Formulary 2017 Master Negative Changes from 2016 to 2017€¦ · BeHealthy 5 Tier to Ideal 6 Tier...
Transcript of Formulary 2017 Master Negative Changes from 2016 to 2017€¦ · BeHealthy 5 Tier to Ideal 6 Tier...
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
1ST TIER UNI MIS
29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
1ST TIER UNI MIS
31GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
1ST TIER UNI MIS
31GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
1ST TIER UNI MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
1ST TIER UNI MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
8-MOP CAP 10MG Not on 2017 formulary
methoxsalen 10 mg
capsules Dermatological Agents Dermatological Agents
ABACAV/LAMIV TAB
/ZIDOVUD
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
ABACAVIR TAB
300MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
ABELCET INJ
5MG/ML Not on 2017 formulary
amphotericin inj,
Ambisome inj Antifungals Antifungals
ABELCET INJ
5MG/ML
On formulary, requires
prior authorization check with your doctor Antifungals Antifungals
ABILIFY DISC TAB 10MG On formulary, tier change tier 4 to tier 5 Antipsychotics 2nd Generation/Atypical
ABILIFY DISC TAB 10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
BeHealthy 5 Tier to Ideal 6 Tier Formulary 2017 Master Negative Changes from 2016 to 2017
Pg. 1 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ABILIFY DISC TAB 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ABILIFY MAIN INJ
300MG On formulary, tier change tier 4 to tier 5 Antipsychotics 2nd Generation/Atypical
ABILIFY MAIN INJ
300MG
On formulary, quantity
limit may apply
1 syringe or vial per 30
days Antipsychotics 2nd Generation/Atypical
ABILIFY MAIN INJ
300MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ABRAXANE INJ
100MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
ACARBOSE TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
ACARBOSE TAB
25MG
On formulary, quantity
limit may apply 360 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
ACARBOSE TAB
50MG
On formulary, quantity
limit may apply 180 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
ACETAZOLAMID TAB
125MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Diuretics, Carbonic
Anhydrase Inhibitors
ACITRETIN CAP 10MG On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents
ACITRETIN CAP
17.5MG On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents
ACITRETIN CAP 25MG On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents
Pg. 2 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ACTEMRA INJ 162/0.9 Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These drugs will need a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents Immune Suppressants
ACTEMRA INJ
200/10ML Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These drugs will need a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents Immune Suppressants
ACYCLOVIR NA INJ
1000MG
On formulary, requires
prior authorization check with your doctor Antivirals Antiherpetic Agents
ACYCLOVIR NA INJ
500MG
On formulary, requires
prior authorization check with your doctor Antivirals Antiherpetic Agents
ACYCLOVIR NA INJ
50MG/ML On formulary, tier change tier 1 to tier 2 Antivirals Antiherpetic Agents
ACYCLOVIR NA INJ
50MG/ML
On formulary, requires
prior authorization check with your doctor Antivirals Antiherpetic Agents
Pg. 3 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ADAPALENE GEL 0.3% Not on 2017 formulary
tretinoin cream (0.025%,
0.05%, 0.1%), tretinoin
gel (0.025%, 0.01%),
Tazorac (cream, gel) Dermatological Agents Dermatological Agents
ADAPALENE GEL PMP
0.3% Not on 2017 formulary
tretinoin cream (0.025%,
0.05%, 0.1%), tretinoin
gel (0.025%, 0.01%),
Tazorac (cream, gel) Dermatological Agents Dermatological Agents
ADCIRCA TAB 20MG
On formulary, quantity
limit may apply 60 tablets per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
ADEMPAS TAB
0.5MG
On formulary, quantity
limit may apply 90 tablets per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
ADVAIR DISKU AER
100/50
On formulary, quantity
limit may apply 1 inhaler per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ADVAIR DISKU AER
250/50
On formulary, quantity
limit may apply 1 inhaler per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ADVAIR DISKU AER
500/50
On formulary, quantity
limit may apply 1 inhaler per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ADVAIR HFA AER
115/21
On formulary, quantity
limit may apply 1 canister per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ADVAIR HFA AER
230/21
On formulary, quantity
limit may apply 1 canister per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ADVAIR HFA AER 45/21
On formulary, quantity
limit may apply 1 canister per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
AFINITOR TAB 10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
AFINITOR TAB 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
Pg. 4 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AFINITOR TAB 2.5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
AFINITOR TAB 2.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
AFINITOR TAB 5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
AFINITOR TAB 5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
AFINITOR TAB 7.5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
AFINITOR TAB 7.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
AFINITOR DIS TAB 2MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
AFINITOR DIS TAB 2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
AFINITOR DIS TAB 3MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antineoplastics Antineoplastics
AFINITOR DIS TAB 3MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
Pg. 5 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AFINITOR DIS TAB 5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
AFINITOR DIS TAB 5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
ALA CORT CRE 1% On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
ALBUTEROL NEB
0.083% On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ALBUTEROL NEB
1.25MG/3 On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ALBUTEROL TAB 2MG On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ALBUTEROL TAB 4MG On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ALBUTEROL TAB 4MG
ER On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ALCOH-GLOVE PAD
CONTOURE On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOHOL PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOHOL PAD PREP On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOHOL PAD
SWABSTIC On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOHOL PREP PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOHOL PREP PAD
70% On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 6 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALCOHOL PREP PAD
MED 70% On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOHOL PREP PAD
PADS 70% On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOHOL SWAB PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOHOL SWAB PAD
EX-THICK On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOHOL WIPE PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALCOH-WIPE PAD
12"X12" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ALENDRONATE TAB
10MG
On formulary, quantity
limit may apply 120 tablets per 30 days
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ALENDRONATE TAB
35MG
On formulary, quantity
limit may apply 4 tablets per 28 days
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ALENDRONATE TAB
40MG Not on 2017 formulary
alendronate tablets (5mg,
10mg, 35mg, 70mg)
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ALENDRONATE TAB
5MG
On formulary, quantity
limit may apply 30 tablets per 30 days
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ALENDRONATE TAB
70MG
On formulary, quantity
limit may apply 4 tablets per 28 days
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ALPHAGAN P SOL
0.1% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents
Ophthalmic Antiglaucoma
Agents
Pg. 7 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALPRAZOLAM CON 1
MG/ML Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
ALPRAZOLAM TAB
0.25 ODT Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 8 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALPRAZOLAM TAB
0.25MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
ALPRAZOLAM TAB
0.5MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 9 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALPRAZOLAM TAB
0.5MG ER Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
ALPRAZOLAM TAB
0.5MG OD Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 10 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALPRAZOLAM TAB
0.5MG XR Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
ALPRAZOLAM TAB
1MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 11 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALPRAZOLAM TAB
1MG ER Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
ALPRAZOLAM TAB
1MG ODT Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 12 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALPRAZOLAM TAB
1MG XR Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
ALPRAZOLAM TAB
2MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 13 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALPRAZOLAM TAB
2MG ER Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
ALPRAZOLAM TAB
2MG ODT Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 14 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALPRAZOLAM TAB
2MG XR Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
ALPRAZOLAM TAB
3MG ER Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 15 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ALPRAZOLAM TAB
3MG XR Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
AMANTADINE TAB
100MG On formulary, tier change tier 2 to tier 4 Antiparkinson Agents
Antiparkinson Agents,
Other
AMBISOME INJ 50MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals
AMBISOME INJ 50MG
On formulary, requires
prior authorization check with your doctor Antifungals Antifungals
Pg. 16 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMCINONIDE CRE
0.1% Not on 2017 formulary
betamethasone
dipropionate 0.05%
(cream), augmented
betamethasone 0.05%
(cream), betamethasone
valerate 0.1% (cream),
clobetasol 0.05%
(solution), clobetasol
emollient 0.05% (cream),
fluocinonide 0.05%
(cream, gel, ointment,
solution), mometasone
0.1% (cream, ointment,
solution), triamcinolone
0.025%/0.1% (cream),
triamcinolone 0.5%
(cream, ointment) Dermatological Agents Dermatological Agents
Pg. 17 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMCINONIDE LOT
0.1% Not on 2017 formulary
betamethasone
dipropionate 0.05%
(cream), augmented
betamethasone 0.05%
(cream), betamethasone
valerate 0.1% (cream),
clobetasol 0.05%
(solution), clobetasol
emollient 0.05% (cream),
fluocinonide 0.05%
(cream, gel, ointment,
solution), mometasone
0.1% (cream, ointment,
solution), triamcinolone
0.025%/0.1% (cream),
triamcinolone 0.5%
(cream, ointment) Dermatological Agents Dermatological Agents
Pg. 18 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMCINONIDE OIN 0.1% Not on 2017 formulary
betamethasone
dipropionate 0.05%
(cream), augmented
betamethasone 0.05%
(cream), betamethasone
valerate 0.1% (cream),
clobetasol 0.05%
(solution), clobetasol
emollient 0.05% (cream),
fluocinonide 0.05%
(cream, gel, ointment,
solution), mometasone
0.1% (cream, ointment,
solution), triamcinolone
0.025%/0.1% (cream),
triamcinolone 0.5%
(cream, ointment) Dermatological Agents Dermatological Agents
AMILOR/HCTZ TAB 5-50 On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Cardiovascular Agents,
Other
AMILORIDE TAB 5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Diuretics, Potassium-
sparing
AMINOPHYLLIN INJ
25MG/ML Not on 2017 formulary
Theochron CR tablets,
theophylline anhydrous
ER/CR tablets Respiratory Tract Agents
Bronchodilators,
Phosphodiesterase
Inhibitors (Xanthines)
AMINOSYN INJ
8.5/LYTE Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
Pg. 19 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMINOSYN 7% INJ
/LYTES Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMINOSYN II INJ 10% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMINOSYN II INJ 7% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMINOSYN II INJ 8.5% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMINOSYN II INJ
8.5/LYTE Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMINOSYN M INJ 3.5% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
Pg. 20 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMINOSYN-HBC INJ 7% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMINOSYN-HF INJ 8% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMINOSYN-PF INJ 10% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMINOSYN-PF INJ 7% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMINOSYN-RF INJ 5.2% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMIODARONE INJ
150MG/3M Not on 2017 formulary
amiodarone tablets (200
mg, 400 mg) Cardiovascular Agents Antiarrhythmics
AMIODARONE INJ
50MG/ML Not on 2017 formulary
amiodarone tablets (200
mg, 400 mg) Cardiovascular Agents Antiarrhythmics
AMIODARONE TAB
100MG Not on 2017 formulary
amiodarone tablets (200
mg, 400 mg) Cardiovascular Agents Antiarrhythmics
AMITIZA CAP 24MCG
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Irritable Bowel Syndrome
Agents
Pg. 21 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMITIZA CAP 8MCG
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Irritable Bowel Syndrome
Agents
AMITRIPTYLIN TAB
100MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
AMITRIPTYLIN TAB
10MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
AMITRIPTYLIN TAB
150MG On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
AMITRIPTYLIN TAB
25MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
AMITRIPTYLIN TAB
50MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
AMITRIPTYLIN TAB
75MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
AMLOD/ATORVA TAB 10-
10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 10-
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 10-
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 10-
80MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB
2.5-10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB
2.5-20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB
2.5-40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 5-
10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
Pg. 22 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMLOD/ATORVA TAB 5-
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 5-
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 5-
80MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/BENAZP CAP 10-
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/BENAZP CAP 10-
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/BENAZP CAP
2.5-10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/BENAZP CAP 5-
10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/BENAZP CAP 5-
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/BENAZP CAP 5-
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/VALSAR TAB
/HCTZ On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/VALSAR TAB
/HCTZ
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/VALSAR TAB 10-
160MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/VALSAR TAB 10-
160MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/VALSAR TAB 10-
320MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/VALSAR TAB 10-
320MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
Pg. 23 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMLOD/VALSAR TAB 5-
160MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/VALSAR TAB 5-
160MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/VALSAR TAB 5-
320MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
AMLOD/VALSAR TAB 5-
320MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
AMOX/K CLAV CHW
200MG On formulary, tier change tier 1 to tier 4 Antibacterials Beta-lactam, Penicillins
AMOX/K CLAV CHW
400MG On formulary, tier change tier 1 to tier 4 Antibacterials Beta-lactam, Penicillins
AMOX/K CLAV SUS
200/5ML On formulary, tier change tier 1 to tier 2 Antibacterials Beta-lactam, Penicillins
AMOXAPINE TAB
100MG On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
AMOXAPINE TAB
150MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
AMOXAPINE TAB
25MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
AMOXAPINE TAB
50MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
AMOXICILLIN CHW
125MG Not on 2017 formulary
amoxicillin capsules (250
mg, 500 mg), amoxicillin
tablets (500 mg, 875 mg),
amoxicillin suspensions
(125/5 mL, 200/5 mL,
250/5 mL, 400/5 mL) Antibacterials Beta-lactam, Penicillins
Pg. 24 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMOXICILLIN CHW
250MG Not on 2017 formulary
amoxicillin capsules (250
mg, 500 mg), amoxicillin
tablets (500 mg, 875 mg),
amoxicillin suspensions
(125/5 mL, 200/5 mL,
250/5 mL, 400/5 mL) Antibacterials Beta-lactam, Penicillins
AMPHET/DEXTR TAB
10MG
On formulary, quantity
limit may apply 60 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR TAB
12.5MG On formulary, tier change tier 1 to tier 2
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR TAB
12.5MG
On formulary, quantity
limit may apply 60 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR TAB
15MG
On formulary, quantity
limit may apply 60 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR TAB
20MG
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR TAB
30MG
On formulary, quantity
limit may apply 60 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR TAB
5MG
On formulary, quantity
limit may apply 60 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR TAB
7.5MG
On formulary, quantity
limit may apply 60 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
Pg. 25 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMPHOTERICIN INJ
50MG On formulary, tier change tier 2 to tier 4 Antifungals Antifungals
AMPHOTERICIN INJ
50MG
On formulary, requires
prior authorization check with your doctor Antifungals Antifungals
AMPICILLIN INJ 125MG Not on 2017 formulary
ampicillin inj (250 mg, 500
mg, 1 gm, 2 gm, 10 gm) Antibacterials Beta-lactam, Penicillins
AMPICILLIN SUS
125/5ML On formulary, tier change tier 1 to tier 4 Antibacterials Beta-lactam, Penicillins
AMPICILLIN SUS
250/5ML On formulary, tier change tier 1 to tier 4 Antibacterials Beta-lactam, Penicillins
AMP-SULBACTA INJ 10-
5GM Not on 2017 formulary
ampicillin/sulbactam inj 2-
1 gm Antibacterials Beta-lactam, Penicillins
AMP-SULBACTA INJ
15GM Not on 2017 formulary
ampicillin/sulbactam inj 2-
1 gm Antibacterials Beta-lactam, Penicillins
AMPYRA TAB 10MG
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
ANDRODERM DIS
2MG/24HR
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
ANDRODERM DIS
2MG/24HR
On formulary, quantity
limit may apply 30 patches per 30 days
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
ANDRODERM DIS
4MG/24HR
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
Pg. 26 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ANDRODERM DIS
4MG/24HR
On formulary, quantity
limit may apply 30 patches per 30 days
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
ANDROID CAP 10MG Not on 2017 formulary
methyltestosterone 10 mg
capsules* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
APAP/CODEINE SOL
120-12/5
On formulary, quantity
limit may apply 2700 mls per 30 days Analgesics
Opioid Analgesics, Short-
acting
APAP/CODEINE TAB 300-
15MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
APAP/CODEINE TAB 300-
30MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
APAP/CODEINE TAB 300-
60MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
APIDRA INJ
SOLOSTAR Not on 2017 formulary
Humalog (vials or
Kwikpen) Blood Glucose Regulators Insulins
APIDRA INJ U-100 Not on 2017 formulary
Humalog (vials or
Kwikpen) Blood Glucose Regulators Insulins
APLENZIN TAB
174MG Not on 2017 formulary
bupropion tablets (IR, SR,
XL) Antidepressants Antidepressants, Other
APLENZIN TAB
348MG Not on 2017 formulary
bupropion tablets (IR, SR,
XL) Antidepressants Antidepressants, Other
Pg. 27 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
APLENZIN TAB
522MG Not on 2017 formulary
bupropion tablets (IR, SR,
XL) Antidepressants Antidepressants, Other
APRACLONIDIN SOL
0.5% OP Not on 2017 formulary
Alphagan P 0.1%,
brimonidine (0.15%,
0.2%) Ophthalmic Agents
Ophthalmic Antiglaucoma
Agents
APRISO CAP
0.375GM On formulary, tier change tier 3 to tier 4
Inflammatory Bowel
Disease Agents Aminosalicylates
APTIOM TAB 200MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents
APTIVUS CAP 250MG
On formulary, quantity
limit may apply 120 capsules per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
APTIVUS SOL
On formulary, quantity
limit may apply 380 mls per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
ARCALYST INJ
220MG
On formulary, requires
prior authorization check with your doctor Immunological Agents Immunomodulators
ARIPIPRAZOLE SOL
1MG/ML
On formulary, quantity
limit may apply 750 mls per 30 days Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE SOL
1MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
10MG ODT On formulary, tier change tier 2 to tier 5 Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
10MG ODT
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 28 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ARIPIPRAZOLE TAB
10MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
15MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
15MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
15MG ODT
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
15MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
2MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
30MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 29 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ARIPIPRAZOLE TAB
30MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB
5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ARRANON INJ
5MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
ASCOMP/COD CAP
30MG Not on 2017 formulary
diclofenac, etodolac,
ketoprofen IR, ibuprofen,
naproxen Analgesics
Opioid Analgesics, Short-
acting
ASTAGRAF XL CAP
0.5MG Not on 2017 formulary
tacrolimus capsule* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Immunological Agents Immune Suppressants
Pg. 30 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ASTAGRAF XL CAP
1MG Not on 2017 formulary
tacrolimus capsule* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Immunological Agents Immune Suppressants
ASTAGRAF XL CAP
5MG Not on 2017 formulary
tacrolimus capsule* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Immunological Agents Immune Suppressants
ATENOL/CHLOR TAB
100-25MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Cardiovascular Agents,
Other
ATENOL/CHLOR TAB 50-
25MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Cardiovascular Agents,
Other
ATORVASTATIN TAB
10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ATORVASTATIN TAB
10MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ATORVASTATIN TAB
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
Pg. 31 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ATORVASTATIN TAB
20MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ATORVASTATIN TAB
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ATORVASTATIN TAB
40MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ATORVASTATIN TAB
80MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ATORVASTATIN TAB
80MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ATRIPLA TAB
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
ATROPINE SUL INJ
0.05MG/1 Not on 2017 formulary check with your doctor Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
ATROPINE SUL INJ
0.05MG/1
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
ATROPINE SUL INJ
0.1MG/ML Not on 2017 formulary check with your doctor Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
ATROPINE SUL INJ
0.1MG/ML
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
ATROPINE SUL INJ
0.4/0.5
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
ATROPINE SUL INJ
0.4MG/ML
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
ATROPINE SUL INJ
1MG/ML
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
ATROVENT HFA AER
17MCG On formulary, tier change tier 3 to tier 4 Respiratory Tract Agents
Bronchodilators,
Anticholinergic
ATROVENT HFA AER
17MCG
On formulary, quantity
limit may apply 2 canisters per 30 days Respiratory Tract Agents
Bronchodilators,
Anticholinergic
Pg. 32 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AUTOSHIELD MIS
29X3/16" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
AUTOSHIELD MIS
29X5/16" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
AUTOSHIELD MIS
30GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
AVANDAMET TAB 2-
1000MG Not on 2017 formulary pioglitazone/metformin Blood Glucose Regulators Antidiabetic Agents
AVANDIA TAB 2MG Not on 2017 formulary pioglitazone Blood Glucose Regulators Antidiabetic Agents
AVANDIA TAB 4MG Not on 2017 formulary pioglitazone Blood Glucose Regulators Antidiabetic Agents
AVANDIA TAB 8MG Not on 2017 formulary pioglitazone Blood Glucose Regulators Antidiabetic Agents
AVODART CAP
0.5MG Not on 2017 formulary dutasteride 0.5 capsules Genitourinary Agents
Benign Prostatic
Hypertrophy Agents
AVONEX KIT 30MCG
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
AVONEX KIT 30MCG
On formulary, quantity
limit may apply 1 kit per 28 days
Central Nervous System
Agents Multiple Sclerosis Agents
AVONEX PREFL KIT
30MCG
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
AVONEX PREFL KIT
30MCG
On formulary, quantity
limit may apply 1 kit per 28 days
Central Nervous System
Agents Multiple Sclerosis Agents
AZACTAM/DEX INJ 1GM On formulary, tier change tier 3 to tier 4 Antibacterials Beta-lactam, Other
AZELASTINE SPR 0.1%
On formulary, quantity
limit may apply 2 bottles per 30 days Respiratory Tract Agents Nasal Agents
AZELASTINE SPR
0.15%
On formulary, quantity
limit may apply 2 bottles per 30 days Respiratory Tract Agents Nasal Agents
Pg. 33 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AZITHROMYCIN POW
1GM PAK On formulary, tier change tier 2 to tier 4 Antibacterials Macrolides
AZITHROMYCIN SUS
100/5ML On formulary, tier change tier 1 to tier 2 Antibacterials Macrolides
AZOPT SUS 1% OP On formulary, tier change tier 3 to tier 4 Ophthalmic Agents
Ophthalmic Antiglaucoma
Agents
AZOR TAB 10-20MG Not on 2017 formulary
amlodipine/valsartan,
amlodipine in combination
with candesartan,
amlodipine in combination
with irbesartan,
amlodipine in combination
with losartan, amlodipine
in combination with
telmisartan Cardiovascular Agents
Antihypertensive
Combinations
AZOR TAB 10-40MG Not on 2017 formulary
amlodipine/valsartan,
amlodipine in combination
with candesartan,
amlodipine in combination
with irbesartan,
amlodipine in combination
with losartan, amlodipine
in combination with
telmisartan Cardiovascular Agents
Antihypertensive
Combinations
Pg. 34 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AZOR TAB 5-20MG Not on 2017 formulary
amlodipine/valsartan,
amlodipine in combination
with candesartan,
amlodipine in combination
with irbesartan,
amlodipine in combination
with losartan, amlodipine
in combination with
telmisartan Cardiovascular Agents
Antihypertensive
Combinations
AZOR TAB 5-40MG Not on 2017 formulary
amlodipine/valsartan,
amlodipine in combination
with candesartan,
amlodipine in combination
with irbesartan,
amlodipine in combination
with losartan, amlodipine
in combination with
telmisartan Cardiovascular Agents
Antihypertensive
Combinations
BACIIM INJ
50000UNT Not on 2017 formulary
aztreonam inj,
colistimethate inj,
Dalvance inj,
metronidazole/NaCl inj,
vancomycin inj Antibacterials Antibacterials, Other
BACITRACIN INJ
50000UNT Not on 2017 formulary
aztreonam inj,
colistimethate inj,
Dalvance inj,
metronidazole/NaCl inj,
vancomycin inj Antibacterials Antibacterials, Other
BACITRACIN OIN OP On formulary, tier change tier 2 to tier 4 Ophthalmic Agents Ophthalmic Anti Infectives
BACLOFEN TAB
10MG On formulary, tier change tier 1 to tier 2
Skeletal Muscle
Relaxants
Skeletal Muscle
Relaxants
Pg. 35 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BALZIVA TAB On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Contraceptives
BAND-AID PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
BANZEL SUS
40MG/ML On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents
BANZEL TAB 400MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents
BD PEN NEEDL MIS
29GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
BD PEN NEEDL MIS
31GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
BD PEN NEEDL MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
BD PEN NEEDL MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
BD SWAB BFLY PAD
SNGL USE On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
BD SWAB REG PAD
SNGL USE On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
BENAZEP/HCTZ TAB 10-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
BENAZEP/HCTZ TAB 20-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
BENAZEP/HCTZ TAB 20-
25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
BENAZEP/HCTZ TAB 5-
6.25 On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
BENAZEPRIL TAB
10MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
Pg. 36 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BENAZEPRIL TAB
20MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
BENAZEPRIL TAB
40MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
BENAZEPRIL TAB 5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
BENICAR TAB 20MG Not on 2017 formulary
candesartan (4 mg, 8 mg,
16 mg, 32 mg), irbesartan
(75 mg, 150 mg, 300 mg),
losartan (25 mg, 50 mg,
100 mg) , telmisartan (20
mg, 40 mg, 80 mg),
valsartan (40 mg, 80 mg,
160 mg, 320 mg) Cardiovascular Agents
Angiotensin II Receptor
Antagonists
BENICAR TAB 40MG Not on 2017 formulary
candesartan (4 mg, 8 mg,
16 mg, 32 mg), irbesartan
(75 mg, 150 mg, 300 mg),
losartan (25 mg, 50 mg,
100 mg) , telmisartan (20
mg, 40 mg, 80 mg),
valsartan (40 mg, 80 mg,
160 mg, 320 mg) Cardiovascular Agents
Angiotensin II Receptor
Antagonists
BENICAR TAB 5MG Not on 2017 formulary
candesartan (4 mg, 8 mg,
16 mg, 32 mg), irbesartan
(75 mg, 150 mg, 300 mg),
losartan (25 mg, 50 mg,
100 mg) , telmisartan (20
mg, 40 mg, 80 mg),
valsartan (40 mg, 80 mg,
160 mg, 320 mg) Cardiovascular Agents
Angiotensin II Receptor
Antagonists
Pg. 37 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BENICAR HCT TAB 20-
12.5 Not on 2017 formulary
candesartan/hydrochlorot
hiazide,
irbesartan/hydrochlorothia
zide,
losartan/hydrochlorothiazi
de,
telmisartan/hydrochlorothi
azide,
valsartan/hydrochlorothiaz
ide Cardiovascular Agents
Antihypertensive
Combinations
BENICAR HCT TAB 40-
12.5 Not on 2017 formulary
candesartan/hydrochlorot
hiazide,
irbesartan/hydrochlorothia
zide,
losartan/hydrochlorothiazi
de,
telmisartan/hydrochlorothi
azide,
valsartan/hydrochlorothiaz
ide Cardiovascular Agents
Antihypertensive
Combinations
BENICAR HCT TAB 40-
25MG Not on 2017 formulary
candesartan/hydrochlorot
hiazide,
irbesartan/hydrochlorothia
zide,
losartan/hydrochlorothiazi
de,
telmisartan/hydrochlorothi
azide,
valsartan/hydrochlorothiaz
ide Cardiovascular Agents
Antihypertensive
Combinations
Pg. 38 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BENLYSTA INJ 120MG
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
BENLYSTA INJ 400MG
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
BENZTROPINE INJ
1MG/ML Not on 2017 formulary check with your doctor Antiparkinson Agents Anticholinergics
BENZTROPINE TAB
0.5MG On formulary, tier change tier 2 to tier 3 Antiparkinson Agents Anticholinergics
BENZTROPINE TAB
1MG On formulary, tier change tier 2 to tier 3 Antiparkinson Agents Anticholinergics
BENZTROPINE TAB
2MG On formulary, tier change tier 1 to tier 3 Antiparkinson Agents Anticholinergics
BETAMETH DIP CRE
0.05% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
BETAMETH VAL CRE
0.1% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
BETAMETH VAL OIN
0.1% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
BETASERON INJ
0.3MG
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
BETASERON INJ
0.3MG
On formulary, quantity
limit may apply
15 vials/syringes per 30
days
Central Nervous System
Agents Multiple Sclerosis Agents
BETAXOLOL SOL 0.5%
OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents
Ophthalmic Antiglaucoma
Agents
BETAXOLOL TAB
10MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
BETAXOLOL TAB
20MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
Pg. 39 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BEXAROTENE CAP
75MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
BIMATOPROST SOL
0.03% Not on 2017 formulary
latanoprost, Lumigan,
Travatan Z Ophthalmic Agents
Ophthalmic
Prostaglandin and
Prostamide Analogs
BIVIGAM INJ 10% Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
BLEO 15K INJ
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
BLEOMYCIN INJ
15UNIT
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
BLEOMYCIN INJ
30UNIT
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
Pg. 40 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BLEPHAMIDE OIN
S.O.P. Not on 2017 formulary
sulfacetamide/prednisolon
e solution,
tobramycin/dexamethaso
ne suspension, Tobradex
ointment,
neomycin/polymyxin/dexa
methasone suspension
and ointment, Poly-dex
ointment, Neo-polycin–HC
ointment,
neomycin/polymyxin/bacitr
acin-HC ointment Ophthalmic Agents
Ophthalmic Anti-
inflammatories
BLEPHAMIDE SUS OP Not on 2017 formulary
sulfacetamide/prednisolon
e solution,
tobramycin/dexamethaso
ne suspension, Tobradex
ointment,
neomycin/polymyxin/dexa
methasone suspension
and ointment, Poly-dex
ointment, Neo-polycin–HC
ointment,
neomycin/polymyxin/bacitr
acin-HC ointment Ophthalmic Agents
Ophthalmic Anti-
inflammatories
BLINCYTO INJ 35MCG
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
BOOSTRIX INJ On formulary, tier change tier 3 to tier 4 Immunological Agents Vaccines
BORDER GAUZE PAD
2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
BOSULIF TAB 100MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antineoplastics Antineoplastics
Pg. 41 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BOSULIF TAB 500MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
BREO ELLIPTA INH 100-
25
On formulary, quantity
limit may apply 1 package per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
BRIELLYN TAB On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Contraceptives
BRISDELLE CAP
7.5MG Not on 2017 formulary venlafaxine, citalopram Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
BUDESONIDE CAP
3MG DR On formulary, tier change tier 2 to tier 5
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
BUDESONIDE CAP
3MG/24HR On formulary, tier change tier 2 to tier 5
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
BUDESONIDE SUS
0.25MG/2
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
BUDESONIDE SUS
0.5MG/2
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
BUDESONIDE SUS
1MG/2ML
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
BUDESONIDE SUS
32MCG Not on 2017 formulary
fluticasone nasal spray,
mometasone nasal spray
(generic Nasonex),
triamcinolone nasal spray Respiratory Tract Agents Nasal Agents
BUMETANIDE INJ
0.25/ML On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Loop
BUMETANIDE TAB
0.5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Loop
Pg. 42 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BUMETANIDE TAB
1MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Loop
BUPREN/NALOX SUB 2-
0.5MG
On formulary, requires
prior authorization check with your doctor
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
BUPREN/NALOX SUB 8-
2MG
On formulary, requires
prior authorization check with your doctor
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
BUPRENORPHIN INJ
0.3MG/ML Not on 2017 formulary
buprenorphine SL tablets*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
BUPRENORPHIN SUB
2MG
On formulary, requires
prior authorization check with your doctor
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
BUPRENORPHIN SUB
8MG
On formulary, requires
prior authorization check with your doctor
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
BUPROPION TAB
100MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antidepressants Antidepressants, Other
BUPROPION TAB
100MG ER
On formulary, quantity
limit may apply 60 tablets per 30 days Antidepressants Antidepressants, Other
BUPROPION TAB
100MG SR
On formulary, quantity
limit may apply 60 tablets per 30 days Antidepressants Antidepressants, Other
BUPROPION TAB
150MG ER
On formulary, quantity
limit may apply 60 tablets per 30 days
Anti-Addiction/Substance
Abuse Treatment Agents
Smoking Cessation
Agents
BUPROPION TAB
150MG SR
On formulary, quantity
limit may apply 60 tablets per 30 days
Anti-Addiction/Substance
Abuse Treatment Agents
Smoking Cessation
Agents
Pg. 43 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BUPROPION TAB
200MG ER
On formulary, quantity
limit may apply 60 tablets per 30 days Antidepressants Antidepressants, Other
BUPROPION TAB
200MG SR
On formulary, quantity
limit may apply 60 tablets per 30 days Antidepressants Antidepressants, Other
BUPROPION TAB
75MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antidepressants Antidepressants, Other
BUPROPN HCL TAB
150MG XL
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
BUPROPN HCL TAB
300MG XL
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
BUSPIRONE TAB
10MG On formulary, tier change tier 1 to tier 2 Anxiolytics Anxiolytics
BUSPIRONE TAB 5MG On formulary, tier change tier 1 to tier 2 Anxiolytics Anxiolytics
BUSULFEX INJ
6MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
BUT/APAP/CAF CAP
CODEINE Not on 2017 formulary
diclofenac, etodolac,
ketoprofen IR, ibuprofen,
naproxen Analgesics
Opioid Analgesics, Short-
acting
BUT/ASA/CAF/ CAP COD
30MG Not on 2017 formulary
diclofenac, etodolac,
ketoprofen IR, ibuprofen,
naproxen Analgesics
Opioid Analgesics, Short-
acting
BUTISOL SOD TAB
30MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Barbiturates
CALCIPOTRIEN OIN
BETAMETH Not on 2017 formulary
betamethasone
dipropionate (cream,
lotion, ointment) and
calcipotriene (cream,
ointment, solution) used
together Dermatological Agents Dermatological Agents
CANCIDAS INJ 50MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals
Pg. 44 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CANCIDAS INJ 70MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals
CANDESA/HCTZ TAB 16-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
CANDESA/HCTZ TAB 16-
12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
CANDESA/HCTZ TAB 32-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
CANDESA/HCTZ TAB 32-
12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
CANDESA/HCTZ TAB 32-
25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
CANDESA/HCTZ TAB 32-
25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
CANDESARTAN TAB
16MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
CANDESARTAN TAB
16MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
CANDESARTAN TAB
32MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
CANDESARTAN TAB
32MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
CANDESARTAN TAB
4MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
CANDESARTAN TAB
4MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
CANDESARTAN TAB
8MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
CANDESARTAN TAB
8MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
CAPRELSA TAB
100MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
Pg. 45 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CAPRELSA TAB
100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
CAPRELSA TAB
300MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
CAPRELSA TAB
300MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
CAPTOPR/HCTZ TAB 25-
15MG Not on 2017 formulary
captopril used in
combination with
hydrochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
CAPTOPR/HCTZ TAB 25-
25MG Not on 2017 formulary
captopril used in
combination with
hydrochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
CAPTOPR/HCTZ TAB 50-
15MG Not on 2017 formulary
captopril used in
combination with
hydrochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
CAPTOPR/HCTZ TAB 50-
25MG Not on 2017 formulary
captopril used in
combination with
hydrochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
CAPTOPRIL TAB
100MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
CAPTOPRIL TAB
12.5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
CAPTOPRIL TAB
25MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
CAPTOPRIL TAB
50MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
Pg. 46 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CARAFATE SUS
1GM/10ML Not on 2017 formulary sucralfate tablets Gastrointestinal Agents Protectants
CARBIDOPA TAB
25MG On formulary, tier change tier 2 to tier 5 Antiparkinson Agents
Dopamine Precursors/ L-
Amino Acid
Decarboxylase Inhibitors
CAREFINE MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CAREFINE MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CAREFINE MIS
32GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CAREFINE MIS
32GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CARIMUNE NF INJ 6GM Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
CAYSTON INH 75MG Not on 2017 formulary check with your doctor Antibacterials Beta-lactam, Other
Pg. 47 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CDP/AMITRIP TAB 10-
25MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule,
mirtazapine, bupropion Antidepressants Tricyclics
CDP/AMITRIP TAB 5-
12.5MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule,
mirtazapine, bupropion Antidepressants Tricyclics
CEFACLOR ER TAB
500MG Not on 2017 formulary
cefaclor capsule (250mg,
500mg) Antibacterials
Beta-lactam,
Cephalosporins
CEFAZOLIN INJ 10GM On formulary, tier change tier 1 to tier 2 Antibacterials
Beta-lactam,
Cephalosporins
CEFAZOLIN INJ
1GM/50ML Not on 2017 formulary
cefazolin inj (500 mg, 1
gm, 10 gm, 20 gm) Antibacterials
Beta-lactam,
Cephalosporins
CEFAZOLIN INJ
500MG On formulary, tier change tier 1 to tier 2 Antibacterials
Beta-lactam,
Cephalosporins
CEFDINIR SUS
125/5ML On formulary, tier change tier 1 to tier 2 Antibacterials
Beta-lactam,
Cephalosporins
CEFDINIR SUS
250/5ML On formulary, tier change tier 1 to tier 2 Antibacterials
Beta-lactam,
Cephalosporins
Pg. 48 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CEFUROXIME INJ
1.5GM On formulary, tier change tier 1 to tier 2 Antibacterials
Beta-lactam,
Cephalosporins
CEFUROXIME INJ
7.5GM On formulary, tier change tier 1 to tier 2 Antibacterials
Beta-lactam,
Cephalosporins
CEFUROXIME INJ
750MG On formulary, tier change tier 1 to tier 2 Antibacterials
Beta-lactam,
Cephalosporins
CELECOXIB CAP
100MG
On formulary, quantity
limit may apply 60 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
CELECOXIB CAP
200MG
On formulary, quantity
limit may apply 60 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
CELECOXIB CAP
400MG
On formulary, quantity
limit may apply 30 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
CELECOXIB CAP
50MG
On formulary, quantity
limit may apply 60 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
CELLCEPT IV INJ
500MG On formulary, tier change tier 3 to tier 4 Immunological Agents Immune Suppressants
CEPHALEXIN SUS
250/5ML On formulary, tier change tier 1 to tier 2 Antibacterials
Beta-lactam,
Cephalosporins
CEPHALEXIN TAB
250MG Not on 2017 formulary
cephalexin capsule
(250mg, 500mg) Antibacterials
Beta-lactam,
Cephalosporins
CEPHALEXIN TAB
500MG Not on 2017 formulary
cephalexin capsule
(250mg, 500mg) Antibacterials
Beta-lactam,
Cephalosporins
CEREBYX INJ
100/2ML Not on 2017 formulary
fosphenytoin inj 100 mg/2
mL Anticonvulsants Sodium Channel Agents
CEREBYX INJ
500/10ML Not on 2017 formulary
fosphenytoin inj 500
mg/10 mL Anticonvulsants Sodium Channel Agents
CESAMET CAP 1MG
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Gastrointestinal Agents,
Other
CETIRIZINE SYP
1MG/ML Not on 2017 formulary levocetirizine tablets Respiratory Tract Agents Antihistamines
Pg. 49 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CHLORAMPHEN INJ
1GM On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
CHLORDIAZEP CAP
10MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
CHLORDIAZEP CAP
25MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 50 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CHLORDIAZEP CAP
5MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
CHLOROQUINE TAB
250MG On formulary, tier change tier 1 to tier 2 Antiparasitics Antiprotozoals
CHLOROQUINE TAB
500MG On formulary, tier change tier 1 to tier 2 Antiparasitics Antiprotozoals
CHLOROTHIAZ TAB
250MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Thiazide
CHLORPROMAZ INJ
25MG/ML On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical
CHLORPROMAZ INJ
25MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
CHLORPROMAZ INJ
50MG/2ML On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical
Pg. 51 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CHLORPROMAZ INJ
50MG/2ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
CHLORPROMAZ TAB
100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
CHLORPROMAZ TAB
10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
CHLORPROMAZ TAB
200MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
CHLORPROMAZ TAB
25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
CHLORPROMAZ TAB
50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
CHLORPROPAM TAB
100MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
CHLORPROPAM TAB
250MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
CHLORTHALID TAB
25MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Thiazide
Pg. 52 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CHLORTHALID TAB
50MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents Diuretics, Thiazide
CHOR GONADOT INJ
10000UNT
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
CIMZIA KIT Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These alternatives
require a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Immunological Agents Immune Suppressants
CIMZIA KIT
STARTER Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These alternatives
require a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Immunological Agents Immune Suppressants
Pg. 53 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CIMZIA PREFL KIT
200MG/ML Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These alternatives
require a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Immunological Agents Immune Suppressants
CINRYZE SOL 500
UNIT
On formulary, quantity
limit may apply 20 vials per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
CIPRODEX SUS 0.3-
0.1% On formulary, tier change tier 3 to tier 4 Otic Agents Otic Agents
CIPROFLOXACN INJ
200MG On formulary, tier change tier 1 to tier 2 Antibacterials Quinolones
CIPROFLOXACN INJ
400MG On formulary, tier change tier 1 to tier 2 Antibacterials Quinolones
CIPROFLOXACN SUS
250MG/5 On formulary, tier change tier 1 to tier 2 Antibacterials Quinolones
CIPROFLOXACN SUS
500MG/5 On formulary, tier change tier 1 to tier 2 Antibacterials Quinolones
CIPROFLOXACN TAB
100MG On formulary, tier change tier 1 to tier 4 Antibacterials Quinolones
CITALOPRAM SOL
10MG/5ML
On formulary, quantity
limit may apply 600 mls per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
CITALOPRAM TAB
10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
CITALOPRAM TAB
20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 54 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CITALOPRAM TAB
40MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
CLADRIBINE INJ
1MG/ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
CLICKFINE MIS
31GX1/4" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CLICKFINE MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CLICKFINE MIS
32GX5/32 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CLINDACIN KIT ETZ
1% Not on 2017 formulary
erythromycin-benzoyl
peroxide gel 5-3%,
clindamycin-benzoyl
peroxide gel 1-5% Dermatological Agents Dermatological Agents
CLINDACIN KIT PAC
1% Not on 2017 formulary
erythromycin-benzoyl
peroxide gel 5-3%,
clindamycin-benzoyl
peroxide gel 1-5% Dermatological Agents Dermatological Agents
CLINDAMYCIN INJ
150MG/ML On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
300/2ML On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
300MG On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
600/4ML On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
600MG On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
900MG On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other
Pg. 55 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLINDAMYCIN SOL
75MG/5ML Not on 2017 formulary clindamycin capsules Antibacterials Antibacterials, Other
CLINIMIX INJ
2.75/D5W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX INJ 4.25/D10 Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX INJ 4.25/D20 Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX INJ 4.25/D25 Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX INJ
4.25/D5W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
Pg. 56 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLINIMIX INJ
5%/D15W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX INJ
5%/D20W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX INJ
5%/D25W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX E INJ
2.75/D10 Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX E INJ
2.75/D5W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX E INJ
4.25/D10 Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
Pg. 57 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLINIMIX E INJ
4.25/D25 Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX E INJ
4.25/D5W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX E INJ
5%/D15W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX E INJ
5%/D20W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLINIMIX E INJ
5%/D25W Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
CLOLAR INJ 1MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
CLOMIPRAMINE CAP
25MG On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
CLOMIPRAMINE CAP
50MG On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
Pg. 58 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLOMIPRAMINE CAP
75MG On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
CLONAZEP ODT TAB
0.125MG On formulary, tier change tier 1 to tier 2 Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
0.125MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
0.125MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
0.25MG On formulary, tier change tier 1 to tier 2 Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
0.25MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
0.25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
0.5MG On formulary, tier change tier 1 to tier 2 Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
0.5MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
0.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
1MG On formulary, tier change tier 1 to tier 2 Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
1MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anticonvulsants Benzodiazepines
Pg. 59 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLONAZEP ODT TAB
1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
2MG On formulary, tier change tier 1 to tier 2 Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
2MG
On formulary, quantity
limit may apply 300 tablets per 30 days Anticonvulsants Benzodiazepines
CLONAZEP ODT TAB
2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
CLONAZEPAM TAB
0.5MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anticonvulsants Benzodiazepines
CLONAZEPAM TAB
0.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
CLONAZEPAM TAB
1MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anticonvulsants Benzodiazepines
CLONAZEPAM TAB
1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
CLONAZEPAM TAB
2MG
On formulary, quantity
limit may apply 300 tablets per 30 days Anticonvulsants Benzodiazepines
CLONAZEPAM TAB
2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
Pg. 60 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLOPIDOGREL TAB
300MG Not on 2017 formulary clopidogrel 75 mg
Blood Products/Modifiers/
Volume Expanders Platelet Modifying Agents
CLORAZ DIPOT TAB
15MG On formulary, tier change tier 1 to tier 2 Anxiolytics Benzodiazepines
CLORAZ DIPOT TAB
15MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
CLORAZ DIPOT TAB
3.75MG On formulary, tier change tier 1 to tier 2 Anxiolytics Benzodiazepines
CLORAZ DIPOT TAB
3.75MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
CLORAZ DIPOT TAB
7.5MG On formulary, tier change tier 1 to tier 2 Anxiolytics Benzodiazepines
CLORAZ DIPOT TAB
7.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
CLOTRIMAZOLE CRE
1% On formulary, tier change tier 1 to tier 2 Antifungals Antifungals
CLOTRIMAZOLE SOL
1% Not on 2017 formulary
clotrimazole 1% cream,
ciclopirox 0.77% (cream,
suspension, gel),
ciclopirox solution (or
Ciclodan solution),
econazole 1% cream, 2%
(cream, shampoo) Dermatological Agents Dermatological Agents
CLOZAPINE TAB
100/ODT
On formulary, quantity
limit may apply 270 tablets per 30 days Antipsychotics Treatment-Resistant
Pg. 61 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLOZAPINE TAB
100/ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics Treatment-Resistant
CLOZAPINE TAB
100MG
On formulary, quantity
limit may apply 270 tablets per 30 days Antipsychotics Treatment-Resistant
CLOZAPINE TAB
100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics Treatment-Resistant
CLOZAPINE TAB
12.5/ODT Not on 2017 formulary
clozapine tablets (25 mg,
50 mg, 100 mg, 200 mg)*,
clozapine ODT tablets (25
mg, 100 mg)* *These
drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antipsychotics Treatment-Resistant
Pg. 62 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLOZAPINE TAB
150/ODT Not on 2017 formulary
clozapine tablets (25 mg,
50 mg, 100 mg, 200 mg)*,
clozapine ODT tablets (25
mg, 100 mg)* *These
drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antipsychotics Treatment-Resistant
CLOZAPINE TAB
200/ODT Not on 2017 formulary
clozapine tablets (25 mg,
50 mg, 100 mg, 200 mg)*,
clozapine ODT tablets (25
mg, 100 mg)* *These
drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antipsychotics Treatment-Resistant
CLOZAPINE TAB
200MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antipsychotics Treatment-Resistant
Pg. 63 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLOZAPINE TAB
200MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics Treatment-Resistant
CLOZAPINE TAB
25MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antipsychotics Treatment-Resistant
CLOZAPINE TAB
25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics Treatment-Resistant
CLOZAPINE TAB
25MG ODT
On formulary, quantity
limit may apply 270 tablets per 30 days Antipsychotics Treatment-Resistant
CLOZAPINE TAB
25MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics Treatment-Resistant
CLOZAPINE TAB
50MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antipsychotics Treatment-Resistant
CLOZAPINE TAB
50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics Treatment-Resistant
COLESTIPOL GRA
5GM On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Dyslipidemics, Other
COMETRIQ KIT
100MG
On formulary, quantity
limit may apply 56 capsules per 28 days Antineoplastics Antineoplastics
COMETRIQ KIT
100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
Pg. 64 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
COMETRIQ KIT
140MG
On formulary, quantity
limit may apply 112 capsules per 28 days Antineoplastics Antineoplastics
COMETRIQ KIT
140MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
COMETRIQ KIT 60MG
On formulary, quantity
limit may apply 84 capsules per 28 days Antineoplastics Antineoplastics
COMETRIQ KIT 60MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
COMFORT EZ MIS
29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
31GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
31GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
32GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
32GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
32GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
33GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 65 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
COMFORT EZ MIS
33GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
33GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMFORT EZ MIS
33GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
COMPLERA TAB
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
COMVAX INJ Not on 2017 formulary check with your doctor Immunological Agents Vaccines
CONDYLOX GEL 0.5% Not on 2017 formulary podofilox 0.5% solution Dermatological Agents Dermatological Agents
CONSTULOSE SOL
10GM/15 On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents Laxatives
COPAXONE INJ
20MG/ML
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
COPAXONE INJ
20MG/ML
On formulary, quantity
limit may apply 30 syringes per 30 days
Central Nervous System
Agents Multiple Sclerosis Agents
COPAXONE INJ
40MG/ML
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
COPAXONE INJ
40MG/ML
On formulary, quantity
limit may apply 12 syringes per 28 days
Central Nervous System
Agents Multiple Sclerosis Agents
COSMEGEN INJ
0.5MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
CRESTOR TAB 10MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
CRESTOR TAB 20MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
CRESTOR TAB 40MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
Pg. 66 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CRESTOR TAB 5MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
CRIXIVAN CAP
200MG
On formulary, quantity
limit may apply 270 capsules per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
CRIXIVAN CAP
400MG
On formulary, quantity
limit may apply 180 capsules per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
CROMOLYN SOD NEB
20MG/2ML On formulary, tier change tier 1 to tier 3 Respiratory Tract Agents Mast Cell Stabilizers
CUBICIN SOL 500MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other
CUBICIN RF SOL
500MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other
CURITY GAUZE PAD
2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CURITY PREP PAD
ALCOHOL On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CURITY SPONG PAD
2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CURITY SWABS PAD
ALCOHOL On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
CYCLOBENZAPR TAB
10MG On formulary, tier change tier 1 to tier 4
Skeletal Muscle
Relaxants
Skeletal Muscle
Relaxants
CYCLOBENZAPR TAB
5MG On formulary, tier change tier 1 to tier 4
Skeletal Muscle
Relaxants
Skeletal Muscle
Relaxants
CYCLOPHOSPH CAP
25MG On formulary, tier change tier 2 to tier 4 Antineoplastics Alkylating Agents
CYCLOPHOSPH CAP
50MG On formulary, tier change tier 2 to tier 4 Antineoplastics Alkylating Agents
CYCLOSET TAB
0.8MG
On formulary, quantity
limit may apply 180 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
CYPROHEPTAD TAB
4MG Not on 2017 formulary check with your doctor Respiratory Tract Agents Antihistamines
Pg. 67 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CYTARABINE INJ
100MG
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
CYTARABINE INJ
100MG/ML
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
CYTARABINE INJ 1GM
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
CYTARABINE INJ
20MG/ML
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
CYTARABINE INJ
500MG
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
D10W/NACL INJ 0.2% Not on 2017 formulary D5W/NACL inj 0.2%
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
D2.5W/NACL INJ 0.45% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
D5W/NACL INJ 0.2% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
D5W/NACL INJ 0.33% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
D5W/NACL INJ 0.9% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
DACARBAZINE INJ
100MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
DALIRESP TAB
500MCG On formulary, tier change tier 3 to tier 4 Respiratory Tract Agents
Respiratory Tract Agents,
Other
DANAZOL CAP
100MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
Pg. 68 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DANAZOL CAP
200MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
DANAZOL CAP 50MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
DARAPRIM TAB 25MG On formulary, tier change tier 4 to tier 5 Antiparasitics Antiprotozoals
DAUNOXOME INJ
2MG/ML Not on 2017 formulary
daunorubicin injection 5
mg/ml Antineoplastics Antineoplastics
DECITABINE INJ 50MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antimetabolites
DELTASONE TAB
20MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
DEMSER CAP
250MG On formulary, tier change tier 4 to tier 5 Cardiovascular Agents
Diuretics, Potassium-
sparing
DEPEN TITRA TAB
250MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antiangiogenic Agents
DEPOCYT INJ
50MG/5ML
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
DESIPRAMINE TAB
75MG On formulary, tier change tier 1 to tier 2 Antidepressants Tricyclics
DESLORATADIN TAB 2.5
ODT Not on 2017 formulary levocetirizine tablets Respiratory Tract Agents Antihistamines
DESLORATADIN TAB
5MG Not on 2017 formulary levocetirizine tablets Respiratory Tract Agents Antihistamines
Pg. 69 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DESLORATADIN TAB
5MG ODT Not on 2017 formulary levocetirizine tablets Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
DESOXIMETAS CRE
0.05% On formulary, tier change tier 2 to tier 4 Dermatological Agents Dermatological Agents
DESVENLAFAX TAB
100MG ER Not on 2017 formulary Pristiq (brand name) Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
DESVENLAFAX TAB
50MG ER Not on 2017 formulary Pristiq (brand name) Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
DEXAMETH PHO INJ
10MG/ML Not on 2017 formulary
dexamethasone sodium
phosphate 4 mg/mL inj
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
DEXAMETH PHO SOL
0.1% OP On formulary, tier change tier 2 to tier 4 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
DEXAMETHASON TAB
1MG On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
DEXAMETHASON TAB
2MG On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
DEXEDRINE TAB
10MG
On formulary, quantity
limit may apply 180 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXEDRINE TAB 5MG
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
Pg. 70 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DEXILANT CAP 30MG
DR Not on 2017 formulary
esomeprazole (20 mg, 40
mg), lansoprazole (15 mg,
30 mg), Nexium granules
(2.5mg, 5 mg, 10 mg, 20
mg, 40 mg), omeprazole
(10mg, 20 mg, 40 mg),
pantoprazole (20 mg, 40
mg), rabeprazole 20mg Gastrointestinal Agents Proton Pump Inhibitors
DEXILANT CAP 60MG
DR Not on 2017 formulary
esomeprazole (20 mg, 40
mg), lansoprazole (15 mg,
30 mg), Nexium granules
(2.5mg, 5 mg, 10 mg, 20
mg, 40 mg), omeprazole
(10mg, 20 mg, 40 mg),
pantoprazole (20 mg, 40
mg), rabeprazole 20mg Gastrointestinal Agents Proton Pump Inhibitors
DEXTROAMPHET CAP
10MG ER
On formulary, quantity
limit may apply 120 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXTROAMPHET CAP
15MG ER
On formulary, quantity
limit may apply 120 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXTROAMPHET CAP
5MG ER
On formulary, quantity
limit may apply 90 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXTROAMPHET TAB
10MG
On formulary, quantity
limit may apply 180 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
Pg. 71 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DEXTROAMPHET TAB
5MG
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXTROSE INJ 10% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Therapeutic Nutrients/
Minerals/ Electrolytes
DIAZEPAM CON
5MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
DIAZEPAM GEL 10MG On formulary, tier change tier 2 to tier 4 Anticonvulsants Benzodiazepines
DIAZEPAM GEL 10MG
On formulary, quantity
limit may apply 5 twin pack(s) per 30 days Anticonvulsants Benzodiazepines
DIAZEPAM GEL
2.5MG On formulary, tier change tier 2 to tier 4 Anticonvulsants Benzodiazepines
DIAZEPAM GEL
2.5MG
On formulary, quantity
limit may apply 5 twin pack(s) per 30 days Anticonvulsants Benzodiazepines
DIAZEPAM GEL 20MG On formulary, tier change tier 2 to tier 4 Anticonvulsants Benzodiazepines
DIAZEPAM GEL 20MG
On formulary, quantity
limit may apply 5 twin pack(s) per 30 days Anticonvulsants Benzodiazepines
DIAZEPAM SOL
1MG/ML On formulary, tier change tier 2 to tier 4 Anxiolytics Benzodiazepines
DIAZEPAM SOL
1MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
DIAZEPAM TAB 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
Pg. 72 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DIAZEPAM TAB 2MG
On formulary, quantity
limit may apply 120 tablets per 30 days Anxiolytics Benzodiazepines
DIAZEPAM TAB 2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
DIAZEPAM TAB 5MG
On formulary, quantity
limit may apply 120 tablets per 30 days Anxiolytics Benzodiazepines
DIAZEPAM TAB 5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
DICLOFEN POT TAB
50MG
On formulary, quantity
limit may apply 120 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
DICLOFENAC GEL 1%
On formulary, requires
step therapy check with your doctor Dermatological Agents Dermatological Agents
DICLOFENAC GEL 3% On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents
DICLOFENAC TAB
100MG ER
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
DICLOFENAC TAB
25MG DR
On formulary, quantity
limit may apply 240 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
DICLOFENAC TAB
50MG DR
On formulary, quantity
limit may apply 120 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
DICLOFENAC TAB
75MG DR On formulary, tier change tier 1 to tier 2 Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
DICLOFENAC TAB
75MG DR
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
DICYCLOMINE CAP
10MG Not on 2017 formulary check with your doctor Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
DICYCLOMINE SOL
10MG/5ML Not on 2017 formulary check with your doctor Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
Pg. 73 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DIDANOSINE CAP
125MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
DIDANOSINE CAP
200MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
DIDANOSINE CAP
250MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
DIDANOSINE CAP
400MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
Pg. 74 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DIFLORASONE CRE
0.05% Not on 2017 formulary
betamethasone
dipropionate 0.05%
(cream), augmented
betamethasone 0.05%
(cream), betamethasone
valerate 0.1% (cream),
clobetasol 0.05%
(solution), clobetasol
emollient 0.05% (cream),
fluocinonide 0.05%
(cream, gel, ointment,
solution), mometasone
0.1% (cream, ointment,
solution), triamcinolone
0.025%/0.1% (cream),
triamcinolone 0.5%
(cream, ointment) Dermatological Agents Dermatological Agents
DIFLORASONE OIN
0.05% On formulary, tier change tier 2 to tier 4 Dermatological Agents Dermatological Agents
Pg. 75 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DIFLUNISAL TAB
500MG Not on 2017 formulary
diclofenac tablets,
etodolac, flurbiprofen,
ibuprofen, ketoprofen IR,
meloxicam, nabumetone,
naproxen, oxaprozin,
piroxicam, sulindac,
tolmetin 400 mg,
celecoxib, diclofenac gel
1% (generic Voltaren)*
*This drug needs a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
DIGITEK TAB
0.125MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Cardiovascular Agents,
Other
DIGITEK TAB
0.125MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
DIGITEK TAB 0.25MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents
Cardiovascular Agents,
Other
DIGITEK TAB 0.25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOX TAB
0.125MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOX TAB
0.125MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
Pg. 76 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DIGOX TAB 0.25MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOX TAB 0.25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOXIN INJ
0.25MG/1 Not on 2017 formulary check with your doctor Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOXIN SOL
50MCG/ML On formulary, tier change tier 1 to tier 4 Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOXIN SOL
50MCG/ML
On formulary, quantity
limit may apply 150 mls per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOXIN TAB
0.125MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOXIN TAB
0.125MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOXIN TAB 0.25MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents
Cardiovascular Agents,
Other
DIGOXIN TAB 0.25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
DIHYDROERGOT INJ
1MG/ML Not on 2017 formulary
naratriptan (1 mg, 2.5
mg), rizatriptan (5 mg, 10
mg, 5 mg ODT, 10 mg
ODT), sumatriptan nasal
spray (5 mg, 20 mg),
sumatriptan inj (4 mg/0.5
mL, 6 mg/0.5 mL),
sumatriptan tablets (25
mg, 50 mg, 100 mg),
Migranal, Migergot Antimigraine Agents Ergot Alkaloids
DILAUDID INJ 1MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
Pg. 77 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DILAUDID INJ 2MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
DILAUDID INJ 4MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
DILAUDID-HP INJ
10MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
DILTIAZEM INJ 100MG Not on 2017 formulary diltiazem IR tablets Cardiovascular Agents
Calcium Channel Blocking
Agents
DILTIAZEM INJ
125/25ML Not on 2017 formulary diltiazem IR tablets Cardiovascular Agents
Calcium Channel Blocking
Agents
DILTIAZEM INJ
25MG/5ML Not on 2017 formulary diltiazem IR tablets Cardiovascular Agents
Calcium Channel Blocking
Agents
DILTIAZEM INJ
50/10ML Not on 2017 formulary diltiazem IR tablets Cardiovascular Agents
Calcium Channel Blocking
Agents
DILTIAZEM TAB
120MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Calcium Channel Blocking
Agents
DILTIAZEM TAB 30MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Calcium Channel Blocking
Agents
DILTIAZEM TAB 60MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Calcium Channel Blocking
Agents
DILTIAZEM TAB 90MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Calcium Channel Blocking
Agents
DIP/TET PED INJ 25-
5LFU On formulary, tier change tier 2 to tier 4 Immunological Agents Vaccines
DIPENTUM CAP
250MG On formulary, tier change tier 4 to tier 5
Inflammatory Bowel
Disease Agents Aminosalicylates
DIPHEN/ATROP LIQ
2.5/5 Not on 2017 formulary loperamide 2mg capsule Gastrointestinal Agents
Gastrointestinal Agents,
Other
DIPHEN/ATROP TAB
2.5MG Not on 2017 formulary loperamide 2mg capsule Gastrointestinal Agents
Gastrointestinal Agents,
Other
Pg. 78 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DIPYRIDAMOLE TAB
25MG On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Platelet Modifying Agents
DIPYRIDAMOLE TAB
50MG On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Platelet Modifying Agents
DIPYRIDAMOLE TAB
75MG On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Platelet Modifying Agents
DISOPYRAMIDE CAP
100MG Not on 2017 formulary
quinidine gluconate CR
tablet 324mg, quinidine
sulfate tablet 200mg Cardiovascular Agents Antiarrhythmics
DISOPYRAMIDE CAP
150MG Not on 2017 formulary
quinidine gluconate CR
tablet 324mg, quinidine
sulfate tablet 200mg Cardiovascular Agents Antiarrhythmics
DOXAZOSIN TAB 1MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
DOXAZOSIN TAB 1MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
DOXAZOSIN TAB 2MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
DOXAZOSIN TAB 2MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
DOXAZOSIN TAB 4MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
DOXAZOSIN TAB 4MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
DOXAZOSIN TAB 8MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
DOXAZOSIN TAB 8MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
DOXEPIN HCL CAP
100MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
Pg. 79 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DOXEPIN HCL CAP
10MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
DOXEPIN HCL CAP
150MG On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
DOXEPIN HCL CAP
25MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
DOXEPIN HCL CAP
50MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
DOXEPIN HCL CAP
75MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
DOXEPIN HCL CON
10MG/ML On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics
DOXIL INJ 2MG/ML Not on 2017 formulary
doxorubicin inj 2 mg/mL*,
Lipodox inj 2 mg/mL*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antineoplastics Antineoplastics
DOXORUBICIN INJ
10MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
2MG/ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
50MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
DOXY 100 INJ 100MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines
Pg. 80 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DOXYCYC MONO TAB
50MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines
DOXYCYCL HYC CAP
100MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines
DOXYCYCL HYC CAP
50MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines
DOXYCYCL HYC INJ
100MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines
DOXYCYCL HYC TAB
100MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines
DOXYCYCLINE SUS
25MG/5ML Not on 2017 formulary
doxycycline tablets,
doxycycline capsules Antibacterials Tetracyclines
DRONABINOL CAP
10MG
On formulary, requires
prior authorization check with your doctor Antiemetics
Emetogenic Therapy
Adjuncts
DRONABINOL CAP
2.5MG
On formulary, requires
prior authorization check with your doctor Antiemetics
Emetogenic Therapy
Adjuncts
DRONABINOL CAP
5MG
On formulary, requires
prior authorization check with your doctor Antiemetics
Emetogenic Therapy
Adjuncts
DULOXETINE CAP
20MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
DULOXETINE CAP
30MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
DULOXETINE CAP
40MG Not on 2017 formulary
duloxetine capsules
(20mg, 30mg, 60mg) Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
DULOXETINE CAP
60MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
DURAMORPH INJ
0.5MG/ML On formulary, tier change tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-
acting
DURAMORPH INJ
0.5MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
Pg. 81 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DURAMORPH INJ
1MG/ML On formulary, tier change tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-
acting
DURAMORPH INJ
1MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
DUTAST/TAMSU CAP
0.5-0.4
On formulary, quantity
limit may apply 30 capsules per 30 days Genitourinary Agents
Benign Prostatic
Hypertrophy Agents
DUTASTERIDE CAP
0.5MG
On formulary, quantity
limit may apply 30 capsules per 30 days Genitourinary Agents
Benign Prostatic
Hypertrophy Agents
EASY COMFORT MIS
31GX1/4" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY COMFORT MIS
31GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY COMFORT MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY COMFORT MIS
32GX5/32 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY TOUCH MIS
29GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY TOUCH MIS
31GX1/4" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY TOUCH MIS
31GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY TOUCH MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY TOUCH MIS
32GX1/4" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY TOUCH MIS
32GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY TOUCH MIS
32GX5/32 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 82 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
EASY TOUCH MIS
32GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EASY TOUCH MIS
32GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
EDURANT TAB 25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
ELIDEL CRE 1%
On formulary, requires
prior authorization check with your doctor Dermatological Agents Dermatological Agents
ELIQUIS TAB 2.5MG
On formulary, quantity
limit may apply 60 tablets per 30 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ELIQUIS TAB 5MG
On formulary, quantity
limit may apply 120 tablets per 30 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ELLENCE INJ
2MG/ML Not on 2017 formulary epirubicin inj 2 mg/mL Antineoplastics Antineoplastics
ELMIRON CAP
100MG Not on 2017 formulary check with your doctor Genitourinary Agents
Genitourinary Agents,
Other
EMTRIVA CAP
200MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
EMTRIVA SOL
10MG/ML On formulary, tier change tier 3 to tier 4 Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
EMTRIVA SOL
10MG/ML
On formulary, quantity
limit may apply 850 mls per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
ENALAPR/HCTZ TAB 10-
25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Cardiovascular Agents,
Other
Pg. 83 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ENALAPR/HCTZ TAB 5-
12.5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
ENALAPRIL TAB 10MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
ENALAPRIL TAB
2.5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
ENALAPRIL TAB 20MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
ENALAPRIL TAB 5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
ENBREL INJ
25/0.5ML
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
ENBREL INJ 25MG
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
ENBREL INJ
50MG/ML
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
ENDOCET TAB 10-
325MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
ENDOCET TAB 2.5-
325
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
ENDOCET TAB 5-
325MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
ENDOCET TAB 7.5-
325
On formulary, quantity
limit may apply 240 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
ENOXAPARIN INJ
100MG/ML
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
120/0.8
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
150MG/ML
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
Pg. 84 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ENOXAPARIN INJ
30/0.3ML
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
300/3ML
On formulary, quantity
limit may apply 10 vials per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
40/0.4ML
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
60/0.6ML
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
80/0.8ML
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENTECAVIR TAB
0.5MG On formulary, tier change tier 2 to tier 5 Antivirals Antihepatitis Agents
ENTECAVIR TAB 1MG On formulary, tier change tier 2 to tier 5 Antivirals Antihepatitis Agents
ENULOSE SOL
10GM/15 On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents Laxatives
EPROSART MES TAB
600MG Not on 2017 formulary
candesartan (4 mg, 8 mg,
16 mg, 32 mg), irbesartan
(75 mg, 150 mg, 300 mg),
losartan (25 mg, 50 mg,
100 mg) , telmisartan (20
mg, 40 mg, 80 mg),
valsartan (40 mg, 80 mg,
160 mg, 320 mg) Cardiovascular Agents
Angiotensin II Receptor
Antagonists
EPZICOM TAB 600-
300
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
EQL GAUZE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 85 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
EQUETRO CAP
100MG Not on 2017 formulary
carbamazepine ER
capsules (generic
Carbatrol),
carbamazepine ER
tablets (generic Tegretol-
XR) Bipolar Agents Mood Stabilizers
EQUETRO CAP
200MG Not on 2017 formulary
carbamazepine ER
capsules (generic
Carbatrol),
carbamazepine ER
tablets (generic Tegretol-
XR) Bipolar Agents Mood Stabilizers
EQUETRO CAP
300MG Not on 2017 formulary
carbamazepine ER
capsules (generic
Carbatrol),
carbamazepine ER
tablets (generic Tegretol-
XR) Bipolar Agents Mood Stabilizers
ERAXIS INJ 100MG Not on 2017 formulary
Cancidas inj, Mycamine
inj Antifungals Antifungals
ERGOLOID MES TAB
1MG ORAL On formulary, tier change tier 2 to tier 3 Antidementia Agents
Antidementia Agents,
Other
ERGOMAR SUB 2MG Not on 2017 formulary
naratriptan (1 mg, 2.5
mg), rizatriptan (5 mg, 10
mg, 5 mg ODT, 10 mg
ODT), sumatriptan nasal
spray (5 mg, 20 mg),
sumatriptan inj (4 mg/0.5
mL, 6 mg/0.5 mL),
sumatriptan tablets (25
mg, 50 mg, 100 mg) Antimigraine Agents Ergot Alkaloids
Pg. 86 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ERIVEDGE CAP
150MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antineoplastics
ERIVEDGE CAP
150MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
ERWINAZE INJ
10000UNT On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
ERYTHROCIN INJ
500MG On formulary, tier change tier 2 to tier 4 Antibacterials Macrolides
ERYTHROCIN TAB
250MG On formulary, tier change tier 2 to tier 4 Antibacterials Macrolides
ERYTHROM ETH TAB
400MG Not on 2017 formulary
erythromycin base tablet
(250mg, 500mg), Ery-tab
DR (250mg, 333mg,
500mg) Antibacterials Macrolides
ERYTHROMYCIN GEL
2% Not on 2017 formulary
clindamycin 1 % (solution,
gel, lotion, pads) ,
erythromycin 2%
(solution, pad),
sulfacetamide 10% lotion Dermatological Agents Dermatological Agents
ERYTHROMYCIN OIN
5MG/GM On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives
ERYTHROMYCIN OIN
OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives
ESBRIET CAP 267MG
On formulary, quantity
limit may apply 270 capsules per 30 days Respiratory Tract Agents
Respiratory Tract Agents,
Other
ESCITALOPRAM SOL
5MG/5ML
On formulary, quantity
limit may apply 600 mls per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
ESCITALOPRAM TAB
10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 87 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ESCITALOPRAM TAB
20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
ESCITALOPRAM TAB
5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
ESOMEPRAZOLE INJ
20MG On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents Proton Pump Inhibitors
ESTAZOLAM TAB 1MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
ESTAZOLAM TAB 2MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
ESTRAD VAL INJ
200MG/5 Not on 2017 formulary check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
ESTRAD VAL INJ
40MG/ML Not on 2017 formulary check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
ESTRADIOL TAB
0.5MG On formulary, tier change tier 1 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
ESTRADIOL TAB 1MG On formulary, tier change tier 1 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
ESTRADIOL TAB 2MG On formulary, tier change tier 1 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
Pg. 88 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ESZOPICLONE TAB
1MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents
GABA Receptor
Modulators
ESZOPICLONE TAB
3MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents
GABA Receptor
Modulators
ETHOSUXIMIDE SOL
250/5ML On formulary, tier change tier 1 to tier 2 Anticonvulsants
Calcium Channel
Modifying Agents
ETODOLAC CAP
200MG
On formulary, quantity
limit may apply 150 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC CAP
300MG
On formulary, quantity
limit may apply 90 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC TAB
400MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC TAB
500MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC ER TAB
400MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC ER TAB
500MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC ER TAB
600MG
On formulary, quantity
limit may apply 30 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
EURAX CRE 10% Not on 2017 formulary permethrin 5% cream Dermatological Agents Dermatological Agents
EVOTAZ TAB 300-
150
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
EVZIO INJ Not on 2017 formulary check with your doctor
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
EXELON DIS 13.3/24 Not on 2017 formulary
rivastigmine 13.3 mg/24
patches Antidementia Agents Cholinesterase Inhibitors
EXELON DIS
4.6MG/24 Not on 2017 formulary
rivastigmine 4.6 mg/24
patches Antidementia Agents Cholinesterase Inhibitors
Pg. 89 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
EXELON DIS
9.5MG/24 Not on 2017 formulary
rivastigmine 9.5 mg/24
patches Antidementia Agents Cholinesterase Inhibitors
EXJADE TAB 125MG On formulary, tier change tier 4 to tier 5
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Modifiers
FAMOTIDINE INJ
20MG/50M Not on 2017 formulary famotidine inj 10mg/mL Gastrointestinal Agents
Histamine2 (H2) Receptor
Antagonists
FAMOTIDINE TAB
20MG On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents
Histamine2 (H2) Receptor
Antagonists
FANAPT PAK
On formulary, quantity
limit may apply
7 packs (56 tablets) per
28 days Antipsychotics 2nd Generation/Atypical
FANAPT PAK
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
FANAPT TAB 10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
FANAPT TAB 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
FANAPT TAB 12MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
FANAPT TAB 12MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
FANAPT TAB 1MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 90 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FANAPT TAB 1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
FANAPT TAB 2MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
FANAPT TAB 2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
FANAPT TAB 4MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
FANAPT TAB 4MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
FANAPT TAB 6MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
FANAPT TAB 6MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
FANAPT TAB 8MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
FANAPT TAB 8MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
FARESTON TAB
60MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
Pg. 91 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FARYDAK CAP 10MG
On formulary, quantity
limit may apply 6 capsules per 21 days Antineoplastics Antineoplastics
FARYDAK CAP 15MG
On formulary, quantity
limit may apply 6 capsules per 21 days Antineoplastics Antineoplastics
FARYDAK CAP 20MG
On formulary, quantity
limit may apply 6 capsules per 21 days Antineoplastics Antineoplastics
FENOFIBRATE CAP
134MG
On formulary, quantity
limit may apply 30 capsules per 30 days Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
FENOFIBRATE CAP
150MG Not on 2017 formulary
fenofibric capsule (45 mg,
135 mg [generic Trilipix]),
fenofibrate tablet (48 mg,
145 mg [generic Tricor]),
fenofibrate tablet (54 mg,
160 mg [generic Lofibra]),
fenofibrate capsule (67
mg, 134 mg, 200 mg
[generic Lofibra]),
gemfibrozil Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
FENOFIBRATE CAP
200MG
On formulary, quantity
limit may apply 30 capsules per 30 days Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
FENOFIBRATE CAP
50MG Not on 2017 formulary
fenofibric capsule (45 mg,
135 mg [generic Trilipix]),
fenofibrate tablet (48 mg,
145 mg [generic Tricor]),
fenofibrate tablet (54 mg,
160 mg [generic Lofibra]),
fenofibrate capsule (67
mg, 134 mg, 200 mg
[generic Lofibra]),
gemfibrozil Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
Pg. 92 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FENOFIBRATE CAP
67MG
On formulary, quantity
limit may apply 30 capsules per 30 days Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
FENOFIBRATE TAB
145MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
FENOFIBRATE TAB
160MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
FENOFIBRATE TAB
48MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
FENOFIBRATE TAB
54MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
FENOPROFEN TAB
600MG Not on 2017 formulary
diclofenac tablets,
etodolac, flurbiprofen,
ibuprofen, ketoprofen IR,
meloxicam, nabumetone,
naproxen, oxaprozin,
piroxicam, sulindac,
tolmetin 400 mg,
celecoxib, diclofenac gel
1% (generic Voltaren)*
*This drug needs a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
Pg. 93 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FENTORA TAB
200MCG Not on 2017 formulary
Abstral*, fentanyl
lozenges (generic)*,
Lazanda*
*These drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Short-
acting
FENTORA TAB
400MCG Not on 2017 formulary
Abstral*, fentanyl
lozenges (generic)*,
Lazanda*
*These drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Short-
acting
Pg. 94 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FENTORA TAB
600MCG Not on 2017 formulary
Abstral*, fentanyl
lozenges (generic)*,
Lazanda*
*These drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Short-
acting
FENTORA TAB
800MCG Not on 2017 formulary
Abstral*, fentanyl
lozenges (generic)*,
Lazanda*
*These drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Short-
acting
FERRIPROX SOL
100MG/ML Not on 2017 formulary Jadenu, Exjade, Chemet
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Modifiers
FERRIPROX TAB
500MG Not on 2017 formulary Jadenu, Exjade, Chemet
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Modifiers
FETZIMA CAP 120MG On formulary, tier change tier 3 to tier 4 Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 95 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FETZIMA CAP 120MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FETZIMA CAP 20MG On formulary, tier change tier 3 to tier 4 Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FETZIMA CAP 20MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FETZIMA CAP 40MG On formulary, tier change tier 3 to tier 4 Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FETZIMA CAP 40MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FETZIMA CAP 80MG On formulary, tier change tier 3 to tier 4 Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FETZIMA CAP 80MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FETZIMA CAP
TITRATIO On formulary, tier change tier 3 to tier 4 Miscellaneous Miscellaneous
FETZIMA CAP
TITRATIO
On formulary, quantity
limit may apply 28 capsules per 28 days Miscellaneous Miscellaneous
FIFTY50 MIS
31GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
FIFTY50 MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
FIFTY50 MIS
31GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
FIFTY50 PEN MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
FIFTY50 PEN MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
FIFTY50 PEN MIS
32GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 96 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FIFTY50 PREP PAD
PADS On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
FINASTERIDE TAB 5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Genitourinary Agents
Benign Prostatic
Hypertrophy Agents
FIRAZYR INJ
30MG/3ML
On formulary, requires
prior authorization check with your doctor Miscellaneous Miscellaneous
FIRAZYR INJ
30MG/3ML
On formulary, quantity
limit may apply 6 syringes per 30 days Miscellaneous Miscellaneous
FLOVENT DISK AER
100MCG
On formulary, quantity
limit may apply 1 inhaler per 30 days Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
FLOVENT DISK AER
250MCG
On formulary, quantity
limit may apply 4 inhalers per 30 days Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
FLOVENT DISK AER
50MCG
On formulary, quantity
limit may apply 1 inhaler per 30 days Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
FLOVENT HFA AER
110MCG
On formulary, quantity
limit may apply 1 canister per 30 days Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
FLOVENT HFA AER
220MCG
On formulary, quantity
limit may apply 2 canisters per 30 days Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
FLOVENT HFA AER
44MCG
On formulary, quantity
limit may apply 1 canister per 30 days Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
FLUNISOLIDE SPR
0.025% Not on 2017 formulary
fluticasone nasal spray,
mometasone nasal spray
(generic Nasonex),
triamcinolone nasal spray Respiratory Tract Agents Nasal Agents
FLUOCIN ACET CRE
0.01% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
Pg. 97 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FLUOCIN ACET CRE
0.025% Not on 2017 formulary
betamethasone
dipropionate 0.05%
(cream), augmented
betamethasone 0.05%
(cream), betamethasone
valerate 0.1% (cream),
clobetasol 0.05%
(solution), clobetasol
emollient 0.05% (cream),
fluocinonide 0.05%
(cream, gel, ointment,
solution), mometasone
0.1% (cream, ointment,
solution), triamcinolone
0.025%/0.1% (cream),
triamcinolone 0.5%
(cream, ointment) Dermatological Agents Dermatological Agents
Pg. 98 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FLUOCIN ACET OIL
0.01%BDY Not on 2017 formulary
betamethasone
dipropionate 0.05%
(cream), augmented
betamethasone 0.05%
(cream), betamethasone
valerate 0.1% (cream),
clobetasol 0.05%
(solution), clobetasol
emollient 0.05% (cream),
fluocinonide 0.05%
(cream, gel, ointment,
solution), mometasone
0.1% (cream, ointment,
solution), triamcinolone
0.025%/0.1% (cream),
triamcinolone 0.5%
(cream, ointment) Dermatological Agents Dermatological Agents
Pg. 99 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FLUOCIN ACET OIL
BODY Not on 2017 formulary
betamethasone
dipropionate 0.05%
(cream), augmented
betamethasone 0.05%
(cream), betamethasone
valerate 0.1% (cream),
clobetasol 0.05%
(solution), clobetasol
emollient 0.05% (cream),
fluocinonide 0.05%
(cream, gel, ointment,
solution), mometasone
0.1% (cream, ointment,
solution), triamcinolone
0.025%/0.1% (cream),
triamcinolone 0.5%
(cream, ointment) Dermatological Agents Dermatological Agents
Pg. 100 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FLUOCIN ACET OIN
0.025% Not on 2017 formulary
betamethasone
dipropionate 0.05%
(cream), augmented
betamethasone 0.05%
(cream), betamethasone
valerate 0.1% (cream),
clobetasol 0.05%
(solution), clobetasol
emollient 0.05% (cream),
fluocinonide 0.05%
(cream, gel, ointment,
solution), mometasone
0.1% (cream, ointment,
solution), triamcinolone
0.025%/0.1% (cream),
triamcinolone 0.5%
(cream, ointment) Dermatological Agents Dermatological Agents
Pg. 101 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FLUOCIN ACET SOL
0.01% Not on 2017 formulary
betamethasone
dipropionate 0.05%
(cream), augmented
betamethasone 0.05%
(cream), betamethasone
valerate 0.1% (cream),
clobetasol 0.05%
(solution), clobetasol
emollient 0.05% (cream),
fluocinonide 0.05%
(cream, gel, ointment,
solution), mometasone
0.1% (cream, ointment,
solution), triamcinolone
0.025%/0.1% (cream),
triamcinolone 0.5%
(cream, ointment) Dermatological Agents Dermatological Agents
FLUOXETINE CAP
10MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUOXETINE CAP
20MG
On formulary, quantity
limit may apply 120 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUOXETINE CAP
40MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUOXETINE CAP
90MG DR
On formulary, quantity
limit may apply 4 capsules per 28 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUOXETINE SOL
20MG/5ML
On formulary, quantity
limit may apply 600 mls per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUOXETINE TAB
10MG On formulary, tier change tier 1 to tier 2 Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUOXETINE TAB
10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 102 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FLUOXETINE TAB
20MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUOXETINE TAB
60MG Not on 2017 formulary
fluoxetine tablets (10 mg,
20 mg), fluoxetine
capsules (10 mg, 20 mg,
40 mg) Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUPHENAZ DE INJ
25MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
FLUPHENAZINE CON
5MG/ML On formulary, tier change tier 2 to tier 4 Antipsychotics 1st Generation/Typical
FLUPHENAZINE CON
5MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
FLUPHENAZINE ELX
2.5/5ML On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical
FLUPHENAZINE ELX
2.5/5ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
FLUPHENAZINE INJ
2.5MG/ML On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical
FLUPHENAZINE INJ
2.5MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
Pg. 103 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FLUPHENAZINE TAB
10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
FLUPHENAZINE TAB
1MG On formulary, tier change tier 1 to tier 2 Antipsychotics 1st Generation/Typical
FLUPHENAZINE TAB
1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
FLUPHENAZINE TAB
2.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
FLUPHENAZINE TAB
5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
FLURAZEPAM CAP
15MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
FLURAZEPAM CAP
30MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
FLURBIPROFEN TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
FLURBIPROFEN TAB
50MG On formulary, tier change tier 1 to tier 2 Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
FLURBIPROFEN TAB
50MG
On formulary, quantity
limit may apply 180 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
FLUTICASONE SPR
50MCG
On formulary, quantity
limit may apply 1 bottle per 30 days Respiratory Tract Agents Nasal Agents
Pg. 104 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FLUVASTATIN CAP
20MG Not on 2017 formulary
atorvastatin, lovastatin,
Livalo, rosuvastatin,
pravastatin, simvastatin Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
FLUVASTATIN CAP
40MG Not on 2017 formulary
atorvastatin, lovastatin,
Livalo, rosuvastatin,
pravastatin, simvastatin Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
FLUVASTATIN TAB
80MG ER Not on 2017 formulary
atorvastatin, lovastatin,
Livalo, rosuvastatin,
pravastatin, simvastatin Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
FLUVOXAMINE CAP
100MG ER Not on 2017 formulary
fluvoxamine IR tablets (25
mg, 50 mg, 100 mg) Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUVOXAMINE CAP
150MG ER Not on 2017 formulary
fluvoxamine IR tablets (25
mg, 50 mg, 100 mg) Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUVOXAMINE TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUVOXAMINE TAB
25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FLUVOXAMINE TAB
50MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
FOLOTYN INJ
20MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
FOLOTYN INJ
40MG/2ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
FONDAPARINUX INJ
10/0.8ML
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FONDAPARINUX INJ
2.5/0.5
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FONDAPARINUX INJ
5/0.4ML
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FONDAPARINUX INJ
7.5/0.6
On formulary, quantity
limit may apply 30 syringes per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
Pg. 105 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FORFIVO XL TAB
450MG Not on 2017 formulary
bupropion tablets (IR, SR,
XL) Antidepressants Antidepressants, Other
FORTEO SOL
600/2.4
On formulary, requires
prior authorization check with your doctor
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
FOSAMAX + D TAB 70-
2800 Not on 2017 formulary
alendronate tablets (5mg,
10 mg, 35 mg, 70 mg)
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
FOSAMAX + D TAB 70-
5600 Not on 2017 formulary
alendronate tablets (5mg,
10 mg, 35 mg, 70 mg)
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
FOSCAVIR INJ
24MG/ML
On formulary, requires
prior authorization check with your doctor Antivirals
Anti-cytomegalovirus
(CMV) Agents
FOSINOP/HCTZ TAB
10/12.5 On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
FOSINOP/HCTZ TAB
20/12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
FOSINOPRIL TAB
10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
FOSINOPRIL TAB
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
FOSINOPRIL TAB
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
FRAGMIN INJ
10000/ML Not on 2017 formulary enoxaparin inj
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FRAGMIN INJ
12500UNT Not on 2017 formulary enoxaparin inj
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FRAGMIN INJ
15000UNT Not on 2017 formulary enoxaparin inj
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FRAGMIN INJ
18000UNT Not on 2017 formulary enoxaparin inj
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FRAGMIN INJ
2500/0.2 Not on 2017 formulary enoxaparin inj
Blood Products/Modifiers/
Volume Expanders Anticoagulants
Pg. 106 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FRAGMIN INJ
5000/0.2 Not on 2017 formulary enoxaparin inj
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FRAGMIN INJ
7500/0.3 Not on 2017 formulary enoxaparin inj
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FRAGMIN INJ
95000UNT Not on 2017 formulary enoxaparin inj
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FREAMINE HBC INJ
6.9% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
FULYZAQ TAB
125MG Not on 2017 formulary loperamide 2mg capsule Gastrointestinal Agents
Gastrointestinal Agents,
Other
FUROSEMIDE SOL
8MG/ML Not on 2017 formulary
furosemide oral solution
(10mg/mL) Cardiovascular Agents Diuretics, Loop
FUZEON INJ 90MG
On formulary, quantity
limit may apply 60 vials per 30 days Antivirals Anti-HIV Agents, Other
GABAPENTIN CAP
100MG
On formulary, quantity
limit may apply
1080 capsules per 30
days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN CAP
300MG
On formulary, quantity
limit may apply 360 capsules per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN CAP
400MG
On formulary, quantity
limit may apply 270 capsules per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN SOL
250/5ML
On formulary, quantity
limit may apply 2160 mls per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
Pg. 107 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GABAPENTIN SOL
300/6ML
On formulary, quantity
limit may apply 2160 mls per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN TAB
600MG
On formulary, quantity
limit may apply 180 tablets per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN TAB
800MG
On formulary, quantity
limit may apply 120 tablets per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GAMASTAN S/D INJ Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
GAMMAGARD INJ
10GM/100 Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
Pg. 108 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GAMMAGARD INJ
1GM/10ML Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
GAMMAGARD INJ
2.5GM/25 Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
GAMMAGARD INJ
20GM/200 Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
Pg. 109 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GAMMAGARD INJ
30GM/300 Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
GAMMAGARD INJ
5GM/50ML Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
GAMMAPLEX INJ
10GM
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAMMAPLEX INJ
2.5GM
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAMMAPLEX INJ
20GM
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAMMAPLEX INJ 5GM
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
10GM/100 On formulary, tier change tier 4 to tier 5 Immunological Agents
Immunizing Agents,
Passive
Pg. 110 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GAMUNEX-C INJ
10GM/100
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
1GM/10ML On formulary, tier change tier 4 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
1GM/10ML
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
2.5GM/25 On formulary, tier change tier 4 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
2.5GM/25
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
20GM/200 On formulary, tier change tier 4 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
20GM/200
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
40/400ML On formulary, tier change tier 4 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
40/400ML
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
5GM/50ML On formulary, tier change tier 4 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
5GM/50ML
On formulary, requires
prior authorization check with your doctor Immunological Agents
Immunizing Agents,
Passive
GAUZE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
GAUZE SPONGE PAD
2X2 8PLY On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
GEMFIBROZIL TAB
600MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Dyslipidemics, Fibric Acid
Derivatives
GENERLAC SOL
10GM/15 On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents Laxatives
Pg. 111 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GENTAM/NACL INJ
0.9MG/ML Not on 2017 formulary
gentamicin in saline
injection (0.8 mg/ml, 1
mg/ml, 1.2 mg/ml, 1.6
mg/ml) Antibacterials Aminoglycosides
GENTAM/NACL INJ
1.4MG/ML Not on 2017 formulary
gentamicin in saline
injection (0.8 mg/ml, 1
mg/ml, 1.2 mg/ml, 1.6
mg/ml) Antibacterials Aminoglycosides
GENTAM/NACL INJ
100MG On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides
GENTAM/NACL INJ
120MG On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides
GENTAM/NACL INJ
60MG On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides
GENTAM/NACL INJ
60MG PB On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides
GENTAM/NACL INJ
80MG On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides
GENTAMICIN CRE
0.1% On formulary, tier change tier 1 to tier 4 Dermatological Agents Dermatological Agents
GENTAMICIN INJ
10MG/ML On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides
GENTAMICIN OIN 0.1% On formulary, tier change tier 1 to tier 4 Dermatological Agents Dermatological Agents
GENTAMICIN SOL 0.3%
OP On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides
GEODON INJ 20MG
On formulary, quantity
limit may apply 60 vials per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 112 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GEODON INJ 20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
GILDAGIA TAB 0.4-35 On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Contraceptives
GILOTRIF TAB 20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
GILOTRIF TAB 30MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
GILOTRIF TAB 40MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
GLEEVEC TAB
100MG Not on 2017 formulary
imatinib 100 mg* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antineoplastics Antineoplastics
Pg. 113 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GLEEVEC TAB
400MG Not on 2017 formulary
imatinib 400 mg* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antineoplastics Antineoplastics
GLEEVEC TAB
400MG Not on 2017 formulary
imatinib 400 mg* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antineoplastics Antineoplastics
GLIMEPIRIDE TAB 1MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIMEPIRIDE TAB 1MG
On formulary, quantity
limit may apply 240 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIMEPIRIDE TAB 2MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIMEPIRIDE TAB 2MG
On formulary, quantity
limit may apply 120 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIMEPIRIDE TAB 4MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents
Pg. 114 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GLIMEPIRIDE TAB 4MG
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIP/METFORM TAB 2.5-
250M On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIP/METFORM TAB 2.5-
250M
On formulary, quantity
limit may apply 240 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIP/METFORM TAB 2.5-
500M On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIP/METFORM TAB 2.5-
500M
On formulary, quantity
limit may apply 120 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIP/METFORM TAB 5-
500MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIP/METFORM TAB 5-
500MG
On formulary, quantity
limit may apply 120 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE TAB 10MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE TAB 10MG
On formulary, quantity
limit may apply 120 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE TAB 5MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE TAB 5MG
On formulary, quantity
limit may apply 240 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE ER TAB
10MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE ER TAB
10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE ER TAB
2.5MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE ER TAB
2.5MG
On formulary, quantity
limit may apply 240 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
Pg. 115 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GLIPIZIDE ER TAB 5MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE ER TAB 5MG
On formulary, quantity
limit may apply 120 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE XL TAB 10MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE XL TAB 10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE XL TAB
2.5MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE XL TAB
2.5MG
On formulary, quantity
limit may apply 240 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE XL TAB 5MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
GLIPIZIDE XL TAB 5MG
On formulary, quantity
limit may apply 120 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
GLOBAL PREP PAD
PADS On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
GLYB/METFORM TAB
1.25-250 Not on 2017 formulary
glipizide/metformin,
glimepiride used in
combination with
metformin tablets Blood Glucose Regulators Antidiabetic Agents
GLYB/METFORM TAB
2.5-500 Not on 2017 formulary
glipizide/metformin,
glimepiride used in
combination with
metformin tablets Blood Glucose Regulators Antidiabetic Agents
GLYB/METFORM TAB 5-
500MG Not on 2017 formulary
glipizide/metformin,
glimepiride used in
combination with
metformin tablets Blood Glucose Regulators Antidiabetic Agents
Pg. 116 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GLYBURID MCR TAB
1.5MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
GLYBURID MCR TAB
3MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
GLYBURID MCR TAB
6MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
GLYBURIDE TAB
1.25MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
GLYBURIDE TAB
2.5MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
GLYBURIDE TAB 5MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
GNP ALCOHOL PAD
SWABS On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
GRANISETRON INJ
0.1MG/ML Not on 2017 formulary ondansetron inj, Aloxi inj Antiemetics
Emetogenic Therapy
Adjuncts
GRANISETRON INJ
1MG/ML Not on 2017 formulary ondansetron inj, Aloxi inj Antiemetics
Emetogenic Therapy
Adjuncts
GRANISETRON INJ
4MG/4ML Not on 2017 formulary ondansetron inj, Aloxi inj Antiemetics
Emetogenic Therapy
Adjuncts
GRISEOFULVIN SUS
125/5ML On formulary, tier change tier 1 to tier 2 Antifungals Antifungals
GUANFACINE TAB
1MG ER Not on 2017 formulary Strattera, clonidine ER
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
GUANFACINE TAB
2MG ER Not on 2017 formulary Strattera, clonidine ER
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 117 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GUANFACINE TAB
3MG ER Not on 2017 formulary Strattera, clonidine ER
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
GUANFACINE TAB
4MG ER Not on 2017 formulary Strattera, clonidine ER
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
GUANIDINE TAB
125MG On formulary, tier change tier 2 to tier 4 Antimyasthenic Agents Parasympathomimetics
HALOPER DEC INJ
100MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
HALOPER DEC INJ
50MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
HALOPER LAC INJ
5MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
HALOPERIDOL CON
2MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB
0.5MG On formulary, tier change tier 1 to tier 2 Antipsychotics 1st Generation/Typical
Pg. 118 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
HALOPERIDOL TAB
0.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB
10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB
1MG On formulary, tier change tier 1 to tier 2 Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB
1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB
20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB
2MG On formulary, tier change tier 1 to tier 2 Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB
2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB
5MG On formulary, tier change tier 1 to tier 2 Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB
5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
Pg. 119 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
HEP SOD/D5W INJ
100/ML Not on 2017 formulary
heparin sodium/D5W
20000 units (40 unit/mL)
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEP SOD/D5W INJ
20000UNT On formulary, tier change tier 1 to tier 2
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEP SOD/D5W INJ
25000UNT Not on 2017 formulary
heparin sodium/D5W
20000 units (40 unit/mL)
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEP SOD/D5W INJ
50UNT/ML Not on 2017 formulary
heparin sodium/D5W
20000 units (40 unit/mL)
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPARIN SOD INJ
1000/ML On formulary, tier change tier 1 to tier 2
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPARIN SOD INJ
10000/ML On formulary, tier change tier 1 to tier 2
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPARIN SOD INJ
20000/ML On formulary, tier change tier 1 to tier 2
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPATAMINE SOL 8% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
HETLIOZ CAP 20MG
On formulary, quantity
limit may apply 30 capsules per 30 days Sleep Disorder Agents Sleep Disorders, Other
HEXALEN CAP 50MG On formulary, tier change tier 4 to tier 5 Antineoplastics Alkylating Agents
HEXALEN CAP 50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Alkylating Agents
Pg. 120 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
HUMATROPE INJ
12MG Not on 2017 formulary
Omnitrope inj* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information.
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
HUMATROPE INJ
24MG Not on 2017 formulary
Omnitrope inj* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information.
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
HUMIRA KIT
20MG/0.4
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
HUMIRA KIT
40MG/0.8
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
HUMIRA PEDIA INJ
CROHNS
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
HUMIRA PEN INJ
40MG/0.8
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
HUMIRA PEN INJ
CROHNS
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
Pg. 121 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
HUMIRA PEN INJ
PSORIASI
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
HUMULIN R INJ U-500
On formulary, requires
prior authorization check with your doctor Blood Glucose Regulators Insulins
HYDRALAZINE INJ
20MG/ML Not on 2017 formulary hydralazine tablet Cardiovascular Agents
Vasodilators, Direct-acting
Arterial
HYDRALAZINE TAB
10MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Vasodilators, Direct-acting
Arterial
HYDRALAZINE TAB
25MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Vasodilators, Direct-acting
Arterial
HYDROCO/APAP SOL
7.5-325 On formulary, tier change tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-
acting
HYDROCO/APAP SOL
7.5-325
On formulary, quantity
limit may apply 3600 mls per 30 days Analgesics
Opioid Analgesics, Short-
acting
HYDROCO/APAP TAB 10-
325MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
HYDROCO/APAP TAB
2.5-325 Not on 2017 formulary
hydrocodone/acetaminop
hen (5/300mg,
7.5/300mg, 10/300mg,
5/325mg, 7.5/325mg,
10/325mg) Analgesics
Opioid Analgesics, Short-
acting
HYDROCO/APAP TAB 5-
325MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
HYDROCO/APAP TAB
7.5-325
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
HYDROCOD/IBU TAB 7.5-
200
On formulary, quantity
limit may apply 150 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
HYDROCORT CRE 1% On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Pg. 122 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
HYDROCORT CRE
2.5% On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
HYDROCORT OIN 1% On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
HYDROCORT/AB OIN
1% On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
HYDROCORTISO CRE
2.5% On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
HYDROMORPHON INJ
10MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
HYDROMORPHON INJ
1MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
HYDROMORPHON INJ
2MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
HYDROMORPHON INJ
4MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
HYDROMORPHON INJ
500/50ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
HYDROMORPHON INJ
50MG/5ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
HYDROMORPHON LIQ
1MG/ML
On formulary, quantity
limit may apply 1440 mls per 30 days Analgesics
Opioid Analgesics, Short-
acting
Pg. 123 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
HYDROMORPHON TAB
12MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Short-
acting
Pg. 124 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
HYDROMORPHON TAB
16MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Short-
acting
HYDROMORPHON TAB
2MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
HYDROMORPHON TAB
4MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
HYDROMORPHON TAB
8MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
Pg. 125 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
HYDROMORPHON TAB
8MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Short-
acting
HYDROXYZ HCL INJ
25MG/ML Not on 2017 formulary check with your doctor Anxiolytics Anxiolytics, Other
HYDROXYZ HCL INJ
50MG/ML Not on 2017 formulary check with your doctor Anxiolytics Anxiolytics, Other
HYDROXYZ HCL SOL
10MG/5ML On formulary, tier change tier 1 to tier 4 Anxiolytics Anxiolytics, Other
HYDROXYZ HCL SYP
10MG/5ML On formulary, tier change tier 1 to tier 4 Anxiolytics Anxiolytics, Other
HYDROXYZ HCL TAB
10MG On formulary, tier change tier 2 to tier 4 Anxiolytics Anxiolytics, Other
HYDROXYZ HCL TAB
25MG On formulary, tier change tier 2 to tier 4 Anxiolytics Anxiolytics, Other
Pg. 126 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
HYDROXYZ HCL TAB
50MG On formulary, tier change tier 2 to tier 4 Anxiolytics Anxiolytics, Other
HYDROXYZ PAM CAP
100MG Not on 2017 formulary check with your doctor Anxiolytics Anxiolytics, Other
HYDROXYZ PAM CAP
25MG Not on 2017 formulary check with your doctor Anxiolytics Anxiolytics, Other
HYDROXYZ PAM CAP
50MG Not on 2017 formulary check with your doctor Anxiolytics Anxiolytics, Other
IBANDRONATE TAB
150MG
On formulary, quantity
limit may apply 1 tablet per 28 days
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
IBRANCE CAP
100MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antineoplastics
IBRANCE CAP
125MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antineoplastics
IBRANCE CAP 75MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antineoplastics
IBUPROFEN SUS
100/5ML On formulary, tier change tier 1 to tier 2 Analgesics
Nonsteroidal Anti-
inflammatory Drugs
IBUPROFEN SUS
100/5ML
On formulary, quantity
limit may apply 4800 mls per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
IBUPROFEN TAB
400MG
On formulary, quantity
limit may apply 240 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
IBUPROFEN TAB
600MG
On formulary, quantity
limit may apply 150 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
IBUPROFEN TAB
800MG
On formulary, quantity
limit may apply 120 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
ICLUSIG TAB 15MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
ICLUSIG TAB 45MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
Pg. 127 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
IDAMYCIN PFS INJ
10/10ML Not on 2017 formulary idarubicin inj 1 mg/mL Antineoplastics Antineoplastics
IDAMYCIN PFS INJ
20/20ML Not on 2017 formulary idarubicin inj 1 mg/mL Antineoplastics Antineoplastics
IDAMYCIN PFS INJ
5MG/5ML Not on 2017 formulary idarubicin inj 1 mg/mL Antineoplastics Antineoplastics
IDARUBICIN INJ
10/10ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
IDARUBICIN INJ
20/20ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
IDARUBICIN INJ
5MG/5ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
IFOSFAMIDE INJ 3GM On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
ILARIS INJ 180MG On formulary, tier change tier 4 to tier 5 Immunological Agents Immunomodulators
ILARIS INJ 180MG
On formulary, requires
prior authorization check with your doctor Immunological Agents Immunomodulators
ILOTYCIN OIN OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives
IMATINIB MES TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antineoplastics Antineoplastics
IMATINIB MES TAB
100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
IMATINIB MES TAB
400MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
IMATINIB MES TAB
400MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
IMBRUVICA CAP
140MG
On formulary, quantity
limit may apply 120 capsules per 30 days Antineoplastics Antineoplastics
Pg. 128 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
IMIPRAM HCL TAB
10MG On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
IMIPRAM HCL TAB
25MG On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
IMIPRAM HCL TAB
50MG On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
IMIPRAM PAM CAP
100MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
IMIPRAM PAM CAP
125MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
Pg. 129 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
IMIPRAM PAM CAP
150MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
IMIPRAM PAM CAP
75MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
IMIQUIMOD CRE 5%
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Dermatological Agents Dermatological Agents
IMOVAX RABIE INJ
2.5/ML
On formulary, requires
prior authorization check with your doctor Immunological Agents Vaccines
IN CONTROL MIS
31GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
IN CONTROL MIS
31GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
IN CONTROL MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 130 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
INCONTROL MIS
29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INCONTROL PAD
ALCOHOL On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INDAPAMIDE TAB
1.25MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Thiazide
INDAPAMIDE TAB
2.5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Thiazide
INDOMETHACIN CAP
25MG Not on 2017 formulary
diclofenac, etodolac IR,
ibuprofen, meloxicam,
nabumetone, naproxen,
sulindac Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
INDOMETHACIN CAP
50MG Not on 2017 formulary
diclofenac, etodolac IR,
ibuprofen, meloxicam,
nabumetone, naproxen,
sulindac Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
INDOMETHACIN CAP
75MG ER Not on 2017 formulary
diclofenac, etodolac IR,
ibuprofen, meloxicam,
nabumetone, naproxen,
sulindac Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
INFUMORPH INJ
10MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
INFUMORPH INJ
25MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
INLYTA TAB 1MG
On formulary, quantity
limit may apply 180 tablets per 30 days Antineoplastics Antineoplastics
INLYTA TAB 1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
Pg. 131 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
INLYTA TAB 5MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antineoplastics Antineoplastics
INLYTA TAB 5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
INSULIN PEN MIS
29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN PEN MIS
31GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN PEN MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYR MIS
0.3/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYR MIS
0.5/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYR MIS
1ML/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
0.3/28G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
0.3/29G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
0.3/30G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
0.3/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
0.5/27G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
0.5/28G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 132 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
INSULIN SYRG MIS
0.5/29G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
0.5/30G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
0.5/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS 1ML On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
1ML/25G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
1ML/26G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
1ML/27G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
1ML/28G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
1ML/29G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
1ML/30G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
1ML/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
2/27.5G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
28GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
29GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
2ML/29G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 133 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
INSULIN SYRG MIS
30GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSULIN SYRG MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSUPEN MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSUPEN MIS
33GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSUPEN SENS MIS
32GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSUPEN SENS MIS
32GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSUPEN ULTR MIS
29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSUPEN ULTR MIS
30GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSUPEN ULTR MIS
31GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INSUPEN ULTR MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
INTELENCE TAB
100MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
INTELENCE TAB
200MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
INTELENCE TAB 25MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
INTRALIPID INJ 20% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
Pg. 134 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
INTRON A INJ 18MU On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
INTRON A INJ 50MU On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
INVEGA TAB 1.5MG Not on 2017 formulary
paliperidone 1.5 mg*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antipsychotics 2nd Generation/Atypical
INVEGA TAB 3MG Not on 2017 formulary
paliperidone 3 mg* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antipsychotics 2nd Generation/Atypical
Pg. 135 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
INVEGA TAB 6MG Not on 2017 formulary
paliperidone 6 mg* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antipsychotics 2nd Generation/Atypical
INVEGA TAB 9MG Not on 2017 formulary
paliperidone 9 mg* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
117/0.75
On formulary, quantity
limit may apply 1 kit per 30 days Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
117/0.75
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
156MG/ML
On formulary, quantity
limit may apply 1 kit per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 136 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
INVEGA SUST INJ
156MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
234/1.5
On formulary, quantity
limit may apply 1 kit per 30 days Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
234/1.5
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
39/0.25
On formulary, quantity
limit may apply 1 kit per 30 days Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
39/0.25
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
78/0.5ML On formulary, tier change tier 4 to tier 5 Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
78/0.5ML
On formulary, quantity
limit may apply 1 kit per 30 days Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ
78/0.5ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ
273MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ
273MG
On formulary, quantity
limit may apply 1 kit per 90 days Antipsychotics 2nd Generation/Atypical
Pg. 137 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
INVEGA TRINZ INJ
410MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ
410MG
On formulary, quantity
limit may apply 1 kit per 90 days Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ
546MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ
546MG
On formulary, quantity
limit may apply 1 kit per 90 days Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ
819MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ
819MG
On formulary, quantity
limit may apply 1 kit per 90 days Antipsychotics 2nd Generation/Atypical
INVIRASE CAP 200MG On formulary, tier change tier 4 to tier 5 Antivirals
Anti-HIV Agents, Protease
Inhibitors
INVIRASE CAP 200MG
On formulary, quantity
limit may apply 300 capsules per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
INVIRASE TAB 500MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
INVOKAMET TAB 150-
1000
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
INVOKAMET TAB 150-
500
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
INVOKAMET TAB 50-
1000
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
Pg. 138 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
INVOKAMET TAB 50-
500MG
On formulary, quantity
limit may apply 120 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
INVOKANA TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
INVOKANA TAB
300MG
On formulary, quantity
limit may apply 30 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
IPRATROPIUM SOL
0.02%INH On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents
Bronchodilators,
Anticholinergic
IPRATROPIUM SOL
INHAL On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents
Bronchodilators,
Anticholinergic
IPRATROPIUM SPR
0.03%
On formulary, quantity
limit may apply 2 bottles per 30 days Respiratory Tract Agents Nasal Agents
IPRATROPIUM SPR
0.06%
On formulary, quantity
limit may apply 3 bottles per 30 days Respiratory Tract Agents Nasal Agents
IPRATROPIUM/ SOL
ALBUTER Not on 2017 formulary check with your doctor Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
IPRATROPIUM/ SOL
SULFATE Not on 2017 formulary check with your doctor Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
IRBESAR/HCTZ TAB 150-
12.5 On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
IRBESAR/HCTZ TAB 150-
12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
IRBESAR/HCTZ TAB 300-
12.5 On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
IRBESAR/HCTZ TAB 300-
12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
IRBESARTAN TAB
150MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
IRBESARTAN TAB
150MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
Pg. 139 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
IRBESARTAN TAB
300MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
IRBESARTAN TAB
300MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
IRBESARTAN TAB
75MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
IRBESARTAN TAB
75MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
IRENKA CAP 40MG Not on 2017 formulary
duloxetine capsules
(20mg, 30mg, 60mg) Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
ISENTRESS CHW
100MG
On formulary, quantity
limit may apply 180 tablets per 30 days Antivirals Anti-HIV Agents, Other
ISENTRESS CHW
25MG
On formulary, quantity
limit may apply 180 tablets per 30 days Antivirals Anti-HIV Agents, Other
ISENTRESS POW
100MG
On formulary, quantity
limit may apply 60 packets per 30 days Antivirals Anti-HIV Agents, Other
ISENTRESS TAB
400MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals Anti-HIV Agents, Other
ISOLYTE-P INJ /D5W Not on 2017 formulary D5W/lactated ringers inj
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
ISOLYTE-S INJ Not on 2017 formulary lactated ringers inj
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
ISONIAZID INJ
100MG/ML On formulary, tier change tier 1 to tier 4 Antimycobacterials Antituberculars
ISONIAZID SYP
50MG/5ML Not on 2017 formulary isoniazid tablets Antimycobacterials Antituberculars
ISOSORB DIN TAB
40MG ER Not on 2017 formulary
isosorbide dinitrate IR
tablet (5 mg, 10 mg, 20
mg, 30 mg), isosorbide
mononitrate ER tablet (30
mg, 60 mg, 120 mg) Cardiovascular Agents
Vasodilators, Direct-acting
Arterial/Venous
Pg. 140 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ISOSORB MONO TAB
30MG ER On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Vasodilators, Direct-acting
Arterial/Venous
ISOSORB MONO TAB
60MG ER On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Vasodilators, Direct-acting
Arterial/Venous
ISRADIPINE CAP
2.5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Calcium Channel Blocking
Agents
ISRADIPINE CAP 5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Calcium Channel Blocking
Agents
IXEMPRA KIT INJ 15MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
IXEMPRA KIT INJ 45MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
J&J GAUZE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
JAKAFI TAB 10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
JAKAFI TAB 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
JAKAFI TAB 15MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
JAKAFI TAB 15MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
JAKAFI TAB 20MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
JAKAFI TAB 20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
Pg. 141 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
JAKAFI TAB 25MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
JAKAFI TAB 25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
JAKAFI TAB 5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
JAKAFI TAB 5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
JALYN CAP Not on 2017 formulary
dutasteride/tamsulosin 0.5
mg/0.4 mg capsules Genitourinary Agents
Benign Prostatic
Hypertrophy Agents
JANUMET TAB 50-
1000
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
JANUMET TAB 50-
500MG
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
JANUMET XR TAB 100-
1000
On formulary, quantity
limit may apply 30 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
JANUMET XR TAB 50-
1000
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
JANUMET XR TAB 50-
500MG
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
JANUVIA TAB 100MG
On formulary, quantity
limit may apply 30 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
JANUVIA TAB 25MG
On formulary, quantity
limit may apply 120 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
JANUVIA TAB 50MG
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
Pg. 142 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
JENTADUETO TAB 2.5-
1000 On formulary, tier change tier 3 to tier 4 Blood Glucose Regulators Antidiabetic Agents
JENTADUETO TAB 2.5-
1000
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
JUXTAPID CAP 10MG
On formulary, requires
prior authorization check with your doctor Cardiovascular Agents Dyslipidemics, Other
JUXTAPID CAP 20MG
On formulary, requires
prior authorization check with your doctor Cardiovascular Agents Dyslipidemics, Other
JUXTAPID CAP 5MG
On formulary, requires
prior authorization check with your doctor Cardiovascular Agents Dyslipidemics, Other
KADIAN CAP 40MG
ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
KALETRA SOL
On formulary, quantity
limit may apply 480 mls per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
Pg. 143 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
KALETRA TAB 100-
25MG
On formulary, quantity
limit may apply 300 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
KALETRA TAB 200-
50MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
KALYDECO PAK
50MG
On formulary, quantity
limit may apply 60 packets per 30 days Respiratory Tract Agents
Respiratory Tract Agents,
Other
KALYDECO PAK
75MG
On formulary, quantity
limit may apply 60 packets per 30 days Respiratory Tract Agents
Respiratory Tract Agents,
Other
KALYDECO TAB
150MG
On formulary, quantity
limit may apply 60 tablets per 30 days Respiratory Tract Agents
Respiratory Tract Agents,
Other
KAZANO 12.5- TAB
1000MG Not on 2017 formulary
Jentadueto, Kombiglyze,
Janumet, Janumet XR Blood Glucose Regulators Antidiabetic Agents
KAZANO 12.5- TAB
500MG Not on 2017 formulary
Jentadueto, Kombiglyze,
Janumet, Janumet XR Blood Glucose Regulators Antidiabetic Agents
KCL/D5W INJ 0.15% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W INJ 0.3% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/LR INJ 0.15% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
.075/.45 On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ .15-
.45% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
.15/.33% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
.15/.45% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
.22/.45 On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
Pg. 144 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
KCL/D5W/NACL INJ
.224/.45 On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
0.15/0.2 Not on 2017 formulary
KCL/D5W/NACL inj
0.15/0.2%
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
0.3/0.45 On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/NACL INJ 0.15-
0.9 Not on 2017 formulary KCL/NACL inj 0.15-0.45
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KEPIVANCE INJ
6.25MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
KETEK TAB 300MG Not on 2017 formulary check with your doctor Antibacterials Macrolides
KETEK TAB 400MG Not on 2017 formulary check with your doctor Antibacterials Macrolides
KETOPROFEN CAP
200MG ER Not on 2017 formulary ketoprofen IR Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
KETOPROFEN CAP
50MG On formulary, tier change tier 1 to tier 2 Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
KETOPROFEN CAP
50MG
On formulary, quantity
limit may apply 180 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
KETOPROFEN CAP
75MG
On formulary, quantity
limit may apply 120 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
KETOROLAC INJ
15MG/ML Not on 2017 formulary
codeine/acetaminophen,
ibuprofen, naproxen,
meloxicam, diclofenac,
nabumetone, etodolac IR,
sulindac,
hydrocodone/acetaminop
hen,
oxycodone/acetaminophe
n Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
Pg. 145 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
KETOROLAC INJ
30MG/ML Not on 2017 formulary
codeine/acetaminophen,
ibuprofen, naproxen,
meloxicam, diclofenac,
nabumetone, etodolac IR,
sulindac,
hydrocodone/acetaminop
hen,
oxycodone/acetaminophe
n Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
KETOROLAC TAB
10MG Not on 2017 formulary
codeine/acetaminophen,
ibuprofen, naproxen,
meloxicam, diclofenac,
nabumetone, etodolac IR,
sulindac,
hydrocodone/acetaminop
hen,
oxycodone/acetaminophe
n Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
KHEDEZLA TAB
100MG ER Not on 2017 formulary
Pristiq (brand name),
duloxetine (20 mg, 30 mg,
60 mg), Fetzima,
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
KHEDEZLA TAB 50MG
ER Not on 2017 formulary
Pristiq (brand name),
duloxetine (20 mg, 30 mg,
60 mg), Fetzima,
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 146 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
KINERET INJ
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
KLOR-CON 10 TAB
10MEQ ER On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KLOR-CON 8 TAB
8MEQ ER On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KLOR-CON M10 TAB
10MEQ ER On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KORLYM TAB 300MG
On formulary, quantity
limit may apply 120 tablets per 30 days
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
KUVAN TAB 100MG
On formulary, requires
prior authorization check with your doctor
Enzyme Replacement/
Modifiers
Enzyme Replacement/
Modifiers
KYNAMRO INJ
200MG/ML
On formulary, requires
prior authorization check with your doctor Cardiovascular Agents Dyslipidemics, Other
LABETALOL INJ
5MG/ML Not on 2017 formulary labetalol tablets Cardiovascular Agents
Beta-adrenergic Blocking
Agents
LACTATED RIN INJ On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
LACTATED RIN SOL
IRRIGAT Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous
LACTULOSE SOL
10GM/15 On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents Laxatives
LACTULOSE SOL
20GM/30 On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents Laxatives
LAMICTAL KIT START
35 Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMICTAL KIT START
49 Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
Pg. 147 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LAMICTAL KIT START
98 Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMICTAL ODT TAB
100MG Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMICTAL ODT TAB
200MG Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMICTAL ODT TAB
25MG Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMICTAL ODT TAB
50MG Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMICTAL XR KIT Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMIVUD/ZIDO TAB 150-
300
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
LAMIVUDINE SOL
10MG/ML
On formulary, quantity
limit may apply 960 mls per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
LAMIVUDINE TAB
150MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
Pg. 148 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LAMIVUDINE TAB
300MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
LAMOTRIGINE TAB
100MG Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
100MG ER Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
200MG Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
200MG ER Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
250MG ER Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
25MG ER Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
25MG ODT Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
300MG ER Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
50MG ER Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
Pg. 149 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LAMOTRIGINE TAB
50MG ODT Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LATUDA TAB 120MG On formulary, tier change tier 3 to tier 5 Antipsychotics 2nd Generation/Atypical
LATUDA TAB 120MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
LATUDA TAB 120MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
LATUDA TAB 20MG On formulary, tier change tier 3 to tier 5 Antipsychotics 2nd Generation/Atypical
LATUDA TAB 20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
LATUDA TAB 20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
LATUDA TAB 40MG On formulary, tier change tier 3 to tier 5 Antipsychotics 2nd Generation/Atypical
LATUDA TAB 40MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
LATUDA TAB 40MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
LATUDA TAB 60MG On formulary, tier change tier 3 to tier 5 Antipsychotics 2nd Generation/Atypical
LATUDA TAB 60MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 150 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LATUDA TAB 60MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
LATUDA TAB 80MG On formulary, tier change tier 3 to tier 5 Antipsychotics 2nd Generation/Atypical
LATUDA TAB 80MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
LATUDA TAB 80MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
LAZANDA SPR
100MCG
On formulary, quantity
limit may apply 30 bottles per 30 days Analgesics
Opioid Analgesics, Short-
acting
LAZANDA SPR
300MCG
On formulary, quantity
limit may apply 30 bottles per 30 days Analgesics
Opioid Analgesics, Short-
acting
LAZANDA SPR
400MCG
On formulary, quantity
limit may apply 30 bottles per 30 days Analgesics
Opioid Analgesics, Short-
acting
LENVIMA CAP 10 MG On formulary, tier change tier 3 to tier 5 Antineoplastics Antineoplastics
LENVIMA CAP 10 MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antineoplastics
LENVIMA CAP 10 MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
LENVIMA CAP 14 MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antineoplastics Antineoplastics
LENVIMA CAP 14 MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
Pg. 151 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LENVIMA CAP 18 MG
On formulary, quantity
limit may apply 90 capsules per 30 days Antineoplastics Antineoplastics
LENVIMA CAP 18 MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
LENVIMA CAP 20 MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antineoplastics Antineoplastics
LENVIMA CAP 20 MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
LENVIMA CAP 24 MG
On formulary, quantity
limit may apply 90 capsules per 30 days Antineoplastics Antineoplastics
LENVIMA CAP 24 MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
LENVIMA CAP 8 MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antineoplastics Antineoplastics
LENVIMA CAP 8 MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
LESCOL XL TAB 80MG Not on 2017 formulary
atorvastatin, lovastatin,
Livalo, rosuvastatin,
pravastatin, simvastatin Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LETAIRIS TAB 10MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Pulmonary
Antihypertensives
LETAIRIS TAB 10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
Pg. 152 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LETAIRIS TAB 5MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Pulmonary
Antihypertensives
LETAIRIS TAB 5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
LEUCOVOR CA INJ
50MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
LEUCOVOR CA TAB
10MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
LEUCOVOR CA TAB
15MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
LEUCOVORIN INJ
CALCIUM On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
LEVETIRACETA TAB
500MG ER Not on 2017 formulary levetiracetam IR tablets Anticonvulsants Anticonvulsants, Other
LEVETIRACETA TAB
750MG ER Not on 2017 formulary levetiracetam IR tablets Anticonvulsants Anticonvulsants, Other
LEVOCARNITIN INJ
200MG/ML Not on 2017 formulary levocarnitine tablet 330mg
Enzyme Replacement/
Modifiers
Enzyme Replacement/
Modifiers
LEVOCARNITIN SOL
1GM/10ML On formulary, tier change tier 1 to tier 2
Enzyme Replacement/
Modifiers
Enzyme Replacement/
Modifiers
LEVOLEUCOVOR INJ
175/17.5 Not on 2017 formulary leucovorin calcium inj Antineoplastics Antineoplastics
LEVOLEUCOVOR INJ
50MG Not on 2017 formulary leucovorin calcium inj Antineoplastics Antineoplastics
LEVOTHYROXIN TAB
100MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
112MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Pg. 153 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LEVOTHYROXIN TAB
125MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
137MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
150MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
175MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
200MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
25MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
300MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
50MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
75MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOTHYROXIN TAB
88MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Pg. 154 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LEVOXYL TAB
100MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOXYL TAB
112MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOXYL TAB
125MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOXYL TAB
137MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOXYL TAB
150MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOXYL TAB
175MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOXYL TAB
200MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOXYL TAB
25MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOXYL TAB
50MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEVOXYL TAB
75MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Pg. 155 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LEVOXYL TAB
88MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
LEXIVA SUS
50MG/ML
On formulary, quantity
limit may apply 1800 mls per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
LEXIVA TAB 700MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
LIDOCAINE INJ 0.5% Not on 2017 formulary check with your doctor Anesthetics Local Anesthetics
LIDOCAINE INJ 2% Not on 2017 formulary check with your doctor Anesthetics Local Anesthetics
LINCOCIN INJ
300MG/ML Not on 2017 formulary
clindamycin inj 150
mg/mL Antibacterials Antibacterials, Other
LINCOMYCIN INJ
300MG/ML Not on 2017 formulary
clindamycin inj 150
mg/mL Antibacterials Antibacterials, Other
LINDANE LOT 1% Not on 2017 formulary
Lindane 1% shampoo,
malathion 0.5% lotion Dermatological Agents Dermatological Agents
LINZESS CAP
145MCG
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Irritable Bowel Syndrome
Agents
LINZESS CAP
290MCG
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Irritable Bowel Syndrome
Agents
LIPODOX INJ
2MG/ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics, Other
LIPODOX 50 INJ
2MG/ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics, Other
LISINOP/HCTZ TAB 10-
12.5 On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
LISINOP/HCTZ TAB 20-
12.5 On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
LISINOP/HCTZ TAB 20-
25MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
LISINOPRIL TAB 10MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
Pg. 156 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LISINOPRIL TAB 2.5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
LISINOPRIL TAB 20MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
LISINOPRIL TAB 30MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
LISINOPRIL TAB 40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
LISINOPRIL TAB 5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
LITETOUCH MIS
29GX12.7 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
LITETOUCH MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
LITHIUM SOL
8MEQ/5ML On formulary, tier change tier 1 to tier 4 Bipolar Agents Mood Stabilizers
LITHOSTAT TAB
250MG Not on 2017 formulary check with your doctor Genitourinary Agents
Genitourinary Agents,
Other
LIVALO TAB 1MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LIVALO TAB 1MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LIVALO TAB 2MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LIVALO TAB 2MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LIVALO TAB 4MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LIVALO TAB 4MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
Pg. 157 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LOFENE TAB 2.5MG Not on 2017 formulary loperamide 2mg capsule Gastrointestinal Agents
Gastrointestinal Agents,
Other
LOMUSTINE CAP
100MG On formulary, tier change tier 2 to tier 4 Antineoplastics Alkylating Agents
LOMUSTINE CAP
10MG On formulary, tier change tier 2 to tier 4 Antineoplastics Alkylating Agents
LOMUSTINE CAP
40MG On formulary, tier change tier 2 to tier 4 Antineoplastics Alkylating Agents
LORAZEPAM CON
2MG/ML Not on 2017 formulary
lorazepam tablets*,
diazepam conc* *This
drug will need a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
LORAZEPAM TAB
0.5MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anxiolytics Benzodiazepines
LORAZEPAM TAB
0.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
LORAZEPAM TAB 1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
Pg. 158 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LORAZEPAM TAB 2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anxiolytics Benzodiazepines
LORCET TAB 5-
325MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
LORCET HD TAB 10-
325MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
LORCET PLUS TAB 7.5-
325
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
LORTAB TAB 10-
325MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
LORTAB TAB 5-
325MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
LORTAB TAB 7.5-325
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
LOSARTAN POT TAB
100MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
LOSARTAN POT TAB
100MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
LOSARTAN POT TAB
25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
LOSARTAN POT TAB
25MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
LOSARTAN POT TAB
50MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
LOSARTAN POT TAB
50MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
LOSARTAN/HCT TAB
100-12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
Pg. 159 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LOSARTAN/HCT TAB
100-12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
LOSARTAN/HCT TAB
100-25 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
LOSARTAN/HCT TAB
100-25
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
LOSARTAN/HCT TAB 50-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
LOSARTAN/HCT TAB 50-
12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
LOTEMAX GEL 0.5% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
LOVASTATIN TAB
10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LOVASTATIN TAB
10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LOVASTATIN TAB
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LOVASTATIN TAB
20MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LOVASTATIN TAB
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LOVASTATIN TAB
40MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LOXAPINE CAP 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
Pg. 160 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LOXAPINE CAP 25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
LOXAPINE CAP 50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
LOXAPINE CAP 5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
LUMIZYME INJ 50MG Not on 2017 formulary check with your doctor
Enzyme Replacement/
Modifiers
Enzyme Replacement/
Modifiers
LUPR DEP-PED INJ
11.25MG On formulary, tier change tier 3 to tier 5
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
LUPR DEP-PED INJ
15MG On formulary, tier change tier 3 to tier 5
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
LUPRON DEPOT INJ
11.25MG On formulary, tier change tier 4 to tier 5
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
LUPRON DEPOT INJ
22.5MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
LUPRON DEPOT INJ
3.75MG On formulary, tier change tier 3 to tier 5 Antineoplastics Antineoplastics
LUPRON DEPOT INJ
30MG On formulary, tier change tier 3 to tier 5 Antineoplastics Antineoplastics
LUPRON DEPOT INJ
7.5MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
LYNPARZA CAP
50MG
On formulary, quantity
limit may apply 480 capsules per 30 days Antineoplastics Antineoplastics
Pg. 161 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MAGNESIUM SU INJ
50% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
MAPROTILINE TAB
25MG On formulary, tier change tier 1 to tier 4 Antidepressants Antidepressants, Other
MAPROTILINE TAB
25MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants Antidepressants, Other
MAPROTILINE TAB
50MG On formulary, tier change tier 2 to tier 4 Antidepressants Antidepressants, Other
MAPROTILINE TAB
50MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants Antidepressants, Other
MAPROTILINE TAB
75MG On formulary, tier change tier 1 to tier 4 Antidepressants Antidepressants, Other
MAPROTILINE TAB
75MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants Antidepressants, Other
MARINOL CAP 10MG
On formulary, requires
prior authorization check with your doctor Antiemetics
Emetogenic Therapy
Adjuncts
MARINOL CAP 2.5MG
On formulary, requires
prior authorization check with your doctor Antiemetics
Emetogenic Therapy
Adjuncts
MARINOL CAP 5MG
On formulary, requires
prior authorization check with your doctor Antiemetics
Emetogenic Therapy
Adjuncts
MATULANE CAP
50MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
MATULANE CAP
50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
MECLIZINE TAB
12.5MG On formulary, tier change tier 1 to tier 2 Antiemetics Antiemetics, Other
MECLIZINE TAB 25MG On formulary, tier change tier 1 to tier 2 Antiemetics Antiemetics, Other
Pg. 162 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MECLOFEN SOD CAP
100MG Not on 2017 formulary
diclofenac tablets,
etodolac, flurbiprofen,
ibuprofen, ketoprofen IR,
meloxicam, nabumetone,
naproxen, oxaprozin,
piroxicam, sulindac,
tolmetin 400 mg,
celecoxib, diclofenac gel
1% (generic Voltaren)*
*This drug needs a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
Pg. 163 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MECLOFEN SOD CAP
50MG Not on 2017 formulary
diclofenac tablets,
etodolac, flurbiprofen,
ibuprofen, ketoprofen IR,
meloxicam, nabumetone,
naproxen, oxaprozin,
piroxicam, sulindac,
tolmetin 400 mg,
celecoxib, diclofenac gel
1% (generic Voltaren)*
*This drug needs a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
MEDROL TAB 16MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
MEDROL TAB 2MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
MEDROL TAB 32MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
MEDROL TAB 4MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
Pg. 164 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MEDROL TAB 8MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
MEGACE ES SUS
625/5ML Not on 2017 formulary check with your doctor Antineoplastics Antineoplastics
MEGESTROL AC SUS
400MG/10 On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
MEGESTROL AC SUS
40MG/ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
MEGESTROL AC TAB
20MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
MEGESTROL AC TAB
40MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
MEKINIST TAB 0.5MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antineoplastics Antineoplastics
MEKINIST TAB 0.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
MEKINIST TAB 2MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
MEKINIST TAB 2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
MELOXICAM SUS
7.5/5ML Not on 2017 formulary
meloxicam tablets,
ibuprofen suspension Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
MELOXICAM TAB
15MG
On formulary, quantity
limit may apply 30 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
MELOXICAM TAB
7.5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
Pg. 165 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MELPHALAN INJ 50MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
MENEST TAB 0.3MG On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
MENEST TAB
0.625MG On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
MENEST TAB
1.25MG On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
MENEST TAB 2.5MG On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
MEPROBAMATE TAB
200MG Not on 2017 formulary
buspirone, escitalopram,
fluoxetine, sertraline,
venlafaxine, duloxetine Anxiolytics Anxiolytics, Other
MEPROBAMATE TAB
400MG Not on 2017 formulary
buspirone, escitalopram,
fluoxetine, sertraline,
venlafaxine, duloxetine Anxiolytics Anxiolytics, Other
Pg. 166 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MESALAMINE KIT 4GM Not on 2017 formulary
Canasa suppository,
mesalamine enema. The
drug being requested is a
kit that contains cleansing
wipes. The kit is not
covered by your plan. The
enema only is covered by
your plan without a prior
authorization.
Inflammatory Bowel
Disease Agents Aminosalicylates
METADATE TAB
20MG ER
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METFORMIN TAB
1000MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents
METFORMIN TAB
1000MG
On formulary, quantity
limit may apply 75 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
METFORMIN TAB
500MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents
METFORMIN TAB
500MG
On formulary, quantity
limit may apply 150 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
METFORMIN TAB
500MG ER On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents
METFORMIN TAB
500MG ER
On formulary, quantity
limit may apply 120 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
METFORMIN TAB
750MG ER On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
METFORMIN TAB
750MG ER
On formulary, quantity
limit may apply 60 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
METFORMIN TAB
850MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents
Pg. 167 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METFORMIN TAB
850MG
On formulary, quantity
limit may apply 90 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
METFORMIN ER TAB
1000MG Not on 2017 formulary
metformin tablet IR and
ER (500 mg, 750 mg
[generic Glucophage
XR])* *Please note, the
requested drug,
metformin ER (generic
Fortamet), is an extended-
release tablet with an
osmotic-release
formulation and is not
covered by your plan.
However, metformin ER
500 mg and 750 mg
(generic Glucophage XR),
which are also extended-
release tablets, are
covered by your plan
without prior
authorization. Please
follow up with your
prescriber with any
questions. Blood Glucose Regulators Antidiabetic Agents
Pg. 168 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHADONE INJ
10MG/ML Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 169 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHADONE SOL
10MG/5ML Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 170 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHADONE SOL
10MG/5ML Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 171 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHADONE SOL
5MG/5ML Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 172 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHADONE SOL
5MG/5ML Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
METHADONE TAB
10MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
METHADONE TAB
5MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
METHOCARBAM TAB
500MG On formulary, tier change tier 2 to tier 4
Skeletal Muscle
Relaxants
Skeletal Muscle
Relaxants
METHOCARBAM TAB
750MG On formulary, tier change tier 2 to tier 4
Skeletal Muscle
Relaxants
Skeletal Muscle
Relaxants
METHOTREXATE INJ
1GM On formulary, tier change tier 1 to tier 2 Antineoplastics Antimetabolites
METHOXSALEN CAP
10MG On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents
Pg. 173 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHYCLOTHIA TAB
5MG Not on 2017 formulary
chlorothiazide,
chlorthalidone,
hydrochlorothiazide,
indapamide, metolazone Cardiovascular Agents Diuretics, Thiazide
METHYLD/HCTZ TAB
250/15 Not on 2017 formulary
clonidine IR tablet,
hydrochlorothiazide, an
ACEI (lisinopril, ramipril,
benazepril), an ARB
(losartan, irbesartan),
beta-blocker (atenolol,
metoprolol), calcium
channel blocker
(amlodipine or nifedipine
ER) Cardiovascular Agents
Antihypertensive
Combinations
METHYLD/HCTZ TAB
250/25 Not on 2017 formulary
clonidine IR tablet,
hydrochlorothiazide, an
ACEI (lisinopril, ramipril,
benazepril), an ARB
(losartan, irbesartan),
beta-blocker (atenolol,
metoprolol), calcium
channel blocker
(amlodipine or nifedipine
ER) Cardiovascular Agents
Antihypertensive
Combinations
METHYLDOPA TAB
250MG Not on 2017 formulary clonidine IR tablet Cardiovascular Agents
Alpha-adrenergic
Agonists
METHYLDOPA TAB
500MG Not on 2017 formulary clonidine IR tablet Cardiovascular Agents
Alpha-adrenergic
Agonists
METHYLDOPATE INJ
250/5ML Not on 2017 formulary clonidine IR tablet Cardiovascular Agents
Alpha-adrenergic
Agonists
Pg. 174 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHYLIN CHW
10MG Not on 2017 formulary
amphetamine/dextroamph
etamine ER capsules
(generic Adderall XR),
amphetamine/dextroamph
etamine IR tablets
(generic Adderall),
dexmethylphenidate IR
tablets (generic Focalin),
methylphenidate IR
tablets (generic Ritalin),
dextroamphetamine IR
(generic Dexedrine),
dextroamphetamine ER
(generic Dexedrine ER
capsule)
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLIN CHW
2.5MG Not on 2017 formulary
amphetamine/dextroamph
etamine ER capsules
(generic Adderall XR),
amphetamine/dextroamph
etamine IR tablets
(generic Adderall),
dexmethylphenidate IR
tablets (generic Focalin),
methylphenidate IR
tablets (generic Ritalin),
dextroamphetamine IR
(generic Dexedrine),
dextroamphetamine ER
(generic Dexedrine ER
capsule)
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 175 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHYLIN CHW 5MG Not on 2017 formulary
amphetamine/dextroamph
etamine ER capsules
(generic Adderall XR),
amphetamine/dextroamph
etamine IR tablets
(generic Adderall),
dexmethylphenidate IR
tablets (generic Focalin),
methylphenidate IR
tablets (generic Ritalin),
dextroamphetamine IR
(generic Dexedrine),
dextroamphetamine ER
(generic Dexedrine ER
capsule)
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID CAP
10MG Not on 2017 formulary
amphetamine/dextroamph
etamine IR tablets and ER
capsules,
dexmethylphenidate IR
(generic Focalin),
dextroamphetamine IR
(generic Dexedrine),
dextroamphetamine ER
(generic Dexedrine ER
capsule),
methylphenidate IR
tablets (generic Ritalin),
methylphenidate ER
20mg tablets (generic
Ritalin SR)
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 176 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHYLPHENID SOL
10MG/5ML Not on 2017 formulary
amphetamine/dextroamph
etamine IR tablets and ER
capsules,
dexmethylphenidate IR
(generic Focalin),
dextroamphetamine IR
(generic Dexedrine),
dextroamphetamine ER
(generic Dexedrine ER
capsule),
methylphenidate IR
tablets (generic Ritalin),
methylphenidate ER
20mg tablets (generic
Ritalin SR)
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID SOL
5MG/5ML Not on 2017 formulary
amphetamine/dextroamph
etamine IR tablets and ER
capsules,
dexmethylphenidate IR
(generic Focalin),
dextroamphetamine IR
(generic Dexedrine),
dextroamphetamine ER
(generic Dexedrine ER
capsule),
methylphenidate IR
tablets (generic Ritalin),
methylphenidate ER
20mg tablets (generic
Ritalin SR)
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 177 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHYLPHENID TAB
10MG On formulary, tier change tier 1 to tier 2
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID TAB
10MG
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID TAB
20MG
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID TAB
20MG ER
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID TAB
20MG SR
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 178 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHYLPHENID TAB
27MG ER Not on 2017 formulary
amphetamine/dextroamph
etamine IR tablets and ER
capsules,
dexmethylphenidate IR
(generic Focalin),
dextroamphetamine IR
(generic Dexedrine),
dextroamphetamine ER
(generic Dexedrine ER
capsule),
methylphenidate IR
tablets (generic Ritalin),
methylphenidate ER
20mg tablets (generic
Ritalin SR)
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID TAB
27MG ER Not on 2017 formulary
amphetamine/dextroamph
etamine IR tablets and ER
capsules,
dexmethylphenidate IR
(generic Focalin),
dextroamphetamine IR
(generic Dexedrine),
dextroamphetamine ER
(generic Dexedrine ER
capsule),
methylphenidate IR
tablets (generic Ritalin),
methylphenidate ER
20mg tablets (generic
Ritalin SR)
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 179 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHYLPHENID TAB
5MG On formulary, tier change tier 1 to tier 2
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID TAB
5MG
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPR ACE INJ
40MG/ML Not on 2017 formulary
methylprednisolone
sodium succinate inj (40
mg, 125 mg, 1000 mg)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
METHYLPR ACE INJ
80MG/ML Not on 2017 formulary
methylprednisolone
sodium succinate inj (40
mg, 125 mg, 1000 mg)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
METHYLPRED TAB
16MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
METHYLPRED TAB
32MG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
METHYLPRED TAB
32MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
METHYLPRED TAB
4MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
METHYLPRED TAB
4MG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
Pg. 180 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHYLPRED TAB
8MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
METHYLTESTOS CAP
10MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
METIPRANOLOL SOL
0.3% OPH Not on 2017 formulary
betaxolol, carteolol,
levobunolol, timolol
maleate (solution, gel) Ophthalmic Agents
Ophthalmic Antiglaucoma
Agents
METOCLOPRAM INJ
10MG/2ML On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents
Gastrointestinal Agents,
Other
METOCLOPRAM INJ
5MG/ML On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents
Gastrointestinal Agents,
Other
METOCLOPRAM SOL
10/10ML On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents
Gastrointestinal Agents,
Other
METOCLOPRAM SOL
5MG/5ML On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents
Gastrointestinal Agents,
Other
METOPRL/HCTZ TAB
100-50MG Not on 2017 formulary
metoprolol/hydrochlorothi
azide (50-25 mg, 100-25
mg) Cardiovascular Agents
Antihypertensive
Combinations
METOPROLOL INJ
1MG/ML Not on 2017 formulary
metoprolol (IR and ER)
tablets Cardiovascular Agents
Beta-adrenergic Blocking
Agents
METOPROLOL INJ
5MG/5ML Not on 2017 formulary
metoprolol (IR and ER)
tablets Cardiovascular Agents
Beta-adrenergic Blocking
Agents
METRONIDAZOL CAP
375MG On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other
METRONIDAZOL TAB
250MG On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other
METRONIDAZOL TAB
500MG On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other
Pg. 181 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MICONAZOLE 3 SUP
200MG Not on 2017 formulary
terconazole cream (0.4%,
0.8%), terconazole 80mg
suppository Genitourinary Agents Vaginal Products
MILLIPRED TAB 5MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
MIRTAZAPINE TAB
15MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
MIRTAZAPINE TAB
15MG ODT
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
MIRTAZAPINE TAB
30MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
MIRTAZAPINE TAB
30MG ODT
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
MIRTAZAPINE TAB
45MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
MIRTAZAPINE TAB
45MG ODT
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
MIRTAZAPINE TAB
7.5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
MIRVASO GEL 0.33% Not on 2017 formulary
Finacea, Oracea,
metronidazole 0.75%
(cream, gel, lotion),
metronidazole 1% gel Dermatological Agents Dermatological Agents
MITOMYCIN INJ 5MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
MITOXANTRON INJ
2MG/ML On formulary, tier change tier 1 to tier 2 Antineoplastics Antineoplastics
MODAFINIL TAB
100MG
On formulary, quantity
limit may apply 30 tablets per 30 days Sleep Disorder Agents Sleep Disorders, Other
MODAFINIL TAB
200MG
On formulary, quantity
limit may apply 30 tablets per 30 days Sleep Disorder Agents Sleep Disorders, Other
Pg. 182 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MOEXIPR/HCTZ TAB 15-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
MOEXIPR/HCTZ TAB 15-
25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
MOEXIPR/HCTZ TAB 7.5-
12.5 On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
MOEXIPRIL TAB 15MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
MOEXIPRIL TAB
7.5MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
MORGIDOX CAP
1X100MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines
MORGIDOX CAP
2X100MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines
Pg. 183 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
100MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 184 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
10MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 185 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
120MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 186 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
20MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 187 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
30MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 188 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
30MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 189 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
45MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 190 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
50MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 191 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
60MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 192 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
60MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 193 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
75MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 194 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
80MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 195 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
90MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
MORPHINE SUL INJ
0.5MG/ML On formulary, tier change tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
0.5MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
10MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
150/30ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
15MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
1MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
Pg. 196 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL INJ
1MG/ML On formulary, tier change tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
25MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
2MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
4MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
50MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
5MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL INJ
8MG/ML
On formulary, requires
prior authorization check with your doctor Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL SOL
100/5ML
On formulary, quantity
limit may apply 270 mls per 30 days Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL SOL
10MG/5ML
On formulary, quantity
limit may apply 2700 mls per 30 days Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL SOL
20MG/5ML On formulary, tier change tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL SOL
20MG/5ML
On formulary, quantity
limit may apply 1350 mls per 30 days Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL TAB
100MG ER
On formulary, quantity
limit may apply 90 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
MORPHINE SUL TAB
15MG On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL TAB
15MG
On formulary, quantity
limit may apply 240 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL TAB
15MG ER
On formulary, quantity
limit may apply 90 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
Pg. 197 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL TAB
30MG On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL TAB
30MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
MORPHINE SUL TAB
30MG ER
On formulary, quantity
limit may apply 90 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
MORPHINE SUL TAB
60MG ER
On formulary, quantity
limit may apply 90 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
MOXEZA SOL 0.5% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents Ophthalmic Anti Infectives
MYCAMINE INJ 50MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals
MYCOPHENOLAT SUS
200MG/ML On formulary, tier change tier 2 to tier 5 Immunological Agents Immune Suppressants
MYRBETRIQ TAB
25MG Not on 2017 formulary
Toviaz, oxybutynin IR,
oxybutynin ER, tolterodine
IR tablets, tolterodine ER
capsules, trospium IR
tablets, trospium ER
capsules Genitourinary Agents Antispasmodics, Urinary
MYRBETRIQ TAB
50MG Not on 2017 formulary
Toviaz, oxybutynin IR,
oxybutynin ER, tolterodine
IR tablets, tolterodine ER
capsules, trospium IR
tablets, trospium ER
capsules Genitourinary Agents Antispasmodics, Urinary
NABUMETONE TAB
500MG
On formulary, quantity
limit may apply 120 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NABUMETONE TAB
750MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NADOLOL TAB 20MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
Pg. 198 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NADOLOL TAB 40MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
NADOLOL/BEND TAB 40-
5MG Not on 2017 formulary
nadolol tablets used in
combination with
hydrochlorothiazide,
propranolol tablets used
in combination with
hydrochlorothiazide,
metoprolol/hydrochlorothi
azide (50-25 mg, 100-25
mg) Cardiovascular Agents
Antihypertensive
Combinations
NADOLOL/BEND TAB 80-
5MG Not on 2017 formulary
nadolol tablets used in
combination with
hydrochlorothiazide,
propranolol tablets used
in combination with
hydrochlorothiazide,
metoprolol/hydrochlorothi
azide (50-25 mg, 100-25
mg) Cardiovascular Agents
Antihypertensive
Combinations
NAFCILLIN INJ 10GM On formulary, tier change tier 2 to tier 5 Antibacterials Beta-lactam, Penicillins
NAFTIFINE CRE HCL
2% Not on 2017 formulary
clotrimazole 1% cream,
ciclopirox 0.77% (cream,
suspension, gel),
ciclopirox solution (or
Ciclodan solution),
econazole 1% cream, 2%
(cream, shampoo) Dermatological Agents Dermatological Agents
Pg. 199 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NAFTIN CRE 2% Not on 2017 formulary
clotrimazole 1% cream,
ciclopirox 0.77% (cream,
suspension, gel),
ciclopirox solution (or
Ciclodan solution),
econazole 1% cream, 2%
(cream, shampoo) Dermatological Agents Dermatological Agents
NALBUPHINE INJ
10MG/ML Not on 2017 formulary check with your doctor Analgesics
Opioid Analgesics, Short-
acting
NALBUPHINE INJ
20MG/ML Not on 2017 formulary check with your doctor Analgesics
Opioid Analgesics, Short-
acting
NALOXONE INJ
1MG/ML On formulary, tier change tier 1 to tier 3
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
NAMENDA XR CAP
14MG Not on 2017 formulary
memantine IR tablets*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antidementia Agents
N-METHYL-D-
ASPARTATE (NMDA)
RECEPTOR
ANTAGONIST
NAMENDA XR CAP
14MG
On formulary, requires
prior authorization check with your doctor Antidementia Agents
N-METHYL-D-
ASPARTATE (NMDA)
RECEPTOR
ANTAGONIST
Pg. 200 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NAMENDA XR CAP
21MG Not on 2017 formulary
memantine IR tablets*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antidementia Agents
N-METHYL-D-
ASPARTATE (NMDA)
RECEPTOR
ANTAGONIST
NAMENDA XR CAP
21MG
On formulary, requires
prior authorization check with your doctor Antidementia Agents
N-METHYL-D-
ASPARTATE (NMDA)
RECEPTOR
ANTAGONIST
NAMENDA XR CAP
28MG Not on 2017 formulary
memantine IR tablets*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antidementia Agents
N-METHYL-D-
ASPARTATE (NMDA)
RECEPTOR
ANTAGONIST
NAMENDA XR CAP
28MG
On formulary, requires
prior authorization check with your doctor Antidementia Agents
N-METHYL-D-
ASPARTATE (NMDA)
RECEPTOR
ANTAGONIST
Pg. 201 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NAMENDA XR CAP
7MG Not on 2017 formulary
memantine IR tablets*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antidementia Agents
N-METHYL-D-
ASPARTATE (NMDA)
RECEPTOR
ANTAGONIST
NAMENDA XR CAP
7MG
On formulary, requires
prior authorization check with your doctor Antidementia Agents
N-METHYL-D-
ASPARTATE (NMDA)
RECEPTOR
ANTAGONIST
NAMENDA XR CAP
TITRATIO
On formulary, requires
prior authorization check with your doctor Antidementia Agents
N-METHYL-D-
ASPARTATE (NMDA)
RECEPTOR
ANTAGONIST
NAPHAZOLINE SOL
0.1% OP On formulary, tier change tier 1 to tier 3 Ophthalmic Agents Ophthalmic Agents, Other
NAPROXEN SUS
125/5ML On formulary, tier change tier 1 to tier 2 Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN SUS
125/5ML
On formulary, quantity
limit may apply 1800 mls per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN TAB
250MG
On formulary, quantity
limit may apply 180 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN TAB
375MG
On formulary, quantity
limit may apply 120 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN TAB
500MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
Pg. 202 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NAPROXEN DR TAB
375MG On formulary, tier change tier 1 to tier 2 Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN DR TAB
375MG
On formulary, quantity
limit may apply 120 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN DR TAB
500MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN SOD TAB
275MG
On formulary, quantity
limit may apply 150 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN SOD TAB
550MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
NATEGLINIDE TAB
120MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
NATEGLINIDE TAB
120MG
On formulary, quantity
limit may apply 90 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
NATEGLINIDE TAB
60MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
NATEGLINIDE TAB
60MG
On formulary, quantity
limit may apply 180 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
NATPARA INJ 25MCG
On formulary, quantity
limit may apply 2 cartridges per 28 days
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
NEBUPENT INH
300MG On formulary, tier change tier 3 to tier 4 Antiparasitics Antiprotozoals
NEFAZODONE TAB
100MG On formulary, tier change tier 2 to tier 4 Antidepressants Antidepressants, Other
NEFAZODONE TAB
150MG On formulary, tier change tier 2 to tier 4 Antidepressants Antidepressants, Other
NEFAZODONE TAB
200MG On formulary, tier change tier 2 to tier 4 Antidepressants Antidepressants, Other
NEFAZODONE TAB
50MG On formulary, tier change tier 1 to tier 2 Antidepressants Antidepressants, Other
NEO/BAC/POLY OIN OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives
Pg. 203 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NEO/POLY GU SOL
40/ML IR On formulary, tier change tier 1 to tier 2 Genitourinary Agents
Genitourinary Agents,
Other
NEO/POLY/BAC OIN /HC
1%OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
NEO/POLY/DEX OIN
0.1% OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
NEO/POLY/HC SUS OP Not on 2017 formulary
sulfacetamide/prednisolon
e solution,
tobramycin/dexamethaso
ne suspension,
neomycin/polymyxin/dexa
methasone suspension Ophthalmic Agents
Ophthalmic Anti-
inflammatories
NEO-POLYCIN OIN HC
1%OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
NEO-POLYCIN OIN OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives
NEPHRAMINE INJ 5.4% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
NESINA TAB 12.5MG Not on 2017 formulary
Tradjenta, Onglyza,
Januvia Blood Glucose Regulators Antidiabetic Agents
NESINA TAB 25MG Not on 2017 formulary
Tradjenta, Onglyza,
Januvia Blood Glucose Regulators Antidiabetic Agents
NESINA TAB 6.25MG Not on 2017 formulary
Tradjenta, Onglyza,
Januvia Blood Glucose Regulators Antidiabetic Agents
NEUPOGEN INJ
300/0.5 Not on 2017 formulary Neulasta, Granix
Blood Products/Modifiers/
Volume Expanders Blood Formation Modifiers
NEUPOGEN INJ
480/0.8 Not on 2017 formulary Neulasta, Granix
Blood Products/Modifiers/
Volume Expanders Blood Formation Modifiers
Pg. 204 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NEUPOGEN INJ
480MCG Not on 2017 formulary Neulasta, Granix
Blood Products/Modifiers/
Volume Expanders Blood Formation Modifiers
NEVANAC SUS 0.1% Not on 2017 formulary
Prolensa, bromfenac
0.09%, diclofenac drops,
flurbiprofen drops,
ketorolac drops, Ilevro Ophthalmic Agents
Ophthalmic Anti-
inflammatories
NEVIRAPINE SUS
50MG/5ML On formulary, tier change tier 2 to tier 4 Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
NEVIRAPINE SUS
50MG/5ML
On formulary, quantity
limit may apply 1200 mls per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
NEVIRAPINE TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
NEVIRAPINE TAB
200MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
NEVIRAPINE TAB
400MG ER
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
NEXAVAR TAB
200MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antineoplastics Antineoplastics
NEXAVAR TAB
200MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
NIACIN TAB 500MG
ER
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents Dyslipidemics, Other
NIACIN ER TAB
1000MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents Dyslipidemics, Other
Pg. 205 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NIACIN ER TAB 500MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents Dyslipidemics, Other
NIACIN ER TAB 750MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents Dyslipidemics, Other
NIACOR TAB 500MG Not on 2017 formulary niacin ER tablets Cardiovascular Agents Dyslipidemics, Other
NICARDIPINE CAP
30MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Calcium Channel Blocking
Agents
NICOTROL INH On formulary, tier change tier 3 to tier 4
Anti-Addiction/Substance
Abuse Treatment Agents
Smoking Cessation
Agents
NIFEDIPINE CAP 10MG Not on 2017 formulary nifedipine ER tablet Cardiovascular Agents
Calcium Channel Blocking
Agents
NIFEDIPINE CAP 20MG Not on 2017 formulary nifedipine ER tablet Cardiovascular Agents
Calcium Channel Blocking
Agents
NILANDRON TAB
150MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
NILUTAMIDE TAB
150MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
NIMODIPINE CAP
30MG Not on 2017 formulary check with your doctor Cardiovascular Agents
Calcium Channel Blocking
Agents
Pg. 206 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NISOLDIPINE TAB
20MG Not on 2017 formulary
amlodipine, diltiazem IR
tablet, diltiazem ER
capsule (generic Cartia-
XT 120mg, 180mg,
240mg, 300mg), diltiazem
ER capsule (generic
Taztia-XT 120mg, 180mg,
240mg, 300mg, 360mg),
diltiazem ER capsule
(generic Dilt-XR 120mg,
180mg, 240mg),
felodipine ER, isradipine,
nicardipine capsule,
nifedipine ER tablet,
verapamil IR and ER Cardiovascular Agents
Calcium Channel Blocking
Agents
Pg. 207 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NISOLDIPINE TAB
30MG Not on 2017 formulary
amlodipine, diltiazem IR
tablet, diltiazem ER
capsule (generic Cartia-
XT 120mg, 180mg,
240mg, 300mg), diltiazem
ER capsule (generic
Taztia-XT 120mg, 180mg,
240mg, 300mg, 360mg),
diltiazem ER capsule
(generic Dilt-XR 120mg,
180mg, 240mg),
felodipine ER, isradipine,
nicardipine capsule,
nifedipine ER tablet,
verapamil IR and ER Cardiovascular Agents
Calcium Channel Blocking
Agents
Pg. 208 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NISOLDIPINE TAB
40MG Not on 2017 formulary
amlodipine, diltiazem IR
tablet, diltiazem ER
capsule (generic Cartia-
XT 120mg, 180mg,
240mg, 300mg), diltiazem
ER capsule (generic
Taztia-XT 120mg, 180mg,
240mg, 300mg, 360mg),
diltiazem ER capsule
(generic Dilt-XR 120mg,
180mg, 240mg),
felodipine ER, isradipine,
nicardipine capsule,
nifedipine ER tablet,
verapamil IR and ER Cardiovascular Agents
Calcium Channel Blocking
Agents
NITROFUR MAC CAP
50MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
NITROFURANTN CAP
100MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
NITROGLYCER INJ
5MG/ML Not on 2017 formulary
Nitrostat tablets,
nitroglycerin lingual spray Cardiovascular Agents
Vasodilators, Direct-acting
Arterial/Venous
NORETHIN ACE TAB
5MG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Progestins
NORMOSOL -M INJ
/D5W On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
NORMOSOL -R INJ
/D5W Not on 2017 formulary D5W/lactated ringers inj
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
Pg. 209 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NORMOSOL-R INJ PH
7.4 Not on 2017 formulary lactated ringers inj
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
NORTRIPTYLIN SOL
10MG/5ML On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics
NORVIR CAP 100MG
On formulary, quantity
limit may apply 360 capsules per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
NORVIR SOL
80MG/ML On formulary, tier change tier 3 to tier 4 Antivirals
Anti-HIV Agents, Protease
Inhibitors
NORVIR SOL
80MG/ML
On formulary, quantity
limit may apply 480 mls per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
NORVIR TAB 100MG
On formulary, quantity
limit may apply 360 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
NOVOFINE MIS
30GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
NOVOFINE MIS
32GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
NOVOFINE AUT MIS
30GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
NOVOFINE PLS MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
NOVOLIN INJ 70/30 Not on 2017 formulary Humulin 70/30 Blood Glucose Regulators Insulins
NOVOLIN N INJ
RELION Not on 2017 formulary Humulin N Blood Glucose Regulators Insulins
NOVOLIN N INJ U-100 Not on 2017 formulary Humulin N Blood Glucose Regulators Insulins
NOVOLIN R INJ
RELION Not on 2017 formulary Humulin R U-100 Blood Glucose Regulators Insulins
NOVOLIN R INJ U-100 Not on 2017 formulary Humulin R U-100 Blood Glucose Regulators Insulins
Pg. 210 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NOVOLIN70/30 INJ
RELION Not on 2017 formulary Humulin 70/30 Blood Glucose Regulators Insulins
NOVOLOG INJ
100/ML Not on 2017 formulary
Humalog (vials or
Kwikpen) Blood Glucose Regulators Insulins
NOVOLOG INJ
FLEXPEN Not on 2017 formulary
Humalog (vials or
Kwikpen) Blood Glucose Regulators Insulins
NOVOLOG MIX INJ
70/30 Not on 2017 formulary
Humalog mix (vials or
Kwikpen) Blood Glucose Regulators Insulins
NOVOLOG MIX INJ
FLEXPEN Not on 2017 formulary
Humalog mix (vials or
Kwikpen) Blood Glucose Regulators Insulins
NOVOTWIST MIS
30GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
NOVOTWIST MIS
32GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
NOXAFIL SUS
40MG/ML On formulary, tier change tier 4 to tier 5 Antifungals Antifungals
NOXAFIL SUS
40MG/ML
On formulary, requires
prior authorization check with your doctor Antifungals Antifungals
NOXAFIL TAB 100MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals
NOXAFIL TAB 100MG
On formulary, requires
prior authorization check with your doctor Antifungals Antifungals
NUCYNTA TAB
100MG Not on 2017 formulary
codeine sulfate,
codeine/acetaminophen,
hydrocodone/acetaminop
hen, hydromorphone,
oxycodone,
oxycodone/acetaminophe
n, morphine sulfate IR
tablets, tramadol,
tramadol/acetaminophen Analgesics
Opioid Analgesics, Short-
acting
Pg. 211 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NUCYNTA TAB 50MG Not on 2017 formulary
codeine sulfate,
codeine/acetaminophen,
hydrocodone/acetaminop
hen, hydromorphone,
oxycodone,
oxycodone/acetaminophe
n, morphine sulfate IR
tablets, tramadol,
tramadol/acetaminophen Analgesics
Opioid Analgesics, Short-
acting
NUCYNTA TAB 75MG Not on 2017 formulary
codeine sulfate,
codeine/acetaminophen,
hydrocodone/acetaminop
hen, hydromorphone,
oxycodone,
oxycodone/acetaminophe
n, morphine sulfate IR
tablets, tramadol,
tramadol/acetaminophen Analgesics
Opioid Analgesics, Short-
acting
NUCYNTA ER TAB
100MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
NUCYNTA ER TAB
150MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
NUCYNTA ER TAB
200MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
NUCYNTA ER TAB
250MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
NUCYNTA ER TAB
50MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
NUTRILIPID EMU 20% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
Pg. 212 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NUTROPIN AQ INJ
20MG/2ML Not on 2017 formulary
Omnitrope inj* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information.
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
NUTROPIN AQ INJ
NUSPIN 5 Not on 2017 formulary
Omnitrope inj* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information.
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
NYSTAT/TRIAM CRE On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
NYSTAT/TRIAM OIN On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
NYSTATIN CRE
100000 On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
NYSTATIN OIN
100000 On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
OCTREOTIDE INJ
1000MCG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
OCTREOTIDE INJ
100MCG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
Pg. 213 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OCTREOTIDE INJ
200MCG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
OCTREOTIDE INJ
500MCG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
OCTREOTIDE INJ
50MCG/ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
OFEV CAP 100MG
On formulary, quantity
limit may apply 60 capsules per 30 days Respiratory Tract Agents
Respiratory Tract Agents,
Other
OFLOXACIN TAB
400MG On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones
OLANZA/FLUOX CAP 12-
25MG Not on 2017 formulary
olanzapine* used in
combination with
fluoxetine *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 214 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OLANZA/FLUOX CAP 12-
50MG Not on 2017 formulary
olanzapine* used in
combination with
fluoxetine *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
OLANZA/FLUOX CAP 3-
25MG Not on 2017 formulary
olanzapine* used in
combination with
fluoxetine *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 215 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OLANZA/FLUOX CAP 6-
25MG Not on 2017 formulary
olanzapine* used in
combination with
fluoxetine *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
OLANZA/FLUOX CAP 6-
50MG Not on 2017 formulary
olanzapine* used in
combination with
fluoxetine *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
OLANZAPINE INJ 10MG
On formulary, quantity
limit may apply 90 vials per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE INJ 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
Pg. 216 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OLANZAPINE TAB
10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
10MG ODT
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
10MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
15MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
15MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
15MG ODT
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
15MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
2.5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
2.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
Pg. 217 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OLANZAPINE TAB
20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
20MG ODT
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
20MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 5MG
ODT
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 5MG
ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
7.5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB
7.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
Pg. 218 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OMEPRA/BICAR CAP 20-
1100 Not on 2017 formulary
esomeprazole (20 mg, 40
mg), lansoprazole (15 mg,
30 mg), Nexium granules
(2.5mg, 5 mg, 10 mg, 20
mg, 40 mg), omeprazole
(10mg, 20 mg, 40 mg),
pantoprazole (20 mg, 40
mg), rabeprazole 20mg Gastrointestinal Agents Proton Pump Inhibitors
OMEPRA/BICAR CAP 40-
1100 Not on 2017 formulary
esomeprazole (20 mg, 40
mg), lansoprazole (15 mg,
30 mg), Nexium granules
(2.5mg, 5 mg, 10 mg, 20
mg, 40 mg), omeprazole
(10mg, 20 mg, 40 mg),
pantoprazole (20 mg, 40
mg), rabeprazole 20mg Gastrointestinal Agents Proton Pump Inhibitors
OMEPRAZOLE CAP
10MG
On formulary, quantity
limit may apply 30 capsules per 30 days Gastrointestinal Agents Proton Pump Inhibitors
OMEPRAZOLE CAP
20MG
On formulary, quantity
limit may apply 60 capsules per 30 days Gastrointestinal Agents Proton Pump Inhibitors
OMEPRAZOLE CAP
40MG
On formulary, quantity
limit may apply 60 capsules per 30 days Gastrointestinal Agents Proton Pump Inhibitors
ONFI SUS
2.5MG/ML
On formulary, quantity
limit may apply 480 mls per 30 days Anticonvulsants Benzodiazepines
ONFI SUS
2.5MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
Pg. 219 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ONFI TAB 10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anticonvulsants Benzodiazepines
ONFI TAB 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
ONFI TAB 20MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anticonvulsants Benzodiazepines
ONFI TAB 20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Anticonvulsants Benzodiazepines
OPANA ER TAB 10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OPANA ER TAB 15MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OPANA ER TAB 20MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OPANA ER TAB 30MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OPANA ER TAB 40MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OPANA ER TAB 5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OPANA ER TAB
7.5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OPSUMIT TAB 10MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Pulmonary
Antihypertensives
OPSUMIT TAB 10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
ORAP TAB 1MG Not on 2017 formulary pimozide 1 mg Antipsychotics 1st Generation/Typical
Pg. 220 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ORAP TAB 2MG Not on 2017 formulary pimozide 2 mg Antipsychotics 1st Generation/Typical
ORAPRED ODT TAB
10MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
ORAPRED ODT TAB
15MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
ORAPRED ODT TAB
30MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
ORENCIA INJ
125MG/ML
On formulary, requires
prior authorization check with your doctor Immunological Agents Immunomodulators
ORENCIA INJ 250MG Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These drugs will need a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents Immunomodulators
Pg. 221 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ORENITRAM TAB
0.125MG Not on 2017 formulary
Adcirca*, Letairis*,
sildenafil*, Tracleer*,
Opsumit* *These drugs
require prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Respiratory Tract Agents
Pulmonary
Antihypertensives
ORENITRAM TAB
0.25MG Not on 2017 formulary
Adcirca*, Letairis*,
sildenafil*, Tracleer*,
Opsumit* *These drugs
require prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Respiratory Tract Agents
Pulmonary
Antihypertensives
Pg. 222 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ORENITRAM TAB 1MG Not on 2017 formulary
Adcirca*, Letairis*,
sildenafil*, Tracleer*,
Opsumit* *These drugs
require prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Respiratory Tract Agents
Pulmonary
Antihypertensives
ORENITRAM TAB
2.5MG Not on 2017 formulary
Adcirca*, Letairis*,
sildenafil*, Tracleer*,
Opsumit* *These drugs
require prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Respiratory Tract Agents
Pulmonary
Antihypertensives
Pg. 223 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ORPHENADRINE INJ
30MG/ML Not on 2017 formulary
tizanidine, diclofenac
tablets, etodolac,
flurbiprofen, ibuprofen,
ketoprofen IR, meloxicam,
nabumetone, naproxen,
oxaprozin, piroxicam,
sulindac, tolmetin 400mg,
celecoxib, diclofenac gel
1% (generic Voltaren)*
*This drug needs a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Skeletal Muscle
Relaxants
Skeletal Muscle
Relaxants
Pg. 224 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ORPHENADRINE TAB
100MG ER Not on 2017 formulary
tizanidine, diclofenac
tablets, etodolac,
flurbiprofen, ibuprofen,
ketoprofen IR, meloxicam,
nabumetone, naproxen,
oxaprozin, piroxicam,
sulindac, tolmetin 400mg,
celecoxib, diclofenac gel
1% (generic Voltaren)*
*This drug needs a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Skeletal Muscle
Relaxants
Skeletal Muscle
Relaxants
OSENI TAB 12.5-15 Not on 2017 formulary
Tradjenta taken in
combination with
pioglitazone, Onglyza
taken in combination with
pioglitazone, Januvia
taken in combination with
pioglitazone Blood Glucose Regulators Antidiabetic Agents
Pg. 225 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OSENI TAB 12.5-30 Not on 2017 formulary
Tradjenta taken in
combination with
pioglitazone, Onglyza
taken in combination with
pioglitazone, Januvia
taken in combination with
pioglitazone Blood Glucose Regulators Antidiabetic Agents
OSENI TAB 12.5-45 Not on 2017 formulary
Tradjenta taken in
combination with
pioglitazone, Onglyza
taken in combination with
pioglitazone, Januvia
taken in combination with
pioglitazone Blood Glucose Regulators Antidiabetic Agents
OSENI TAB 25-
15MG Not on 2017 formulary
Tradjenta taken in
combination with
pioglitazone, Onglyza
taken in combination with
pioglitazone, Januvia
taken in combination with
pioglitazone Blood Glucose Regulators Antidiabetic Agents
OSENI TAB 25-
30MG Not on 2017 formulary
Tradjenta taken in
combination with
pioglitazone, Onglyza
taken in combination with
pioglitazone, Januvia
taken in combination with
pioglitazone Blood Glucose Regulators Antidiabetic Agents
Pg. 226 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OSENI TAB 25-
45MG Not on 2017 formulary
Tradjenta taken in
combination with
pioglitazone, Onglyza
taken in combination with
pioglitazone, Januvia
taken in combination with
pioglitazone Blood Glucose Regulators Antidiabetic Agents
OTREXUP INJ 10MG Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics
OTREXUP INJ
12.5/0.4 Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics
OTREXUP INJ 15MG Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics
OTREXUP INJ
17.5/0.4 Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics
OTREXUP INJ 20MG Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics
OTREXUP INJ
22.5/0.4 Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics
OTREXUP INJ 25MG Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics
OTREXUP INJ 7.5/0.4 Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics
OXALIPLATIN INJ
100MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
OXALIPLATIN INJ 50MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
OXANDROLONE TAB
10MG On formulary, tier change tier 2 to tier 5
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Anabolic Steroids
OXANDROLONE TAB
10MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Anabolic Steroids
Pg. 227 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXANDROLONE TAB
2.5MG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Anabolic Steroids
OXANDROLONE TAB
2.5MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Anabolic Steroids
OXAPROZIN TAB
600MG
On formulary, quantity
limit may apply 90 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
OXAZEPAM CAP
10MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 228 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXAZEPAM CAP
15MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
OXAZEPAM CAP
30MG Not on 2017 formulary
clorazepate*,
clonazepam*, diazepam
(tablets, oral solution, oral
concentrate)*, lorazepam
tablets* *These drugs will
need a prior authorization.
To download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Anxiolytics Benzodiazepines
Pg. 229 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXTELLAR XR TAB
150MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants Sodium Channel Agents
OXTELLAR XR TAB
300MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants Sodium Channel Agents
OXTELLAR XR TAB
600MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants Sodium Channel Agents
OXYBUTYNIN SYP
5MG/5ML
On formulary, quantity
limit may apply 600 mls per 30 days Genitourinary Agents Antispasmodics, Urinary
OXYBUTYNIN TAB
10MG ER
On formulary, quantity
limit may apply 60 tablets per 30 days Genitourinary Agents Antispasmodics, Urinary
OXYBUTYNIN TAB
15MG ER
On formulary, quantity
limit may apply 60 tablets per 30 days Genitourinary Agents Antispasmodics, Urinary
OXYBUTYNIN TAB
5MG On formulary, tier change tier 1 to tier 2 Genitourinary Agents Antispasmodics, Urinary
OXYBUTYNIN TAB
5MG
On formulary, quantity
limit may apply 120 tablets per 30 days Genitourinary Agents Antispasmodics, Urinary
OXYBUTYNIN TAB
5MG ER
On formulary, quantity
limit may apply 30 tablets per 30 days Genitourinary Agents Antispasmodics, Urinary
OXYCOD/APAP TAB 10-
325MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
OXYCOD/APAP TAB 2.5-
325
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
OXYCOD/APAP TAB 5-
325MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
Pg. 230 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXYCOD/APAP TAB 7.5-
325
On formulary, quantity
limit may apply 240 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
OXYCOD/ASA TAB
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
OXYCOD/IBU TAB 5-
400MG Not on 2017 formulary
codeine sulfate,
codeine/acetaminophen,
hydrocodone/acetaminop
hen, hydromorphone,
oxycodone,
oxycodone/acetaminophe
n, morphine sulfate IR
tablets, tramadol,
tramadol/acetaminophen Analgesics
Opioid Analgesics, Short-
acting
OXYCODONE CAP
5MG Not on 2017 formulary oxycodone 5 mg tablet Analgesics
Opioid Analgesics, Short-
acting
OXYCODONE TAB
10MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
OXYCODONE TAB
15MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
OXYCODONE TAB
20MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
OXYCODONE TAB
30MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
OXYCODONE TAB
5MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
OXYCONTIN TAB
10MG CR
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OXYCONTIN TAB
15MG CR
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OXYCONTIN TAB
20MG CR
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
Pg. 231 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXYCONTIN TAB
30MG CR
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OXYCONTIN TAB
40MG CR
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OXYCONTIN TAB
60MG CR
On formulary, quantity
limit may apply 120 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OXYCONTIN TAB
80MG CR
On formulary, quantity
limit may apply 120 tablets per 30 days Analgesics
Opioid Analgesics, Long-
acting
OXYMORPHONE TAB
10MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 232 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXYMORPHONE TAB
15MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 233 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXYMORPHONE TAB
20MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 234 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXYMORPHONE TAB
30MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 235 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXYMORPHONE TAB
40MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 236 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXYMORPHONE TAB
5MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
Pg. 237 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXYMORPHONE TAB
7.5MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), Nucynta ER,
tramadol ER, morphine
sulfate ER tablets,
methadone tablets,
Opana ER (crush
resistant), Oxycontin,
Zohydro ER* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Analgesics
Opioid Analgesics, Long-
acting
OXYMORPHONE TAB
HCL 10MG Not on 2017 formulary
codeine sulfate,
codeine/acetaminophen,
hydrocodone/acetaminop
hen, hydromorphone,
oxycodone,
oxycodone/acetaminophe
n, morphine sulfate IR
tablets, tramadol,
tramadol/acetaminophen Analgesics
Opioid Analgesics, Short-
acting
Pg. 238 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OXYMORPHONE TAB
HCL 5MG Not on 2017 formulary
codeine sulfate,
codeine/acetaminophen,
hydrocodone/acetaminop
hen, hydromorphone,
oxycodone,
oxycodone/acetaminophe
n, morphine sulfate IR
tablets, tramadol,
tramadol/acetaminophen Analgesics
Opioid Analgesics, Short-
acting
PACERONE TAB
100MG Not on 2017 formulary
amiodarone tablets (200
mg, 400 mg) Cardiovascular Agents Antiarrhythmics
PACLITAXEL INJ
150/25ML Not on 2017 formulary
paclitaxel inj
(30mg/5mL,100mg/16.7m
L, 300mg/50mL) Antineoplastics Antineoplastics
PALIPERIDONE TAB ER
1.5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
PALIPERIDONE TAB ER
1.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
PALIPERIDONE TAB ER
3MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
PALIPERIDONE TAB ER
3MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
PALIPERIDONE TAB ER
6MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 239 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PALIPERIDONE TAB ER
6MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
PALIPERIDONE TAB ER
9MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
PALIPERIDONE TAB ER
9MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
PAMIDRONATE INJ
30/10ML Not on 2017 formulary zoledronic acid injection
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
PAMIDRONATE INJ
6MG/ML Not on 2017 formulary zoledronic acid injection
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
PAMIDRONATE INJ
90/10ML Not on 2017 formulary zoledronic acid injection
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
PANRETIN GEL 0.1% On formulary, tier change tier 4 to tier 5 Dermatological Agents Dermatological Agents
PAROXETIN ER TAB
12.5MG Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PAROXETIN ER TAB
37.5MG Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PAROXETINE TAB
10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PAROXETINE TAB
20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PAROXETINE TAB
25MG ER Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 240 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PAROXETINE TAB
30MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PAROXETINE TAB
40MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PAXIL SUS
10MG/5ML
On formulary, quantity
limit may apply 900 mls per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PEDIAPRED SOL
6.7/5ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PEGASYS INJ
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEGASYS INJ
180MCG/M
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEGASYS INJ
PROCLICK
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEGINTRON KIT
120MCG
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEGINTRON KIT
150MCG
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEGINTRON KIT
50MCG
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEGINTRON KIT
80MCG
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEG-INTRON KIT 120
RP
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEG-INTRON KIT
120MCG
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEG-INTRON KIT 150
RP
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEG-INTRON KIT
150MCG
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
Pg. 241 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PEG-INTRON KIT
50MCG
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEG-INTRON KIT
50MCG RP
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEG-INTRON KIT
80MCG
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEG-INTRON KIT
80MCG RP
On formulary, requires
prior authorization check with your doctor Antivirals Antihepatitis Agents
PEN G SOD INJ
5000000 On formulary, tier change tier 1 to tier 4 Antibacterials Beta-lactam, Penicillins
PEN NEEDLE MIS
29GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLE MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
29GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
29GX10MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
29GX12.7 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
30GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
31GX1/4" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
31GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 242 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PEN NEEDLES MIS
31GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
31GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
32GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
32GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PEN NEEDLES MIS
32GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PENICILLN GK INJ 5MU On formulary, tier change tier 1 to tier 2 Antibacterials Beta-lactam, Penicillins
PENTAM 300 INJ
300MG
On formulary, requires
prior authorization check with your doctor Antiparasitics Antiprotozoals
PENTAZ/NALOX TAB 50-
0.5MG Not on 2017 formulary
codeine/acetaminophen,
ibuprofen, naproxen,
meloxicam, diclofenac,
nabumetone, etodolac IR,
sulindac,
hydrocodone/acetaminop
hen (5/300, 7.5/300,
10/300, 5/325, 7.5/325,
10/325),
oxycodone/acetaminophe
n (2.5/325, 5/325,
7.5/325, 10/325) Analgesics
Opioid Analgesics, Short-
acting
PENTIPS MIS
29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 243 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PENTIPS MIS
31GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PENTIPS MIS
31GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PENTIPS MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PENTIPS MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PERINDOPRIL TAB
2MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
PERINDOPRIL TAB
4MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
PERINDOPRIL TAB
8MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
PERPHEN/AMIT TAB 2-
10MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule,
mirtazapine, bupropion Antipsychotics 1st Generation/Typical
Pg. 244 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PERPHEN/AMIT TAB 2-
25MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule,
mirtazapine, bupropion Antipsychotics 1st Generation/Typical
PERPHEN/AMIT TAB 4-
10MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule,
mirtazapine, bupropion Antipsychotics 1st Generation/Typical
PERPHEN/AMIT TAB 4-
25MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule,
mirtazapine, bupropion Antipsychotics 1st Generation/Typical
Pg. 245 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PERPHEN/AMIT TAB 4-
50MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule,
mirtazapine, bupropion Antipsychotics 1st Generation/Typical
PERPHENAZINE TAB
16MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
PERPHENAZINE TAB
2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
PERPHENAZINE TAB
4MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
PERPHENAZINE TAB
8MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
PEXEVA TAB 10MG Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PEXEVA TAB 20MG Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 246 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PEXEVA TAB 30MG Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PEXEVA TAB 40MG Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PHENADOZ SUP
12.5MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines
PHENADOZ SUP
12.5MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents Antihistamines
PHENERGAN SUP
12.5MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines
PHENERGAN SUP
12.5MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents Antihistamines
PHENERGAN SUP
50MG Not on 2017 formulary check with your doctor Respiratory Tract Agents Antihistamines
PHENOBARB ELX
20MG/5ML On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
PHENOBARB SOL
20MG/5ML On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
PHENOBARB TAB
100MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
PHENOBARB TAB
15MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
PHENOBARB TAB
16.2MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
PHENOBARB TAB
30MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
PHENOBARB TAB
32.4MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
Pg. 247 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PHENOBARB TAB
60MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
PHENOBARB TAB
64.8MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
PHENOBARB TAB
97.2MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates
PHENYTOIN INJ
50MG/ML Not on 2017 formulary
phenytoin (chewable
tablets, ER capsules,
125/5 mL suspension) Anticonvulsants Sodium Channel Agents
PHILITH TAB 0.4-35 On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Contraceptives
PHOSPHOLINE SOL
0.125%OP On formulary, tier change tier 3 to tier 4 Ophthalmic Agents
Ophthalmic Antiglaucoma
Agents
PHYSIOLYTE SOL Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous
PHYSIOSOL SOL
IRRIGAT Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous
PICATO GEL 0.015%
On formulary, quantity
limit may apply 3 tubes per 30 days Dermatological Agents Dermatological Agents
PICATO GEL 0.05%
On formulary, quantity
limit may apply 2 tubes per 30 days Dermatological Agents Dermatological Agents
PINDOLOL TAB 10MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
PINDOLOL TAB 5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
PIOGLIT/GLIM TAB 30-
2MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
PIOGLIT/GLIM TAB 30-
2MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
Pg. 248 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PIOGLIT/GLIM TAB 30-
4MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
PIOGLIT/GLIM TAB 30-
4MG
On formulary, quantity
limit may apply 30 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
PIOGLITA/MET TAB 15-
500MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
PIOGLITA/MET TAB 15-
500MG
On formulary, quantity
limit may apply 90 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
PIOGLITA/MET TAB 15-
850MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
PIOGLITA/MET TAB 15-
850MG
On formulary, quantity
limit may apply 90 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
PIOGLITAZONE TAB
15MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
PIOGLITAZONE TAB
15MG
On formulary, quantity
limit may apply 90 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
PIOGLITAZONE TAB
30MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
PIOGLITAZONE TAB
30MG
On formulary, quantity
limit may apply 30 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
PIOGLITAZONE TAB
45MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
PIOGLITAZONE TAB
45MG
On formulary, quantity
limit may apply 30 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
PIROXICAM CAP
10MG
On formulary, quantity
limit may apply 60 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
PIROXICAM CAP
20MG On formulary, tier change tier 1 to tier 2 Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
PIROXICAM CAP
20MG
On formulary, quantity
limit may apply 30 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
Pg. 249 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PLASMA-LYTE INJ -148 Not on 2017 formulary lactated ringers inj
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
PLASMA-LYTE INJ
56/D5W Not on 2017 formulary D5W/lactated ringers inj
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
PODOFILOX SOL 0.5% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
POLY-DEX OIN 0.1%
OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
POMALYST CAP 1MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antineoplastics
POMALYST CAP 1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
POMALYST CAP 2MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antineoplastics
POMALYST CAP 2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
POMALYST CAP 3MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antineoplastics
POMALYST CAP 3MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
POMALYST CAP 4MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antineoplastics
Pg. 250 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
POMALYST CAP 4MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
POT CHLORIDE INJ
10MEQ Not on 2017 formulary
potassium chloride inj 2
mEq/mL
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
POT CHLORIDE INJ
20MEQ Not on 2017 formulary
potassium chloride inj 2
mEq/mL
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
POT CHLORIDE TAB
10MEQ CR On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
POT CHLORIDE TAB
10MEQ ER On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
POT CHLORIDE TAB
8MEQ ER On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
POT CHLORIDE TAB
8MEQ SR On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
POT CL MICRO TAB
10MEQ CR On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
POT CL MICRO TAB
10MEQ ER On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
POTIGA TAB 200MG On formulary, tier change tier 3 to tier 4 Anticonvulsants Anticonvulsants, Other
POTIGA TAB 300MG On formulary, tier change tier 3 to tier 4 Anticonvulsants Anticonvulsants, Other
POTIGA TAB 400MG On formulary, tier change tier 3 to tier 4 Anticonvulsants Anticonvulsants, Other
POTIGA TAB 50MG On formulary, tier change tier 3 to tier 4 Anticonvulsants Anticonvulsants, Other
PRADAXA CAP 75MG
On formulary, quantity
limit may apply 60 capsules per 30 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
PRANDIMET TAB 1-
500MG Not on 2017 formulary
repaglinide tablets used in
combination with
metformin tablets Blood Glucose Regulators Antidiabetic Agents
Pg. 251 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PRANDIMET TAB 2-
500MG Not on 2017 formulary
repaglinide tablets used in
combination with
metformin tablets Blood Glucose Regulators Antidiabetic Agents
PRAVASTATIN TAB
10MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
PRAVASTATIN TAB
10MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
PRAVASTATIN TAB
20MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
PRAVASTATIN TAB
20MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
PRAVASTATIN TAB
40MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
PRAVASTATIN TAB
40MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
PRAVASTATIN TAB
80MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
PRAVASTATIN TAB
80MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
PRAZOSIN HCL CAP
1MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
PRAZOSIN HCL CAP
2MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
PRAZOSIN HCL CAP
5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
PRED SOD PHO SOL 1%
OP Not on 2017 formulary
dexamethasone drops,
Lotemax, Durezol,
fluorometholone drops,
prednisolone suspension
1% drops Ophthalmic Agents
Ophthalmic Anti-
inflammatories
Pg. 252 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PRED SOD PHO SOL
5MG/5ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNICARBAT CRE
0.1% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
PREDNICARBAT OIN
0.1% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
PREDNISOLONE SOL
15MG/5ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISOLONE SOL
25MG/5ML Not on 2017 formulary
prednisolone solution
(15mg/5mL, 5mg/mL),
prednisolone syrup
15mg/5mL
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISOLONE SYP
15MG/5ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISOLONE TAB
10MG ODT Not on 2017 formulary
prednisolone solution
(15mg/5mL, 5mg/mL),
prednisolone syrup
15mg/5mL
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISOLONE TAB
10MG ODT
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISOLONE TAB
15MG ODT Not on 2017 formulary
prednisolone solution
(15mg/5mL, 5mg/mL),
prednisolone syrup
15mg/5mL
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISOLONE TAB
15MG ODT
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
Pg. 253 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PREDNISOLONE TAB
30MG ODT Not on 2017 formulary
prednisolone solution
(15mg/5mL, 5mg/mL),
prednisolone syrup
15mg/5mL
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISOLONE TAB
30MG ODT
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISONE SOL
5MG/5ML On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISONE SOL
5MG/5ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISONE TAB
10MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISONE TAB
1MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISONE TAB
2.5MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISONE TAB
20MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISONE TAB
50MG On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREDNISONE TAB
50MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
Pg. 254 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PREDNISONE TAB
5MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
PREGNYL INJ
10000UNT
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
PREMARIN INJ 25MG Not on 2017 formulary check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMARIN TAB
0.3MG On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMARIN TAB
0.45MG On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMARIN TAB
0.625MG On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMARIN TAB
0.9MG On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMARIN TAB
1.25MG On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
Pg. 255 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PREMASOL SOL 6% On formulary, tier change tier 1 to tier 2
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
PREMPHASE TAB On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMPRO TAB .625-
2.5 On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMPRO TAB 0.3-
1.5 On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMPRO TAB 0.45-
1.5 On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMPRO TAB 0.625-
5 On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PRENATAL TAB 27-
1MG Not on 2017 formulary check with your doctor
Therapeutic Nutrients/
Minerals/ Electrolytes Vitamins
PREP PADS PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PREPLUS TAB 27-
1MG Not on 2017 formulary check with your doctor
Therapeutic Nutrients/
Minerals/ Electrolytes Vitamins
Pg. 256 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PREPOPIK PAK Not on 2017 formulary
Suprep, PEG-3350,
Gavilyte-N, Gavilyte-G,
Gavilyte-C, Trilyte,
Moviprep Gastrointestinal Agents Laxatives
PREZISTA SUS
100MG/ML On formulary, tier change tier 4 to tier 5 Antivirals
Anti-HIV Agents, Protease
Inhibitors
PREZISTA SUS
100MG/ML
On formulary, quantity
limit may apply 400 mls per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
PREZISTA TAB
150MG On formulary, tier change tier 3 to tier 4 Antivirals
Anti-HIV Agents, Protease
Inhibitors
PREZISTA TAB
150MG
On formulary, quantity
limit may apply 180 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
PREZISTA TAB
600MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
PREZISTA TAB 75MG
On formulary, quantity
limit may apply 300 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
PREZISTA TAB
800MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
PRISTIQ TAB 100MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PRISTIQ TAB 25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
PRISTIQ TAB 50MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 257 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PRIVIGEN INJ
20GRAMS Not on 2017 formulary
Gammaplex*, Gamunex-
C* *These drugs require a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents
Immunizing Agents,
Passive
PRO COMFORT PAD
ALCOHOL On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
PROAIR HFA AER
On formulary, quantity
limit may apply 2 canisters per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
PROCAINAMIDE INJ
100MG/ML Not on 2017 formulary
quinidine gluconate CR
tablet 324mg, quinidine
sulfate tablet 200mg Cardiovascular Agents Antiarrhythmics
PROCALAMINE INJ 3% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
PROCRIT INJ
2000/ML On formulary, tier change tier 3 to tier 4
Blood Products/Modifiers/
Volume Expanders Blood Formation Modifiers
PROCRIT INJ
3000/ML On formulary, tier change tier 3 to tier 4
Blood Products/Modifiers/
Volume Expanders Blood Formation Modifiers
PROCYSBI CAP 25MG Not on 2017 formulary Cystagon Genitourinary Agents
Genitourinary Agents,
Other
PROCYSBI CAP 75MG Not on 2017 formulary Cystagon Genitourinary Agents
Genitourinary Agents,
Other
Pg. 258 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PROGLYCEM SUS
50MG/ML On formulary, tier change tier 3 to tier 4 Blood Glucose Regulators Glycemic Agents
PROLASTIN-C INJ
1000MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Respiratory Tract Agents,
Other
PROLIA SOL
60MG/ML
On formulary, requires
prior authorization check with your doctor
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
PROMACTA TAB
12.5MG
On formulary, requires
prior authorization check with your doctor
Blood Products/Modifiers/
Volume Expanders Blood Formation Modifiers
PROMACTA TAB
25MG
On formulary, requires
prior authorization check with your doctor
Blood Products/Modifiers/
Volume Expanders Blood Formation Modifiers
PROMACTA TAB
50MG
On formulary, requires
prior authorization check with your doctor
Blood Products/Modifiers/
Volume Expanders Blood Formation Modifiers
PROMACTA TAB
75MG
On formulary, requires
prior authorization check with your doctor
Blood Products/Modifiers/
Volume Expanders Blood Formation Modifiers
PROMETHAZINE INJ
25MG/ML Not on 2017 formulary check with your doctor Respiratory Tract Agents Antihistamines
PROMETHAZINE INJ
50MG/ML Not on 2017 formulary check with your doctor Respiratory Tract Agents Antihistamines
PROMETHAZINE SOL
6.25/5ML On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines
PROMETHAZINE SUP
12.5MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines
PROMETHAZINE SUP
12.5MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents Antihistamines
PROMETHAZINE SUP
50MG Not on 2017 formulary check with your doctor Respiratory Tract Agents Antihistamines
PROMETHAZINE SYP
6.25/5ML On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines
PROMETHAZINE TAB
12.5MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines
Pg. 259 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PROMETHAZINE TAB
25MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines
PROMETHAZINE TAB
50MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines
PROMETHEGAN SUP
12.5MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines
PROMETHEGAN SUP
12.5MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents Antihistamines
PROMETHEGAN SUP
50MG Not on 2017 formulary check with your doctor Respiratory Tract Agents Antihistamines
PROPRAN/HCTZ TAB
40/25 Not on 2017 formulary
propranolol tablets used
in combination with
hydrochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
PROPRAN/HCTZ TAB
80/25 Not on 2017 formulary
propranolol tablets used
in combination with
hydrochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
PROPRANOLOL INJ
1MG/ML On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
PROPRANOLOL SOL
20MG/5ML Not on 2017 formulary
propranolol IR tablets and
ER capsules (60mg,
80mg, 120mg, 160mg) Cardiovascular Agents
Beta-adrenergic Blocking
Agents
PROPRANOLOL SOL
40MG/5ML Not on 2017 formulary
propranolol IR tablets and
ER capsules (60mg,
80mg, 120mg, 160mg) Cardiovascular Agents
Beta-adrenergic Blocking
Agents
PROPRANOLOL TAB
10MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
PROPRANOLOL TAB
20MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
PROPRANOLOL TAB
40MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
Pg. 260 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PROPRANOLOL TAB
80MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
PROSOL INJ 20% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
PULMICORT INH
180MCG Not on 2017 formulary
Arnuity Ellipta, Flovent
(Diskus, HFA), Asmanex
(HFA, Twisthaler), Qvar Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
PULMICORT INH
90MCG Not on 2017 formulary
Arnuity Ellipta, Flovent
(Diskus, HFA), Asmanex
(HFA, Twisthaler), Qvar Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
PULMICORT SUS
0.25MG/2
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
PULMICORT SUS
0.5MG/2
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
PULMICORT SUS
1MG/2ML Not on 2017 formulary
budesonide 1 mg/2 mL
suspension* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
PULMICORT SUS
1MG/2ML
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
Pg. 261 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PURIXAN SUS
20MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antimetabolites
QC ALCOHOL PAD
SWABS On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
QNAPRIL/HCTZ TAB 10-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
QNAPRIL/HCTZ TAB 20-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
QNAPRIL/HCTZ TAB 20-
25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
QUDEXY XR CAP
100/24HR Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
QUDEXY XR CAP
150/24HR Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
QUDEXY XR CAP
200/24HR Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
QUDEXY XR CAP
25/24HR Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
QUDEXY XR CAP
50/24HR Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
Pg. 262 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
QUETIAPINE TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
200MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
200MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
25MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
300MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
300MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
400MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
400MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
Pg. 263 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
QUETIAPINE TAB
50MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB
50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
QUINAPRIL TAB 10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
QUINAPRIL TAB 20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
QUINAPRIL TAB 40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
QUINAPRIL TAB 5MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
QUINIDINE SU TAB
200MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents Antiarrhythmics
QUINIDINE SU TAB
300MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents Antiarrhythmics
QUININE SULF CAP
324MG Not on 2017 formulary check with your doctor Antiparasitics Antiprotozoals
QVAR AER 40MCG
On formulary, quantity
limit may apply 1 canister per 30 days Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
QVAR AER 80MCG
On formulary, quantity
limit may apply 2 canisters per 30 days Respiratory Tract Agents
Anti-inflammatories,
Inhaled Corticosteroids
RA ALCOHOL PAD
SWABS On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
RA PEN NEEDL MIS
31GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
RA STERILE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 264 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
RABAVERT INJ
On formulary, requires
prior authorization check with your doctor Immunological Agents Vaccines
RAMIPRIL CAP
1.25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
RAMIPRIL CAP 10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
RAMIPRIL CAP 2.5MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
RAMIPRIL CAP 5MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
RANITIDINE INJ
150/6ML Not on 2017 formulary
ranitidine (tablets,
capsules) Gastrointestinal Agents
Histamine2 (H2) Receptor
Antagonists
RANITIDINE INJ
50MG/2ML Not on 2017 formulary
ranitidine (tablets,
capsules) Gastrointestinal Agents
Histamine2 (H2) Receptor
Antagonists
RAPAFLO CAP 4MG
On formulary, quantity
limit may apply 30 capsules per 30 days Genitourinary Agents
Benign Prostatic
Hypertrophy Agents
RAPAFLO CAP 8MG
On formulary, quantity
limit may apply 30 capsules per 30 days Genitourinary Agents
Benign Prostatic
Hypertrophy Agents
RAPAMUNE SOL
1MG/ML On formulary, tier change tier 3 to tier 5 Immunological Agents Immune Suppressants
RAVICTI LIQ
1.1GM/ML Not on 2017 formulary Buphenyl 500mg tablet
Enzyme Replacement/
Modifiers
Enzyme Replacement/
Modifiers
REALITY SWAB PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
REGRANEX GEL
0.01%
On formulary, requires
prior authorization check with your doctor Dermatological Agents Dermatological Agents
REGRANEX GEL
0.01%
On formulary, quantity
limit may apply 15 grams per 30 days Dermatological Agents Dermatological Agents
RELENZA MIS
DISKHALE Not on 2017 formulary Tamiflu Antivirals Anti-influenza Agents
Pg. 265 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
RELION PEN MIS
29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
RELION PEN MIS
31GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
RELION PEN MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
RELION PEN MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
RELISTOR INJ
12/0.6ML
On formulary, requires
prior authorization check with your doctor Gastrointestinal Agents
Gastrointestinal Agents,
Other
RELPAX TAB 20MG Not on 2017 formulary
naratriptan (1 mg, 2.5
mg), rizatriptan (5 mg, 10
mg, 5 mg ODT, 10 mg
ODT), sumatriptan nasal
spray (5 mg, 20 mg),
sumatriptan inj (4 mg/0.5
mL, 6 mg/0.5 mL),
sumatriptan tablets (25
mg, 50 mg, 100 mg) Antimigraine Agents
Serotonin (5-HT) 1b/1d
Receptor Agonists
RELPAX TAB 40MG Not on 2017 formulary
naratriptan (1 mg, 2.5
mg), rizatriptan (5 mg, 10
mg, 5 mg ODT, 10 mg
ODT), sumatriptan nasal
spray (5 mg, 20 mg),
sumatriptan inj (4 mg/0.5
mL, 6 mg/0.5 mL),
sumatriptan tablets (25
mg, 50 mg, 100 mg) Antimigraine Agents
Serotonin (5-HT) 1b/1d
Receptor Agonists
RENVELA PAK 0.8GM On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders
Pg. 266 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
RENVELA PAK 2.4GM On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders
RENVELA TAB
800MG On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders
REPAGLINIDE TAB
0.5MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
REPAGLINIDE TAB
0.5MG
On formulary, quantity
limit may apply 960 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
REPAGLINIDE TAB 1-
500MG Not on 2017 formulary
repaglinide tablets used in
combination with
metformin tablets Blood Glucose Regulators Antidiabetic Agents
REPAGLINIDE TAB 1MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
REPAGLINIDE TAB 1MG
On formulary, quantity
limit may apply 480 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
REPAGLINIDE TAB 2-
500MG Not on 2017 formulary
repaglinide tablets used in
combination with
metformin tablets Blood Glucose Regulators Antidiabetic Agents
REPAGLINIDE TAB 2MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
REPAGLINIDE TAB 2MG
On formulary, quantity
limit may apply 240 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
RESCRIPTOR TAB 100
MG On formulary, tier change tier 3 to tier 4 Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
RESCRIPTOR TAB 100
MG
On formulary, quantity
limit may apply 360 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
RESCRIPTOR TAB
200MG On formulary, tier change tier 3 to tier 4 Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
Pg. 267 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
RESCRIPTOR TAB
200MG
On formulary, quantity
limit may apply 180 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
RESERPINE TAB
0.1MG Not on 2017 formulary
clonidine IR tablet,
hydrochlorothiazide, an
ACEI (lisinopril, ramipril,
benazepril), an ARB
(losartan, irbesartan),
beta-blocker (atenolol,
metoprolol), calcium
channel blocker
(amlodipine or nifedipine
ER) Cardiovascular Agents
Cardiovascular Agents,
Other
RESTASIS EMU 0.05% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents Ophthalmic Agents, Other
RESTASIS EMU 0.05%
On formulary, requires
prior authorization check with your doctor Ophthalmic Agents Ophthalmic Agents, Other
RESTASIS EMU 0.05%
On formulary, quantity
limit may apply 60 vials per 30 days Ophthalmic Agents Ophthalmic Agents, Other
REVLIMID CAP 10MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antiangiogenic Agents
REVLIMID CAP 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
REVLIMID CAP 15MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antiangiogenic Agents
REVLIMID CAP 15MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
Pg. 268 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
REVLIMID CAP 2.5MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antiangiogenic Agents
REVLIMID CAP 2.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
REVLIMID CAP 20MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antiangiogenic Agents
REVLIMID CAP 20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
REVLIMID CAP 25MG
On formulary, quantity
limit may apply 21 capsules per 28 days Antineoplastics Antiangiogenic Agents
REVLIMID CAP 25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
REVLIMID CAP 5MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antiangiogenic Agents
REVLIMID CAP 5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
REYATAZ CAP
150MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
REYATAZ CAP
200MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
REYATAZ CAP
300MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
Pg. 269 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
REYATAZ POW
50MG
On formulary, quantity
limit may apply 240 packets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
RHEUMATREX TAB
2.5MG Not on 2017 formulary methotrexate tablet Antineoplastics Antineoplastics
RIBAPAK PAK
1000/DAY Not on 2017 formulary
ribavirin tablet and
capsule, Ribasphere
tablet, Ribapak (800/day
and 1200/day) Antivirals Antihepatitis Agents
RIBASPHERE TAB
400MG On formulary, tier change tier 2 to tier 4 Antivirals Antihepatitis Agents
RIFAMPIN CAP
150MG On formulary, tier change tier 1 to tier 2 Antimycobacterials Antituberculars
RIFAMPIN INJ 600 MG On formulary, tier change tier 1 to tier 2 Antimycobacterials Antituberculars
RIFATER TAB Not on 2017 formulary
isoniazid tablets in
combination with rifampin
capsules Antimycobacterials Antituberculars
RIMANTADINE TAB
100MG On formulary, tier change tier 1 to tier 2 Antivirals Anti-influenza Agents
RINGERS INJ Not on 2017 formulary lactated ringers inj
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
RINGERS IRR SOL Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous
RIOMET SOL Not on 2017 formulary
metformin tablet IR and
ER (500 mg, 750 mg
[generic Glucophage XR]) Blood Glucose Regulators Antidiabetic Agents
RIOMET SOL
500/5ML Not on 2017 formulary
metformin tablet IR and
ER (500 mg, 750 mg
[generic Glucophage XR]) Blood Glucose Regulators Antidiabetic Agents
RISEDRON SOD TAB
35MG DR
On formulary, quantity
limit may apply 4 tablets per 28 days
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
Pg. 270 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
RISEDRONATE TAB
150MG
On formulary, quantity
limit may apply 1 tablet per 28 days
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
RISPERDAL INJ
12.5MG
On formulary, quantity
limit may apply 2 vials per 28 days Antipsychotics 2nd Generation/Atypical
RISPERDAL INJ
12.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERDAL INJ 25MG
On formulary, quantity
limit may apply 2 vials per 28 days Antipsychotics 2nd Generation/Atypical
RISPERDAL INJ 25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERDAL INJ
37.5MG
On formulary, quantity
limit may apply 2 vials per 28 days Antipsychotics 2nd Generation/Atypical
RISPERDAL INJ
37.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERDAL INJ 50MG
On formulary, quantity
limit may apply 2 vials per 28 days Antipsychotics 2nd Generation/Atypical
RISPERDAL INJ 50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE SOL
1MG/ML
On formulary, quantity
limit may apply 480 mls per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 271 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
RISPERIDONE SOL
1MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 0.25
ODT
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 0.25
ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
0.25MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
0.25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
0.5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
0.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
0.5MG OD
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
0.5MG OD
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
1MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 272 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
RISPERIDONE TAB
1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
1MG ODT
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
1MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
2MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
2MG ODT
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
2MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
3MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
3MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
3MG ODT
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 273 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
RISPERIDONE TAB
3MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
4MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
4MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
4MG ODT
On formulary, quantity
limit may apply 120 tablets per 30 days Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB
4MG ODT
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
RITUXAN INJ 100MG On formulary, tier change tier 3 to tier 5 Antineoplastics Antineoplastics
RITUXAN INJ 100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
RITUXAN INJ 500MG On formulary, tier change tier 3 to tier 5 Antineoplastics Antineoplastics
RITUXAN INJ 500MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
ROMYCIN OIN OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives
ROSUVASTATIN TAB
10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ROSUVASTATIN TAB
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
Pg. 274 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ROSUVASTATIN TAB
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ROSUVASTATIN TAB
5MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
ROTATEQ SOL On formulary, tier change tier 3 to tier 4 Immunological Agents Vaccines
ROXICET TAB 5-
325MG
On formulary, quantity
limit may apply 360 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
ROZEREM TAB 8MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents
GABA Receptor
Modulators
SAIZEN INJ 5MG Not on 2017 formulary
Omnitrope inj* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information.
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
SAIZEN INJ 8.8MG Not on 2017 formulary
Omnitrope inj* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information.
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Pituitary)
Pg. 275 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SANCUSO DIS 3.1MG Not on 2017 formulary
granisetron tablets*,
ondansetron (ODT,
tablets, solution)* *These
drugs require a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Antiemetics
Emetogenic Therapy
Adjuncts
SANDIMMUNE CAP
100MG Not on 2017 formulary
cyclosporine 100 mg
capsules* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Immunological Agents Immune Suppressants
Pg. 276 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SANDIMMUNE CAP
25MG Not on 2017 formulary
cyclosporine 25 mg
capsules* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Immunological Agents Immune Suppressants
SANDOSTATIN KIT LAR
10MG Not on 2017 formulary
Somatuline inj*,
Octreotide inj*, Signifor
inj*, Signifor LAR inj*
*These drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
Pg. 277 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SANDOSTATIN KIT LAR
20MG Not on 2017 formulary
Somatuline inj*,
Octreotide inj*, Signifor
inj*, Signifor LAR inj*
*These drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SANDOSTATIN KIT LAR
30MG Not on 2017 formulary
Somatuline inj*,
Octreotide inj*, Signifor
inj*, Signifor LAR inj*
*These drugs require prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SAPHRIS SUB 10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
SAPHRIS SUB 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
Pg. 278 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SAPHRIS SUB 2.5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
SAPHRIS SUB 2.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
SAPHRIS SUB 5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
SAPHRIS SUB 5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
SAPS CARE PAD
ALCOHOL On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SAVELLA MIS TITR
PAK Not on 2017 formulary
gabapentin, Lyrica,
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ),and ER capsule
Central Nervous System
Agents Fibromyalgia Agents
SAVELLA TAB 100MG Not on 2017 formulary
gabapentin, Lyrica,
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ),and ER capsule
Central Nervous System
Agents Fibromyalgia Agents
Pg. 279 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SAVELLA TAB
12.5MG Not on 2017 formulary
gabapentin, Lyrica,
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ),and ER capsule
Central Nervous System
Agents Fibromyalgia Agents
SAVELLA TAB 25MG Not on 2017 formulary
gabapentin, Lyrica,
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ),and ER capsule
Central Nervous System
Agents Fibromyalgia Agents
SAVELLA TAB 50MG Not on 2017 formulary
gabapentin, Lyrica,
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ),and ER capsule
Central Nervous System
Agents Fibromyalgia Agents
SB ALCOHOL PAD
PREP On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SECONAL CAP
100MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Barbiturates
SECONAL SOD CAP
100MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Barbiturates
Pg. 280 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SELENIUM SUL LOT
2.5% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
SELZENTRY TAB
150MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals Anti-HIV Agents, Other
SELZENTRY TAB
300MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antivirals Anti-HIV Agents, Other
SENSIPAR TAB 30MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Parathyroid)
Hormonal Agents,
Suppressant (Parathyroid)
SENSIPAR TAB 60MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Parathyroid)
Hormonal Agents,
Suppressant (Parathyroid)
SENSIPAR TAB 90MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Parathyroid)
Hormonal Agents,
Suppressant (Parathyroid)
SEREVENT DIS AER
50MCG
On formulary, quantity
limit may apply 1 inhaler per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
SEROQUEL XR TAB
150MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
150MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
150MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
200MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
200MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 281 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SEROQUEL XR TAB
200MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
300MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
300MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
300MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
400MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
400MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
400MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
50MG On formulary, tier change tier 3 to tier 4 Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
50MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB
50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
SERTRALINE CON
20MG/ML
On formulary, quantity
limit may apply 300 mls per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 282 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SERTRALINE TAB
100MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
SERTRALINE TAB
25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
SERTRALINE TAB
50MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
SIGNIFOR INJ
0.3MG/ML On formulary, tier change tier 4 to tier 5
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SIGNIFOR INJ
0.3MG/ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SIGNIFOR INJ
0.6MG/ML On formulary, tier change tier 4 to tier 5
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SIGNIFOR INJ
0.6MG/ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SIGNIFOR INJ
0.9MG/ML On formulary, tier change tier 4 to tier 5
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SIGNIFOR INJ
0.9MG/ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SILDENAFIL INJ Not on 2017 formulary
sildenafil tablets* *This
drug requires a prior
authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Respiratory Tract Agents
Pulmonary
Antihypertensives
SILDENAFIL TAB 20MG
On formulary, quantity
limit may apply 90 tablets per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
SILVER SULFA CRE 1% On formulary, tier change tier 1 to tier 2 Antibacterials Sulfonamides
Pg. 283 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SIMPONI INJ
100MG/ML Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These drugs will need a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents Immune Suppressants
SIMPONI INJ
100MG/ML Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These drugs will need a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents Immune Suppressants
Pg. 284 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SIMPONI INJ
50/0.5ML Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These drugs will need a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents Immune Suppressants
SIMPONI INJ
50/0.5ML Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These drugs will need a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents Immune Suppressants
Pg. 285 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SIMPONI ARIA SOL
50MG/4ML Not on 2017 formulary
Humira*, Enbrel*, Stelara*
*These drugs will need a
prior authorization. To
download the specific
form, please visit
www.MyPrime.com. You
may also call the number
on the back of your
insurance card for more
information. Immunological Agents Immune Suppressants
SIMULECT INJ 10MG
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
SIMULECT INJ 20MG
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
SIMVASTATIN TAB
10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
SIMVASTATIN TAB
10MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
SIMVASTATIN TAB
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
SIMVASTATIN TAB
20MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
SIMVASTATIN TAB
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
SIMVASTATIN TAB
40MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
SIMVASTATIN TAB 5MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
SIMVASTATIN TAB 5MG
On formulary, quantity
limit may apply 45 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
Pg. 286 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SIMVASTATIN TAB
80MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
SIMVASTATIN TAB
80MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
SIROLIMUS TAB 2MG On formulary, tier change tier 2 to tier 5 Immunological Agents Immune Suppressants
SM ALCOHOL PAD
PREP On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SM GAUZE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SM STERILE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SMZ-TMP INJ 400-
80/5 On formulary, tier change tier 2 to tier 4 Antibacterials Sulfonamides
SMZ-TMP SUS 200-
40/5 On formulary, tier change tier 1 to tier 2 Antibacterials Sulfonamides
SOD CHLORIDE INJ
2.5/ML Not on 2017 formulary check with your doctor
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
SOD CHLORIDE INJ 3% Not on 2017 formulary check with your doctor
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
SOD CHLORIDE INJ 5% Not on 2017 formulary check with your doctor
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
SOD FLUORIDE TAB
1MG F Not on 2017 formulary check with your doctor
Therapeutic Nutrients/
Minerals/ Electrolytes Vitamins
SOD LACTATE INJ
5MEQ/ML Not on 2017 formulary check with your doctor
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
SOD SULFACET SOL
10% OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives
SOMATULINE INJ
120/.5ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
Pg. 287 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SOMATULINE INJ
60/0.2ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SOMATULINE INJ
90/0.3ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SOMAVERT INJ 10MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SOMAVERT INJ 15MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SOMAVERT INJ 20MG
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
SPIRIVA CAP
HANDIHLR
On formulary, quantity
limit may apply 30 capsules per 30 days Respiratory Tract Agents
Bronchodilators,
Anticholinergic
SPIRIVA SPR 2.5MCG
On formulary, quantity
limit may apply 1 inhaler per 30 days Respiratory Tract Agents
Bronchodilators,
Anticholinergic
SPRYCEL TAB
100MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
SPRYCEL TAB
100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SPRYCEL TAB
140MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
SPRYCEL TAB
140MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
Pg. 288 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SPRYCEL TAB 20MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
SPRYCEL TAB 20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SPRYCEL TAB 50MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
SPRYCEL TAB 50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SPRYCEL TAB 70MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
SPRYCEL TAB 70MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SPRYCEL TAB 80MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
SPRYCEL TAB 80MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SSD CRE 1% On formulary, tier change tier 1 to tier 2 Antibacterials Sulfonamides
STAVUDINE CAP
15MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
Pg. 289 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
STAVUDINE CAP
20MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
STAVUDINE CAP
30MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
STAVUDINE CAP
40MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
STAVUDINE SOL
1MG/ML
On formulary, quantity
limit may apply 2400 mls per 30 days Respiratory Tract Agents Antihistamines
STELARA INJ
45MG/0.5
On formulary, requires
prior authorization check with your doctor Immunological Agents Immune Suppressants
STERILE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
STERILE GAUZ PAD
2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
STIVARGA TAB 40MG
On formulary, quantity
limit may apply 84 tablets per 28 days Antineoplastics Antineoplastics
STRATTERA CAP
100MG On formulary, tier change tier 3 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
100MG
On formulary, quantity
limit may apply 30 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 290 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
STRATTERA CAP
10MG On formulary, tier change tier 3 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
10MG
On formulary, quantity
limit may apply 60 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
18MG On formulary, tier change tier 3 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
18MG
On formulary, quantity
limit may apply 60 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
25MG On formulary, tier change tier 3 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
25MG
On formulary, quantity
limit may apply 60 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
40MG On formulary, tier change tier 3 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 291 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
STRATTERA CAP
40MG
On formulary, quantity
limit may apply 60 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
60MG On formulary, tier change tier 3 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
60MG
On formulary, quantity
limit may apply 30 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
80MG On formulary, tier change tier 3 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STRATTERA CAP
80MG
On formulary, quantity
limit may apply 30 capsules per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
STREPTOMYCIN INJ
1GM On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
STRIBILD TAB
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals Anti-HIV Agents, Other
SUBOXONE MIS 12-
3MG On formulary, tier change tier 3 to tier 4
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
SUBOXONE MIS 12-
3MG
On formulary, requires
prior authorization check with your doctor
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
SUBOXONE MIS 2-
0.5MG On formulary, tier change tier 3 to tier 4
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
Pg. 292 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SUBOXONE MIS 2-
0.5MG
On formulary, requires
prior authorization check with your doctor
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
SUBOXONE MIS 4-
1MG On formulary, tier change tier 3 to tier 4
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
SUBOXONE MIS 4-
1MG
On formulary, requires
prior authorization check with your doctor
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
SUBOXONE MIS 8-
2MG On formulary, tier change tier 3 to tier 4
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
SUBOXONE MIS 8-
2MG
On formulary, requires
prior authorization check with your doctor
Anti-Addiction/Substance
Abuse Treatment Agents Opioid Antagonists
SULF/PRED NA SOL OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
SULFACET SOD SOL
10% OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives
SULFADIAZINE TAB
500MG On formulary, tier change tier 2 to tier 4 Antibacterials Sulfonamides
SULFATRIM PD SUS 200-
40/5 On formulary, tier change tier 1 to tier 2 Antibacterials Sulfonamides
SULINDAC TAB
150MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
SULINDAC TAB
200MG
On formulary, quantity
limit may apply 60 tablets per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
SUMATRIPTAN TAB
100MG
On formulary, quantity
limit may apply 18 tablets per 30 days Antimigraine Agents
Serotonin (5-HT) 1b/1d
Receptor Agonists
SUMATRIPTAN TAB
25MG
On formulary, quantity
limit may apply 18 tablets per 30 days Antimigraine Agents
Serotonin (5-HT) 1b/1d
Receptor Agonists
SUMATRIPTAN TAB
50MG
On formulary, quantity
limit may apply 18 tablets per 30 days Antimigraine Agents
Serotonin (5-HT) 1b/1d
Receptor Agonists
SUPRAX SUS
200/5ML Not on 2017 formulary
Suprax 400 mg capsules,
Suprax chewable tablets
(100 mg, 200 mg) Antibacterials
Beta-lactam,
Cephalosporins
Pg. 293 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SURE COMFORT MIS
29GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SURE COMFORT MIS
30GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SURE COMFORT MIS
31GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SURE COMFORT MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SURE COMFORT MIS
32GX5/32 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SURE COMFORT MIS
32GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SURE-FINE MIS
29GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SURE-FINE MIS
31GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SURE-FINE MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
SURMONTIL CAP
100MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
Pg. 294 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SURMONTIL CAP
25MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
SURMONTIL CAP
50MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
SUSTIVA CAP 200MG On formulary, tier change tier 3 to tier 5 Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
SUSTIVA CAP 200MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
SUSTIVA CAP 50MG On formulary, tier change tier 3 to tier 4 Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
SUSTIVA CAP 50MG
On formulary, quantity
limit may apply 90 capsules per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
Pg. 295 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SUSTIVA TAB 600MG On formulary, tier change tier 3 to tier 5 Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
SUSTIVA TAB 600MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
SUTENT CAP
12.5MG
On formulary, quantity
limit may apply 90 capsules per 30 days Antineoplastics Antineoplastics
SUTENT CAP
12.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SUTENT CAP 25MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antineoplastics
SUTENT CAP 25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SUTENT CAP
37.5MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antineoplastics
SUTENT CAP
37.5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SUTENT CAP 50MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antineoplastics
SUTENT CAP 50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
Pg. 296 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SYLATRON KIT
200MCG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SYLATRON KIT
300MCG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SYLATRON KIT
600MCG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
SYMBICORT AER 160-
4.5
On formulary, quantity
limit may apply 1 canister per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
SYMBICORT AER 80-
4.5
On formulary, quantity
limit may apply 1 canister per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
SYNAGIS INJ 50MG On formulary, tier change tier 3 to tier 5 Immunological Agents
Immunizing Agents,
Passive
SYNERCID INJ 500MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other
SYPRINE CAP 250MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antiangiogenic Agents
TAFINLAR CAP 50MG
On formulary, quantity
limit may apply 120 capsules per 30 days Antineoplastics Antineoplastics
TAFINLAR CAP 50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
TAFINLAR CAP 75MG
On formulary, quantity
limit may apply 120 capsules per 30 days Antineoplastics Antineoplastics
Pg. 297 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TAFINLAR CAP 75MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
TAMOXIFEN TAB
10MG On formulary, tier change tier 1 to tier 2 Antineoplastics Antineoplastics
TAMOXIFEN TAB
20MG On formulary, tier change tier 1 to tier 2 Antineoplastics Antineoplastics
TAMSULOSIN CAP
0.4MG
On formulary, quantity
limit may apply 60 capsules per 30 days Genitourinary Agents
Benign Prostatic
Hypertrophy Agents
TARCEVA TAB
100MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
TARCEVA TAB
100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
TARCEVA TAB
150MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics
TARCEVA TAB
150MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
TARCEVA TAB 25MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
TARCEVA TAB 25MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
Pg. 298 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TARGRETIN CAP
75MG Not on 2017 formulary
bexarotene 75mg capsule
* *This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antineoplastics Antineoplastics
TASIGNA CAP 150MG
On formulary, quantity
limit may apply 120 capsules per 30 days Antineoplastics Antineoplastics
TASIGNA CAP 150MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
TASIGNA CAP 200MG
On formulary, quantity
limit may apply 120 capsules per 30 days Antineoplastics Antineoplastics
TASIGNA CAP 200MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
TAXOTERE INJ
20MG/ML Not on 2017 formulary docetaxel inj 20 mg/mL Antineoplastics Antineoplastics
TAXOTERE INJ
80MG/4ML Not on 2017 formulary
docetaxel inj 80 mg/4 mL
(20 mg/mL) Antineoplastics Antineoplastics
TECFIDERA CAP
120MG
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
TECFIDERA CAP
120MG
On formulary, quantity
limit may apply 60 capsules per 30 days
Central Nervous System
Agents Multiple Sclerosis Agents
Pg. 299 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TECFIDERA CAP
240MG
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
TECFIDERA CAP
240MG
On formulary, quantity
limit may apply 60 capsules per 30 days
Central Nervous System
Agents Multiple Sclerosis Agents
TECFIDERA MIS
STARTER
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
TECFIDERA MIS
STARTER
On formulary, quantity
limit may apply 60 capsules per 30 days
Central Nervous System
Agents Multiple Sclerosis Agents
TEFLARO INJ 400MG On formulary, tier change tier 4 to tier 5 Antibacterials
Beta-lactam,
Cephalosporins
TEFLARO INJ 600MG On formulary, tier change tier 4 to tier 5 Antibacterials
Beta-lactam,
Cephalosporins
TEGRETOL-XR TAB
100MG Not on 2017 formulary
carbamazepine ER 100
mg tablets Anticonvulsants Sodium Channel Agents
TEKTURNA TAB
150MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
TEKTURNA TAB
300MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Cardiovascular Agents,
Other
TELMIS/AMLOD TAB 40-
10MG Not on 2017 formulary
amlodipine in
combination with
telmisartan Cardiovascular Agents
Antihypertensive
Combinations
TELMIS/AMLOD TAB 40-
5MG Not on 2017 formulary
amlodipine in
combination with
telmisartan Cardiovascular Agents
Antihypertensive
Combinations
TELMIS/AMLOD TAB 80-
10MG Not on 2017 formulary
amlodipine in
combination with
telmisartan Cardiovascular Agents
Antihypertensive
Combinations
TELMIS/AMLOD TAB 80-
5MG Not on 2017 formulary
amlodipine in
combination with
telmisartan Cardiovascular Agents
Antihypertensive
Combinations
Pg. 300 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TELMISA/HCTZ TAB 40-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
TELMISA/HCTZ TAB 40-
12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
TELMISA/HCTZ TAB 80-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
TELMISA/HCTZ TAB 80-
12.5
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
TELMISA/HCTZ TAB 80-
25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
TELMISA/HCTZ TAB 80-
25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
TELMISARTAN TAB
20MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
TELMISARTAN TAB
20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
TELMISARTAN TAB
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
TELMISARTAN TAB
40MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
TELMISARTAN TAB
80MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
TELMISARTAN TAB
80MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
TEMAZEPAM CAP
15MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
TEMAZEPAM CAP
22.5MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
TEMAZEPAM CAP
30MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
Pg. 301 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TEMAZEPAM CAP
7.5MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
TERAZOSIN CAP
10MG
On formulary, quantity
limit may apply 60 capsules per 30 days Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
TERAZOSIN CAP 1MG
On formulary, quantity
limit may apply 30 capsules per 30 days Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
TERAZOSIN CAP 2MG
On formulary, quantity
limit may apply 30 capsules per 30 days Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
TERAZOSIN CAP 5MG
On formulary, quantity
limit may apply 30 capsules per 30 days Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
TERBUTALINE INJ
1MG/ML Not on 2017 formulary terbutaline tablets Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
TERCONAZOLE SUP
80MG On formulary, tier change tier 1 to tier 2 Genitourinary Agents Vaginal Products
TESTOST CYP INJ
100MG/ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTOST CYP INJ
200MG/ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTOST ENAN INJ
200MG/ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTOSTERONE GEL
1%(25MG)
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
Pg. 302 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TESTOSTERONE GEL
1%(25MG)
On formulary, quantity
limit may apply 90 packets per 30 days
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTOSTERONE GEL
1%(50MG)
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTOSTERONE GEL
1%(50MG)
On formulary, quantity
limit may apply 60 packets per 30 days
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTOSTERONE GEL
PUMP 1%
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTOSTERONE GEL
PUMP 1%
On formulary, quantity
limit may apply
4 pump bottles per 30
days
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTRED CAP 10MG Not on 2017 formulary
methyltestosterone 10 mg
capsules* *This drug
requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
Pg. 303 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TETANUS TOX INJ 5LF
ADS
On formulary, requires
prior authorization check with your doctor Immunological Agents Vaccines
TETRABENAZIN TAB
12.5MG
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents
Central Nervous System,
Other
TETRABENAZIN TAB
12.5MG
On formulary, quantity
limit may apply 240 tablets per 30 days
Central Nervous System
Agents
Central Nervous System,
Other
TETRABENAZIN TAB
25MG
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents
Central Nervous System,
Other
TETRABENAZIN TAB
25MG
On formulary, quantity
limit may apply 120 tablets per 30 days
Central Nervous System
Agents
Central Nervous System,
Other
TEVETEN HCT TAB 600-
25MG Not on 2017 formulary
candesartan/hydrochlorot
hiazide,
irbesartan/hydrochlorothia
zide,
losartan/hydrochlorothiazi
de,
telmisartan/hydrochlorothi
azide,
valsartan/hydrochlorothiaz
ide Cardiovascular Agents
Antihypertensive
Combinations
THALOMID CAP
100MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antiangiogenic Agents
THALOMID CAP
100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
THALOMID CAP
150MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antineoplastics Antiangiogenic Agents
Pg. 304 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
THALOMID CAP
150MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
THALOMID CAP
200MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antineoplastics Antiangiogenic Agents
THALOMID CAP
200MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
THALOMID CAP 50MG
On formulary, quantity
limit may apply 30 capsules per 30 days Antineoplastics Antiangiogenic Agents
THALOMID CAP 50MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antiangiogenic Agents
THIORIDAZINE TAB
100MG On formulary, tier change tier 2 to tier 4 Antipsychotics 1st Generation/Typical
THIORIDAZINE TAB
10MG On formulary, tier change tier 2 to tier 4 Antipsychotics 1st Generation/Typical
THIORIDAZINE TAB
25MG On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical
THIORIDAZINE TAB
50MG On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical
THIOTHIXENE CAP
10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
Pg. 305 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
THIOTHIXENE CAP
1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
THIOTHIXENE CAP
2MG On formulary, tier change tier 1 to tier 2 Antipsychotics 1st Generation/Typical
THIOTHIXENE CAP
2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
THIOTHIXENE CAP
5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
TICLOPIDINE TAB
250MG Not on 2017 formulary
clopidogrel 75 mg tablet,
Effient
Blood Products/Modifiers/
Volume Expanders Platelet Modifying Agents
TIER UNI PLS MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
TIKOSYN CAP
125MCG Not on 2017 formulary dofetilide 125 mcg Cardiovascular Agents Antiarrhythmics
TIKOSYN CAP
250MCG Not on 2017 formulary dofetilide 250 mcg Cardiovascular Agents Antiarrhythmics
TIKOSYN CAP
500MCG Not on 2017 formulary dofetilide 500 mcg Cardiovascular Agents Antiarrhythmics
TIMOLOL MAL TAB
10MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
TIMOLOL MAL TAB
20MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
TIMOLOL MAL TAB 5MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
TIS-U-SOL SOL Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous
Pg. 306 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TIVICAY TAB 10MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals Anti-HIV Agents, Other
TIVICAY TAB 25MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals Anti-HIV Agents, Other
TIVICAY TAB 50MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals Anti-HIV Agents, Other
TOBRADEX OIN 0.3-
0.1% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
TOBRADEX ST SUS 0.3-
0.05 Not on 2017 formulary
sulfacetamide/prednisolon
e solution,
tobramycin/dexamethaso
ne suspension, Tobradex
ointment,
neomycin/polymyxin/dexa
methasone suspension
and ointment, Poly-dex
ointment, Neo-polycin–HC
ointment,
neomycin/polymyxin/bacitr
acin-HC ointment Ophthalmic Agents
Ophthalmic Anti-
inflammatories
TOBRAMYCIN NEB
300/5ML On formulary, tier change tier 2 to tier 5 Antibacterials Aminoglycosides
TOLAZAMIDE TAB
250MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
TOLAZAMIDE TAB
500MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
TOLBUTAMIDE TAB
500MG Not on 2017 formulary
glimepiride, glipizide,
glipizide ER Blood Glucose Regulators Antidiabetic Agents
TOLMETIN SOD CAP
400MG
On formulary, quantity
limit may apply 120 capsules per 30 days Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
Pg. 307 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TOLMETIN SOD TAB
600MG Not on 2017 formulary tolmetin 400 mg tablets Anti-inflammatory Agents
Nonsteroidal Anti-
inflammatory Drugs
TOLTERODINE TAB
1MG
On formulary, quantity
limit may apply 60 tablets per 30 days Genitourinary Agents Antispasmodics, Urinary
TOLTERODINE TAB
2MG
On formulary, quantity
limit may apply 60 tablets per 30 days Genitourinary Agents Antispasmodics, Urinary
TOPIRAMATE CAP ER
100MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
TOPIRAMATE CAP ER
150MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
TOPIRAMATE CAP ER
200MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
TOPIRAMATE CAP ER
25MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
TOPIRAMATE CAP ER
50MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
TOPOTECAN INJ 4MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
TOPOTECAN INJ
4MG/4ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics
TORISEL SOL
25MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
Pg. 308 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TPN ELECTROL INJ Not on 2017 formulary lactated ringers inj
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
TRACLEER TAB
125MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Pulmonary
Antihypertensives
TRACLEER TAB
125MG
On formulary, quantity
limit may apply 60 tablets per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
TRACLEER TAB
62.5MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Pulmonary
Antihypertensives
TRACLEER TAB
62.5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
TRADJENTA TAB 5MG On formulary, tier change tier 3 to tier 4 Blood Glucose Regulators Antidiabetic Agents
TRADJENTA TAB 5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
TRAMADL/APAP TAB
37.5-325
On formulary, quantity
limit may apply 240 tablets per 30 days Analgesics
Opioid Analgesics, Short-
acting
TRANDOLAPRIL TAB
1MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
TRANDOLAPRIL TAB
2MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
TRANDOLAPRIL TAB
4MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin-converting
Enzyme (ACE) Inhibitors
TRANSDERM-SC DIS
1MG Not on 2017 formulary check with your doctor Antiemetics Antiemetics, Other
TRAVASOL INJ 10% Not on 2017 formulary
Premasol 6%,
Hepatamine 8%,
Aminosyn-HF 8%,
Plenamine 15%, Clinisol
SF 15%
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
Pg. 309 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TRAVOPROST DRO
0.004% Not on 2017 formulary
latanoprost, Lumigan,
Travatan Z Ophthalmic Agents
Ophthalmic
Prostaglandin and
Prostamide Analogs
TREANDA INJ
180/2ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
TREANDA INJ
45/0.5ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
TRETINOIN CAP 10MG On formulary, tier change tier 1 to tier 5 Antineoplastics Antineoplastics
TRETINOIN CAP 10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
TREXALL TAB 10MG Not on 2017 formulary
methotrexate 2.5 mg
tablet Immunological Agents Immune Suppressants
TREXALL TAB 15MG Not on 2017 formulary
methotrexate 2.5 mg
tablet Immunological Agents Immune Suppressants
TREXALL TAB 5MG Not on 2017 formulary
methotrexate 2.5 mg
tablet Immunological Agents Immune Suppressants
TREXALL TAB 7.5MG Not on 2017 formulary
methotrexate 2.5 mg
tablet Immunological Agents Immune Suppressants
TRIAMCINOLON CRE
0.025% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
TRIAMCINOLON CRE
0.1% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
TRIAMCINOLON CRE
0.5% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
TRIAMCINOLON OIN
0.1% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
Pg. 310 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TRIAMT/HCTZ CAP 50-
25MG Not on 2017 formulary
triamterene/hydrochlorothi
azide (37.5/25mg,
75/50mg) Cardiovascular Agents
Antihypertensive
Combinations
TRIAZOLAM TAB
0.125MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
TRIAZOLAM TAB
0.25MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines
TRIBENZOR20- TAB 5-
12.5MG Not on 2017 formulary
amlodipine/valsartan/hydr
ochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
TRIBENZOR40- TAB 10-
12.5 Not on 2017 formulary
amlodipine/valsartan/hydr
ochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
TRIBENZOR40- TAB 10-
25MG Not on 2017 formulary
amlodipine/valsartan/hydr
ochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
TRIBENZOR40- TAB 5-
12.5MG Not on 2017 formulary
amlodipine/valsartan/hydr
ochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
TRIBENZOR40- TAB 5-
25MG Not on 2017 formulary
amlodipine/valsartan/hydr
ochlorothiazide Cardiovascular Agents
Antihypertensive
Combinations
TRIDERM CRE 0.1% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents
TRIFLUOPERAZ TAB
10MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
TRIFLUOPERAZ TAB
1MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
TRIFLUOPERAZ TAB
2MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
Pg. 311 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TRIFLUOPERAZ TAB
5MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 1st Generation/Typical
TRIHEXYPHEN ELX
0.4MG/ML Not on 2017 formulary
selegiline,
carbidopa/levodopa,
ropinirole, pramipexole,
entacapone Antiparkinson Agents Anticholinergics
TRIHEXYPHEN TAB
2MG Not on 2017 formulary
selegiline,
carbidopa/levodopa,
ropinirole, pramipexole,
entacapone Antiparkinson Agents Anticholinergics
TRIHEXYPHEN TAB
5MG Not on 2017 formulary
selegiline,
carbidopa/levodopa,
ropinirole, pramipexole,
entacapone Antiparkinson Agents Anticholinergics
TRINTELLIX TAB 10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
TRINTELLIX TAB 20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
TRINTELLIX TAB 5MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
TRIUMEQ TAB On formulary, tier change tier 4 to tier 5 Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
TRIUMEQ TAB
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
Pg. 312 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TROKENDI XR CAP
100MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
TROKENDI XR CAP
200MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
TROKENDI XR CAP
25MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
TROKENDI XR CAP
50MG Not on 2017 formulary
topiramate IR (tablets,
capsules), lamotrigine IR
tablets, levetiracetam IR
tablets Anticonvulsants
Glutamate Reducing
Agents
TRUVADA TAB 100-
150
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
TRUVADA TAB 133-
200
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
TRUVADA TAB 167-
250
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
Pg. 313 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TRUVADA TAB 200-
300
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
TYBOST TAB 150MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
TYGACIL INJ 50MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other
TYKERB TAB 250MG
On formulary, quantity
limit may apply 180 tablets per 30 days Antineoplastics Antineoplastics
TYKERB TAB 250MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
TYSABRI INJ
300/15ML
On formulary, requires
prior authorization check with your doctor
Central Nervous System
Agents Multiple Sclerosis Agents
TYZINE PED DRO
0.05% Not on 2017 formulary check with your doctor Respiratory Tract Agents Nasal Agents
UCERIS TAB 9MG Not on 2017 formulary
Apriso, Asacol HD,
balsalazide, Delzicol,
Dipentum, Lialda,
Pentasa, sulfasalazine (IR
tablet or delayed-release
tablet)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
ULTICARE MIS
0.3/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ULTICARE MIS
0.5/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
ULTICARE MIS
1ML/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
Pg. 314 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ULTICARE PAD
ALCOHOL On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNFINE PNTP MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNIFINE PNTP MIS
29GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNIFINE PNTP MIS
29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNIFINE PNTP MIS
31GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNIFINE PNTP MIS
31GX5/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNIFINE PNTP MIS
31GX5MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNIFINE PNTP MIS
31GX6MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNIFINE PNTP MIS
31GX8MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNIFINE PNTP MIS
32GX4MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNIFINE PNTP MIS
32GX5/32 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents
UNITH DIRECT TAB
100MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITH DIRECT TAB
112MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITH DIRECT TAB
125MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Pg. 315 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
UNITH DIRECT TAB
150MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITH DIRECT TAB
175MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITH DIRECT TAB
200MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITH DIRECT TAB
25MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITH DIRECT TAB
300MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITH DIRECT TAB
50MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITH DIRECT TAB
75MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITH DIRECT TAB
88MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
100MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
112MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Pg. 316 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
UNITHROID TAB
125MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
137MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
150MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
175MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
200MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
25MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
300MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
50MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
75MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
UNITHROID TAB
88MCG On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Hormonal Agents,
Stimulant/Replacement/
Modifying (Thyroid)
Pg. 317 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
URSODIOL TAB
250MG Not on 2017 formulary ursodiol 300 mg capsules Gastrointestinal Agents
Gastrointestinal Agents,
Other
URSODIOL TAB
500MG Not on 2017 formulary ursodiol 300 mg capsules Gastrointestinal Agents
Gastrointestinal Agents,
Other
VALCHLOR GEL
0.016% On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
VALGANCICLOV TAB
450MG On formulary, tier change tier 2 to tier 5 Antivirals
Anti-cytomegalovirus
(CMV) Agents
VALPROATE INJ
100MG/ML On formulary, tier change tier 1 to tier 2 Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
VALPROATE INJ
500/5ML On formulary, tier change tier 1 to tier 2 Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
VALSART/HCTZ TAB 160-
12.5 On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents
VALSART/HCTZ TAB 160-
12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents
VALSART/HCTZ TAB 160-
25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
VALSART/HCTZ TAB 160-
25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
VALSART/HCTZ TAB 320-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
VALSART/HCTZ TAB 320-
12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
VALSART/HCTZ TAB 320-
25MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
VALSART/HCTZ TAB 320-
25MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
Pg. 318 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
VALSART/HCTZ TAB 80-
12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Antihypertensive
Combinations
VALSART/HCTZ TAB 80-
12.5
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Antihypertensive
Combinations
VALSARTAN TAB
160MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
VALSARTAN TAB
160MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
VALSARTAN TAB
320MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
VALSARTAN TAB
320MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
VALSARTAN TAB
40MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
VALSARTAN TAB
40MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
VALSARTAN TAB
80MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents
Angiotensin II Receptor
Antagonists
VALSARTAN TAB
80MG
On formulary, quantity
limit may apply 60 tablets per 30 days Cardiovascular Agents
Angiotensin II Receptor
Antagonists
VANCOMYCIN CAP
250MG On formulary, tier change tier 2 to tier 5 Antibacterials Antibacterials, Other
VECTIBIX INJ 100MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics
VENLAFAXINE CAP
150MG ER
On formulary, quantity
limit may apply 30 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE CAP
37.5 ER
On formulary, quantity
limit may apply 30 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE CAP
75MG ER
On formulary, quantity
limit may apply 90 capsules per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
Pg. 319 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
VENLAFAXINE TAB
150MG ER
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE TAB
225MG ER Not on 2017 formulary
venlafaxine IR tablet, ER
tablet (37.5mg, 75mg,
150mg ), and ER capsule Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE TAB
25MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE TAB 37.5
ER
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE TAB
37.5MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE TAB
50MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE TAB
75MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENLAFAXINE TAB
75MG ER
On formulary, quantity
limit may apply 90 tablets per 30 days Antidepressants
Serotonin/Norepinephrine
Reuptake Inhibitors
VENTAVIS SOL
10MCG/ML On formulary, tier change tier 4 to tier 5 Respiratory Tract Agents
Pulmonary
Antihypertensives
VENTAVIS SOL
10MCG/ML
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Pulmonary
Antihypertensives
VENTAVIS SOL
10MCG/ML
On formulary, quantity
limit may apply 270 mLs per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
VENTAVIS SOL
20MCG/ML On formulary, tier change tier 4 to tier 5 Respiratory Tract Agents
Pulmonary
Antihypertensives
VENTAVIS SOL
20MCG/ML
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Pulmonary
Antihypertensives
VENTAVIS SOL
20MCG/ML
On formulary, quantity
limit may apply 270 mLs per 30 days Respiratory Tract Agents
Pulmonary
Antihypertensives
VENTOLIN HFA AER
On formulary, quantity
limit may apply 2 canisters per 30 days Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
Pg. 320 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
VERAPAMIL INJ
2.5MG/ML Not on 2017 formulary verapamil IR tablet Cardiovascular Agents
Calcium Channel Blocking
Agents
VERDROCET TAB 2.5-
325 Not on 2017 formulary
hydrocodone/acetaminop
hen (5/300, 7.5/300,
10/300, 5/325, 7.5/325,
10/325) Analgesics
Opioid Analgesics, Short-
acting
VERIPRED 20 SOL
20MG/5ML
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Glucocorticoids/Mineraloc
orticoids
VERSACLOZ SUS
50MG/ML On formulary, tier change tier 4 to tier 5 Antipsychotics Treatment-Resistant
VERSACLOZ SUS
50MG/ML
On formulary, quantity
limit may apply 540 mls per 30 days Antipsychotics Treatment-Resistant
VERSACLOZ SUS
50MG/ML
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics Treatment-Resistant
VESICARE TAB 10MG Not on 2017 formulary
Toviaz, oxybutynin IR,
oxybutynin ER, tolterodine
IR tablets, tolterodine ER
capsules, trospium IR
tablets, trospium ER
capsules Genitourinary Agents Antispasmodics, Urinary
VESICARE TAB 5MG Not on 2017 formulary
Toviaz, oxybutynin IR,
oxybutynin ER, tolterodine
IR tablets, tolterodine ER
capsules, trospium IR
tablets, trospium ER
capsules Genitourinary Agents Antispasmodics, Urinary
VICTOZA INJ
18MG/3ML
On formulary, quantity
limit may apply 1 package per 30 days Blood Glucose Regulators Antidiabetic Agents
Pg. 321 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
VIDEX SOL 2GM On formulary, tier change tier 3 to tier 4 Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
VIDEX SOL 2GM
On formulary, quantity
limit may apply 1200 mls per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
VIDEX SOL 4GM On formulary, tier change tier 3 to tier 4 Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
VIDEX SOL 4GM
On formulary, quantity
limit may apply 1200 mls per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
VIIBRYD KIT On formulary, tier change tier 3 to tier 4 Antidepressants Antidepressants, Other
VIIBRYD KIT
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
VIIBRYD KIT
STARTER On formulary, tier change tier 3 to tier 4 Antidepressants Antidepressants, Other
VIIBRYD KIT
STARTER
On formulary, quantity
limit may apply 1 kit per 30 days Antidepressants Antidepressants, Other
VIIBRYD TAB 10MG On formulary, tier change tier 3 to tier 4 Antidepressants Antidepressants, Other
VIIBRYD TAB 10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
VIIBRYD TAB 20MG On formulary, tier change tier 3 to tier 4 Antidepressants Antidepressants, Other
VIIBRYD TAB 20MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
VIIBRYD TAB 40MG On formulary, tier change tier 3 to tier 4 Antidepressants Antidepressants, Other
Pg. 322 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
VIIBRYD TAB 40MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antidepressants Antidepressants, Other
VINBLASTINE INJ
1MG/ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics
VINCASAR PFS INJ
1MG/ML
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
VINCRISTINE INJ
1MG/ML
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics
VIRACEPT TAB
250MG
On formulary, quantity
limit may apply 270 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
VIRACEPT TAB
625MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antivirals
Anti-HIV Agents, Protease
Inhibitors
VIRAMUNE XR TAB
100MG Not on 2017 formulary
nevirapine SR 100 mg
tablet Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
VIRAZOLE INH 6GM On formulary, tier change tier 4 to tier 5 Antivirals Anti-influenza Agents
VIREAD POW
40MG/GM
On formulary, quantity
limit may apply 240 grams per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
VIREAD TAB 150MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
VIREAD TAB 200MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
Pg. 323 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
VIREAD TAB 250MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
VIREAD TAB 300MG
On formulary, quantity
limit may apply 30 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
VOLTAREN GEL 1% Not on 2017 formulary
diclofenac 1% gel* *This
drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Dermatological Agents Dermatological Agents
VORICONAZOLE INJ
200MG
On formulary, requires
prior authorization check with your doctor Antifungals Antifungals
VORICONAZOLE SUS
40MG/ML
On formulary, requires
prior authorization check with your doctor Antifungals Antifungals
VORICONAZOLE TAB
200MG
On formulary, requires
prior authorization check with your doctor Antifungals Antifungals
VOTRIENT TAB
200MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antineoplastics Antineoplastics
VOTRIENT TAB
200MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
VPRIV INJ 400UNIT On formulary, tier change tier 4 to tier 5 Miscellaneous Miscellaneous
Pg. 324 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
VRAYLAR CAP 1.5-
3MG Not on 2017 formulary
Vraylar capsules (1.5 mg,
3 mg, 4.5 mg, 6 mg)*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information. Antipsychotics 2nd Generation/Atypical
VYFEMLA TAB 0.4-35 On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Contraceptives
WEBCOL PREP PAD
LARGE On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
WEBCOL PREP PAD
MEDIUM On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents
XALKORI CAP 200MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antineoplastics Antineoplastics
XALKORI CAP 250MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antineoplastics Antineoplastics
XARELTO TAB 10MG
On formulary, quantity
limit may apply 35 tablets per 90 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
XARELTO TAB 15MG
On formulary, quantity
limit may apply 60 tablets per 30 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
XARELTO TAB 20MG
On formulary, quantity
limit may apply 30 tablets per 30 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
XARELTO STAR TAB
15/20MG
On formulary, quantity
limit may apply 51 tablets per 30 days
Blood Products/Modifiers/
Volume Expanders Anticoagulants
Pg. 325 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
XELJANZ TAB 5MG Not on 2017 formulary
methotrexate tablets,
leflunomide Immunological Agents Immune Suppressants
XENAZINE TAB
12.5MG Not on 2017 formulary
tetrabenzine 12.5mg*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Central Nervous System
Agents
Central Nervous System,
Other
XENAZINE TAB 25MG Not on 2017 formulary
tetrabenazine 25 mg*
*This drug requires prior
authorization. To
download the specific
form, please visit
www.MyPrime.com or
contact the number on the
back of your insurance
card for more information.
Central Nervous System
Agents
Central Nervous System,
Other
XIFAXAN TAB 550MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other
XOLAIR SOL 150MG
On formulary, requires
prior authorization check with your doctor Respiratory Tract Agents
Respiratory Tract Agents,
Other
XTANDI CAP 40MG
On formulary, quantity
limit may apply 120 capsules per 30 days Antineoplastics Antineoplastics
Pg. 326 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
XULANE DIS 150-35 Not on 2017 formulary check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Contraceptives
XYREM SOL
500MG/ML
On formulary, requires
prior authorization check with your doctor Sleep Disorder Agents Sleep Disorders, Other
XYREM SOL
500MG/ML
On formulary, quantity
limit may apply 540 mls per 30 days Sleep Disorder Agents Sleep Disorders, Other
ZALEPLON CAP 10MG On formulary, tier change tier 2 to tier 3 Sleep Disorder Agents
GABA Receptor
Modulators
ZALEPLON CAP 5MG On formulary, tier change tier 2 to tier 3 Sleep Disorder Agents
GABA Receptor
Modulators
ZAZOLE SUP 80MG On formulary, tier change tier 1 to tier 2 Genitourinary Agents Vaginal Products
ZELBORAF TAB
240MG
On formulary, quantity
limit may apply 240 tablets per 30 days Antineoplastics Antineoplastics
ZELBORAF TAB
240MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
ZEMPLAR INJ
2MCG/ML Not on 2017 formulary paricalcitol 2 mcg/ml inj
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ZEMPLAR INJ
5MCG/ML Not on 2017 formulary paricalcitol 5 mcg/ml inj
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ZENCHENT TAB On formulary, tier change tier 1 to tier 2
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Contraceptives
ZENZEDI TAB 10MG
On formulary, quantity
limit may apply 180 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
Pg. 327 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ZENZEDI TAB 5MG
On formulary, quantity
limit may apply 90 tablets per 30 days
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
ZETIA TAB 10MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents Dyslipidemics, Other
ZETIA TAB 10MG
On formulary, quantity
limit may apply 30 tablets per 30 days Cardiovascular Agents Dyslipidemics, Other
ZIAGEN SOL
20MG/ML
On formulary, quantity
limit may apply 960 mls per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
ZIDOVUDINE CAP
100MG
On formulary, quantity
limit may apply 180 capsules per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
ZIDOVUDINE SYP
50MG/5ML
On formulary, quantity
limit may apply 1920 mls per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
ZIDOVUDINE TAB
300MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antivirals
Anti-HIV Agents,
Nucleoside and
Nucleotide Reverse
Transcriptase Inhibitors
ZIPRASIDONE CAP
20MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antipsychotics 2nd Generation/Atypical
ZIPRASIDONE CAP
20MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ZIPRASIDONE CAP
40MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antipsychotics 2nd Generation/Atypical
Pg. 328 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ZIPRASIDONE CAP
40MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ZIPRASIDONE CAP
60MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antipsychotics 2nd Generation/Atypical
ZIPRASIDONE CAP
60MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ZIPRASIDONE CAP
80MG
On formulary, quantity
limit may apply 60 capsules per 30 days Antipsychotics 2nd Generation/Atypical
ZIPRASIDONE CAP
80MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ZIRGAN GEL 0.15% Not on 2017 formulary trifluridine 1% solution Ophthalmic Agents Ophthalmic Anti Infectives
ZOLINZA CAP 100MG
On formulary, quantity
limit may apply 120 capsules per 30 days Antineoplastics Antineoplastics
ZOLINZA CAP 100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
ZOLPIDEM TAB 10MG On formulary, tier change tier 2 to tier 4 Sleep Disorder Agents
GABA Receptor
Modulators
ZOLPIDEM TAB 5MG On formulary, tier change tier 2 to tier 4 Sleep Disorder Agents
GABA Receptor
Modulators
ZOMETA INJ
4MG/100 On formulary, tier change tier 4 to tier 5
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ZOSTAVAX INJ
On formulary, quantity
limit may apply 1 vaccine per lifetime Immunological Agents Vaccines
Pg. 329 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ZYDELIG TAB 100MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
ZYDELIG TAB 100MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
ZYDELIG TAB 150MG
On formulary, quantity
limit may apply 60 tablets per 30 days Antineoplastics Antineoplastics
ZYDELIG TAB 150MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
ZYFLO TAB 600MG Not on 2017 formulary montelukast, zafirlukast Respiratory Tract Agents Antileukotrienes
ZYFLO CR TAB
600MG Not on 2017 formulary montelukast, zafirlukast Respiratory Tract Agents Antileukotrienes
ZYKADIA CAP 150MG
On formulary, quantity
limit may apply 150 capsules per 30 days Antineoplastics Antineoplastics
ZYKADIA CAP 150MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
ZYPREXA RELP INJ
210MG
On formulary, quantity
limit may apply 2 vials per 28 days Antipsychotics 2nd Generation/Atypical
ZYPREXA RELP INJ
210MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ZYPREXA RELP INJ
300MG On formulary, tier change tier 4 to tier 5 Antipsychotics 2nd Generation/Atypical
ZYPREXA RELP INJ
300MG
On formulary, quantity
limit may apply 2 vials per 28 days Antipsychotics 2nd Generation/Atypical
Pg. 330 of 331
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ZYPREXA RELP INJ
300MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ZYPREXA RELP INJ
405MG On formulary, tier change tier 4 to tier 5 Antipsychotics 2nd Generation/Atypical
ZYPREXA RELP INJ
405MG
On formulary, quantity
limit may apply 1 vial per 28 days Antipsychotics 2nd Generation/Atypical
ZYPREXA RELP INJ
405MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antipsychotics 2nd Generation/Atypical
ZYTIGA TAB 250MG
On formulary, quantity
limit may apply 120 tablets per 30 days Antineoplastics Antineoplastics
ZYTIGA TAB 250MG
On formulary, requires
prior authorization if claim
history shows a missed
refill check with your doctor Antineoplastics Antineoplastics
ZYVOX SOL
2MG/ML Not on 2017 formulary linezolid injection 2mg/ml Antibacterials Antibacterials, Other
Pg. 331 of 331