2020 TIER ONE FORMULARY - ShieldPBMAcyclovir 200 MG Capsule 25 Generic Acyclovir 200 MG/5 ML...
Transcript of 2020 TIER ONE FORMULARY - ShieldPBMAcyclovir 200 MG Capsule 25 Generic Acyclovir 200 MG/5 ML...
1 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
0.9 % Sodium Chloride 0.9% Solution 4 Generic
0.9 % Sodium Chloride 0.9% Syringe 40 Generic
AA 3%/Electrolyte-TPN Soln/Gly 3% Parenteral Solution 30 Brand
Acamprosate Calcium 333 MG Tablet DR/EC 90 Generic
Acarbose 100 MG Tablet 30 Generic
Acarbose 25 MG Tablet 30 Generic
Acarbose 50 MG Tablet 90 Generic
Acebutolol HCL 200 MG Capsule 30 Generic
Acebutolol HCL 400 MG Capsule 8 Generic
Acetaminophen 1000 MG/100 Solution 30 Brand
Acetaminophen 325 MG Tablet 30 Generic
Acetaminophen w/ Codeine 120-12 MG/5 Solution 60 Generic
Acetaminophen w/ Codeine 300 MG-15 MG Tablet 30 Generic
Acetaminophen w/ Codeine 300 MG-30 MG Tablet 30 Generic
Acetaminophen w/ Codeine 300 MG-60 MG Tablet 30 Generic
Acetazolamide 125 MG Tablet 14 Generic
Acetazolamide 250 MG Tablet 30 Generic
Acetazolamide 500 MG Capsule ER 30 Generic
Acetic Acid 2% Solution 60 Generic
Acyclovir 200 MG Capsule 25 Generic
Acyclovir 200 MG/5 ML Suspension 100 Generic
Acyclovir 400 MG Tablet 30 Generic
Acyclovir 5% Ointment 5 Generic
Acyclovir 800 MG Tablet 30 Generic
Adapalene 0.1% Gel 45 Generic
Adapalene 0.3% Gel 45 Generic
Adapalene/Benzoyl Peroxide 0.1%-2.5% Gel 45 Generic
Albumin Human 25% Parenteral Solution 30 Generic
Albumin Human 25% Parenteral Solution 30 Generic
Albumin Human 5% Parenteral Solution 30 Generic
Albumin Human 5% Parenteral Solution 30 Generic
Albuterol Sulfate 4 MG Tablet 12-Hr ER 30 Brand
Albuterol Sulfate 90 MCG HFA Aerosol Inhaler 8 Brand
Albuterol Sulfate Syrup 2 MG/5 ML 2 MG/5 ML Syrup 30 Generic
Alclometasone Dipropionate 0.05% Cream 30 Generic
Alclometasone Dipropionate 0.05% Ointment 15 Generic
Alendronate Sodium 10 MG Tablet 5 Generic
Alendronate Sodium 35 MG Tablet 4 Generic
Alendronate Sodium 5 MG Tablet 30 Generic
Alendronate Sodium 70 MG Tablet 4 Generic
Alfuzosin HCL ER 10 MG Tablet 24-Hr ER 30 Generic
Allopurinol 100 MG Tablet 30 Generic
Allopurinol 300 MG Tablet 30 Generic
Alprazolam 0.25 MG Disintegrating Tablet 6 Generic
Alprazolam 0.25 MG Tablet 10 Generic
Alprazolam 0.5 MG Disintegrating Tablet 1 Generic
Alprazolam 0.5 MG Tablet 20 Generic
Alprazolam 0.5 MG Tablet 24-Hr ER 10 Generic
Alprazolam 1 MG Disintegrating Tablet 20 Generic
Alprazolam 1 MG Tablet 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Alprazolam 1 MG Tablet 24-Hr ER 30 Generic
Alprazolam 2 MG Tablet 30 Generic
Alprazolam 2 MG Tablet 24-Hr ER 30 Generic
Alprazolam 3 MG Tablet 24-Hr ER 30 Generic
Amantadine HCL 100 MG Capsule 30 Generic
Amantadine HCL 100 MG Tablet 10 Generic
Amantadine HCL 50 MG/5 ML Solution 50 Generic
Amiloride HCL 5 MG Tablet 30 Generic
Amiloride/Hydrochlorothiazide 5 MG-50 MG Tablet 30 Generic
Amiodarone HCL 100 MG Tablet 15 Generic
Amiodarone HCL 200 MG Tablet 30 Generic
Amiodarone HCL 400 MG Tablet 5 Generic
Amitriptyline HCL 10 MG Tablet 30 Generic
Amitriptyline HCL 100 MG Tablet 30 Generic
Amitriptyline HCL 150 MG Tablet 30 Generic
Amitriptyline HCL 25 MG Tablet 30 Generic
Amitriptyline HCL 50 MG Tablet 30 Generic
Amitriptyline HCL 75 MG Tablet 30 Generic
Amitriptyline/Chlordiazepoxide 12.5 MG-5 MG Tablet 30 Brand
Amitriptyline/Chlordiazepoxide 25 MG-10 MG Tablet 30 Brand
Amlodipine Bes/Olmesartan Med 10 MG-20 MG Tablet 30 Generic
Amlodipine Bes/Olmesartan Med 10 MG-40 MG Tablet 30 Generic
Amlodipine Bes/Olmesartan Med 5 MG-20 MG Tablet 30 Generic
Amlodipine Besylate 10 MG Tablet 30 Generic
Amlodipine Besylate 2.5 MG Tablet 30 Generic
Amlodipine Besylate 5 MG Tablet 30 Generic
Amlodipine Besylate/Benazepril 10 MG-20 MG Capsule 30 Generic
Amlodipine Besylate/Benazepril 10 MG-40 MG Capsule 30 Generic
Amlodipine Besylate/Benazepril 2.5 MG-10 MG Capsule 30 Generic
Amlodipine Besylate/Benazepril 5 MG-10 MG Capsule 30 Generic
Amlodipine Besylate/Benazepril 5 MG-20 MG Capsule 30 Generic
Amlodipine Besylate/Benazepril 5 MG-40 MG Capsule 30 Generic
Amlodipine/Atorvastatin 10 MG-20 MG Tablet 30 Generic
Amlodipine/Atorvastatin 10 MG-40 MG Tablet 30 Generic
Amlodipine/Atorvastatin 5 MG-20 MG Tablet 30 Generic
Amlodipine/Atorvastatin 5 MG-40 MG Tablet 30 Generic
Amlodipine/Valsartan 10 MG-160 MG Tablet 30 Generic
Amlodipine/Valsartan 10 MG-320 MG Tablet 30 Generic
Amlodipine/Valsartan 5 MG-160 MG Tablet 30 Generic
Amlodipine/Valsartan 5 MG-320 MG Tablet 30 Generic
Amlodipine/Valsartan/Hcthiazid 10 MG-160 MG Tablet 30 Generic
Amlodipine/Valsartan/Hcthiazid 10-160-25 Tablet 30 Generic
Amlodipine/Valsartan/Hcthiazid 10-320-25 Tablet 30 Generic
Amlodipine/Valsartan/Hcthiazid 5-160-12.5 Tablet 30 Generic
Ammonium Lactate 12% Cream 140 Generic
Ammonium Lactate 12% Lotion 30 Generic
Ammonium Lactate 12% Lotion 225 Generic
Amoxapine 100 MG Tablet 30 Brand
Amoxapine 150 MG Tablet 30 Brand
Amoxapine 25 MG Tablet 30 Brand
2 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Amoxapine 50 MG Tablet 30 Brand
Amoxicillin 125 MG Chewable Tablet 15 Brand
Amoxicillin 125 MG/5 ML Suspension for Reconstitution 80 Generic
Amoxicillin 200 MG/5 ML Suspension for Reconstitution 75 Generic
Amoxicillin 250 MG Capsule 30 Generic
Amoxicillin 250 MG/5 ML Suspension for Reconstitution 80 Generic
Amoxicillin 400 MG/5 ML Suspension for Reconstitution 75 Generic
Amoxicillin 500 MG Capsule 20 Generic
Amoxicillin 500 MG Tablet 30 Generic
Amoxicillin 875 MG Tablet 14 Generic
Amoxicillin/Potassium Clav 1000-62.5 Tablet 12-Hr ER 14 Generic
Amoxicillin/Potassium Clav 200-28.5 MG Chewable Tablet 14 Brand
Amoxicillin/Potassium Clav 200-28.5/5 Suspension for Reconstitution 50 Generic
Amoxicillin/Potassium Clav 250-125 MG Tablet 30 Generic
Amoxicillin/Potassium Clav 250-62.5/5 Suspension for Reconstitution 75 Generic
Amoxicillin/Potassium Clav 400-57 MG Chewable Tablet 14 Brand
Amoxicillin/Potassium Clav 400-57 MG/5 Suspension for Recon 50 Generic
Amoxicillin/Potassium Clav 500-125 MG Tablet 10 Generic
Amoxicillin/Potassium Clav 600-42.9/5 Suspension for Reconstitution 75 Generic
Amoxicillin/Potassium Clav 875-125 MG Tablet 14 Generic
Ampicillin Trihydrate 250 MG Capsule 30 Generic
Ampicillin Trihydrate 500 MG Capsule 30 Brand
Antihemoph.FVIII, Brand-Domain Del 1000 (+/-) Solution 30 Brand
Antihemoph.FVIII, Brand-Domain Del 2000 (+/-) Solution 30 Brand
Antihemoph.FVIII, Brand-Domain Del 250 (+/-) Solution 30 Brand
Antihemoph.FVIII, Brand-Domain Del 3000 (+/-) Syringe 30 Brand
Antihemoph.FVIII, Brand-Domain Del 500 (+/-) Solution 30 Brand
Antihemoph.FVIII, Full Length 4000 (+/-) Recon Solution 30 Brand
Antihemoph.FVIII, Full Length 500 (+/-) Recon Solution 30 Brand
Antihemophilic Factor/VWF 1000 (400) Recon Solution 30 Brand
Antihemophilic Factor/VWF 1500 (600) Recon Solution 30 Brand
Antihemophilic Factor/VWF 2000 (800) Recon Solution 30 Brand
Antihemophilic Factor/VWF 250 (100) Recon Solution 30 Brand
Antihemophilic Factor/VWF 500 (200) Recon Solution 30 Brand
Apraclonidine HCL 0.5% Drops 5 Generic
Aprepitant 40 MG Capsule 1 Generic
Aripiprazole 10 MG Disintegrating Tablet 2 Generic
Aspirin/Dipyridamole 25 MG-200 MG Multiphase Capsule 12-Hr ER 30 Generic
Atenolol 100 MG Tablet 30 Generic
Atenolol 25 MG Tablet 15 Generic
Atenolol 50 MG Tablet 30 Generic
Atenolol/Chlorthalidone 100 MG-25 MG Tablet 30 Generic
Atenolol/Chlorthalidone 50 MG-25 MG Tablet 30 Generic
Atomoxetine HCL 10 MG Capsule 5 Generic
Atomoxetine HCL 18 MG Capsule 7 Generic
Atorvastatin Calcium 10 MG Tablet 30 Generic
Atorvastatin Calcium 20 MG Tablet 30 Generic
Atorvastatin Calcium 40 MG Tablet 30 Generic
Atorvastatin Calcium 80 MG Tablet 30 Generic
Atovaquone/Proguanil HCL 250-100 MG Tablet 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Atovaquone/Proguanil HCL 62.5-25 MG Tablet 30 Generic
Atropine Sulfate 1% Ointment 4 Brand
Azathioprine 50 MG Tablet 30 Generic
Azelastine HCL 0.05% Drops 6 Generic
Azelastine HCL 137 MCG (0.1%) Nasal Spray 30 Generic
Azelastine HCL 205.5 MCG Non-Aerosol Spray 30 Generic
Azithromycin 100 MG/5 ML Suspension for Reconstitution 15 Generic
Azithromycin 200 MG/5 ML Suspension for Reconstitution 15 Generic
Azithromycin 250 MG Tablet 6 Generic
Azithromycin 500 MG Tablet 3 Generic
Azithromycin 600 MG Tablet 3 Generic
B Complex & C No. 20/Folic Acid 1 MG Capsule 30 Generic
B3/Azel Ac/Zinc/B6/Copper/FA 600-5-500 Tablet 30 Generic
Bacitracin/Polymyxin Brand Sulfate 500-10 K/Generic Ointment 4 Generic
Baclofen 10 MG Tablet 30 Generic
Baclofen 20 MG Tablet 30 Generic
Baclofen 5 MG Tablet 30 Generic
Bacteriostatic Sodium Chloride 0.9% Solution 30 Generic
Balsalazide Disodium 750 MG Capsule 90 Generic
Benazepril HCL 10 MG Tablet 30 Generic
Benazepril HCL 20 MG Tablet 30 Generic
Benazepril HCL 40 MG Tablet 30 Generic
Benazepril HCL 5 MG Tablet 15 Generic
Benazepril/Hydrochlorothiazide 10-12.5 MG Tablet 30 Generic
Benazepril/Hydrochlorothiazide 20 MG-25 MG Tablet 30 Generic
Benazepril/Hydrochlorothiazide 20-12.5 MG Tablet 30 Generic
Benazepril/Hydrochlorothiazide 5-6.25 MG Tablet 30 Generic
Benzocaine 10% Gel 30 Generic
Benzonatate 100 MG Capsule 30 Generic
Benzonatate 200 MG Capsule 30 Generic
Benzoyl Peroxide 10% Cleanser 227 Generic
Benzoyl Peroxide 10% Gel 60 Generic
Benzoyl Peroxide 2.5% Cleanser 30 Generic
Benzoyl Peroxide 5% Gel 60 Generic
Benzoyl Peroxide 7% Cleanser 360 Generic
Benzoyl Peroxide 9.5% Foam 1 Brand
Benzphetamine HCL 25 MG Tablet 30 Generic
Benzphetamine HCL 50 MG Tablet 30 Generic
Benztropine Mesylate 0.5 MG Tablet 30 Generic
Benztropine Mesylate 1 MG Tablet 30 Generic
Benztropine Mesylate 2 MG Tablet 30 Generic
Betamet Acet/Betamet Na Ph 6 MG/ML Suspension 5 Generic
Betamethasone Dipropionate 0.05% Cream 30 Generic
Betamethasone Dipropionate 0.05% Lotion 60 Generic
Betamethasone Dipropionate 0.05% Ointment 15 Generic
Betamethasone Valerate 0.1% Cream 30 Generic
Betamethasone Valerate 0.1% Lotion 60 Generic
Betamethasone Valerate 0.1% Ointment 15 Generic
Betamethasone Valerate 0.12% Foam 30 Generic
Betamethasone/Propylene Glyc 0.05% Lotion 30 Generic
3 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Betamethasone/Propylene Glyc 0.05% Ointment 15 Generic
Betaxolol HCL 0.5% Drops 5 Generic
Betaxolol HCL 10 MG Tablet 30 Generic
Betaxolol HCL 20 MG Tablet 30 Generic
Bethanechol Chloride 10 MG Tablet 30 Generic
Bethanechol Chloride 25 MG Tablet 30 Generic
Bethanechol Chloride 5 MG Tablet 60 Generic
Bethanechol Chloride 50 MG Tablet 2 Generic
Bisac/NaCl/NaHCo3/KCL/Peg 3350 5 MG-210 Generic Kit 1 Generic
Bisoprolol Fumarate 10 MG Tablet 30 Generic
Bisoprolol Fumarate 5 MG Tablet 15 Generic
Bisoprolol Fumarate/HCTZ 10-6.25 MG Tablet 30 Generic
Bisoprolol Fumarate/HCTZ 2.5-6.25 MG Tablet 30 Generic
Bisoprolol Fumarate/HCTZ 5-6.25 MG Tablet 30 Generic
Brimonidine Tartrate 0.2% Drops 5 Generic
Bromocriptine Mesylate 2.5 MG Tablet 30 Generic
Brompheniramine/Pseudoephed/DM 2-30-10/5 Syrup 120 Generic
Budesonide 0.25 MG/2 ML Suspension for Nebulization 60 Generic
Budesonide 0.5 MG/2 ML Suspension for Nebulization 60 Generic
Budesonide 32 MCG Non-Aerosol Spray 9 Generic
Bumetanide 0.25 MG/ML Solution 30 Generic
Bumetanide 0.5 MG Tablet 12 Generic
Bumetanide 1 MG Tablet 15 Generic
Bumetanide 2 MG Tablet 30 Generic
Bupivacaine HCL 2.5 MG/ML Solution 30 Brand
Bupivacaine HCL 5 MG/ML Solution 100 Generic
Bupivacaine HCL/Dex-Water/PF 0.75% Solution 30 Brand
Bupivacaine HCL/Epinephrine 0.25-.0005 Solution 30 Brand
Bupivacaine HCL/Epinephrine 0.5-1:200 K Solution 30 Brand
Bupivacaine HCL/Epinephrine/PF 0.5-1:200 K Solution 30 Generic
Bupivacaine HCL/Epinephrine/PF 0.75-.0005 Solution 30 Brand
Bupivacaine HCL/PF 2.5 MG/ML Solution 30 Generic
Bupivacaine HCL/PF 5 MG/ML Solution 30 Generic
Bupivacaine HCL/PF 7.5 MG/ML Solution 30 Generic
Buprenorphine HCL 8 MG Sublingual Tablet 30 Generic
Bupropion HCL 100 MG Tablet 30 Generic
Bupropion HCL 150 MG Tablet 12-Hr SR 30 Brand
Bupropion HCL 200 MG Tablet ER 30 Generic
Bupropion HCL 300 MG Tablet 24-Hr ER 30 Generic
Bupropion HCL 75 MG Tablet 30 Generic
Bupropion HCL SR 150 MG Tablet 12-Hr SR 60 Generic
Bupropion SR 100 MG Tablet ER 30 Generic
Bupropion XL 150 MG Tablet 24-Hr ER 30 Generic
Buspirone HCL 10 MG Tablet 30 Generic
Buspirone HCL 15 MG Tablet 60 Generic
Buspirone HCL 30 MG Tablet 30 Generic
Buspirone HCL 5 MG Tablet 30 Generic
Buspirone HCL 7.5 MG Tablet 30 Generic
Butalb/Acetaminophen/Caffeine 50-300-40 Capsule 30 Generic
Butalb/Acetaminophen/Caffeine 50-325-40 Capsule 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Butalb/Acetaminophen/Caffeine 50-325-40 Tablet 30 Generic
Butalbital/Acetamin/Caff/Codeine 50-325-30 Capsule 30 Generic
Butalbital/Acetaminophen 50 MG-325 MG Tablet 30 Generic
Butalbital/Aspirin/Caffeine 50-325-40 Capsule 30 Generic
Butorphanol Tartrate 10 MG/ML Non-Aerosol Spray 5 Generic
Calcipotriene 0.005% Solution 60 Generic
Calcitonin,Salmon,Synthetic 200/Spray Non-Aerosol Spray 4 Generic
Calcitriol 0.25 MCG Capsule 30 Brand
Calcitriol 0.5 MCG Capsule 12 Generic
Calcitriol 1 MCG/ML Solution 10 Generic
Calcium Acetate 667 MG Capsule 90 Generic
Calcium Acetate 667 MG Tablet 90 Generic
Calcium Acetate 667 MG/5 ML Solution 30 Brand
Calcium Carbonate/Mag Carb/FA 200-400-1 Tablet 100 Brand
Candesartan Cilexetil 16 MG Tablet 30 Generic
Candesartan Cilexetil 32 MG Tablet 30 Generic
Candesartan Cilexetil 4 MG Tablet 30 Generic
Candesartan Cilexetil 8 MG Tablet 15 Generic
Candesartan/Hydrochlorothiazid 16-12.5 MG Tablet 30 Generic
Candesartan/Hydrochlorothiazid 32 MG-25 MG Tablet 30 Generic
Candesartan/Hydrochlorothiazid 32-12.5 MG Tablet 30 Generic
Captopril 100 MG Tablet 30 Generic
Captopril 12.5 MG Tablet 15 Generic
Captopril 25 MG Tablet 30 0
Captopril 50 MG Tablet 30 Generic
Captopril/Hydrochlorothiazide 25 MG-25 MG Tablet 30 Brand
Carbamazepine 100 MG Chewable Tablet 30 Generic
Carbamazepine 100 MG Tablet 12-Hr ER 30 Generic
Carbamazepine 100 MG/5 ML Suspension 150 Generic
Carbamazepine 200 MG Multiphase Capsule 12-Hr ER 30 Generic
Carbamazepine 200 MG Tablet 30 Generic
Carbamazepine 200 MG Tablet 12-Hr ER 90 Generic
Carbamazepine 300 MG Multiphase Capsule 12-Hr ER 30 Generic
Carbamazepine 400 MG Tablet 12-Hr ER 30 Generic
Carbidopa/Levodopa 10 MG-100 MG Disintegrating Tablet 30 Generic
Carbidopa/Levodopa 10 MG-100 MG Tablet 30 Generic
Carbidopa/Levodopa 25 MG-100 MG Disintegrating Tablet 90 Generic
Carbidopa/Levodopa 25 MG-100 MG Tablet 30 Generic
Carbidopa/Levodopa 25 MG-100 MG Tablet ER 30 Generic
Carbidopa/Levodopa 25 MG-250 MG Tablet 30 Generic
Carbidopa/Levodopa 50 MG-200 MG Tablet ER 30 Generic
Carbinoxamine Maleate 4 MG Tablet 30 Generic
Carbinoxamine Maleate 4 MG/5 ML Liquid 30 Generic
Carisoprodol 250 MG Tablet 30 Generic
Carisoprodol 350 MG Tablet 30 Generic
Carvedilol 12.5 MG Tablet 30 Generic
Carvedilol 25 MG Tablet 60 Generic
Carvedilol 3.125 MG Tablet 30 Generic
Carvedilol 6.25 MG Tablet 30 Generic
Cefaclor 250 MG Capsule 30 Generic
4 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Cefaclor 500 MG Capsule 14 Generic
Cefadroxil 250 MG/5 ML Suspension for Reconstitution 100 Generic
Cefadroxil 500 MG Capsule 30 Generic
Cefadroxil 500 MG/5 ML Suspension for Reconstitution 75 Generic
Cefazolin Sodium 10 Generic Recon Solution 1 Generic
Cefdinir 125 MG/5 ML Suspension for Reconstitution 60 Generic
Cefdinir 250 MG/5 ML Suspension for Reconstitution 60 Generic
Cefdinir 300 MG Capsule 20 Generic
Cefixime 100 MG/5 ML Suspension for Reconstitution 50 Generic
Cefixime 400 MG Capsule 1 Brand
Cefpodoxime Proxetil 100 MG Tablet 14 Generic
Cefpodoxime Proxetil 100 MG/5 ML Suspension for Reconstitution 100 Generic
Cefpodoxime Proxetil 200 MG Tablet 20 Generic
Cefpodoxime Proxetil 50 MG/5 ML Suspension for Reconstitution 30 Generic
Cefprozil 125 MG/5 ML Suspension for Reconstitution 100 Generic
Cefprozil 250 MG Tablet 14 Generic
Cefprozil 250 MG/5 ML Suspension for Reconstitution 50 Generic
Cefprozil 500 MG Tablet 10 Generic
Ceftriaxone Sodium 1 G Recon Solution (Injection) 5 Generic
Ceftriaxone Sodium 250 MG Recon Solution 1 Generic
Cefuroxime Axetil 250 MG Tablet 30 Generic
Cefuroxime Axetil 500 MG Tablet 10 Generic
Cefuroxime Sodium 750 MG Recon Solution (Injection) 30 Generic
Celecoxib 100 MG Capsule 30 Generic
Celecoxib 200 MG Capsule 30 Generic
Celecoxib 400 MG Capsule 15 Generic
Celecoxib 50 MG Capsule 20 Generic
Cephalexin 125 MG/5 ML Suspension for Reconstitution 100 Generic
Cephalexin 250 MG Capsule 30 Generic
Cephalexin 250 MG Tablet 21 Brand
Cephalexin 250 MG/5 ML Suspension for Reconstitution 100 Generic
Cephalexin 500 MG Capsule 30 Generic
Cephalexin 500 MG Tablet 10 Brand
Cephalexin 750 MG Capsule 30 Generic
Cetirizine HCL 1 MG/ML Solution 120 Generic
Cetirizine HCL 5 MG/5 ML Solution 75 Generic
Cevimeline HCL 30 MG Capsule 30 Generic
Chlordiazepoxide HCL 10 MG Capsule 30 Generic
Chlordiazepoxide HCL 25 MG Capsule 30 Generic
Chlordiazepoxide HCL 5 MG Capsule 30 Generic
Chlordiazepoxide-Clidinium BR 5 MG-2.5 MG Capsule 30 Generic
Chlorhexidine Gluconate 0.12% Mouthwash 473 Generic
Chloroprocaine HCL 10 MG/ML Solution 30 Brand
Chloroprocaine HCL 20 MG/ML Solution 30 Brand
Chloroprocaine HCL/PF 20 MG/ML Solution 30 Brand
Chloroquine Phosphate 500 MG Tablet 4 Generic
Chlorothiazide 250 MG Tablet 30 Brand
Chlorothiazide 250 MG/5 ML Suspension 40 Brand
Chlorothiazide 500 MG Tablet 30 Generic
Chlorpheniramine/Phenyleph/DM 4-10-15/5 Liquid 60 Generic
Name/Strength/Form Default Qty. Brand/Generic
Chlorpheniramine/Pseudoephed 2-30 MG/5 ML Liquid 30 Generic
Chlorpromazine HCL 10 MG Tablet 30 Generic
Chlorpromazine HCL 25 MG Tablet 20 Generic
Chlorpropamide 100 MG Tablet 30 Brand
Chlorpropamide 250 MG Tablet 90 Brand
Chlorthalidone 25 MG Tablet 30 Generic
Chlorthalidone 50 MG Tablet 30 Generic
Chlorzoxazone 500 MG Tablet 30 Brand
Cholestyramine (w/ Sugar) 4 Generic Powder 30 Generic
Cholestyramine (w/ Sugar) 4 Generic Powder in Packet 30 Generic
Cholestyramine/Aspartame - No Sugar 4 Generic Powder 210 Generic
Cholestyramine/Aspartame 4 Generic Powder in Packet 30 Generic
Choline Sal/Mag Salicylate 500 MG/5 ML Liquid 30 Generic
Ciclopirox 0.77% Gel 30 Generic
Ciclopirox 0.77% Suspension 30 Generic
Ciclopirox 1% Shampoo 120 Generic
Ciclopirox 8% Solution 20 Generic
Ciclopirox Olamine 0.77% Cream 30 Generic
Cilostazol 100 MG Tablet 30 Generic
Cilostazol 50 MG Tablet 30 Generic
Cimetidine 200 MG Tablet 30 Generic
Cimetidine 300 MG Tablet 1 Generic
Cimetidine 400 MG Tablet 30 Generic
Cimetidine 800 MG Tablet 30 Generic
Cimetidine HCL 300 MG/5 ML Solution 150 Brand
Ciprofloxacin 500 MG/5 ML Suspension, Micro-capsule Recon 50 Generic
Ciprofloxacin Eye Preparations 0.3% Ophthalm Solution 5 Generic
Ciprofloxacin HCL 250 MG Tablet 30 Generic
Ciprofloxacin HCL 250 MG/5 ML Suspension, Micro-capsule Recon 45 Generic
Ciprofloxacin HCL 500 MG Tablet 14 Generic
Ciprofloxacin HCL 750 MG Tablet 4 Generic
Citalopram Hydrobromide 10 MG Tablet 15 Generic
Citalopram Hydrobromide 10 MG/5 ML Solution 90 Generic
Citalopram Hydrobromide 20 MG Tablet 30 Generic
Citalopram Hydrobromide 40 MG Tablet 30 Generic
Citric Ac/Gluconolact/Mag Carb 6.602 Generic/100 Solution 30 Brand
Citric Acid/Sodium Citrate 334-500 MG Solution 180 Generic
Clarithromycin 250 MG Tablet 30 Generic
Clarithromycin 500 MG Tablet 10 Generic
Clarithromycin 500 MG Tablet 24-Hr ER 20 Generic
Clemastine Fumarate 2.68 MG Tablet 30 Brand
Clindamycin HCL 150 MG Capsule 21 Generic
Clindamycin HCL 150 MG/ML Solution 180 Generic
Clindamycin HCL 2% Cream 40 Generic
Clindamycin HCL 300 MG Capsule 30 Generic
Clindamycin HCL 600 MG/4 ML Solution 30 Generic
Clindamycin HCL 75 MG Capsule 30 Generic
Clindamycin HCL 75 MG/5 ML Recon Solution 100 Generic
Clindamycin HCL 900 MG/6 ML Solution 30 Generic
Clindamycin Phos/Benzoyl Peroxide 1.2 (1)%-5% Gel 45 Generic
5 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Clindamycin Phosphate 1% Lotion 60 Generic
Clindamycin Phosphate 1% Solution 30 Generic
Clindamycin Phosphate 1% Swab 60 Generic
Clindamycin Phosphate/D5W 300 MG/50 ML Piggyback 30 Generic
Clindamycin Phosphate/D5W 600 MG/50 ML Piggyback 30 Generic
Clindamycin Phosphate/D5W 900 MG/50 ML Piggyback 30 Generic
Clobetasol Propionate 0.05% Cream 15 Generic
Clobetasol Propionate 0.05% Gel 30 Generic
Clobetasol Propionate 0.05% Solution 50 Generic
Clobetasol Propionate/Emoll 0.05% Cream 30 Generic
Clomiphene Citrate 50 MG Tablet 5 Generic
Clonazepam 0.125 MG Disintegrating Tablet 10 Generic
Clonazepam 0.25 MG Disintegrating Tablet 15 Generic
Clonazepam 0.5 MG Disintegrating Tablet 15 Generic
Clonazepam 0.5 MG Tablet 30 Generic
Clonazepam 1 MG Disintegrating Tablet 12 Generic
Clonazepam 1 MG Tablet 30 Generic
Clonazepam 2 MG Disintegrating Tablet 6 Generic
Clonazepam 2 MG Tablet 30 Generic
Clonidine 0.1 MG/24-Hr Weekly Patch 2 Generic
Clonidine HCL 0.1 MG Tablet 30 Generic
Clonidine HCL 0.1 MG Tablet 12-Hr ER 30 Generic
Clonidine HCL 0.2 MG Tablet 30 Generic
Clonidine HCL 0.3 MG Tablet 30 Generic
Clopidogrel Bi-sulfate 300 MG Tablet 1 Generic
Clopidogrel Bi-sulfate 75 MG Tablet 30 Generic
Clorazepate Dipotassium 15 MG Tablet 30 Generic
Clorazepate Dipotassium 3.75 MG Tablet 30 Generic
Clorazepate Dipotassium 7.5 MG Tablet 30 Generic
Clotrimazole 1% Cream & Gel Combo Pack 30 Generic
Clotrimazole 1% Solution 30 Generic
Clotrimazole 10 MG Troche 30 Generic
Clotrimazole/Betamethasone Dip 1%-0.05% Cream 30 Generic
Clotrimazole/Betamethasone Dip 1%-0.05% Lotion 30 Generic
Clozapine 100 MG Tablet 90 Generic
Clozapine 12.5 MG Disintegrating Tablet 30 Generic
Clozapine 200 MG Tablet 7 Generic
Clozapine 25 MG Disintegrating Tablet 30 Generic
Clozapine 25 MG Tablet 21 Generic
Clozapine 50 MG Tablet 20 Generic
Codeine Poli/Chlorphenir Polis 14.7-2.8/5 Suspension 12-Hr ER 30 Brand
Codeine/Butalbital/Asa/Caffeine 30-50-325 Capsule 30 Generic
Colchicine/Probenecid 0.5-500 MG Tablet 30 Generic
Colestipol HCL 1 Generic Tablet 30 Generic
Colestipol HCL 5 Generic Granules 30 Generic
Colestipol HCL 5 Generic Packet 1 Generic
Cortisone Acetate 25 MG Tablet 30 Brand
Cromolyn Sodium 4% Drops 20 Generic
Cyanocobalamin (Vitamin Brand-12) 1000 MCG/ML Solution 10 Generic
Cyanocobalamin/FA/Pyridoxine 1-2.2-25 MG Tablet 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Cyanocobalamin/FA/Pyridoxine 2-2.5-25 MG Tablet 30 Generic
Cyanocobalamin/Folic Acid 0.5 MG-1 MG Tablet 30 Brand
Cyclobenzaprine HCL 10 MG Tablet 30 Generic
Cyclobenzaprine HCL 5 MG Tablet 15 Generic
Cyclobenzaprine HCL 7.5 MG Tablet 30 Generic
Cyclopentolate HCL 1% Drops 15 Generic
Cyclosporine, Modified 100 MG Capsule 30 Generic
Cyclosporine, Modified 25 MG Capsule 60 Generic
Cyclosporine, Modified 50 MG Capsule 30 Generic
Cyproheptadine HCL 2 MG/5 ML Syrup 120 Generic
Cyproheptadine HCL 4 MG Tablet 30 Generic
Danazol 100 MG Capsule 12 Generic
Danazol 50 MG Capsule 30 Generic
Dantrolene Sodium 25 MG Capsule 30 Generic
Dapsone 25 MG Tablet 22 Generic
Delavirdine Mesylate 100 MG Dispersible Tablet 30 Brand
Delavirdine Mesylate 200 MG Tablet 30 Brand
Desipramine HCL 10 MG Tablet 30 Generic
Desipramine HCL 25 MG Tablet 30 Generic
Desipramine HCL 50 MG Tablet 30 Generic
Desloratadine 2.5 MG/5 ML Syrup 75 Brand
Desloratadine 5 MG Tablet 30 Generic
Desmopressin Acetate 0.1 MG Tablet 30 Generic
Desmopressin Acetate 0.2 MG Tablet 30 Generic
Desmopressin Acetate 10/Spray Aerosol 5 Generic
Desog-E.estradiol/E.estradiol 21-5 Tablet 28 Generic
Desogestrel-Ethinyl Estradiol 0.15-0.03 Tablet 28 Generic
Desogestrel-Ethinyl Estradiol 7 Days x3 Tablet 28 Generic
Desonide 0.05% Cream 30 Generic
Desonide 0.05% Ointment 15 Generic
Desoximetasone 0.25% Cream 15 Generic
Desoximetasone 0.25% Ointment 15 Generic
Desvenlafaxine Succinate 100 MG Tablet 24-Hr ER 30 Generic
Desvenlafaxine Succinate 25 MG Tablet 24-Hr ER 30 Generic
Desvenlafaxine Succinate 50 MG Tablet 24-Hr ER 30 Generic
Dexamethasone 0.1% Solution 30 Generic
Dexamethasone 0.1% Suspension Drops 5 Brand
Dexamethasone 0.5 MG Tablet 30 Generic
Dexamethasone 0.5 MG/5 ML Elixir 30 Generic
Dexamethasone 1 MG Tablet 30 Brand
Dexamethasone 1 MG/ML Drops 30 Brand
Dexamethasone 2 MG Tablet 30 Brand
Dexamethasone Sod Phosphate 0.75 MG Tablet 15 Generic
Dexamethasone Sod Phosphate 1.5 MG Tablet 8 Generic
Dexamethasone Sod Phosphate 4 MG Tablet 30 Generic
Dexamethasone Sod Phosphate 4 MG/ML Solution 5 Generic
Dexamethasone Sod Phosphate 6 MG Tablet 1 Generic
Dexmethylphenidate HCL 10 MG Biphasic Capsule ER 50-50 30 Generic
Dexmethylphenidate HCL 10 MG Tablet 30 Generic
Dexmethylphenidate HCL 15 MG Biphasic Capsule ER 50-50 30 Generic
6 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Dexmethylphenidate HCL 2.5 MG Tablet 30 Generic
Dexmethylphenidate HCL 20 MG Biphasic Capsule ER 50-50 30 Generic
Dexmethylphenidate HCL 30 MG Biphasic Capsule ER 50-50 30 Generic
Dexmethylphenidate HCL 40 MG Biphasic Capsule ER 50-50 30 Generic
Dexmethylphenidate HCL 5 MG Biphasic Capsule ER 50-50 30 Generic
Dexmethylphenidate HCL 5 MG Tablet 15 Generic
Dextroamphet/Amphet (Base) 2.5 MG/ML Susp, IR-ER, Biphasic 24-Hr 30 Brand
Dextroamphetamine Sulfate 10 MG Capsule ER 30 Generic
Dextroamphetamine Sulfate 10 MG Tablet 30 Generic
Dextroamphetamine Sulfate 15 MG Capsule ER 30 Generic
Dextroamphetamine Sulfate 5 MG Capsule ER 30 Generic
Dextroamphetamine Sulfate 5 MG Tablet 30 Generic
Dextroamphetamine/Amphetamine 10 MG Capsule 24-Hr ER 30 Generic
Dextroamphetamine/Amphetamine 10 MG Tablet 30 Generic
Dextroamphetamine/Amphetamine 12.5 MG Tablet 14 Generic
Dextroamphetamine/Amphetamine 15 MG Capsule 24-Hr ER 30 Generic
Dextroamphetamine/Amphetamine 15 MG Tablet 30 Generic
Dextroamphetamine/Amphetamine 20 MG Capsule 24-Hr ER 30 Generic
Dextroamphetamine/Amphetamine 20 MG Tablet 30 Generic
Dextroamphetamine/Amphetamine 25 MG Capsule 24-Hr ER 30 Generic
Dextroamphetamine/Amphetamine 30 MG Capsule 24-Hr ER 30 Generic
Dextroamphetamine/Amphetamine 30 MG Tablet 30 Generic
Dextroamphetamine/Amphetamine 5 MG Capsule 24-Hr ER 30 Generic
Dextroamphetamine/Amphetamine 5 MG Tablet 30 Generic
Dextroamphetamine/Amphetamine 7.5 MG Tablet 6 Generic
Diazepam 10 MG Tablet 30 Generic
Diazepam 2 MG Tablet 15 Generic
Diazepam 5 MG Tablet 30 Generic
Diclofenac Potassium 50 MG Tablet 30 Generic
Diclofenac Sodium 0.1% Drops 2 Generic
Diclofenac Sodium 1% Gel 100 Generic
Diclofenac Sodium 1.5% Drops 150 Generic
Diclofenac Sodium 100 MG Tablet 24-Hr ER 30 Generic
Diclofenac Sodium 25 MG Tablet DR/EC 10 Generic
Diclofenac Sodium 50 MG Tablet DR/EC 30 Generic
Diclofenac Sodium 75 MG Tablet DR/EC 20 Generic
Diclofenac Sodium/Misoprostol 50 MG-200 Tablet, IR, DR, Biphasic 30 Generic
Diclofenac Sodium/Misoprostol 75 MG-200 Tablet, IR, DR, Biphasic 30 Generic
Dicloxacillin Sodium 250 MG Capsule 90 Generic
Dicloxacillin Sodium 500 MG Capsule 14 Generic
Dicyclomine HCL 10 MG Capsule 30 Generic
Dicyclomine HCL 20 MG Tablet 30 Generic
Didanosine FNL 10 MG/ML Recon Solution 30 Brand
Diethylpropion HCL 25 MG Tablet 30 Generic
Diethylpropion HCL 75 MG Tablet ER 30 Brand
Diflunisal 500 MG Tablet 30 Generic
Digoxin 125 MCG Tablet 15 Generic
Digoxin 250 MCG Tablet 30 Generic
Digoxin 250 MCG/ML Solution 30 Generic
Diltiazem HCL 120 MG Capsule 12-Hr ER 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Diltiazem HCL 120 MG Capsule 24-Hr ER 30 Generic
Diltiazem HCL 120 MG Capsule ER 30 Generic
Diltiazem HCL 120 MG Degradable Capsule ER 30 Generic
Diltiazem HCL 120 MG Tablet 30 Generic
Diltiazem HCL 180 MG Capsule 24-Hr ER 30 Generic
Diltiazem HCL 180 MG Capsule ER 15 Generic
Diltiazem HCL 180 MG Degradable Capsule ER 30 Generic
Diltiazem HCL 180 MG Tablet 24-Hr ER 30 Generic
Diltiazem HCL 240 MG Capsule 24-Hr ER 30 Generic
Diltiazem HCL 240 MG Capsule ER 30 Generic
Diltiazem HCL 240 MG Degradable Capsule ER 30 Generic
Diltiazem HCL 240 MG Tablet 24-Hr ER 30 Generic
Diltiazem HCL 30 MG Tablet 30 Generic
Diltiazem HCL 300 MG Capsule 24-Hr ER 30 Generic
Diltiazem HCL 300 MG Capsule ER 28 Generic
Diltiazem HCL 300 MG Tablet 24-Hr ER 30 Generic
Diltiazem HCL 360 MG Capsule ER 30 Generic
Diltiazem HCL 360 MG Tablet 24-Hr ER 7 Generic
Diltiazem HCL 420 MG Capsule ER 30 Generic
Diltiazem HCL 60 MG Capsule 12-Hr ER 30 Generic
Diltiazem HCL 60 MG Tablet 30 Generic
Diltiazem HCL 90 MG Capsule 12-Hr ER 30 Generic
Diltiazem HCL 90 MG Tablet 34 Generic
Dimenhydrinate 50 MG Tablet 30 Generic
Diphenhydramine HCL 12.5 MG/5 ML Elixir 30 Generic
Diphenhydramine HCL 25 MG Capsule 30 Generic
Diphenhydramine HCL 50 MG Capsule 30 Generic
Diphenoxylate HCL/Atropine 2.5-.025 MG Tablet 30 Generic
Diphenoxylate HCL/Atropine 2.5-.025/5 Liquid 30 Brand
Dipyridamole 25 MG Tablet 30 Generic
Dipyridamole 50 MG Tablet 30 Generic
Dipyridamole 75 MG Tablet 30 Generic
Disopyramide Phosphate 100 MG Capsule 30 Generic
Disulfiram 250 MG Tablet 30 Generic
Disulfiram 500 MG Tablet 14 Generic
Divalproex Sodium 125 MG Tablet DR/EC 30 Generic
Divalproex Sodium 250 MG Tablet 24-Hr ER 30 Generic
Divalproex Sodium 250 MG Tablet DR/EC 30 Generic
Divalproex Sodium 500 MG Tablet 24-Hr ER 30 Generic
Divalproex Sodium 500 MG Tablet DR/EC 30 Generic
Docusate Sodium 250 MG Capsule 30 Generic
Dofetilide 125 MCG Capsule 56 Brand
Dofetilide 250 MCG Capsule 60 Brand
Dofetilide 500 MCG Capsule 60 Brand
Donepezil HCL 10 MG Tablet 30 Generic
Donepezil HCL 23 MG Tablet 25 Generic
Donepezil HCL 5 MG Tablet 15 Generic
Dorzolamide HCL 2% Drops 30 Generic
Dorzolamide HCL/Timolol Maleat 22.3-6.8/1 Drops 30 Generic
Doxazosin Mesylate 1 MG Tablet 30 Generic
7 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Doxazosin Mesylate 2 MG Tablet 30 Generic
Doxazosin Mesylate 4 MG Tablet 15 Generic
Doxazosin Mesylate 8 MG Tablet 30 Generic
Doxepin HCL 10 MG Capsule 30 Generic
Doxepin HCL 10 MG/ML Concentrate 20 Generic
Doxepin HCL 100 MG Capsule 30 Generic
Doxepin HCL 150 MG Capsule 24 Generic
Doxepin HCL 25 MG Capsule 30 Generic
Doxepin HCL 50 MG Capsule 30 Generic
Doxepin HCL 75 MG Capsule 5 Generic
Doxercalciferol 0.5 MCG Capsule 30 Generic
Doxercalciferol 4 MCG/2 ML Solution 30 Generic
Doxycycline Calcium 50 MG/5 ML Syrup 60 Brand
Doxycycline Hyclate 100 MG Capsule 30 Generic
Doxycycline Hyclate 100 MG Tablet 30 Generic
Doxycycline Hyclate 100 MG Tablet DR/EC 14 Generic
Doxycycline Hyclate 20 MG Tablet 30 Generic
Doxycycline Hyclate 50 MG Capsule 30 Generic
Doxycycline Mono-hydrate 100 MG Capsule 30 Generic
Doxycycline Mono-hydrate 100 MG Tablet 30 Generic
Doxycycline Mono-hydrate 150 MG Tablet 20 Generic
Doxycycline Mono-hydrate 25 MG/5 ML Suspension for Reconstitution 300 Generic
Doxycycline Mono-hydrate 50 MG Capsule 30 Generic
Doxycycline Mono-hydrate 50 MG Tablet 30 Generic
Doxylamine Succinate 25 MG Tablet 30 Generic
Dronabinol 2.5 MG Capsule 14 Generic
Dronabinol 5 MG Capsule 20 Generic
Drospir/Eth Estra/Levomefolate Ca 3-0.02(24) Tablet 28 Generic
Duloxetine HCL 20 MG Capsule DR/EC 30 Generic
Duloxetine HCL 30 MG Capsule DR/EC 30 Generic
Duloxetine HCL 40 MG Capsule DR/EC 30 Generic
Duloxetine HCL 60 MG Capsule DR/EC 30 Generic
Dutasteride 0.5 MG Capsule 30 Generic
Dutasteride/Tamsulosin HCL 0.5-0.4 MG Multiphase Cap 24-Hr ER 30 Generic
Econazole Nitrate 1% Cream 30 Generic
Efavirenz 50 MG Capsule 30 Brand
Emtricitabine 10 MG/ML Solution 30 Brand
Enalapril Maleate 10 MG Tablet 30 Generic
Enalapril Maleate 2.5 MG Tablet 30 Generic
Enalapril Maleate 20 MG Tablet 30 Generic
Enalapril Maleate 5 MG Tablet 30 Generic
Enalapril/Hydrochlorothiazide 10 MG-25 MG Tablet 30 Generic
Enalapril/Hydrochlorothiazide 5 MG-12.5 MG Tablet 30 Generic
Enoxaparin Sodium 30 MG/0.3 ML Syringe 3 Generic
Enoxaparin Sodium 40 MG/0.4 ML Syringe 3 Generic
Entecavir 1 MG Tablet 4 Generic
Epinastine HCL 0.05% Drops 5 Generic
Eplerenone 25 MG Tablet 30 Generic
Eplerenone 50 MG Tablet 30 Generic
Erythromycin Base 5 MG/Generic Capsule 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Erythromycin Base 5 MG/Generic Ointment 4 Generic
Erythromycin Base/Ethanol 2% Gel 30 Generic
Erythromycin Base/Ethanol 2% Solution 60 Generic
Erythromycin Base/Ethanol 2% Swab 30 Generic
Erythromycin Ethylsuccinate 400 MG Tablet 30 Brand
Erythromycin/Benzoyl Peroxide 3%-5% Gel 23 Generic
Escitalopram Oxalate 10 MG Tablet 30 Generic
Escitalopram Oxalate 20 MG Tablet 30 Generic
Escitalopram Oxalate 5 MG Tablet 15 Generic
Esmolol HCL 100 MG/10 ML Solution 30 Generic
Esmolol in NaCl, ISO 2.5 Generic/250 ML Parenteral Solution 30 Brand
Esomeprazole Magnesium 20 MG Capsule DR/EC 30 Generic
Estazolam 1 MG Tablet 14 Generic
Estazolam 2 MG Tablet 30 Generic
Estradiol .025 MG/24-Hr Weekly Patch 4 Generic
Estradiol .0375 MG/24 Weekly Patch 4 Generic
Estradiol .075 MG/24-Hr Semiweekly Patch 8 Generic
Estradiol .075 MG/24-Hr Weekly Patch 4 Generic
Estradiol 0.0375 MG/24-Hr Twice Weekly Patch 8 Generic
Estradiol 0.05 MG/24-Hr Semiweekly Patch 8 Generic
Estradiol 0.06 MG/24-Hr Weekly Patch 4 Generic
Estradiol 0.1 MG/24-Hr Weekly Patch 4 Generic
Estradiol 0.5 MG Tablet 30 Generic
Estradiol 1 MG Tablet 30 Generic
Estradiol 2 MG Tablet 30 Generic
Estradiol Transdermal Patch 0.05 MG/24-Hr Weekly Patch 4 Generic
Estradiol/Norethindrone Acet 0.5-0.1 MG Tablet 28 Generic
Estradiol/Norethindrone Acet 1 MG-0.5 MG Tablet 28 Generic
Estrogen, Ester/Me-Testosterone 0.625-1.25 Tablet 30 Generic
Estrogen, Ester/Me-Testosterone 1.25-2.5 MG Tablet 30 Generic
Estrogens, Esterified 0.3 MG Tablet 30 Brand
Estropipate 0.75 MG Tablet 30 Generic
Estropipate 1.5 MG Tablet 30 Generic
Eszopiclone 1 MG Tablet 15 Generic
Eszopiclone 2 MG Tablet 30 Generic
Eszopiclone 3 MG Tablet 15 Generic
Ethambutol HCL 100 MG Tablet 180 Generic
Ethambutol HCL 400 MG Tablet 30 Generic
Ethinyl Estradiol/Drospirenone 0.03 MG-3 MG Tablet 28 Generic
Ethosuximide 250 MG Capsule 90 Generic
Ethosuximide 250 MG/5 ML Solution 240 Generic
Ethynodiol D-Ethinyl Estradiol 1 MG-35 MCG Tablet 28 Generic
Ethynodiol D-Ethinyl Estradiol 1 MG-50 MCG Tablet 28 Generic
Etodolac 200 MG Capsule 20 Generic
Etodolac 300 MG Capsule 15 Generic
Etodolac 400 MG Tablet 20 Generic
Etodolac 400 MG Tablet 24-Hr ER 14 Generic
Etodolac 500 MG Tablet 30 Generic
Etodolac 500 MG Tablet 24-Hr ER 30 Generic
Etodolac 600 MG Tablet 24-Hr ER 30 Generic
8 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Etomidate 2 MG/ML Solution 30 Generic
Etomidate 2 MG/ML Syringe 30 Generic
Etoposide 20 MG/ML Solution 30 Generic
Ezetimibe 10 MG Tablet 30 Generic
Ezetimibe/Simvastatin 10 MG-10 MG Tablet 30 Generic
Ezetimibe/Simvastatin 10 MG-40 MG Tablet 30 Generic
Famciclovir 125 MG Tablet 10 Generic
Famciclovir 250 MG Tablet 30 Generic
Famciclovir 500 MG Tablet 3 Generic
Famotidine 10 MG/ML Solution 30 Generic
Famotidine 20 MG Tablet 30 Generic
Famotidine 40 MG Tablet 30 Generic
Famotidine 40 MG/5 ML Suspension 50 Generic
Fat Emulsions 20% Emulsion 30 Generic
Fe Fumarate/Vit C/B12-If/FA 110-0.5 MG Capsule 30 Generic
Felbamate 600 MG/5 ML Suspension 30 Generic
Felodipine 10 MG Tablet 24-Hr ER 30 Generic
Felodipine 2.5 MG Tablet 24-Hr ER 29 Generic
Felodipine 5 MG Tablet 24-Hr ER 30 Generic
Fenofibrate Nanocrystallized 145 MG Tablet 30 Generic
Fenofibrate Nanocrystallized 160 MG Tablet 30 Generic
Fenofibrate Nanocrystallized 48 MG Tablet 30 Generic
Fenofibrate Micronized 160 MG Tablet 30 Generic
Fenofibrate Micronized 54 MG Tablet 30 Generic
Fenofibrate Micronized 130 MG Capsule 30 Generic
Fenofibrate Micronized 134 MG Capsule 30 Generic
Fenofibrate Micronized 200 MG Capsule 30 Generic
Fenofibrate Micronized 43 MG Capsule 30 Generic
Fenofibrate Micronized 67 MG Capsule 30 Generic
Fenofibric Acid DR Capsules 135 MG Capsule DR/EC 30 Generic
Fenofibric Acid DR Capsules 45 MG Capsule DR/EC 30 Generic
Fentanyl 12 MCG/Hr 75-Hr Patch 5 Generic
Fentanyl 25 MCG/Hr 75-Hr Patch 5 Generic
Fentanyl 50 MCG/Hr 75-Hr Patch 5 Generic
Fentanyl 75 MCG/Hr 75-Hr Patch 5 Generic
Ferrous Fumarate/Folic Acid 106 MG-1 MG Tablet 30 Generic
Finasteride 1 MG Tablet 30 Generic
Finasteride 5 MG Tablet 30 Generic
Flavoxate HCL 100 MG Tablet 30 Generic
Flecainide Acetate 100 MG Tablet 30 Generic
Flecainide Acetate 150 MG Tablet 30 Generic
Flecainide Acetate 50 MG Tablet 30 Generic
Fluconazole 10 MG/ML Suspension for Reconstitution 35 Generic
Fluconazole 100 MG Tablet 3 Generic
Fluconazole 150 MG Tablet 1 Generic
Fluconazole 200 MG Tablet 1 Generic
Fluconazole 40 MG/ML Suspension for Reconstitution 35 Generic
Fluconazole 50 MG Tablet 30 Generic
Fludrocortisone Acetate 0.1 MG Tablet 30 Generic
Fluocinolone Acetonide 0.01% Cream 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Fluocinolone Acetonide 0.01% Oil 118 Generic
Fluocinolone Acetonide 0.01% Solution 60 Generic
Fluocinolone Acetonide 0.025% Cream 30 Generic
Fluocinolone Acetonide 0.025% Ointment 15 Generic
Fluocinolone Acetonide Oil 0.01% Drops 20 Generic
Fluocinolone/Shower Cap 0.01% Oil 30 Generic
Fluocinonide 0.05% Cream 30 Generic
Fluocinonide 0.05% Gel 30 Generic
Fluocinonide 0.05% Ointment 15 Generic
Fluocinonide 0.05% Solution 60 Generic
Fluocinonide/Emollient Base 0.05% Cream 30 Generic
Fluorometholone 0.1% Suspension Drops 5 Generic
Fluorouracil 1 Generic/20 ML Solution 30 Generic
Fluorouracil 2% Solution 10 Brand
Fluorouracil 2.5 Generic/50 ML Solution 30 Generic
Fluorouracil 5 Generic/100 ML Solution 30 Generic
Fluorouracil 500 MG/10 ML Solution 50 Generic
Fluoxetine HCL 10 MG Capsule 30 Generic
Fluoxetine HCL 10 MG Tablet 15 Generic
Fluoxetine HCL 20 MG Capsule 30 Generic
Fluoxetine HCL 20 MG Tablet 30 Generic
Fluoxetine HCL 20 MG/5 ML Solution 30 Generic
Fluphenazine Decanoate 25 MG/ML Solution 5 Generic
Fluphenazine HCL 5 MG Tablet 7 Generic
Fluphenazine HCL 5 MG/ML Concentrate 30 Brand
Flurazepam HCL 15 MG Capsule 30 Brand
Flurazepam HCL 30 MG Capsule 15 Brand
Flurbiprofen 100 MG Tablet 10 Generic
Flurbiprofen 50 MG Tablet 30 Generic
Flurbiprofen Sodium 0.03% Drops 5 Generic
Flutamide 125 MG Capsule 24 Generic
Fluticasone Propionate 0.005% Ointment 15 Generic
Fluticasone Propionate 0.05% Cream 15 Generic
Fluticasone Propionate 50 MCG Suspension Spray 16 Generic
Fluticasone Propionate 50 MCG Suspension Spray 30 Generic
Fluvastatin Sodium 20 MG Capsule 30 Generic
Fluvoxamine Maleate 100 MG Capsule 24-Hr ER 30 Generic
Fluvoxamine Maleate 100 MG Tablet 15 Generic
Fluvoxamine Maleate 150 MG Capsule 24-Hr ER 14 Generic
Fluvoxamine Maleate 50 MG Tablet 30 Generic
Folic Acid 1 MG Tablet 30 Generic
Folic Acid 5 MG/ML Solution 10 Brand
Foltanx Tablet 2-3-35 MG Tablet 30 Brand
Formaldehyde 10% Solution 30 Generic
Formaldehyde 10% Solution w/ Applicator 30 Generic
Fosamprenavir Calcium 50 MG/ML Suspension 30 Brand
Fosinopril Sodium 10 MG Tablet 30 Generic
Fosinopril Sodium 20 MG Tablet 30 Generic
Fosinopril Sodium 40 MG Tablet 30 Generic
Fosinopril/Hydrochlorothiazide 10-12.5 MG Tablet 30 Generic
9 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Fosinopril/Hydrochlorothiazide 20-12.5 MG Tablet 30 Generic
Furosemide 10 MG/ML Solution 12 Generic
Furosemide 10 MG/ML Solution (Oral) 30 Generic
Furosemide 20 MG Tablet 30 Generic
Furosemide 40 MG Tablet 30 Generic
Furosemide 80 MG Tablet 30 Generic
Gabapentin 100 MG Capsule 30 Generic
Gabapentin 250 MG/5 ML Solution 150 Generic
Gabapentin 300 MG Capsule 30 Generic
Gabapentin 400 MG Capsule 30 Generic
Gabapentin 600 MG Tablet 30 Generic
Gabapentin 800 MG Tablet 30 Generic
Galantamine HBR 12 MG Tablet 60 Generic
Galantamine HBR 16 MG Capsule 24-Hr ER Pellets 30 Generic
Galantamine HBR 8 MG Tablet 30 Generic
Gatifloxacin Opthalmic Solution 0.5% Drops 5 Generic
Gemfibrozil 600 MG Tablet 30 Generic
Generic for Procardia XL 30 MG Tablet 24-Hr ER 30 Generic
Generic for Procardia XL 60 MG Tablet 24-Hr ER 30 Generic
Gentamicin Sulfate 0.1% Cream 30 Generic
Gentamicin Sulfate 0.1% Ointment 30 Generic
Gentamicin Sulfate 0.3% Drops 5 Generic
Gentamicin Sulfate 0.3% Ointment 4 Generic
Gentamicin Sulfate 40 MG/ML Solution 10 Generic
Glimepiride 1 MG Tablet 15 Generic
Glimepiride 2 MG Tablet 30 Generic
Glimepiride 4 MG Tablet 30 Generic
Glipizide 10 MG Tablet 60 Generic
Glipizide 10 MG Tablet 24-Hr ER 30 Generic
Glipizide 2.5 MG Tablet 24-Hr ER 30 Generic
Glipizide 5 MG Tablet 30 Generic
Glipizide 5 MG Tablet 24-Hr ER 30 Generic
Glipizide/Metformin HCL 2.5-250 MG Tablet 60 Generic
Glipizide/Metformin HCL 2.5-500 MG Tablet 30 Generic
Glipizide/Metformin HCL 5 MG-500 MG Tablet 60 Generic
Glyburide 1.25 MG Tablet 30 Generic
Glyburide 2.5 MG Tablet 30 Generic
Glyburide 5 MG Tablet 30 Generic
Glyburide,Micronized 1.5 MG Tablet 30 Generic
Glyburide,Micronized 3 MG Tablet 15 Generic
Glyburide,Micronized 6 MG Tablet 30 Generic
Glyburide/Metformin HCL 1.25-250 MG Tablet 30 Generic
Glyburide/Metformin HCL 2.5-500 MG Tablet 60 Generic
Glyburide/Metformin HCL 5 MG-500 MG Tablet 90 Generic
Glycopyrrolate 1 MG Tablet 30 Generic
Glycopyrrolate 2 MG Tablet 30 Generic
Griseofulvin Ultramicrosize 250 MG Tablet 30 Generic
Griseofulvin, Micro-size 125 MG/5 ML Suspension 150 Generic
Guaifenesin 600 MG Tablet 12-Hr ER 30 Generic
Guaifenesin/D-Methorphan HB/PE 30-10-250 Capsule 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Guaifenesin/Pseudoephedrine HCL 400 MG-60 MG Tablet 30 Generic
Guanfacine HCL 1 MG Tablet 15 Generic
Guanfacine HCL 1 MG Tablet 24-Hr ER 7 Generic
Guanfacine HCL 2 MG Tablet 30 Generic
Guanfacine HCL 2 MG Tablet 24-Hr ER 30 Generic
Halobetasol Propionate 0.05% Cream 15 Generic
Halobetasol Propionate 0.05% Ointment 50 Generic
Haloperidol 5 MG Tablet 30 Generic
Haloperidol Lactate 0.5 MG Tablet 15 Generic
Haloperidol Lactate 1 MG Tablet 30 Generic
Haloperidol Lactate 10 MG Tablet 30 Generic
Haloperidol Lactate 2 MG Tablet 30 Generic
Haloperidol Lactate 2 MG/ML Concentrate 50 Generic
Haloperidol Lactate 20 MG Tablet 60 Generic
Haloperidol Lactate 5 MG/ML Solution 30 Generic
Heparin Sodium,Porcine 5000/ML Solution 30 Generic
Heparin Sodium,Porcine/PF 10 Unit/ML Syringe 20 Generic
Hepatitis A Virus Vaccine/PF 25/0.5 ML Suspension 30 Generic
Hepatitis A Virus Vaccine/PF 25/0.5 ML Syringe 30 Brand
Hepatitis A Virus Vaccine/PF 50 Unit/ML Suspension 30 Brand
Hepatitis A Virus Vaccine/PF 50 Unit/ML Syringe 30 Generic
Hepatitis Brand Virus Vaccine/PF 10 MCG/ML Suspension 30 Generic
Hepatitis Brand Virus Vaccine/PF 40 MCG/ML Suspension 30 Brand
Hepatitis Brand Virus Vaccine/PF 5 MCG/0.5 ML Suspension 30 Brand
Hepatitis Brand Virus Vaccine/PF 5 MCG/0.5 ML Syringe 30 Generic
Hetastarch in 0.9 % NaCl 6%-0.9% Solution 30 Generic
Homatropine HBR 5% Drops 5 Generic
Hyaluronate Sodium 0.2% Gel 30 Generic
Hydralazine HCL 10 MG Tablet 30 Generic
Hydralazine HCL 100 MG Tablet 60 Generic
Hydralazine HCL 25 MG Tablet 30 Generic
Hydralazine HCL 50 MG Tablet 90 Generic
Hydrochlorothiazide 12.5 MG Capsule 30 Generic
Hydrochlorothiazide 12.5 MG Tablet 15 Generic
Hydrochlorothiazide 25 MG Tablet 30 Generic
Hydrochlorothiazide 50 MG Tablet 30 Generic
Hydrocodone Bit/Homatrop ME-BR 5 MG-1.5 MG Tablet 30 Generic
Hydrocodone Bit/Homatrop Me-BR 5-1.5 MG/5 Syrup 100 Generic
Hydrocodone/Acetaminophen 10 MG-325 MG Tablet 30 Generic
Hydrocodone/Acetaminophen 10-300/15 Solution 100 Brand
Hydrocodone/Acetaminophen 2.5-325 MG Tablet 30 Generic
Hydrocodone/Acetaminophen 5 MG-300 MG Tablet 30 Generic
Hydrocodone/Acetaminophen 5 MG-325 MG Tablet 30 Generic
Hydrocodone/Acetaminophen 7.5-300 MG Tablet 30 Generic
Hydrocodone/Acetaminophen 7.5-325 MG Tablet 30 Generic
Hydrocodone/Acetaminophen 7.5-325/15 Solution 120 Generic
Hydrocodone/Cpm/Pseudoephed 5-4-60 MG/5 Solution 60 Brand
Hydrocodone/Ibuprofen 5 MG-200 MG Tablet 30 Generic
Hydrocodone/Ibuprofen 7.5-200 MG Tablet 30 Generic
Hydrocort/Pramoxin/Emol/Pram#1 2.5%-1%-1% Cream & Towelette Kit 1 Generic
10 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Hydrocort/Pramoxin/Emol/Pram #1 2.5-1% (4 Generic) Cream & Towelette Kit 1 Generic
Hydrocort/Sal Acid/Sulf/Shmp #1 2%-2%-2% Combo Pack 30 Brand
Hydrocortisone 1% Cream 28 Generic
Hydrocortisone 1% Cream 30 Generic
Hydrocortisone 1% Ointment 30 Generic
Hydrocortisone 10 MG Tablet 30 Generic
Hydrocortisone 2% Lotion 30 Generic
Hydrocortisone 2.5% Cream 30 Generic
Hydrocortisone 2.5% Cream & Gel Combo Pack (Topical) 30 Generic
Hydrocortisone 2.5% Lotion 59 Generic
Hydrocortisone 2.5% Ointment 20 Generic
Hydrocortisone 20 MG Tablet 30 Generic
Hydrocortisone 5 MG Tablet 30 Generic
Hydrocortisone Acetate 1% Cream 30 Generic
Hydrocortisone Acetate 1% Ointment 30 Generic
Hydrocortisone Butyrate 0.1% Cream 15 Generic
Hydrocortisone Butyrate 0.1% Ointment 30 Generic
Hydrocortisone Butyrate 0.1% Solution 60 Generic
Hydrocortisone Valerate 0.2% Cream 30 Generic
Hydrocortisone Valerate 0.2% Ointment 30 Generic
Hydrocortisone/Aloe Vera 1% Cream 30 Generic
Hydrocortisone/Iodoquinol 1%-1% Cream 28 Generic
Hydrocortisone/Pramoxine 1%-1% Foam 10 Brand
Hydromorphone HCL 1 MG/ML Liquid 100 Generic
Hydromorphone HCL 12 MG Tablet 24-Hr ER 10 Generic
Hydromorphone HCL 2 MG Tablet 30 Generic
Hydromorphone HCL 4 MG Tablet 30 Generic
Hydromorphone HCL 8 MG Tablet 60 Generic
Hydromorphone HCL 8 MG Tablet 24-Hr ER 30 Generic
Hydromorphone HCL/PF 10 MG/ML Solution 30 Generic
Hydroquinone 4% Cream 28 Generic
Hydroxychloroquine Sulfate 200 MG Tablet 30 Generic
Hydroxyurea 200 MG Capsule 30 Brand
Hydroxyurea 300 MG Capsule 30 Brand
Hydroxyurea 400 MG Capsule 60 Brand
Hydroxyurea 500 MG Capsule 30 Generic
Hydroxyzine HCL 10 MG Tablet 30 Generic
Hydroxyzine HCL 10 MG/5 ML Solution 60 Generic
Hydroxyzine HCL 25 MG Tablet 30 Generic
Hydroxyzine HCL 50 MG Tablet 20 Generic
Hydroxyzine Pamoate 100 MG Capsule 15 Brand
Hydroxyzine Pamoate 25 MG Capsule 30 Generic
Hydroxyzine Pamoate 50 MG Capsule 30 Generic
Hyoscyamine Sulfate 0.125 MG Disintegrating Tablet 30 Brand
Hyoscyamine Sulfate 0.125 MG Sublingual Tablet 30 Generic
Hyoscyamine Sulfate 0.125 MG Tablet 30 Generic
Hyoscyamine Sulfate 0.125 MG/ML Drops 30 Generic
Hyoscyamine Sulfate 0.125-0.25 Multiphase Tablet ER 30 Brand
Hyoscyamine Sulfate 0.375 MG Tablet 12-Hr ER 30 Generic
Hyoscyamine Sulfate 125 MCG/5 ML Elixir 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Ibandronate Sodium 150 MG Tablet 1 Generic
Ibuprofen 100 MG/5 ML Suspension 118 Generic
Ibuprofen 400 MG Tablet 30 Generic
Ibuprofen 600 MG Tablet 30 Generic
Ibuprofen 800 MG Tablet 30 Generic
Icosapent Ethyl 0.5 Generic Capsule 30 Brand
Icosapent Ethyl 1 Generic Capsule 30 Brand
Imipramine HCL 10 MG Tablet 30 Generic
Imipramine HCL 25 MG Tablet 30 Generic
Imipramine HCL 50 MG Tablet 30 Generic
Imiquimod 5% Cream Packet 24 Generic
Indapamide 1.25 MG Tablet 30 Generic
Indapamide 2.5 MG Tablet 30 Generic
Indinavir Sulfate 200 MG Capsule 30 Brand
Indomethacin 25 MG Capsule 30 Generic
Indomethacin 50 MG Capsule 30 Generic
Indomethacin 75 MG Capsule ER 30 Generic
Influenza Vaccine Injection Vaccine 1 Generic
Ipratropium Bromide 0.2 MG/ML Solution 62 Generic
Ipratropium Bromide 21 MCG Non-Aerosol Spray 30 Generic
Ipratropium Bromide 42 MCG Non-Aerosol Spray 30 Generic
Ipratropium/Albuterol Sulfate 0.5-3 MG/3 Solution for Nebulization 90 Generic
Irbesartan 150 MG Tablet 15 Generic
Irbesartan 300 MG Tablet 30 Generic
Irbesartan 75 MG Tablet 15 Generic
Irbesartan/Hydrochlorothiazide 150-12.5 MG Tablet 30 Generic
Irbesartan/Hydrochlorothiazide 300-12.5 MG Tablet 30 Generic
Iron Carb, GL/FA/B12/C/Docusate 90-1-50 MG Tablet 30 Brand
Iron Dextran Complex 100 MG/2 ML Solution 2 Brand
Iron Fum & PS Cmp/FA/Vit C/B3 125-1-40-3 Capsule 30 Brand
Iron Fum & Polysac #1/FA/MV No.18 106 MG-1 MG Capsule 30 Brand
Iron Fumarate/Vit C/Vit B12/FA 200-250 MG Capsule 30 Brand
Iron Fumarate/Vit C/Vit B12/FA 460-60 MG Capsule 30 Generic
Iron Polysac/Iron Heme/FA/B12 22-6-1-25 Tablet 30 Brand
Iron PS Cmplx/Vit B12/FA 150-25-1 Capsule 30 Generic
Iron, Carb/DSS/B12 IF/FA/MV-MN 150-50-1 MG Tablet 24-Hr ER 30 Generic
Iron,Carbonyl/Vit C/Vit B12/FA 100-250-1 Tablet 30 Brand
Iron/FA/B12/C/Docusate Sodium 90-1-50 MG Tablet 30 Brand
Isoflurane 99.9% Liquid 30 Generic
Isomethepten/Caf/Acetaminophen 65-20-325 Tablet 30 Generic
Isoniazid 300 MG Tablet 30 Generic
Isosorbide Dinitrate 10 MG Tablet 30 Generic
Isosorbide Dinitrate 20 MG Tablet 30 Generic
Isosorbide Dinitrate 30 MG Tablet 30 Generic
Isosorbide Dinitrate 5 MG Tablet 30 Generic
Isosorbide Mono-nitrate 10 MG Tablet 30 Generic
Isosorbide Mono-nitrate 120 MG Tablet 24-Hr ER 30 Generic
Isosorbide Mono-nitrate 20 MG Tablet 30 Generic
Isosorbide Mono-nitrate 30 MG Tablet 24-Hr ER 15 Generic
Isosorbide Mono-nitrate 60 MG Tablet 24-Hr ER 30 Generic
11 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Isoxsuprine HCL 10 MG Tablet 30 Generic
Isoxsuprine HCL 20 MG Tablet 30 Generic
Isradipine 2.5 MG Capsule 30 Generic
Isradipine 5 MG Capsule 30 Generic
Ivermectin 3 MG Tablet 10 Generic
Ketamine HCL 10 MG/ML Solution 30 Brand
Ketamine HCL 100 MG/ML Solution 30 Generic
Ketamine HCL 50 MG/ML Solution 30 Generic
Ketoconazole 2% Cream 30 Generic
Ketoconazole 2% Shampoo 120 Generic
Ketoconazole 200 MG Tablet 2 Generic
Ketoprofen 75 MG Capsule 15 Generic
Ketorolac Tromethamine 0.4% Drops 5 Generic
Ketorolac Tromethamine 0.5% Drops 5 Generic
Ketorolac Tromethamine 10 MG Tablet 30 Generic
Ketorolac Tromethamine 30 MG/ML(1) Solution 1 Generic
Ketorolac Tromethamine/PF 0.45% Dropperette 5 Brand
Ketotifen Fumarate 0.025% Drops 5 Generic
Labetalol HCL 100 MG Tablet 30 Generic
Labetalol HCL 200 MG Tablet 30 Generic
Labetalol HCL 300 MG Tablet 30 Generic
Lactic Acid 10% Cream 113 Generic
Lactic Acid 10% Lotion 355 Generic
Lactobacillus Casei/Folic Acid 60-1.25 MG Capsule 30 Brand
Lactulose 10 Generic/15 ML Solution 300 Generic
Lactulose 10 Generic/15 ML Solution 300 Generic
Lactulose 10 G/15 ML (15 ML) Solution 100 Generic
Lactulose 20 Generic/30 ML Solution 30 Generic
Lamivudine 25 MG/5 ML Solution 30 Brand
Lamotrigine 100 MG Tablet 30 Generic
Lamotrigine 200 MG Tablet 30 Generic
Lamotrigine 25 MG Chewable Dispersible Tablet 60 Generic
Lamotrigine 25 MG Tablet 30 Generic
Lamotrigine 250 MG Tablet 24-Hr ER 3 Generic
Lansoprazole 15 MG Capsule DR/EC 28 Generic
Lansoprazole 30 MG Capsule DR/EC 30 Generic
Latanoprost 0.005% Drops 5 Generic
Letrozole 2.5 MG Tablet 5 Generic
Leucovorin Calcium 15 MG Tablet 6 Brand
Leucovorin Calcium 5 MG Tablet 4 Generic
Levalbuterol HCL 0.31 MG/3 ML Solution for Nebulization 72 Generic
Levalbuterol HCL 1.25 MG/0.5 Solution for Nebulization 30 Generic
Levalbuterol HCL 1.25 MG/3 ML Solution for Nebulization 72 Generic
Levetiracetam 100 MG/ML Solution 90 Generic
Levetiracetam 250 MG Tablet 30 Generic
Levetiracetam 500 MG Tablet 24-Hr ER 60 Generic
Levetiracetam 500 MG/5 ML Solution 30 Generic
Levetiracetam 750 MG Tablet 60 Generic
Levetiracetam 750 MG Tablet 24-Hr ER 30 Generic
Levobunolol HCL 0.5% Drops 5 Generic
Name/Strength/Form Default Qty. Brand/Generic
Levocarnitine 100 MG/ML Solution 30 Generic
Levocarnitine 100 MG/ML Solution 60 Brand
Levocarnitine 330 MG Tablet 30 Generic
Levocetirizine Dihydrochloride 2.5 MG/5 ML Solution 75 Generic
Levocetirizine Dihydrochloride 5 MG Tablet 30 Generic
Levofloxacin 0.5% Drops 5 Generic
Levofloxacin 250 MG Tablet 5 Generic
Levofloxacin 250 MG/10 ML Solution 40 Generic
Levofloxacin 500 MG Tablet 7 Generic
Levofloxacin 750 MG Tablet 5 Generic
Levomefolate Calcium 15 MG Tablet 30 Brand
Levomilnacipran HCL 20 MG Capsule 24-Hr ER 2 Brand
Levonorgestrel 1.5 MG Tablet 1 Generic
Levonorgestrel-Ethin Estradiol 0.1-0.02 Tablet 28 Generic
Levonorgestrel-Ethin Estradiol 0.15-0.03 Tablet 28 Generic
Levonorgestrel-Ethin Estradiol 6-5-10 Tablet 28 Generic
Levonorgestrel-Ethin Estradiol 90-20 MCG Tablet 28 Generic
Levothyroxine Sodium 100 MCG Tablet 30 Generic
Levothyroxine Sodium 112 MCG Tablet 30 Generic
Levothyroxine Sodium 125 MCG Tablet 30 Generic
Levothyroxine Sodium 137 MCG Tablet 30 Generic
Levothyroxine Sodium 150 MCG Tablet 30 Generic
Levothyroxine Sodium 175 MCG Tablet 15 Generic
Levothyroxine Sodium 200 MCG Tablet 30 Generic
Levothyroxine Sodium 25 MCG Capsule 12 Brand
Levothyroxine Sodium 25 MCG Tablet 15 Generic
Levothyroxine Sodium 300 MCG Tablet 30 Generic
Levothyroxine Sodium 50 MCG Tablet 30 Generic
Levothyroxine Sodium 75 MCG Capsule 14 Brand
Levothyroxine Sodium 75 MCG Tablet 30 Generic
Levothyroxine Sodium 88 MCG Tablet 30 Generic
Lidocaine 5% Ointment 30 Generic
Lidocaine HCL 10 MG/ML Solution 30 Generic
Lidocaine HCL 15 MG/ML Solution 30 Brand
Lidocaine HCL 2% Solution 40 Generic
Lidocaine HCL 20 MG/ML Solution 30 Brand
Lidocaine HCL 3% Cream 28 Generic
Lidocaine HCL 3% Lotion 30 Generic
Lidocaine HCL 40 MG/ML Solution 50 Generic
Lidocaine HCL 5 MG/ML Solution 30 Generic
Lidocaine HCL 5 MG/ML Solution 30 Generic
Lidocaine HCL/Epinephrine 0.5-1:200 K Solution 30 Brand
Lidocaine HCL/Epinephrine 1%-1:100 K Solution 30 Generic
Lidocaine HCL/Epinephrine 2%-1:100 K Solution 20 Generic
Lidocaine HCL/Epinephrine Bit 2%-1:100 K Cartridge 30 Generic
Lidocaine HCL/Epinephrine Bit 2%-1:50000 Cartridge 30 Generic
Lidocaine HCL/Epinephrine/PF 1.5-1:200 K Solution 30 Generic
Lidocaine HCL/Epinephrine/PF 2%-1:200 K Solution 30 Generic
Lidocaine HCL/PF 10 MG/ML Solution 5 Generic
Lidocaine/Prilocaine 2.5%-2.5% Cream 30 Generic
12 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Lidocaine-Hydrocortisone Acetate 3%-0.5% Cream Kit 30 Generic
Linezolid 200 MG/0.1l Parenteral Solution 30 Brand
Liothyronine Sodium 25 MCG Tablet 15 Generic
Liothyronine Sodium 5 MCG Tablet 30 Generic
Liothyronine Sodium 50 MCG Tablet 30 Generic
Liotrix 25-100 MCG Tablet 30 Brand
Liotrix 3.1-12.5 Tablet 30 Brand
Liotrix 37.5-150 Tablet 30 Brand
Liotrix 6.25-25 MCG Tablet 30 Brand
Lipase/Protease/Amylase 8 K-28.75 K Capsule DR/EC 30 Brand
Lisinopril 10 MG Tablet 30 Generic
Lisinopril 2.5 MG Tablet 30 Generic
Lisinopril 20 MG Tablet 30 Generic
Lisinopril 30 MG Tablet 30 Generic
Lisinopril 40 MG Tablet 30 Generic
Lisinopril 5 MG Tablet 30 Generic
Lisinopril/Hydrochlorothiazide 10-12.5 MG Tablet 30 Generic
Lisinopril/Hydrochlorothiazide 20 MG-25 MG Tablet 30 Generic
Lisinopril/Hydrochlorothiazide 20-12.5 MG Tablet 30 Generic
Lithium Carbonate 150 MG Capsule 30 Generic
Lithium Carbonate 300 MG Capsule 30 Generic
Lithium Carbonate 300 MG Tablet 30 Generic
Lithium Carbonate 300 MG Tablet ER 30 Generic
Lithium Carbonate 450 MG Tablet ER 30 Generic
Lithium Carbonate 600 MG Capsule 30 Generic
Lithium Citrate 8 MEQ/5 ML Solution 150 Brand
L-Norgest/E.estradiol-E.estrad 150-30 (84) 3-Mo Tablet Dose Pack 91 Generic
Loperamide HCL 2 MG Capsule 30 Generic
Lorazepam 0.5 MG Tablet 15 Generic
Lorazepam 1 MG Tablet 20 Generic
Lorazepam 2 MG Tablet 30 Generic
Lorazepam 2 MG/ML Concentrate 30 Generic
Lorazepam 2 MG/ML Solution 1 Generic
Lorazepam 2 MG/ML Syringe 30 Generic
Lorazepam 4 MG/ML Solution 30 Generic
Lorazepam 4 MG/ML Syringe 30 Generic
Losartan Potassium 100 MG Tablet 30 Generic
Losartan Potassium 25 MG Tablet 15 Generic
Losartan Potassium 50 MG Tablet 30 Generic
Losartan/Hydrochlorothiazide 100 MG-25 MG Tablet 30 Generic
Losartan/Hydrochlorothiazide 100-12.5 MG Tablet 30 Generic
Losartan/Hydrochlorothiazide 50-12.5 MG Tablet 30 Generic
Lovastatin 10 MG Tablet 30 Generic
Lovastatin 20 MG Tablet 30 Generic
Lovastatin 40 MG Tablet 30 Generic
Loxapine Succinate 10 MG Capsule 30 Generic
Loxapine Succinate 25 MG Capsule 60 Generic
Loxapine Succinate 5 MG Capsule 30 Generic
Loxapine Succinate 50 MG Capsule 60 Generic
Mag Hydrox/Al Hydrox/Simeth 700-300 MG Chewable Tablet 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Magnesium Oxide 420 MG Tablet 30 Generic
Maprotiline HCL 25 MG Tablet 46 Brand
Maprotiline HCL 75 MG Tablet 15 Brand
Measles, Mumps & Rubella Vacc/PF 12500/0.5 Recon Solution 30 Brand
Meclizine HCL 12.5 MG Tablet 30 Generic
Meclizine HCL 25 MG Chewable Tablet 30 Generic
Meclizine HCL 25 MG Tablet 30 Generic
Medroxyprogesterone Acetate 10 MG Tablet 30 Generic
Medroxyprogesterone Acetate 150 MG/ML Suspension 1 Generic
Medroxyprogesterone Acetate 150 MG/ML Syringe 1 Generic
Medroxyprogesterone Acetate 2.5 MG Tablet 30 Generic
Medroxyprogesterone Acetate 5 MG Tablet 10 Generic
Mefloquine HCL 250 MG Tablet 4 Brand
Megestrol Acetate 20 MG Tablet 30 Generic
Megestrol Acetate 40 MG Tablet 30 Generic
Megestrol Acetate 400 MG/10 ML Suspension 150 Generic
Megestrol Acetate 800 MG/20 ML Suspension 30 Generic
Meloxicam 15 MG Tablet 30 Generic
Meloxicam 7.5 MG Tablet 30 Generic
Memantine HCL 10 MG Tablet 30 Generic
Memantine HCL 2 MG/ML Solution 30 Generic
Memantine HCL 5 MG Tablet 14 Generic
Meningococcin Vac A, C, Y, W-135/PF 50 MCG Recon Solution 30 Generic
Meperidine HCL 100 MG Tablet 10 Generic
Meperidine HCL 100 MG/ML Solution 30 Generic
Meperidine HCL 50 MG Tablet 30 Generic
Meperidine HCL 50 MG/5 ML Solution 3 Brand
Meperidine HCL 50 MG/ML Solution 30 Generic
Meperidine HCL/PF 100 MG/2 ML Solution 30 Brand
Meperidine HCL/PF 100 MG/ML Solution 30 Generic
Meperidine HCL/PF 100 MG/ML Syringe 30 Generic
Meperidine HCL/PF 25 MG/ML Syringe 30 Generic
Meperidine HCL/PF 50 MG/ML Solution 30 Generic
Meperidine HCL/PF 50 MG/ML Syringe 30 Generic
Meperidine HCL/PF 75 MG/1.5 ML Solution 30 Brand
Mepivacaine HCL 10 MG/ML Solution 30 Brand
Mepivacaine HCL 20 MG/ML Solution 30 Brand
Mepivacaine HCL/PF 10 MG/ML Solution 30 Brand
Mepivacaine HCL/PF 15 MG/ML Solution 30 Brand
Mepivacaine HCL/PF 20 MG/ML Solution 30 Generic
Meprobamate 400 MG Tablet 30 Generic
Mercaptopurine 50 MG Tablet 30 Generic
Mesna 100 MG/ML Solution 30 Generic
Metaproterenol Sulfate 10 MG Tablet 90 Brand
Metaproterenol Sulfate 10 MG/5 ML Syrup 30 Brand
Metaproterenol Sulfate 20 MG Tablet 30 Brand
Metaxalone 800 MG Tablet 30 Generic
Metformin HCL 1000 MG Tablet 30 Generic
Metformin HCL 500 MG Tablet 60 Generic
Metformin HCL 850 MG Tablet 30 Generic
13 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Metformin HCL ER 500 MG Tablet 24-Hr ER 30 Generic
Metformin HCL ER 750 MG Tablet 24-Hr ER 30 Generic
Meth/Meblue/Sod Phos/Psal/Hyos 118-10-36 Capsule 30 Generic
Methadone HCL 10 MG Tablet 90 Generic
Methadone HCL 40 MG Soluble Tablet 30 Generic
Methadone HCL 5 MG Tablet 30 Generic
Methazolamide 25 MG Tablet 60 Generic
Methazolamide 50 MG Tablet 30 Generic
Methen/M-Blue/Sal/Na Phos/Hyos 120-0.12 MG Capsule 30 Generic
Methenam/Me Blue/Ba/Salicy/Hyo 81.6-0.12 Tablet 30 Brand
Methenamine Hippurate 1 Generic Tablet 30 Generic
Methenamine Mandelate 1 Generic Tablet 30 Generic
Methenamine Mandelate 500 MG Tablet 90 Generic
Methimazole 10 MG Tablet 30 Generic
Methimazole 5 MG Tablet 15 Generic
Methocarbamol 500 MG Tablet 30 Generic
Methocarbamol 750 MG Tablet 30 Generic
Methotrexate Sodium 2.5 MG Tablet 20 Generic
Methotrexate Sodium 2.5 MG Tablet Dose Pack 24 Generic
Methscopolamine Bromide 2.5 MG Tablet 30 Generic
Methscopolamine Bromide 5 MG Tablet 30 Generic
Methyclothiazide 5 MG Tablet 30 Brand
Methyldopa 250 MG Tablet 30 Generic
Methyldopa 500 MG Tablet 30 Generic
Methyldopa/Hydrochlorothiazide 250 MG-15 MG Tablet 30 Brand
Methylphenidate HCL 10 MG Biphasic Capsule ER 30-70 30 Generic
Methylphenidate HCL 10 MG Tablet 30 Generic
Methylphenidate HCL 10 MG Tablet ER 30 Generic
Methylphenidate HCL 10 MG/5 ML Solution 150 Brand
Methylphenidate HCL 2.5 MG Chewable Tablet 30 Generic
Methylphenidate HCL 20 MG Biphasic Capsule ER 30-70 30 Generic
Methylphenidate HCL 20 MG Biphasic Capsule ER 50-50 30 Generic
Methylphenidate HCL 20 MG Tablet 30 Generic
Methylphenidate HCL 20 MG Tablet ER 30 Generic
Methylphenidate HCL 30 MG Biphasic Capsule ER 30-70 30 Generic
Methylphenidate HCL 30 MG Biphasic Capsule ER 50-50 30 Generic
Methylphenidate HCL 40 MG Biphasic Capsule ER 30-70 30 Generic
Methylphenidate HCL 40 MG Biphasic Capsule ER 50-50 30 Generic
Methylphenidate HCL 5 MG Chewable Tablet 30 Generic
Methylphenidate HCL 5 MG Tablet 30 Generic
Methylphenidate HCL 5 MG/5 ML Solution 150 Brand
Methylphenidate HCL 50 MG Biphasic Capsule ER 30-70 28 Generic
Methylphenidate HCL 60 MG Biphasic Capsule ER 30-70 30 Generic
Methylprednisolone 16 MG Tablet 4 Generic
Methylprednisolone 2 MG Tablet 30 Brand
Methylprednisolone 32 MG Tablet 2 Generic
Methylprednisolone 4 MG Tablet 30 Generic
Methylprednisolone 8 MG Tablet 8 Generic
Methylprednisolone Acetate 80 MG/ML Suspension 5 Generic
Methylprednisolone Sod Succ/PF 125 MG/2 ML Recon Solution 1 Generic
Name/Strength/Form Default Qty. Brand/Generic
Methylprednisolone Sod Succ/PF 40 MG/ML Recon Solution 3 Generic
Metoclopramide HCL 10 MG Tablet 30 Generic
Metoclopramide HCL 5 MG Tablet 20 Generic
Metoclopramide HCL 5 MG/5 ML Solution 30 Generic
Metoclopramide HCL 5 MG/ML Solution 30 Generic
Metolazone 10 MG Tablet 30 Generic
Metolazone 5 MG Tablet 12 Generic
Metoprolol Succinate ER 100 MG Tablet 24-Hr ER 30 Generic
Metoprolol Succinate ER 200 MG Tablet 24-Hr ER 15 Generic
Metoprolol Succinate ER 25 MG Tablet 24-Hr ER 15 Generic
Metoprolol Succinate ER 50 MG Tablet 24-Hr ER 30 Generic
Metoprolol Tartrate 100 MG Tablet 30 Generic
Metoprolol Tartrate 25 MG Tablet 30 Generic
Metoprolol Tartrate 5 MG/5 ML Solution 30 Generic
Metoprolol Tartrate 50 MG Tablet 30 Generic
Metoprolol Tartrate 75 MG Tablet 30 Brand
Metoprolol/Hydrochlorothiazide 100 MG-25 MG Tablet 30 Generic
Metoprolol/Hydrochlorothiazide 100 MG-50 MG Tablet 15 Brand
Metoprolol/Hydrochlorothiazide 50 MG-25 MG Tablet 30 Generic
Metronidazole 0.75% Gel 70 Generic
Metronidazole 0.75% Gel 45 Generic
Metronidazole 0.75% Lotion 59 Generic
Metronidazole 1% Gel 60 Generic
Metronidazole 1% Gel Pump 30 Generic
Metronidazole 250 MG Tablet 30 Generic
Metronidazole 500 MG Tablet 30 Generic
Metronidazole/Sodium Chloride 500 MG/0.1 L Piggyback 30 Generic
Midodrine HCL 10 MG Tablet 30 Generic
Midodrine HCL 2.5 MG Tablet 30 Generic
Midodrine HCL 5 MG Tablet 30 Generic
Minocycline HCL 100 MG Capsule 14 Generic
Minocycline HCL 100 MG Tablet 20 Generic
Minocycline HCL 50 MG Capsule 30 Generic
Minocycline HCL 50 MG Tablet 30 Generic
Minocycline HCL 75 MG Capsule 30 Generic
Minoxidil 10 MG Tablet 30 Generic
Minoxidil 2.5 MG Tablet 30 Generic
Mirtazapine 15 MG Disintegrating Tablet 30 Generic
Mirtazapine 15 MG Tablet 30 Generic
Mirtazapine 30 MG Disintegrating Tablet 30 Generic
Mirtazapine 30 MG Tablet 15 Generic
Mirtazapine 45 MG Disintegrating Tablet 30 Generic
Mirtazapine 45 MG Tablet 30 Generic
Mirtazapine 7.5 MG Tablet 15 Generic
Misoprostol 100 MCG Tablet 60 Generic
Misoprostol 200 MCG Tablet 1 Generic
Moexipril HCL 15 MG Tablet 30 Generic
Moexipril HCL 7.5 MG Tablet 30 Generic
Moexipril/Hydrochlorothiazide 15-12.5 MG Tablet 30 Generic
Moexipril/Hydrochlorothiazide 15-25 MG Tablet 15 Generic
14 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Moexipril/Hydrochlorothiazide 7.5-12.5 MG Tablet 7 Generic
Mometasone Furoate 0.1% Cream 30 Generic
Mometasone Furoate 0.1% Ointment 15 Generic
Mometasone Furoate 0.1% Solution 30 Generic
Mometasone Furoate 50 MCG Non-Aerosol Spray 17 Generic
Montelukast Sodium 10 MG Tablet 30 Generic
Montelukast Sodium 4 MG Chewable Tablet 30 Generic
Montelukast Sodium 4 MG Granules Packet 15 Generic
Montelukast Sodium 5 MG Chewable Tablet 30 Generic
Morphine Sulfate 10 MG Capsule ER Pellets 30 Generic
Morphine Sulfate 10 MG/5 ML Solution 30 Generic
Morphine Sulfate 100 MG Tablet ER 30 Generic
Morphine Sulfate 100 MG/5 ML Solution 15 Generic
Morphine Sulfate 15 MG Tablet ER 30 Generic
Morphine Sulfate 20 MG Capsule ER Pellets 30 Generic
Morphine Sulfate 20 MG/5 ML Solution 120 Generic
Morphine Sulfate 30 MG Capsule ER Pellets 30 Generic
Morphine Sulfate 30 MG Tablet ER 30 Generic
Morphine Sulfate 60 MG Tablet ER 30 Generic
Morphine Sulfate/PF 0.5 MG/ML Solution 30 Generic
Morphine Sulfate/PF 1 MG/ML Solution 30 Generic
Morphine Sulfate/PF 1 MG/ML Solution 30 Generic
Morphine Sulfate/PF 10 MG/ML Solution 30 Brand
Morphine Sulfate/PF 25 MG/ML Solution 30 Brand
Moxifloxacin HCL 0.5% Drops 3 Generic
Moxifloxacin HCL 400 MG Tablet 5 Generic
Moxifloxacin in Na Cl (ISO-OSM) 400 MG/.25l Piggyback 30 Generic
Multivitamin w/ Folic Acid 1 MG 1 MG Capsule 30 Brand
Mupirocin 2% Ointment 22 Generic
Mycophenolate Mofetil 250 MG Capsule 60 Generic
Mycophenolate Sodium 180 MG Tablet DR/EC 60 Generic
Nabumetone 500 MG Tablet 30 Generic
Nabumetone 750 MG Tablet 20 Generic
Nadolol 20 MG Tablet 30 Generic
Nadolol 40 MG Tablet 15 Generic
Nadolol 80 MG Tablet 15 Generic
Naftifine HCL 1% Cream 30 Generic
Nalbuphine HCL 20 MG/ML Solution 10 Generic
Naltrexone HCL 50 MG Tablet 30 Generic
Naproxen 125 MG/5 ML Suspension 120 Generic
Naproxen 250 MG Tablet 10 Generic
Naproxen 375 MG Tablet 14 Generic
Naproxen 375 MG Tablet DR/EC 6 Generic
Naproxen 500 MG Tablet 30 Generic
Naproxen 500 MG Tablet DR/EC 30 Generic
Naproxen Sodium 275 MG Tablet 30 Generic
Naproxen Sodium 550 MG Tablet 30 Generic
Naratriptan HCL 1 MG Tablet 5 Generic
Naratriptan HCL 2.5 MG Tablet 6 Generic
Nateglinide 120 MG Tablet 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Nateglinide 60 MG Tablet 30 Generic
Nebivolol HCL 20 MG Tablet 15 Brand
Needles & Syringes 3 ML / 22 Generic / 1.5 Inch Syringe 30 Brand
Needles & Syringes 3 ML / 25 Generic / 1 Inch Syringe 30 Brand
Nefazodone HCL 100 MG Tablet 30 Brand
Nefazodone HCL 200 MG Tablet 30 Brand
Nefazodone HCL 250 MG Tablet 60 Generic
Nefazodone HCL 50 MG Tablet 30 Generic
Neo/Polymyx Brand Sulf/Dexameth 3.5-10 K-.1 Ointment 4 Generic
Neomycin Su/Bacitra/Polymyxin 3.5 MG-400 Ointment 10 Generic
Neomycin Su/Polymyx Brand Sulf 40-200 K/ML Solution 1 Generic
Neomycin Sulfate 500 MG Tablet 20 Generic
Neomycin/Fluocinolone/Emol #65 0.5-0.025% Cream 30 Brand
Neomycin/Polymyx Brand Sulf/Dexamethasone 0.1% Susp Drops 30 Generic
Neostigmine Methylsulfate 0.5 MG/ML Solution 30 Brand
Nevirapine 50 MG/5 ML Suspension 4 Generic
Niacin 1000 MG Tablet 24-Hr ER 30 Generic
Niacin 500 MG Tablet 24-Hr ER 30 Generic
Niacin 750 MG Tablet 24-Hr ER 30 Generic
Nicardipine in Na Cl, ISO-OSM 40 MG/200 ML Piggyback 30 Brand
Nifedipine 10 MG Capsule 30 Generic
Nifedipine 20 MG Capsule 30 Generic
Nifedipine 30 MG Tablet ER 30 Generic
Nifedipine 60 MG Tablet ER 30 Generic
Nifedipine 90 MG Tablet 24-Hr ER 30 Generic
Nifedipine 90 MG Tablet ER 30 Generic
Nisoldipine 20 MG Tablet 24-Hr ER 5 Brand
Nisoldipine 34 MG Tablet 24-Hr ER 30 Generic
Nitrofurantoin 25 MG/5 ML Suspension 60 Generic
Nitrofurantoin Macro-crystal 100 MG Capsule 10 Generic
Nitrofurantoin Macro-crystal 50 MG Capsule 30 Generic
Nitrofurantoin Monohyd/M-Cryst 100 MG Capsule 30 Generic
Nitroglycerin 0.1 MG/Hr 24-Hr Patch 10 Generic
Nitroglycerin 0.2 MG/Hr 24-Hr Patch 30 Generic
Nitroglycerin 0.4 MG/Hr 24-Hr Patch 30 Generic
Nitroglycerin 0.4% (W/W) Ointment 30 Brand
Nitroglycerin 0.6 MG/Hr 24-Hr Patch 30 Generic
Nitroglycerin 400 MCG/Spray Non-Aerosol Spray 5 Generic
Nitroglycerin 6.5 MG Capsule ER 90 Generic
Nitroglycerin Tablets 0.3 MG Sublingual Tablet 100 Brand
Nitroglycerin Tablets 0.4 MG Sublingual Tablet 30 Brand
Nitroglycerin Tablets 0.6 MG Sublingual Tablet 100 Brand
Nizatidine 15 MG/ML Solution (Oral) 30 Brand
Nizatidine 150 MG Capsule 30 Generic
Noreth-Ethinyl Estradiol/Iron 0.4-35 (21) Chewable Tablet 28 Generic
Noreth-Ethinyl Estradiol/Iron 0.8-25 (24) Chewable Tablet 28 Generic
Norethindrone 0.35 MG Tablet 28 Generic
Norethindrone Acetate 5 MG Tablet 30 Generic
Norethindrone Ac-Eth Estradiol 0.5 MG-2.5 Tablet 28 Generic
Norethindrone Ac-Eth Estradiol 1 MG-20 MCG Tablet 21 Generic
15 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Norethindrone Ac-Eth Estradiol 1 MG-5 MCG Tablet 28 Generic
Norethindrone Ac-Eth Estradiol 1.5-0.03 MG Tablet 21 Generic
Norethindrone-E.estradiol-Iron 1 MG-20(21) Tablet 28 Generic
Norethindrone-E.estradiol-Iron 1.5-30(21) Tablet 28 Generic
Norethindrone-E.estradiol-Iron 5-7-9-7 Tablet 28 Generic
Norethindrone-Ethinyl Estrad 0.4-0.035 Tablet 28 Generic
Norethindrone-Ethinyl Estrad 0.5-0.035 Tablet 28 Generic
Norethindrone-Ethinyl Estrad 1 MG-35 MCG Tablet 28 Generic
Norethindrone-Ethinyl Estrad 7 Days x3 Tablet 28 Generic
Norethindrone-Ethinyl Estrad 7-9-5 Tablet 28 Generic
Norgestimate-Ethinyl Estradiol .18-.215-.25---.025 7 Days x3 Lo Tablet 28 Generic
Norgestimate-Ethinyl Estradiol .18-.215-.25---.035 7 Days x3 28 Tablet 28 Generic
Norgestimate-Ethinyl Estradiol 0.25-0.035 Tablet 28 Generic
Norgestrel-Ethinyl Estradiol 0.3-0.03 MG Tablet 28 Generic
Norgestrel-Ethinyl Estradiol 0.5 MG-50 Tablet 28 Brand
Nortriptyline HCL 10 MG Capsule 30 Generic
Nortriptyline HCL 25 MG Capsule 30 Generic
Nortriptyline HCL 50 MG Capsule 30 Generic
Nortriptyline HCL 75 MG Capsule 30 Generic
Nystatin 100000/Generic Cream 15 Generic
Nystatin 100000/Generic Ointment 15 Generic
Nystatin 100000/ML Suspension 60 Generic
Nystatin 500k Unit Tablet 30 Generic
Nystatin/Triamcin 100000-0.1 Cream 30 Generic
Nystatin/Triamcin 100000-0.1 Ointment 30 Generic
Olanzapine 2.5 MG Tablet 15 Generic
Olanzapine 5 MG Disintegrating Tablet 14 Generic
Olanzapine 5 MG Tablet 15 Generic
Olanzapine 7.5 MG Tablet 14 Generic
Olanzapine/Fluoxetine HCL 6 MG-25 MG Capsule 15 Generic
Olmesartan Medoxomil 20 MG Tablet 30 Generic
Olmesartan Medoxomil 40 MG Tablet 30 Generic
Olmesartan Medoxomil 5 MG Tablet 30 Generic
Olmesartan/Hydrochlorothiazide 20-12.5 MG Tablet 30 Generic
Olmesartan/Hydrochlorothiazide 40-12.5 MG Tablet 30 Generic
Olopatadine HCL 0.1% Drops 5 Generic
Olopatadine HCL 0.6% Non-Aerosol Spray 30 Generic
Omega-3 Acid Ethyl Esters 1 Generic Capsule 30 Generic
Omeprazole 20 MG Capsule DR/EC 30 Generic
Omeprazole 40 MG Capsule DR/EC 30 Generic
Once Daily Multivitamin N/A Tablet 30 Generic
Ondansetron HCL 2 MG/ML Solution 30 Generic
Ondansetron HCL 4 MG/5 ML Solution 15 Generic
Ondansetron HCL/PF 4 MG/2 ML Syringe 30 Generic
Orlistat 120 MG Capsule 30 Brand
Orphenadrine Citrate 100 MG Tablet ER 30 Generic
Oseltamivir Phosphate 30 MG Capsule 20 Generic
Oseltamivir Phosphate 45 MG Capsule 10 Generic
Oseltamivir Phosphate 6 MG/ML Suspension for Reconstitution 60 Generic
Oseltamivir Phosphate 75 MG Capsule 10 Generic
Name/Strength/Form Default Qty. Brand/Generic
Oxandrolone 2.5 MG Tablet 30 Generic
Oxaprozin 600 MG Tablet 30 Generic
Oxazepam 10 MG Capsule 30 Generic
Oxazepam 15 MG Capsule 6 Generic
Oxazepam 30 MG Capsule 12 Brand
Oxcarbazepine 150 MG Tablet 30 Generic
Oxcarbazepine 300 MG Tablet 30 Generic
Oxcarbazepine 300 MG/5 ML Suspension 150 Generic
Oxcarbazepine 600 MG Tablet 60 Generic
Oxybutynin Chloride 10 MG Tablet 24-Hr ER 30 Generic
Oxybutynin Chloride 15 MG Tablet 24-Hr ER 30 Generic
Oxybutynin Chloride 5 MG Tablet 30 Generic
Oxybutynin Chloride 5 MG Tablet 24-Hr ER 30 Generic
Oxybutynin Chloride 5 MG/5 ML Syrup 100 Generic
Oxycodone HCL 10 MG Tablet 30 Generic
Oxycodone HCL 15 MG Tablet 60 Generic
Oxycodone HCL 20 MG Tablet 40 Generic
Oxycodone HCL 30 MG Tablet 60 Generic
Oxycodone HCL 5 MG Capsule 30 Generic
Oxycodone HCL 5 MG Tablet 30 Generic
Oxycodone HCL 5 MG/5 ML Solution 15 Generic
Oxycodone HCL ER (Generic) 10 MG Oral Tablet 12-Hr ER 30 Brand
Oxycodone HCL/Acetaminophen 10 MG-325 MG Tablet 30 Generic
Oxycodone HCL/Acetaminophen 2.5-325 MG Tablet 8 Generic
Oxycodone HCL/Acetaminophen 5 MG-325 MG Tablet 30 Generic
Oxycodone HCL/Acetaminophen 7.5-325 MG Tablet 20 Generic
Oxycodone HCL/Aspirin 4.8355-325 Tablet 30 Generic
Oxymorphone HCL 10 MG Tablet 30 Generic
Oxymorphone HCL 5 MG Oral Tablet 12-Hr ER 30 Brand
Oxymorphone HCL 5 MG Tablet 30 Generic
Oxymorphone HCL ER 20 MG Tablet 12-Hr ER 30 Generic
Oxyquinoline/Sod.lauryl Sulfate 0.025-0.01 Gel 30 Brand
Oxytocin 10 Unit/ML Solution 30 Generic
Paliperidone 3 MG Tablet 24-Hr ER 6 Generic
Pantoprazole Sodium 20 MG Tablet DR/EC 30 Generic
Pantoprazole Sodium 40 MG Tablet DR/EC 30 Generic
Parenteral Amino Acid 10% No.4 10% Parenteral Solution 30 Brand
Parenteral Amino Acid 15% No. 1 15% Parenteral Solution 30 Generic
Paroxetine HCL 10 MG Tablet 15 Generic
Paroxetine HCL 12.5 MG Tablet 24-Hr ER 30 Generic
Paroxetine HCL 20 MG Tablet 30 Generic
Paroxetine HCL 25 MG Tablet 24-Hr ER 30 Generic
Paroxetine HCL 30 MG Tablet 15 Generic
Paroxetine HCL 37.5 MG Tablet 24-Hr ER 30 Generic
Paroxetine HCL 40 MG Tablet 15 Generic
Pedi MVI No.12/Sodium Fluoride 0.25 MG Chewable Tablet 25 Generic
Pedi MVI No.12/Sodium Fluoride 0.5 MG Chewable Tablet 30 Generic
Pedi MVI No.12/Sodium Fluoride 1 MG Chewable Tablet 30 Generic
Pedi MVI No.16 w/ Fluoride 0.25 MG Chewable Tablet 30 Generic
Pedi MVI No.16 w/ Fluoride 0.5 MG Chewable Tablet 30 Generic
16 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Pedi MVI No.16 w/ Fluoride 1 MG Chewable Tablet 30 Generic
Pen Needles 5mm / 31 Generic (3/16") Pen Needles 30 Generic
Penicillin V Potassium 250 MG Tablet 30 Generic
Penicillin V Potassium 500 MG Tablet 30 Generic
Pentazocine HCL/Naloxone HCL 50 MG-0.5 MG Tablet 30 Generic
Pentoxifylline 400 MG Tablet ER 30 Generic
Perindopril Erbumine 2 MG Tablet 30 Generic
Perindopril Erbumine 4 MG Tablet 30 Generic
Perindopril Erbumine 8 MG Tablet 30 Generic
Permethrin 5% Cream 60 Generic
Perphenazine 16 MG Tablet 30 Generic
Perphenazine 4 MG Tablet 45 Generic
Perphenazine 8 MG Tablet 30 Generic
Perphenazine/Amitriptyline HCL 2 MG-10 MG Tablet 30 Brand
Perphenazine/Amitriptyline HCL 2 MG-25 MG Tablet 30 Brand
Petrolatum,White 61% Cream 30 Generic
Phenazopyridine HCL 100 MG Tablet 30 Generic
Phenazopyridine HCL 200 MG Tablet 30 Generic
Phendimetrazine Tartrate 35 MG Tablet 30 Generic
Phenelzine Sulfate 15 MG Tablet 30 Generic
Phenobarbital 100 MG Tablet 30 Generic
Phenobarbital 15 MG Tablet 30 Brand
Phenobarbital 16.2 MG Tablet 30 Generic
Phenobarbital 20 MG/5 ML Elixir 300 Generic
Phenobarbital 30 MG Tablet 30 Generic
Phenobarbital 60 MG Tablet 10 Generic
Phenobarbital 64.8 MG Tablet 30 Generic
Phentermine HCL 15 MG Capsule 30 Generic
Phentermine HCL 30 MG Capsule 30 Generic
Phentermine HCL 37.5 MG Capsule 30 Generic
Phentermine HCL 37.5 MG Tablet 30 Generic
Phentermine/Topiramate 3.75-23 MG Multiphase Capsule 24-Hr ER 5 Brand
Phenytoin 50 MG Chewable Tablet 30 Generic
Phenytoin Sodium Extended 100 MG Capsule 90 Generic
Phenytoin Sodium Extended 30 MG Capsule 30 Brand
Phenytoin Sodium Extended 300 MG Capsule 14 Brand
Phosphorus #1 250 MG Tablet 30 Generic
Pilocarpine HCL 1% Drops 30 Generic
Pilocarpine HCL 2% Drops 15 Generic
Pilocarpine HCL 5 MG Tablet 90 Generic
Pimozide 1 MG Tablet 30 Generic
Pimozide 2 MG Tablet 30 Generic
Pindolol 10 MG Tablet 30 Generic
Pindolol 5 MG Tablet 15 Generic
Pioglitazone HCL 15 MG Tablet 30 Generic
Pioglitazone HCL 30 MG Tablet 30 Generic
Pioglitazone HCL 45 MG Tablet 30 Generic
Pioglitazone HCL/Metformin HCL 15 MG-850 MG Tablet 30 Generic
Piroxicam 10 MG Capsule 30 Generic
Piroxicam 20 MG Capsule 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
PNV #15/Iron Fum,PS/Folic Acid 85 MG-1 MG Capsule 30 Brand
PNV Prenatal Plus Tablet 27 MG-1 MG Tablet 30 Brand
Pnv39/Iron Fumarate/FA/DSS/DHA 30-1.2-55 Capsule 30 Brand
Podofilox 0.5% Solution 4 Generic
Polyethylene Glycol 3350 17 Generic Powder in Packet 30 Generic
Polymyxin Brand Sulf/Trimethoprim 10000-1/ML Drops 30 Generic
Polyvinyl Alcohol 1.4% Drops 30 Generic
Pot Chloride/Pot Bicarb/Cit Ac 25 MEQ Effervescent Tablet 30 Generic
Potassium Aminobenzoate 500 MG Capsule 30 Brand
Potassium Bicarbonate/Cit Ac 10 MEQ Effervescent Tablet 15 Brand
Potassium Bicarbonate/Cit Ac 20 MEQ Effervescent Tablet 30 Brand
Potassium Bicarbonate/Cit Ac 25 MEQ Effervescent Tablet 30 Generic
Potassium Chloride 10 MEQ Capsule ER 30 Generic
Potassium Chloride 10 MEQ Particles/Crystals Tablet ER 30 Generic
Potassium Chloride 10 MEQ Tablet ER 30 Generic
Potassium Chloride 15 MEQ Particles/Crystals Tablet ER 30 Brand
Potassium Chloride 20 MEQ Packet 30 Generic
Potassium Chloride 20 MEQ Particles/Crystals Tablet ER 30 Generic
Potassium Chloride 20 MEQ Tablet ER 30 Generic
Potassium Chloride 20 MEQ/15 ML Liquid 240 Generic
Potassium Chloride 40 MEQ/15 ML Liquid 100 Generic
Potassium Chloride 8 MEQ Capsule ER 15 Generic
Potassium Chloride 8 MEQ Tablet ER 30 Generic
Potassium Citrate 10 MEQ Tablet ER 30 Generic
Potassium Citrate 15 MEQ Tablet ER 30 Generic
Potassium Citrate 5 MEQ Tablet ER 30 Generic
Potassium Citrate/Citric Acid 1100-334/5 Solution 540 Generic
Potassium Citrate/Citric Acid 3300-1002 Packet 60 Generic
Potassium Phosphate, Mono-basic 500 MG Soluble Tablet 30 Brand
Povidone-Iodine 5% Solution 30 Brand
Pramipexole Di-HCL 0.125 MG Tablet 30 Generic
Pramipexole Di-HCL 0.25 MG Tablet 30 Generic
Pramipexole Di-HCL 0.5 MG Tablet 30 Generic
Pramipexole Di-HCL 0.75 MG Tablet 30 Generic
Pramipexole Di-HCL 1 MG Tablet 30 Generic
Pramipexole Di-HCL 1.5 MG Tablet 30 Generic
Pramoxine HCL/Calamine 1%-8% Lotion 30 Generic
Pravastatin Sodium 10 MG Tablet 30 Generic
Pravastatin Sodium 20 MG Tablet 30 Generic
Pravastatin Sodium 40 MG Tablet 30 Generic
Pravastatin Sodium 80 MG Tablet 30 Generic
Prazosin HCL 1 MG Capsule 30 Generic
Prazosin HCL 2 MG Capsule 30 Generic
Prazosin HCL 5 MG Capsule 30 Generic
Prednisolone Acetate 1% Suspension Drops 5 Generic
Prednisolone Sod Phosphate 1% Drops 10 Brand
Prednisolone Sod Phosphate 10 MG Disintegrating Tablet 5 Generic
Prednisolone Sod Phosphate 15 MG Disintegrating Tablet 3 Generic
Prednisolone Sod Phosphate 15 MG/5 ML Solution 30 Generic
Prednisolone Sod Phosphate 30 MG Disintegrating Tablet 3 Generic
17 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Prednisolone Sod Phosphate 5 MG/5 ML Solution 30 Generic
Prednisone 1 MG Tablet 30 Generic
Prednisone 10 MG Tablet 30 Generic
Prednisone 10 MG Tablet Dose Pack 30 Generic
Prednisone 2.5 MG Tablet 15 Generic
Prednisone 20 MG Tablet 5 Generic
Prednisone 5 MG Tablet 30 Generic
Prednisone 5 MG Tablet Dose Pack 21 Brand
Prednisone 50 MG Tablet 5 Brand
Pregabalin 20 MG/ML Solution 30 Brand
Prilosec 10 MG Capsule DR/EC 30 Generic
Primidone 250 MG Tablet 30 Generic
Primidone 50 MG Tablet 30 Generic
Probenecid 500 MG Tablet 30 Generic
Prochlorperazine Maleate 10 MG Tablet 30 Generic
Prochlorperazine Maleate 5 MG Tablet 15 Generic
Progesterone IM in Oil 50 MG/ML 50 MG/ML Oil 30 Generic
Progesterone, Micronized 100 MG Capsule 10 Generic
Progesterone, Micronized 200 MG Capsule 30 Generic
Promethazine HCL 12.5 MG Suppository 5 Generic
Promethazine HCL 12.5 MG Tablet 10 Generic
Promethazine HCL 25 MG Suppository 5 Generic
Promethazine HCL 25 MG Tablet 10 Generic
Promethazine HCL 25 MG/ML Solution 25 Generic
Promethazine HCL 50 MG Tablet 30 Generic
Promethazine HCL 6.25 MG/5 ML Syrup 60 Generic
Promethazine HCL/Codeine 6.25-10/5 Syrup 120 Generic
Promethazine/Dextromethorphan 6.25-15 MG/5 ML Syrup 30 Generic
Promethazine/Phenyleph/Codeine 6.25-5-10 Syrup 120 Generic
Promethazine-Phenylephrine .025 MG/24-Hr Syrup 30 Generic
Propafenone HCL 150 MG Tablet 30 Generic
Propafenone HCL 225 MG Capsule 12-Hr ER 30 Generic
Propafenone HCL 225 MG Tablet 30 Generic
Propafenone HCL 300 MG Tablet 30 Generic
Proparacaine HCL 0.5% Drops 15 Generic
Propranolol HCL 10 MG Tablet 30 Generic
Propranolol HCL 120 MG Capsule 24-Hr ER 30 Generic
Propranolol HCL 160 MG Capsule 24-Hr ER 30 Generic
Propranolol HCL 20 MG Tablet 30 Generic
Propranolol HCL 20 MG/ML Solution 30 Generic
Propranolol HCL 40 MG Tablet 30 Generic
Propranolol HCL 60 MG Capsule 24-Hr ER 30 Generic
Propranolol HCL 60 MG Tablet 30 Generic
Propranolol HCL 80 MG Capsule 24-Hr ER 30 Generic
Propranolol HCL 80 MG Tablet 30 Generic
Propranolol/Hydrochlorothiazid 80 MG-25 MG Tablet 30 Brand
Propylthiouracil 50 MG Tablet 30 Generic
Protriptyline HCL 5 MG Tablet 30 Generic
Pseudoephedrine HCL 60 MG Tablet 30 Generic
Pyridostigmine Bromide 60 MG Tablet 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Pyridostigmine Bromide 60 MG/5 ML Syrup 30 Brand
Quetiapine Fumarate 100 MG Tablet 15 Generic
Quetiapine Fumarate 25 MG Tablet 15 Generic
Quetiapine Fumarate 50 MG Tablet 30 Generic
Quetiapine Fumarate ER 50 MG Tablet 24-Hr ER 30 Generic
Quinapril HCL 10 MG Tablet 30 Generic
Quinapril HCL 20 MG Tablet 30 Generic
Quinapril HCL 40 MG Tablet 30 Generic
Quinapril HCL 5 MG Tablet 30 Generic
Quinapril/Hydrochlorothiazide 10-12.5 MG Tablet 30 Generic
Quinapril/Hydrochlorothiazide 20 MG-25 MG Tablet 30 Generic
Quinapril/Hydrochlorothiazide 20-12.5 MG Tablet 30 Generic
Quinidine Sulfate 200 MG Tablet 30 Brand
Quinidine Sulfate 300 MG Tablet 45 Brand
Quinine Sulfate 324 MG Capsule 30 Generic
Rabeprazole Sodium 20 MG Tablet DR/EC 30 Generic
Raloxifene HCL 60 MG Tablet 30 Generic
Raltegravir Potassium 25 MG Chewable Tablet 30 Brand
Ramipril 1.25 MG Capsule 30 Generic
Ramipril 10 MG Capsule 30 Generic
Ramipril 2.5 MG Capsule 30 Generic
Ramipril 5 MG Capsule 30 Generic
Ranitidine HCL 15 MG/ML Syrup 60 Generic
Ranitidine HCL 150 MG Capsule 30 Generic
Ranitidine HCL 150 MG Tablet 30 Generic
Ranitidine HCL 300 MG Capsule 30 Generic
Ranitidine HCL 300 MG Tablet 30 Generic
Repaglinide 0.5 MG Tablet 30 Generic
Repaglinide 1 MG Tablet 60 Generic
Repaglinide 2 MG Tablet 90 Generic
Ribavirin 40 MG/ML Solution 30 Brand
Rifampin 150 MG Capsule 20 Generic
Rifampin 300 MG Capsule 30 Generic
Rimantadine HCL 100 MG Tablet 20 Generic
Risedronate Sodium 150 MG Tablet 1 Generic
Risedronate Sodium 35 MG Tablet 4 Generic
Risedronate Sodium 5 MG Tablet 30 Generic
Risperidone 0.25 MG Tablet 30 Generic
Risperidone 0.5 MG Disintegrating Tablet 28 Generic
Risperidone 0.5 MG Tablet 30 Generic
Risperidone 1 MG Disintegrating Tablet 15 Generic
Risperidone 1 MG Tablet 30 Generic
Risperidone 1 MG/ML Solution 30 Generic
Risperidone 2 MG Tablet 30 Generic
Risperidone 3 MG Tablet 15 Generic
Rivastigmine Tartrate 1.5 MG Capsule 60 Generic
Rivastigmine Tartrate 3 MG Capsule 30 Generic
Rivastigmine Tartrate 4.5 MG Capsule 60 Generic
Rivastigmine Tartrate 6 MG Capsule 30 Generic
Rizatriptan Benzoate 10 MG Disintegrating Tablet 10 Generic
18 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Rizatriptan Benzoate 10 MG Tablet 10 Generic
Rizatriptan Benzoate 5 MG Disintegrating Tablet 6 Generic
Rizatriptan Benzoate 5 MG Tablet 6 Generic
Ropinirole HCL 0.25 MG Tablet 30 Generic
Ropinirole HCL 0.5 MG Tablet 30 Generic
Ropinirole HCL 1 MG Tablet 30 Generic
Ropinirole HCL 12 MG Tablet 24-Hr ER 3 Generic
Ropinirole HCL 2 MG Tablet 30 Generic
Ropinirole HCL 2 MG Tablet 24-Hr ER 30 Generic
Ropinirole HCL 3 MG Tablet 30 Generic
Ropinirole HCL 4 MG Tablet 30 Generic
Ropinirole HCL 4 MG Tablet 24-Hr ER 15 Generic
Ropinirole HCL 5 MG Tablet 30 Generic
Ropinirole HCL 6 MG Tablet 24-Hr ER 15 Generic
Ropinirole HCL 8 MG Tablet 24-Hr ER 30 Generic
Ropivacaine HCL/PF 2 MG/ML Solution 30 Generic
Ropivacaine HCL/PF 5 MG/ML Solution 30 Generic
Ropivacaine HCL/PF 7.5 MG/ML Solution 30 Brand
Rosiglitazone Maleate 2 MG Tablet 30 Brand
Rosuvastatin Calcium 10 MG Tablet 30 Generic
Rosuvastatin Calcium 20 MG Tablet 30 Generic
Rosuvastatin Calcium 40 MG Tablet 30 Generic
Rosuvastatin Calcium 5 MG Tablet 15 Generic
Salicylic Acid 17% Gel 7 Generic
Salicylic Acid 6% Combo Pack 400 Generic
Salicylic Acid 6% Cream 400 Generic
Salicylic Acid 6% Lotion 414 Generic
Salicylic Acid 6%-6% Shampoo & Gel Kit 1 Brand
Salsalate 500 MG Tablet 30 Generic
Salsalate 750 MG Tablet 90 Generic
Selegiline HCL 5 MG Capsule 90 Generic
Selenium Sulfide 2.5% Prescription Only 2.5% Shampoo 30 Generic
Sertraline HCL 20 MG/ML Concentrate 30 Generic
Sertraline HCL 25 MG Tablet 15 Generic
Sertraline HCL 50 MG Tablet 15 Generic
Sildenafil Citrate 100 MG Tablet 3 Generic
Sildenafil Citrate 25 MG Tablet 3 Generic
Sildenafil Citrate 50 MG Tablet 5 Generic
Silodosin 4 MG Capsule 30 Generic
Silver Sulfadiazine 1% Cream 20 Generic
Simvastatin 10 MG Tablet 30 Generic
Simvastatin 20 MG Tablet 30 Generic
Simvastatin 40 MG Tablet 30 Generic
Simvastatin 5 MG Tablet 30 Generic
Simvastatin 80 MG Tablet 15 Generic
Sirolimus 1 MG Tablet 15 Generic
Sod/Pot/K Cit/Sod Cit/Cit Acid 500-550/5 Solution 30 Brand
Sodium Bicarbonate 0.48 MEQ/ML Solution 30 Brand
Sodium Chloride 0.9% Vial 30 Generic
Sodium Chloride for Inhalation 3.5% Solution for Nebulization 240 Brand
Name/Strength/Form Default Qty. Brand/Generic
Sodium Chloride for Inhalation 6% Solution for Nebulization 30 Brand
Sodium Chloride for Inhalation 7% Solution for Nebulization 360 Generic
Sodium Fluoride 0.125/Drop Drops 30 Generic
Sodium Fluoride 0.2% Solution 473 Generic
Sodium Fluoride 0.25 MG/0.6 Drops 60 Brand
Sodium Fluoride 0.25(0.55) Chewable Tablet 30 Generic
Sodium Fluoride 0.5 MG/ML Drops 50 Generic
Sodium Fluoride 0.5(1.1)MG Chewable Tablet 30 Generic
Sodium Fluoride 1 MG(2.2 MG) Chewable Tablet 30 Generic
Sodium Fluoride 1.1% Cream 51 Brand
Sodium Fluoride 1.1% Gel 60 Generic
Sodium Fluoride 1.1% Gel 100 Brand
Sodium Fluoride 2.5 MG/ML Drops 30 Generic
Sodium Fluoride Paste 1.1% Paste 30 Brand
Sodium Fluoride/Potassium Nit 1.1%-5% Paste 100 Brand
Sodium Polystyrene Sulfonate 15 Generic/60 ML Suspension 60 Generic
Sodium Polystyrene Sulfonate 30 Generic/120 ML Enema 30 Generic
Sodium Polystyrene Sulfonate N/A Powder 30 Generic
Sodium/K+/Mag/Ca/Chlor/Acetate 35-20-5 MEQ Solution 30 Generic
Sotalol HCL 120 MG Tablet 30 Generic
Sotalol HCL 160 MG Tablet 30 Generic
Sotalol HCL 240 MG Tablet 6 Generic
Sotalol HCL 5 MG/ML Solution 30 Brand
Sotalol HCL 80 MG Tablet 15 Generic
Spironolactone 100 MG Tablet 30 Generic
Spironolactone 25 MG Tablet 30 Generic
Spironolactone 50 MG Tablet 30 Generic
Spironolactone/Hydrochlorothiazide 25 MG-25 MG Tablet 30 Generic
Stannous Fluoride 0.4% Gel 122 Generic
Stavudine 1 MG/ML Recon Solution 30 Brand
Succinylcholine Chloride 20 MG/ML Solution 30 Generic
Sucralfate 1 Generic Tablet 30 Generic
Sufentanil Citrate 50 MCG/ML Solution 30 Generic
Sulfacetamide Sod/Sulfur/Urea 10%-5%-10% Cleanser 30 Brand
Sulfacetamide Sodium 10% Cleanser 180 Generic
Sulfacetamide Sodium 10% Cleanser ER 30 Generic
Sulfacetamide Sodium 10% Drops 5 Generic
Sulfacetamide Sodium 10% Ointment 4 Brand
Sulfacetamide Sodium 10% Shampoo 30 Brand
Sulfacetamide Sodium 10% Suspension 118 Generic
Sulfacetamide Sodium/Sulfur 10-5% (W/W) Cleanser 227 Generic
Sulfacetamide Sodium/Sulfur 9%-4.5% Cleanser 454 Generic
Sulfacetamide/Prednisolone Sp 10%-0.23% Drops 5 Generic
Sulfamethoxazole/Trimethoprim 200-40 MG/5 Suspension 100 Generic
Sulfamethoxazole/Trimethoprim 400 MG-80 MG Tablet 30 Generic
Sulfamethoxazole/Trimethoprim 800-160 MG Tablet 20 Generic
Sulfasalazine 500 MG Tablet 90 Generic
Sulfasalazine 500 MG Tablet DR/EC 90 Generic
Sulindac 150 MG Tablet 28 Generic
Sulindac 200 MG Tablet 30 Generic
19 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Sumatriptan 100 MG Tablet 9 Generic
Sumatriptan 25 MG Tablet 9 Generic
Sumatriptan 4 MG/0.5 ML Pen Injector 1 Generic
Sumatriptan 50 MG Tablet 10 Generic
Sumatriptan 6 MG/0.5 ML Solution 1 Generic
Synthroid (Brand) 50 MCG Tablet 30 Generic
Tacrolimus 0.03% Ointment 30 Generic
Tacrolimus 0.1% Ointment 30 Generic
Tacrolimus 0.5 MG Capsule 30 Generic
Tacrolimus 0.5 MG Capsule 24-Hr ER 30 Brand
Tacrolimus 1 MG Capsule 60 Generic
Tadalafil Tablets 2.5 MG Tablet 18 Generic
Tadalafil Tablets 20 MG Tablet 3 Generic
Tadalafil Tablets 5 MG Tablet 6 Generic
Tamoxifen Citrate 10 MG Tablet 30 Generic
Tamoxifen Citrate 20 MG Tablet 30 Generic
Tamsulosin HCL 0.4 MG Capsule 24-Hr ER 30 Generic
Telmisartan 40 MG Tablet 30 Generic
Telmisartan 80 MG Tablet 30 Generic
Telmisartan/Amlodipine 80 MG-5 MG Tablet 10 Generic
Telmisartan/Hydrochlorothiazid 40-12.5 MG Tablet 30 Generic
Telmisartan/Hydrochlorothiazid 80 MG-25 MG Tablet 30 Generic
Telmisartan/Hydrochlorothiazid 80-12.5 MG Tablet 30 Generic
Temazepam 15 MG Capsule 30 Generic
Temazepam 22.5 MG Capsule 15 Generic
Temazepam 30 MG Capsule 15 Generic
Temazepam 7.5 MG Capsule 15 Generic
Temozolomide 20 MG Capsule 5 Generic
Terazosin HCL 1 MG Capsule 30 Generic
Terazosin HCL 10 MG Capsule 30 Generic
Terazosin HCL 2 MG Capsule 30 Generic
Terazosin HCL 5 MG Capsule 30 Generic
Terbutaline Sulfate 2.5 MG Tablet 20 Generic
Terconazole 0.4% Cream 45 Generic
Terconazole 0.8% Cream 20 Generic
Terconazole 80 MG Suppository 3 Generic
Testosterone 50 MG (1%) Gel 30 Generic
Testosterone Cypionate 100 MG/ML Oil 10 Generic
Testosterone Cypionate 200 MG/ML Oil Injection 1 Generic
Testosterone Enanthate 200 MG/ML Oil 5 Generic
Tetracaine HCL 0.5% Drops 15 Generic
Tetracaine HCL 0.5% Viscous Dropperette 30 Generic
Tetracaine HCL 0.5% Viscous Drops 30 Generic
Tetracycline HCL 250 MG Capsule 30 Generic
Theophylline Anhydrous 100 MG Tablet 12-Hr ER 30 Generic
Theophylline Anhydrous 200 MG Tablet 12-Hr ER 30 Generic
Theophylline Anhydrous 400 MG Tablet 12-Hr ER 30 Generic
Theophylline Anhydrous 400 MG Tablet ER 30 Generic
Theophylline Anhydrous 600 MG Tablet ER 30 Generic
Thiamine HCL 100 MG Tablet 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Thioridazine HCL 10 MG Tablet 90 Generic
Thioridazine HCL 100 MG Tablet 90 Generic
Thioridazine HCL 25 MG Tablet 30 Generic
Thioridazine HCL 50 MG Tablet 5 Generic
Thiothixene 1 MG Capsule 30 Generic
Thiothixene 2 MG Capsule 30 Generic
Thiothixene 5 MG Capsule 30 Generic
Thyroid (Pork) 120mg (2gr) Tablet 30 Generic
Thyroid, Pork 113.75 MG (1.75 Grain) Tablet 30 Brand
Thyroid, Pork 146.25 MG (2.25 Grain) Tablet 30 Brand
Thyroid, Pork 15 MG Tablet 30 Brand
Thyroid, Pork 16.25 MG (0.25 Grain) Tablet 30 Brand
Thyroid, Pork 162.5 MG (2.5 Grain) Tablet 30 Brand
Thyroid, Pork 180 MG Tablet 30 Brand
Thyroid, Pork 240 MG Tablet 30 Brand
Thyroid, Pork 300 MG Tablet 30 Brand
Thyroid, Pork 32.5 MG (0.5 Grain) Tablet 30 Brand
Thyroid, Pork 325 MG (5 Grain) Tablet 30 Brand
Thyroid, Pork 48.75 MG (3/4 Grain) Tablet 30 Brand
Thyroid, Pork 65 MG (1 Grain) Tablet 30 Brand
Thyroid, Pork 81.25 MG (1.25 Grain) Tablet 30 Brand
Thyroid, Pork 97.5 MG (1.5 Grain) Tablet 30 Brand
Thyroid, Pork 130 MG Tablet 30 Brand
Thyroid, Pork 195 MG Tablet 15 Brand
Ticlopidine HCL 250 MG Tablet 30 Generic
Timolol Maleate 0.25% Drops 5 Generic
Timolol Maleate 0.25% Gel Forming Solution 5 Generic
Timolol Maleate 0.5% Drops 5 Generic
Timolol Maleate 0.5% Gel Forming Solution 5 Generic
Timolol Maleate 10 MG Tablet 30 Brand
Timolol Maleate 20 MG Tablet 30 Brand
Timolol Maleate 5 MG Tablet 30 Brand
Tinidazole 250 MG Tablet 14 Generic
Tinidazole 500 MG Tablet 4 Generic
Tizanidine HCL 2 MG Capsule 15 Generic
Tizanidine HCL 2 MG Tablet 30 Generic
Tizanidine HCL 4 MG Capsule 30 Generic
Tizanidine HCL 4 MG Tablet 30 Generic
Tizanidine HCL 6 MG Capsule 28 Generic
Tobramycin 0.3% Drops 5 Generic
Tolazamide 250 MG Tablet 30 Brand
Tolmetin Sodium 200 MG Tablet 30 Brand
Tolnaftate 1% Aerosol Powder 30 Generic
Tolnaftate 1% Cream 30 Generic
Tolnaftate 1% Powder 45 Generic
Tolterodine Tartrate 1 MG Tablet 15 Generic
Tolterodine Tartrate 2 MG Tablet 30 Generic
Tolterodine Tartrate 4 MG Capsule 24-Hr ER 30 Generic
Topiramate 100 MG Tablet 30 Generic
Topiramate 15 MG Sprinkle Capsule 30 Generic
20 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Topiramate 200 MG Tablet 30 Generic
Topiramate 25 MG Sprinkle Capsule 30 Generic
Topiramate 25 MG Tablet 30 Generic
Topiramate 50 MG Tablet 30 Generic
Torsemide 10 MG Tablet 30 Generic
Torsemide 100 MG Tablet 15 Generic
Torsemide 20 MG Tablet 30 Generic
Torsemide 5 MG Tablet 15 Generic
Tramadol HCL 100 MG Tablet 24-Hr ER 28 Generic
Tramadol HCL 200 MG Tablet 24-Hr ER 30 Generic
Tramadol HCL 300 MG Tablet 24-Hr ER 28 Generic
Tramadol HCL 50 MG Tablet 30 Generic
Tramadol HCL/Acetaminophen 37.5-325 MG Tablet 30 Generic
Trandolapril 1 MG Tablet 15 Generic
Trandolapril 2 MG Tablet 30 Generic
Trandolapril 4 MG Tablet 30 Generic
Trandolapril/Verapamil HCL 1-240 MG Tablet, IR - ER, Biphasic 24-Hr 30 Generic
Trandolapril/Verapamil HCL 2-240 MG Tablet, IR - ER, Biphasic 24-Hr 30 Generic
Tranexamic Acid 650 MG Tablet 30 Generic
Trazodone HCL 100 MG Tablet 30 Generic
Trazodone HCL 150 MG Tablet 15 Generic
Trazodone HCL 300 MG Tablet 5 Generic
Trazodone HCL 50 MG Tablet 30 Generic
Tretinoin 0.01% Gel 15 Generic
Tretinoin 0.025% Cream 20 Generic
Tretinoin 0.025% Gel 15 Generic
Tretinoin 0.05% Cream 20 Generic
Tretinoin 0.1% Cream 20 Generic
Tretinoin Microspheres 0.04% Gel 20 Generic
Tretinoin Microspheres 0.1% Gel 20 Generic
Triamcinolone Acetonide 0.025% Cream & Gel Combo Pack 30 Generic
Triamcinolone Acetonide 0.025% Lotion 60 Generic
Triamcinolone Acetonide 0.025% Ointment 15 Generic
Triamcinolone Acetonide 0.05% Ointment 34 Brand
Triamcinolone Acetonide 0.1% Lotion 60 Generic
Triamcinolone Acetonide 0.1% Ointment 15 Generic
Triamcinolone Acetonide 0.1% Paste 5 Generic
Triamcinolone Acetonide 0.5% Cream & Gel Combo Pack 30 Generic
Triamcinolone Acetonide 0.5% Ointment 15 Generic
Triamcinolone Acetonide 10 MG/ML Suspension 5 Brand
Triamcinolone/Emollient Cmb #86 0.1% Cream 30 Brand
Triamterene/Hydrochlorothiazid 37.5-25 MG Capsule 30 Generic
Triamterene/Hydrochlorothiazid 37.5-25 MG Tablet 30 Generic
Triamterene/Hydrochlorothiazid 75 MG-50 MG Tablet 30 Generic
Triazolam 0.125 MG Tablet 30 Generic
Triazolam 0.25 MG Tablet 1 Generic
Trifluoperazine HCL 1 MG Tablet 30 Generic
Trifluoperazine HCL 2 MG Tablet 30 Generic
Trifluoperazine HCL 5 MG Tablet 30 Generic
Trihexyphenidyl HCL 2 MG Tablet 30 Generic
Name/Strength/Form Default Qty. Brand/Generic
Trihexyphenidyl HCL 2 MG/5 ML Elixir 180 Generic
Trihexyphenidyl HCL 5 MG Tablet 30 Generic
Trimethobenzamide HCL 300 MG Capsule 30 Generic
Trimethoprim 100 MG Tablet 30 Generic
Tropicamide 0.5% Drops 30 Generic
Tropicamide 1% Drops 15 Generic
Trospium Chloride 20 MG Tablet 30 Generic
Trospium Chloride 60 MG Capsule 24-Hr ER 30 Generic
Umeclidinium Brm/Vilanterol Tr 62.5-25 MCG Inhaler 1 Brand
Urea 40% Foam 30 Brand
Urea 40% Nail Film Suspension 30 Generic
Urea/Lactic Ac/Zn Undecylenate 50% Emulsion 30 Generic
Ursodiol 250 MG Tablet 90 Generic
Ursodiol 300 MG Capsule 30 Generic
Valacyclovir HCL 1000 MG Tablet 4 Generic
Valacyclovir HCL 500 MG Tablet 30 Generic
Valproic Acid (as Sodium Salt) 250 MG Capsule 30 Generic
Valproic Acid (as Sodium Salt) 500 MG/5 ML Solution 30 Generic
Valsartan 160 MG Tablet 30 Generic
Valsartan 320 MG Tablet 30 Generic
Valsartan 40 MG Tablet 15 Generic
Valsartan 80 MG Tablet 30 Generic
Valsartan/Hydrochlorothiazide 160-12.5 MG Tablet 30 Generic
Valsartan/Hydrochlorothiazide 160-25 MG Tablet 30 Generic
Valsartan/Hydrochlorothiazide 320 MG-25 MG Tablet 30 Generic
Valsartan/Hydrochlorothiazide 320-12.5 MG Tablet 30 Generic
Valsartan/Hydrochlorothiazide 80-12.5 MG Tablet 30 Generic
Vancomycin HCL 1 Generic Recon Solution 10 Generic
Vancomycin HCL 10 Generic Recon Solution 1 Generic
Vardenafil HCL 10 MG Disintegrating Tablet 2 Brand
Venlafaxine HCL 100 MG Tablet 30 Generic
Venlafaxine HCL 150 MG Capsule 24-Hr ER 30 Generic
Venlafaxine HCL 150 MG Tablet 24-Hr ER 30 Generic
Venlafaxine HCL 25 MG Tablet 30 Generic
Venlafaxine HCL 37.5 MG Capsule 24-Hr ER 7 Generic
Venlafaxine HCL 37.5 MG Tablet 30 Generic
Venlafaxine HCL 37.5 MG Tablet 24-Hr ER 30 Generic
Venlafaxine HCL 50 MG Tablet 30 Generic
Venlafaxine HCL 75 MG Capsule 24-Hr ER 30 Generic
Venlafaxine HCL 75 MG Tablet 30 Generic
Venlafaxine HCL 75 MG Tablet 24-Hr ER 30 Generic
Verapamil HCL 120 MG Capsule 24-Hr ER Pellets 30 Generic
Verapamil HCL 120 MG Tablet 30 Generic
Verapamil HCL 120 MG Tablet ER 30 Generic
Verapamil HCL 180 MG Capsule 24-Hr ER Pellets 30 Generic
Verapamil HCL 180 MG Tablet ER 30 Generic
Verapamil HCL 200 MG Capsule 24-Hr ER Pellet Ct 30 Generic
Verapamil HCL 240 MG Capsule 24-Hr ER Pellets 30 Generic
Verapamil HCL 240 MG Tablet ER 30 Generic
Verapamil HCL 40 MG Tablet 15 Generic
21 of 21 2020 TIER ONE FORMULARY
A B C D E F G–H I K–L M N O–P Q–R S T U–V W–Z SUBSCRIPTION DETAILS
Name/Strength/Form Default Qty. Brand/Generic
Verapamil HCL 80 MG Tablet 30 Generic
Vinorelbine Tartrate 10 MG/ML Solution 30 Generic
Vit A,C & E/Lutein/Minerals 1000-60-2 Tablet 30 Generic
Vit A/Vit C/Vit E/Zinc/Copper 14320-226 Capsule 30 Generic
Vit C/E/Zn/Copper/Lutein/Zeaxan 60 MG-6 MG Capsule 30 Generic
Vit C/Vit E Ac/Lut/Copper/Zinc 226-200-5 Capsule 30 Generic
Vitamin E Mixed 200 Unit Capsule 30 Generic
Warfarin Sodium 1 MG Tablet 30 Generic
Warfarin Sodium 10 MG Tablet 30 Generic
Warfarin Sodium 2 MG Tablet 30 Generic
Warfarin Sodium 2.5 MG Tablet 30 Generic
Warfarin Sodium 3 MG Tablet 15 Generic
Warfarin Sodium 4 MG Tablet 30 Generic
Warfarin Sodium 5 MG Tablet 30 Generic
Warfarin Sodium 6 MG Tablet 30 Generic
Warfarin Sodium 7.5 MG Tablet 15 Generic
Zafirlukast 10 MG Tablet 30 Generic
Zafirlukast 20 MG Tablet 30 Generic
Zaleplon 10 MG Capsule 30 Generic
Zaleplon 5 MG Capsule 15 Generic
Name/Strength/Form Default Qty. Brand/Generic
Zanamivir 5 MG Blister w/ Device 20 Brand
Zidovudine 10 MG/ML Syrup 45 Generic
Zinc Acetate 25 MG Capsule 30 Brand
Zinc Oxide 10% Ointment 85 Generic
Zinc Sulf/Cuso 4 P-Hyd/MN/Cr/Se 20-1000 Solution 30 Brand
Zinc/Copper/Mangan/Chromic CHL 0.5-0.1-30 Solution 30 Brand
Ziprasidone HCL 20 MG Capsule 30 Generic
Ziprasidone HCL 40 MG Capsule 30 Generic
Ziprasidone HCL 60 MG Capsule 30 Generic
Ziprasidone HCL 80 MG Capsule 30 Generic
Zoledronic Acid 4 MG/100 ML Solution 30 Brand
Zolmitriptan 2.5 MG Tablet 6 Generic
Zolmitriptan 5 MG Tablet 10 Generic
Zolpidem Tartrate 10 MG Tablet 30 Generic
Zolpidem Tartrate 5 MG Tablet 15 Generic
Zolpidem Tartrate 6.25 MG Multiphase Tablet ER 15 Generic
Zolpidem Tartrate ER 12.5 MG Multiphase Tablet ER 30 Generic
Zonisamide 100 MG Capsule 30 Generic
Zonisamide 25 MG Capsule 30 Generic
Zonisamide 50 MG Capsule 30 Generic
TIER 1
• $50 deductible.
• $15 co-pay (generics/brands up to $100 cost) at retail pharmacy.
• $30 (or less) co-pay for Home Delivery, depending on medication.
• Maintenance meds allowed – 1 (one) 30-day retail pharmacy pick-up. Plan will then be converted to Home Delivery, if drug is available.
• Up to a 15-day emergency supply can be approved via SHIELD PBM or a Plan Administrator.
• Diabetic Testing Supplies will be covered at 100% when using Home Delivery.
• For assistance, please call one of our SHIELD PBM Customer Care Specialists at (877) 659 6101.