl
didanosine
diflorasone diacetate
diflunisal
digoxin
dihydroergotamine mesylate
DILATRATE-SR
diltiazem 24hr cd
diltiazem er
diltiazem hcl
diphenhydramine hcl
diphenoxylate w/atropine
dipyridamole
diskets
disopyramide phosphate
disulfiram
divalproex sodium
divalproex sodium er
DIVIGEL
dorzolamide hcl
dorzolamide-timolol
doxazosin mesylate
doxepin hcl
doxycycline hyclate
doxycycline monohydrate
drithocreme hp
dronabinol
DROXIA
DUAVEE
duloxetine hcl
DYMISTA
E
econazole nitrate
EDURANT
EFFIENT
ELIDEL
ELIGARD
elinest
ELIQUIS
elite-ob
EMCYT
emoquette
EMTRIVA
enalapril maleate
ENBREL
ENGERIX-B
enoxaparin sodium
enpresse
enskyce
entacapone
ENTRESTO
ENTYVIO
EPIDUO
epinastine hcl
EPINEPHRINE
EPIPEN
EPIPEN JR.
epitol
EPIVIR HBV
eplerenone
eprosartan mesylate
errin
erygel
ery-tab
erythromycin
erythromycin ethylsuccinate
erythromycin-benzoyl peroxide escitalopram oxalate
estarylla
estazolam
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B4G Participant: N
E
ESTRACE
estradiol
estradiol-norethindrone acetat
estrogen & methyltestosterone
eszopiclone
ethambutol hcl
ethosuximide
etidronate disodium
etodolac
exemestane
EXJADE
EXTAVIA
F
falmina
famciclovir
famotidine
FARESTON
FARXIGA
felbamate
felodipine er
fenofibrate
fenofibric acid
fenoprofen calcium
fentanyl
fentanyl citrate
FETZIMA
FINACEA
finasteride
flavoxate hcl
flecainide acetate
FLECTOR
FLOVENT DISKUS
FLOVENT HFA
flucaine
fluconazole
flucytosine
fludrocortisone acetate
flunisolide
fluocinolone acetonide
fluocinonide
fluocinonide-e
fluorescein-benoxinate
fluoride
fluorometholone
fluorouracil
fluoxetine hcl
fluphenazine hcl
flurazepam hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate
fluvastatin sodium
fluvoxamine maleate
folic acid
fondaparinux sodium
FORTEO
fosinopril sodium
fosinopril-hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FRAGMIN
furosemide
FYCOMPA
G
gabapentin
GABITRIL
galantamine er
GARDASIL
gatifloxacin
GELSYN-3
gemfibrozil
gengraf
gentamicin sulfate
GENVOYA
gianvi
gildagia
GILENYA
GILOTRIF
glimepiride
glipizide er
glipizide-metformin
GLUCAGEN
GLUCAGON EMERGENCY KIT
glyburide
glyburide micronized
glyburide-metformin hcl
glycopyrrolate
GLYXAMBI
GONAL-F
granisetron hcl
griseofulvin
griseofulvin ultramicrosize
guaifenesin with codeine
guanfacine hcl
guanidine hcl
H
halobetasol propionate
haloperidol
haloperidol decanoate
haloperidol lactate
HAVRIX
heather
heparin sodium
homatropine hydrobromide
HUMIRA
HYCAMTIN
hydralazine hcl
hydrochlorothiazide
hydrocodone bit-ibuprofen
hydrocodone w/acetaminophen hydrocodone/homatropine
hydrocodone-chlorpheniramine hydrocortisone
hydrocortisone butyrate
hydromorphone hcl
hydroxychloroquine sulfate
hydroxyurea
hydroxyzine hcl
hydroxyzine pamoate
hyoscyamine sulfate
HYSINGLA ER
I
ibandronate sodium
ICLUSIG
ILEVRO
imatinib mesylate
IMBRUVICA
imipramine hcl
imipramine pamoate
imiquimod
indapamide
indomethacin
INFANRIX
INLYTA
INSULIN- SYRINGE
INTELENCE
INTRON A
introvale
INVIRASE
ipratropium bromide
ipratropium-albuterol
irbesartan
irbesartan-hydrochlorothiazide
ISENTRESS
isoniazid
isosorbide dinitrate
isosorbide mononitrate
isradipine
itraconazole
J
JAKAFI
jantoven
JANUMET
JANUMET XR
JANUVIA
JARDIANCE
jencycla
JENTADUETO
jinteli
jolessa
jolivette
junel
JUXTAPID
K
KALETRA
KALYDECO
kariva
kelnor 1-35
ketoconazole
ketoprofen
ketorolac tromethamine
KINEVAC
klor-con
kurvelo
L
labetalol hcl
lactulose
LAMICTAL XR
lamivudine
lamivudine-zidovudine
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B4G Participant: N
L
lamotrigine
lansoprazol-amoxicil-clarithro
lansoprazole
LANTUS
LANTUS SOLOSTAR
larin fe
latanoprost
LATUDA
leena
lessina
LETAIRIS
letrozole
leucovorin calcium
LEUKERAN
levalbuterol hcl
LEVEMIR
levetiracetam
levobunolol hcl
levocetirizine dihydrochloride
levofloxacin hemihydrate
levonest
levora
levothyroxine sodium
levoxyl
LEXIVA
lidocaine
lidocaine-hc
lidocaine-prilocaine
lindane
linezolid
LINZESS
liothyronine sodium
LIPOFEN
lisinopril
lisinopril-hctz
lithium carbonate
lithium citrate
LO LOESTRIN FE
lomedia 24 fe
loperamide hcl
lorazepam
lorazepam intensol
loryna
losartan potassium
losartan-hydrochlorothiazide
LOTEMAX
lovastatin
low-ogestrel
loxapine succinate
lutera
LYRICA
LYSODREN
lyza
M
malathion
maprotiline hcl
marlissa
MATULANE
MAVYRET
meclizine hcl
meclofenamate sodium
mefenamic acid
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam
MENOPUR
meperidine hcl
MEPHYTON
meprobamate
mercaptopurine
mesalamine
MESNEX
metaproterenol sulfate
metaxalone
metformin hcl
metformin hcl er
methadone hcl
methazolamide
methenamine hippurate
methenamine mandelate
methimazole
methocarbamol
methotrexate
methscopolamine bromide
methyclothiazide
methyldopa
methyldopa/hydrochlorothiazide methylphenidate er
methylphenidate hcl
methylphenidate hcl cd
methylprednisolone
methylprednisolone acetate
metipranolol
metoclopramide hcl
metolazone
metoprolol tartrate
metronidazole
mexiletine hcl
miconazole 3
microgestin
midazolam hcl
midodrine hcl
MINIVELLE
minocycline hcl
minoxidil
mirtazapine
MIRVASO
misoprostol
MITIGARE
modafinil
moderiba
moexipril hcl
moexipril-hydrochlorothiazide
mometasone furoate
mono-linyah
mononessa
montelukast sodium
morgidox
morphine sulfate
morphine sulfate er
MOVANTIK
MOXEZA
mupirocin
MUSE
mycophenolate mofetil
myorisan
MYRBETRIQ
myzilra
N
nabumetone
nadolol
nadolol-bendroflumethiazide
naltrexone hydrochloride
NAMENDA XR
naproxen
naproxen sodium
naratriptan hcl
NARCAN
NASCOBAL
NATACYN
NATAZIA
nateglinide
nature-throid
necon
nefazodone hcl
neo/polymyxin/dexamethasone neomycin/bacitracin/poly/hc
neomycin/bacitracin/polymyxin neomycin/polymyxin/gramicidin neomycin/polymyxin/hc
NEORAL
NEULASTA
NEUPRO
NEVANAC
nevirapine
NEXAVAR
niacin er
nifedipine
nifedipine er
nimodipine
nisoldipine
nitro-bid
nitrofurantoin
nitrofurantoin macrocrystal
nitroglycerin
nizatidine
nora-be
NORDITROPIN FLEXPRO
norethindrone acetate
nortrel
nortriptyline hcl
NORVIR
NOVAREL
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOXAFIL
NUCYNTA
NUCYNTA ER
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B4G Participant: N
N
NUEDEXTA
NUVARING
nystatin
nystatin w/triamcinolone
O
obstetrix dha
ocella
ODEFSEY
ofloxacin
ogestrel
olanzapine
olanzapine odt
olanzapine-fluoxetine hcl
olmesartan medoxomil
omeprazole
omeprazole-sodium bicarbonate ondansetron hcl
ondansetron odt
ONE TOUCH ULTRA TEST STRIPS ONE TOUCH VERIO
ONFI
ORACEA
ORENCIA
ORENCIA CLICKJECT
orphenadrine citrate
orsythia
OTREXUP
oxandrolone
oxaprozin
oxazepam
oxcarbazepine
OXTELLAR XR
oxybutynin chloride
oxybutynin chloride er
oxycodone hcl
oxycodone hcl-ibuprofen
oxycodone w/acetaminophen
oxycodone w/aspirin
OXYCONTIN
oxymorphone hcl
P
pacerone
pantoprazole sodium
paromomycin sulfate
paroxetine er
paroxetine hcl
PEGANONE
PEGASYS
penicillin v potassium
PENTASA
pentoxifylline
PERFOROMIST
perindopril erbumine
permethrin
perphenazine
phenelzine sulfate
phenobarbital
phenytoin
phenytoin sodium
philith
PICATO
pilocarpine hcl
pimtrea
pindolol
pioglitazone hcl
pioglitazone-glimepiride
pioglitazone-metformin
pirmella
piroxicam
PNEUMOVAX 23
podofilox
polymyxin b sul-trimethoprim
POMALYST
portia
potassium chloride
POTIGA
PRALUENT PEN
PRALUENT SYRINGE
pravastatin sodium
prazosin hcl
PRED MILD
prednicarbate
prednisolone
prednisolone acetate
prednisone
PREMARIN
PREMPHASE
PREMPRO
prenatabs rx
prenatal plus
prevalite
previfem
PREVNAR 13
PREZISTA
PRIMAQUINE
primidone
PROAIR HFA
probenecid
probenecid w/colchicine
procainamide hcl
prochlorperazine maleate
PROCRIT
progesterone
PROLENSA
promethazine hcl
promethazine vc w/codeine
promethazine w/dm
propafenone hcl
proparacaine hcl
propranolol hcl
propranolol hcl-hctz
protriptyline hcl
PULMICORT FLEXHALER
PULMOZYME
PYLERA
pyrazinamide
Q
QNASL
quasense
quazepam
quetiapine fumarate
quetiapine fumarate er
QUILLICHEW ER
QUILLIVANT XR
quinapril
quinapril-hydrochlorothiazide
quinidine gluconate
quinidine sulfate
quinine sulfate
QVAR
R
rabeprazole sodium
ramipril
RANEXA
ranitidine hcl
RAPAFLO
RAPAMUNE
RASUVO
REBIF
reclipsen
RECOMBIVAX HB
REGRANEX
RELISTOR
repaglinide
REPATHA SURECLICK
REPATHA SYRINGE
RESCRIPTOR
reserpine
RESTASIS
REVLIMID
REYATAZ
ribapak
ribasphere
ribavirin
rifampin
riluzole
rimantadine hcl
RISPERDAL CONSTA
risperidone
risperidone odt
rivastigmine
rizatriptan
ropinirole hcl
rosadan
rosuvastatin calcium
ROTATEQ
ROZEREM
r-tanna
S
SABRIL
SAFYRAL
salsalate
SANCUSO
SANDIMMUNE
SANDIMMUNE
SANTYL
SAPHRIS
SAVELLA
SAXENDA
selegiline hcl
selenium sulfide
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B4G Participant: N
S
SELZENTRY
SEREVENT DISKUS
sertraline hcl
sildenafil citrate
SILIQ
silver sulfadiazine
simvastatin
sirolimus
SIRTURO
SKYLA
sodium sulfacetamide
sodium sulfacetamide/sulfur
SOLODYN
SOLU-CORTEF
sorine
sotalol
sotalol af
SPIRIVA
SPIRIVA RESPIMAT
spironolactone
spironolactone w/hctz
SPORANOX
sprintec
SPRYCEL
sronyx
stavudine
STIOLTO RESPIMAT
STIVARGA
STRIBILD
STRIVERDI RESPIMAT
SUBOXONE
SUCRAID
sucralfate
sulfacetamide sodium
sulfacetamide w/prednisolone
sulfadiazine
sulfamethoxazole/trimethoprim SULFAMYLON
sulfasalazine
sulfasalazine dr
sulindac
sumatriptan succinate
SUPARTZ FX
SUPREP
SUSTIVA
SUTENT
syeda
SYLATRON
SYMBICORT
SYMLINPEN 120
SYNJARDY
SYNVISC
SYNVISC-ONE
T
TABLOID
TACLONEX
tacrolimus
TAFINLAR
TAMIFLU
tamoxifen citrate
TARCEVA
TASIGNA
TAZORAC
taztia xt
TECFIDERA
TEKAMLO
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan-amlodipine
telmisartan-hydrochlorothiazid
temazepam
temozolomide
terazosin hcl
terbinafine
terbutaline sulfate
terconazole
testosterone cypionate
tetracaine hcl
tetracycline hcl
THALOMID
theophylline anhydrous
thermazene
thioridazine hcl
thiothixene
tiagabine hcl
ticlopidine hcl
tilia fe
timolol maleate
tinidazole
TIVICAY
tizanidine hcl
TOBI PODHALER
TOBRADEX
TOBRADEX ST
tobramycin sulfate
tobramycin-dexamethasone
tolmetin sodium
tolterodine tartrate
tolterodine tartrate er
topiramate
torsemide
TOUJEO SOLOSTAR
TRACLEER
TRADJENTA
tramadol hcl
tramadol hcl er
tramadol hcl-acetaminophen
trandolapril
tranylcypromine sulfate
TRAVATAN Z
trazodone hcl
TRESIBA FLEXTOUCH U-200
tretinoin
tretinoin microsphere
TREXALL
TREXIMET
triamcinolone acetonide
triamterene w/hctz
trianex
triderm
tri-estarylla
trifluoperazine hcl
trifluridine
trihexyphenidyl hcl
tri-linyah
trimethobenzamide hcl
trimethoprim
trinessa
tri-previfem
tri-sprintec
trivora
TROKENDI XR
tropicamide
trospium chloride
TRULICITY
TRUVADA
TUSSICAPS
TWINRIX
TYKERB
U
ULORIC
unithroid
ursodiol
V
valacyclovir
valproic acid
valsartan
valsartan-hydrochlorothiazide
vancomycin hcl
VASCEPA
velivet
venlafaxine hcl
venlafaxine hcl er
VENTOLIN HFA
verapamil er pm
verapamil hcl
VESICARE
vestura
VICTOZA
VIDEX
VIIBRYD
VIMPAT
VIOKACE
viorele
VIRACEPT
VIREAD
VIVITROL
voriconazole
VOTRIENT
VYVANSE
W
warfarin sodium
WELCHOL
wera
wymzya fe
X
XALKORI
XARELTO
XIFAXAN
XIGDUO XR
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B4G Participant: N
X
XOLAIR
Z
zafirlukast
zaleplon
zarah
ZARXIO
ZELAPAR
ZELBORAF
zenchent
ZENPEP
ZEPATIER
ZIAGEN
zidovudine
ZIOPTAN
ziprasidone hcl
ZOLINZA
zolmitriptan
zolmitriptan odt
zolpidem tartrate er
ZOMIG
zonisamide
ZORTRESS
ZORVOLEX
ZOSTAVAX
zovia
ZUBSOLV
ZYLET
ZYTIGA
Printed Date:11/1/2017
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B4G Participant: N