Prescribing Guide and 4-Tier Drug Formulary 2012

Prescribing Guide 

and 

4-Tier Drug Formulary 

2012 

Effective: January 2012

DEVELOPMENT OF THE DRUG FORMULARY 

The Drug Formulary is the cornerstone of drug therapy quality assurance and cost containment efforts. The 

Drug Formulary has been successfully used by hospitals and managed care organizations to provide 

comprehensive, cost-effective pharmacy services. 

This Drug Formulary document is developed by the New West Health Services Pharmacy and Therapeutics 

Committee (P&T Committee). This committee, composed of physicians from various medical specialties, as well 

as pharmacists, reviewed the medications in all therapeutic categories based on safety, effectiveness, and cost 

and selected the most cost-effective agent(s) in each class. 

Formulary development and maintenance is a dynamic process. The P&T Committee reviews new and existing 

medications quarterly to ensure the Formulary remains responsive to the needs of our members and providers. 

This often results in tier changes for medications, especially as brand name medications become generic. The 

most current Formulary will be posted at www.newwesthealth.com for reference, or you may call us at 

(800) 290-3657 to determine how a medication will be covered. 

As you use this Formulary guide, we invite your suggestions to improve the format or content. Thank you for 

your cooperation. 

HOW TO USE THIS DOCUMENT 

The Formulary is a listing of the most commonly prescribed medications sorted by therapy class marketed at 

the time of the Formulary printing. It is intended for use by health plan physicians, pharmacy providers and 

members. Unless exceptions are noted, all forms (i.e. tablet, capsule, liquid, powder, topical) and strengths of a 

medication product are covered as indicated. At the end of the Formulary is an index which lists medications 

alphabetically with the corresponding chapter number where other medications in that class can be found. 

LEGEND 

boldface 

d 

delayed-rel 

ext-rel 

lowercase 

OTC 

PA 

QLL 

ST 

Rx 

Susp 

UPPERCASE 

Generic available. Please note: Out-of-pocket costs may be higher than expected if 

the generic drug is not used. 

Drug Efficacy Study Implementation (DESI) drug. 

Delayed-release (also known as enteric-coated), refer to the reference brand listed for 

clarification. 

Extended-release (also known as sustained-release), refer to the reference brand 

listed for clarification. 

Medications listed in lower case letters are generic medications. 

Over the counter (generally not covered). 

Prior authorization of the medication is required (see below). 

Quantity Limit – only a certain amount available for the medication (see below). 

Step Therapy – requires trial of less expensive medication before moving to a more 

expensive product. 

Prescription 

Suspension, liquid medication made from powder form. 

Medications listed in all UPPER CASE letters are brand name medications. 

This document also indicates how each medication is covered, meaning which copay tier the medication falls 

into: 1 st , 2 nd or 3 rd . 

These categories are defined as follows: 

 

 

Tier 1: Generic medications and a few select brand medications. Generic medications contain the same 

active ingredient(s) as their corresponding brand name medication and have been approved by the 

Food and Medication Administration (FDA) for therapeutic equivalency to their brand name product. 

Tier 2: Medications that have been reviewed by the Pharmacy & Therapeutics Committee and found to 

have therapeutic advantage or overall value over non-formulary medications, factoring safety, efficacy, 

and cost.

to contact the physician to request a change to a Formulary product. If the physician is unwilling to change, or 

is unavailable, the pharmacist will dispense the prescription as written. The member must pay the higher copay 

or out of pocket penalty as stated above. 

Out of Pocket Costs for the Member: 

The member will pay the indicated 1 st , 2 nd or 3 rd tier copay for the prescription unless one of the following 

conditions applies: 

1. If a physician indicates "Dispense As Written" (DAW) or if a member chooses the brand name product 

for a prescription of a medication included on the MAC list, the member must pay the applicable copay 

plus the cost difference between the brand name product and the MAC amount (ancillary charge). 

2. If a prescription is written for a medication available as an OTC product in the identical dosage, form, 

strength, and active ingredient, the prescription product will not be covered. The pharmacist should 

refer the member to the OTC product. If the member or physician insists on the prescription equivalent 

product, the member will be responsible for the entire cost of the prescription. 

3. If a physician prescribes a medication that is not covered, and no satisfactory alternative product is 

available, the member must pay the entire prescription cost. 

4. If the member is enrolled in a prescription plan that has an integrated medical and pharmacy deductible 

benefit and/or a prescription deductible plan, they will pay the entire cost for all medications until the 

deductible is met. 

5. Not all prescription drug endorsements have 1 st , 2 nd , and 3 rd -tier copays, and some endorsements 

cover generic drugs only. Refer to the prescription drug endorsement for details on prescription 

coverage and any applicable copays, or contact New West Health Services at (800) 290-3657. 

Copay Overrides / Prior Authorization / Quantity Level Limits 

Copay Overrides: 

The physicians and pharmacists consulted in the Formulary development attempted to include medications to 

meet all therapeutic needs. New West offers an “open” formulary meaning that non-formulary medications are 

available to members at the 3 rd tier copay, therefore copay overrides/tiering exceptions are not made. If a 

physician wishes to suggest tiering changes to New West for future consideration, please contact us at (800) 

290-3657. It is anticipated that physicians should be able to find a Formulary medication for the vast majority of 

therapeutic needs. If a medication is not listed in this formulary, it is non-formulary and may be obtained at the 

highest tier. 

Prior Authorization: 

To promote the most appropriate utilization, selected high-risk or high-cost medications require prior 

authorization by the health plan to be eligible for coverage. The P&T Committee have established prior 

authorization criteria with input from physicians, pharmacists, and consideration of the current medical 

literature. Medications requiring a prior authorization for coverage are indicated by (PA) after the medication 

name. 

Specialty Drug: 

To maximize cost savings and ensure quality and safety with respect to the use of specialty medications, all 

specialty drugs must be obtained through the specialty pharmacy (after a one time fill at a local retail 

pharmacy). These require prior authorization by New West. 

Step Therapy: 

New West medical management may require and initiate step therapy programs at any time to help contain the 

rising costs of health care and promote the use of generic medications. This step process is only applied to 

certain medications and does require our members to try a less expensive drug known to treat certain health 

conditions before moving to a more expensive drug. The process requires authorization and requires the 

member to try the less expensive drug to determine it’s effectiveness before New West will cover the next drug 

in the step therapy process. Please contact our medical management department at (800) 290-3657, option 

#2, for details as needed. 

Quantity Level Limits: 

Some medications may be subject to quantity level limits based on the manufacturer’s packaging size or 

adopted clinical safety guidelines. These medications are designated in the Drug Formulary by (QLL) by the 

medication name. The purpose of these maximum quantity limits is to ensure the proper billing of products 

and/or encourage the use of therapeutically indicated medication regimens.

All Prior authorization, Step Therapy and exceptions to Quantity Level Limit requests should be directed to: 

NWHS Medical Services 

130 Neill Avenue 

Helena, MT 59601 

Telephone: (800) 290-3657 

Confidential fax: (406) 457-2298 

If a physician provider requests that a new or existing medication be added to the Formulary, a letter indicating 

the significant advantages of the medication product over current formulary medications should be mailed to the 

above address.

Preventative Medications 

Below is a list of preventative medications that are available to you at no cost at your participating pharmacy as 

long as you meet the requirements listed next to the medication and have a prescription to obtain the product. 

Drug Category 

Age/Gender Edit 

Recommendations 

(all included in standard options) 

Men age 45 to 79 years AND 

Women age 55 to 79 years 

Children from birth through 5 years old 

Children from birth to 12 months of age 

Aspirin to prevent cardiovascular disease 

(CVD) 

Oral fluoride supplementation 

Iron supplementation in children 

Folic acid supplementation Women of child bearing age (18 to 45) 

Smoking Cessation 

All legend smoking and OTC generic smoking 

cessation products are covered. Please see section 

5.9.5 for product listings and rules. 

Vaccines 

The following vaccines are available to you at no cost at your participating pharmacy as long as you meet the 

requirements listed next to the medication (if applicable) and the pharmacy is providing this injectable vaccine 

as part of their services. 

Drug Category 

Hepatitis A 

Hepatitis B and Haemophilus 

Rotavirus 

Diphtheria, Tetanus, Pertusis 

Tetanus 

Pneumococcal 

Polio 

Influenza (A, B and H1N1) 

MMR, Varicella 

Meningococcal 

Human papillomavirus 

Zoster 

Haemophilus 

Age/Gender Edit 

Recommendations 

(all included in standard options) 

No age or administration restriction 


Children from birth to 12 months of age 


Anyone age 7 years or greater 

Pneumovax: Anyone 2 years or greater 

Prevnar and Prevnar 13: Anyone less than 5 years 

Children from birth to 18 years of age 


Anyone age 1 year or greater 


Anyone aged 9 through 26 years old (female only) 


Children from birth to 2 years of age

New West Health Services Prescribing Guide 

DRUG NAME 

1.2 TOPICAL ANESTHETICS 

lidocaine hcl 

lidocaine‐prilocaine 

LIDODERM 

TIER 

1 2 3 4 

CHAPTER 1: ANESTHETICS 

X 

X 

X 

SUGGESTED PREFFERED ALTERNATIVES 

CHAPTER 2: ANTIINFECTIVES 

2.1.1 CEPHALOSPORINS 

cefaclor, ‐er 

X 

cefadroxil 

X 

cefdinir 

X 

cefpodoxime proxetil 

X 

cefprozil 

X 

cefuroxime 

X 

cephalexin 

X 

CEDAX X amox/clavulnate,cefdinr,cefpod 

CEFDITOREN PIVOXIL X amox/clavulnate,cefdinr,cefpod 

SUPRAX X cefpodoxime,cefuroxime,cefdinr 

2.1.3 CLINDAMYCINS 

clindamycin, ‐ hcl, ‐phosphate 

clindamycin phosphate 

2.1.4 ERYTHROMYCINS 

erythromycin 

2.1.4.1 OTHER MACROLIDES 

azithromycin 

clarithromycin, ‐er 

2.1.5 PENICILLINS 

amox tr‐potassium clavulanate 

X 

amoxicillin 

X 

dicloxacillin sodium 

X 

penicillin v potassium 

X 

AUGMENTIN XR X amox/clavulanate (immed rel) 

MOXATAG X amoxicillin trihydrate 

2.1.6 SULFONAMIDES 

sulfamethoxazole‐trimethoprim 

2.1.7 TETRACYCLINES 

doxycycline hyclate 

doxycycline monohydrate 

minocycline hcl 

tetracycline hcl 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

PA=prior authorization ST=step therapy QLL=quantity level limit 

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TIER 

DRUG NAME 

1 2 3 4 SUGGESTED PREFFERED ALTERNATIVES 

DORYX X doxycycline 

ORACEA X doxycycline 20MG tab 

SOLODYN X generic minocycline caps/tabs 

2.1.8 URINARY ANTIINFECTIVES 

nitrofurantoin, ‐mono‐macro 

trimethoprim 

2.1.9 QUINOLONES 

ciprofloxacin, ‐er, ‐hcl 

X 

levofloxacin 

X 

ofloxacin 

X 

AVELOX, ‐ABC PACK X ciprofloxacin, levofloxacin 

FACTIVE X ciprofloxacin, levofloxacin 

LEVAQUIN X levofloxacin 

NOROXIN X ciprofloxacin, levofloxacin 

PROQUIN XR X ciprofloxacin, levofloxacin 

2.2 TOPICAL ANTIBACTERIAL DRUGS 

gentamicin sulfate 

X 

mupirocin 

X 

silver sulfadiazine 

X 

ALTABAX X mupirocin ointment 

CENTANY X mupirocin 

2.3 ORAL ANTIFUNGAL DRUGS 

fluconazole 

itraconazole 

ketoconazole 

nystatin 

terbinafine hcl 

ORAVIG 

2.4.1 VAGINAL ANTIFUNGALS 

clotrimazole 

nystatin 

2.4.2 OTHER TOPICAL ANTIFUNGALS 

ciclopirox 

X 

clotrimazole 

X 

econazole nitrate 

X 

ketoconazole 

X 

nystatin 

X 

ERTACZO X generic/otc antifungal 

EXELDERM 

X 

LAMISIL X otc lamisil 

LOPROX X generic/otc antifungal 

MENTAX X otc lotrimin ultra 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 


Page 8 of 50

DRUG NAME 

OXISTAT 

2.4.3 TOPICAL ANTIFUNGAL‐CORTICOSTEROID COMB. 

clotrimazole‐betamethasone 

nystatin‐triamcinolone 

2.5.1 ANTIRETROVIRALS & PROTEASE INHIBITORS 

TIER 

1 2 3 4 

ATRIPLA PA X 

COMBIVIR PA X 

EPIVIR PA X 

EPZICOM PA X 

INCIVEK PA X specialty 

ISENTRESS PA X 

KALETRA PA X 

NORVIR PA X 

PREZISTA PA X 

REYATAZ PA X 

SUSTIVA PA X 

TRUVADA PA X 

VIRAMUNE PA X 

VIREAD PA X 

2.5.2 OTHER ANTIVIRAL DRUGS 

acyclovir 

X 

amantadine 

X 

famciclovir 

X 

ribapak PA X 

ribavirin PA X 

DENAVIR 

X 

EPIVIR HBV PA X 

RELENZA 

X 

TAMIFLU 

X 

VALTREX 

X 

2.6 TOPICAL ANTIVIRAL DRUGS 

ZOVIRAX 

2.7.2 ANTITUBERCULOSIS DRUGS 

ethambutol hcl 

isoniazid 

rifampin 

MYCOBUTIN 

2.7.3 PLASMODICIDES 

chloroquine phosphate 

hydroxychloroquine sulfate 

mefloquine hcl 

MALARONE 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 



Page 9 of 50

DRUG NAME 

QUALAQUIN 

2.7.4 SULFONES 

DAPSONE 

2.7.5 TRICHOMONOCIDES 

metronidazole 

2.8 OTHER ANTIINFECTIVE DRUGS 

bacitracin 

polymyxin b sulfate 

MEPRON 

NEBUPENT 

VANCOCIN HCL 

XIFAXAN 

ZYVOX 

2.8.2 AMINOGLYCOSIDES 

TIER 

1 2 3 4 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 



X 

tobramycin sulfate 

X 

TOBI PA X 

CHAPTER 3: ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS 

3.0 ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS 

anagrelide hcl 

X 

anastrozole PA X 

azathioprine PA X 

cyclosporine PA X 

hydroxyurea PA X 

leflunomide PA X 

letrozole PA X 

leucovorin calcium PA X 

megestrol acetate PA X 

mercaptopurine PA X 

methotrexate PA X 

tamoxifen citrate PA X 

tretinoin PA X 

ACTEMRA ST/PA X Enbrel, Humira preferred 

ARIMIDEX PA X anastrozole 

CELLCEPT PA X specialty ‐ mycophenolate preferred 

CIMZIA ST/PA X specialty ‐ Enbrel, Humira preferred 

ELIGARD PA X specialty 

ENBREL PA X specialty 

FEMARA PA X letrozole 

FIRMAGON PA X specialty 

GLEEVEC PA X specialty 

HUMIRA PA X specialty 


Page 10 of 50

TIER 

DRUG NAME 


KINERET ST/PA X specialty ‐ Enbrel, Humira preferred 

MEGACE ES X megestrol acetate 40mg/ml 

MYFORTIC PA X 

PROGRAF PA tacrolimus anhydrous 

RAPAMUNE PA X 

REMICADE ST/PA X specialty ‐ Enbrel, Humira preferred 

REVLIMID PA X specialty 

SANDOSTATIN LAR PA X specialty 

SIMPONI ST/PA X specialty ‐ Enbrel, Humira preferred 

SOMATULINE DEPOT PA X specialty 

SPRYCEL PA X specialty 

SUTENT PA X specialty 

TARCEVA PA X specialty 

TEMODAR PA X specialty 

TRELSTAR, ‐ DEPOT, ‐LA PA X specialty 

TYKERB PA X specialty 

TYSABRI X specialty 

XELODA PA X specialty 

ZOLADEX PA X specialty 

ZORTRESS TABLETS 

X 

CHAPTER 4: CARDIOVASCULAR MEDICATIONS 

4.1 CARDIAC GLYCOSIDES 

digoxin 

X 

LANOXIN X digoxin 

4.2 CALCIUM ANTAGONISTS 

amlodipine besylate 

X 

cartia xt 

X 

diltiazem/er 

X 

felodipine er 

X 

nifediac cc 

X 

nifedical xl 

X 

nifedipine er 

X 

nisoldipine 

X 

verapamil 

X 

CARDENE SR X generic calcium channel blockers 

CARDIZEM LA X generic calcium channel blockers 

COVERA‐HS X generic calcium channel blockers 

DYNACIRC CR X generic calcium channel blockers 

SULAR X generic calcium channel blockers 

4.3.1 LOOP DIURETICS 

bumetanide 

furosemide 

X 

X 


Page 11 of 50

DRUG NAME 

torsemide 

4.3.2 THIAZIDE AND RELATED DRUGS 

chlorthalidone 

hydrochlorothiazide 

indapamide 

metolazone 

4.3.3 POTASSIUM SPARING DIURETICS 

amiloride hcl 

eplerenone 

spironolactone, ‐hctz 

triamterene‐hctz 

4.4 BETA‐ADRENERGIC ANTAGONIST DRUGS 

TIER 

1 2 3 4 

acebutolol hcl 

X 

atenolol 

X 

bisoprolol fumarate 

X 

carvedilol 

X 

labetalol hcl 

X 

metoprolol, ‐succinate, ‐tartrate X 

nadolol 

X 

pindolol 

X 

propranolol hcl 

X 

timolol maleate 

X 

BYSTOLIC X atenolol, carvedilol 

COREG CR 

X 

INNOPRAN XL X propranolol la 

TOPROL XL X metoprolol succinate 

4.5.1 VASODILATOR ANTIHYPERTENSIVES 

doxazosin mesylate 

X 

minoxidil 

X 

prazosin hcl 

X 

terazosin hcl 

X 

CARDURA XL X doxazosin,tamsulosin 

4.5.2 CENTRALLY ACTING ANTIHYPERTENSIVES 

clonidine hcl 

X 

guanfacine hcl 

X 

methyldopa 

X 

4.5.4.1 ANGIOTENSIN CONVERTING ENZYME INHIBITORS 

benazepril hcl 

captopril 

enalapril maleate 

fosinopril sodium 

lisinopril 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 



Page 12 of 50

TIER 

DRUG NAME 


moexipril hcl 

X 

quinapril hcl 

X 

ramipril 

X 

trandolapril 

X 

ACEON X generic ace inhibitor 

4.5.4.2 ANGIOTENSIN II RECEPTOR ANTAGONISTS 

losartan 

X 

ATACAND, ‐HCT 

X 

AVALIDE X losartan/hctz, BENICAR/HCT, DIOVAN/HCT 

AVAPRO X losartan/hctz, BENICAR/HCT, DIOVAN/HCT 

BENICAR, ‐HCT 

X 

COZAAR X losartan 

DIOVAN, ‐HCT 

X 

HYZAAR X losartan‐hctz 

MICARDIS, ‐HCT X losartan/hctz, BENICAR/HCT, DIOVAN/HCT 

TEVETEN. ‐ HCT X losartan/hctz, BENICAR/HCT, DIOVAN/HCT 

4.5.6 OTHER ANTIHYPERTENSIVES 

amlodipine‐benazepril 

X 

amlodipine besylate‐benazepril 

X 

atenolol‐chlorthalidone 

X 

captopril‐hydrochlorothiazide 

X 

fosinopril‐hydrochlorothiazide 

X 

losartan‐hydrochlorothiazide 

X 

metoprolol‐hydrochlorothiazide X 

moexipril‐hydrochlorothiazide 

X 

quinapril‐hydrochlorothiazide 

X 

AZOR X amlodipine + BENICAR 

EXFORGE X amlodipine + arb 

EXFORGE HCT X amlodipine + arb + hct 

LOTREL X amlodipine‐benazepril 

TARKA X verapamil + trandalopril 

TEKTURNA X gen ACE inh, BENCAR, MICARD+ HCT 

TEKTURNA HCT X gen ACE inh, BENCAR, MICARD+ HCT 

TWYNSTA X amlodipine + MICARDIS 

VALTURNA X generic ACE, BENICAR, MICARDIS 

4.6.1 NITRATES 

isosorbide, ‐dinitrate 

nitroglycerin, ‐patch 

4.6.2 OTHER VASODILATING DRUGS 

ADCIRCA PA X specialty 

BIDIL X isosorbide dn, hydralazine 

REVATIO PA X specialty 

X 

X 


Page 13 of 50

DRUG NAME 

4.6.3 ENDOTHELIN RECEPTOR ANTAGONIST 

TIER 

1 2 3 4 

LETAIRIS PA X specialty 

TRACLEER PA X specialty 

4.7.1.3 CLASS 1C 

flecainide acetate 

X 

propafenone hcl 

X 

RYTHMOL SR X propafenone ir 

4.7.3 AMIODARONES 

amiodarone hcl 

X 

PACERONE X amiodarone hcl 

4.7.5 OTHER ANTIARRHYTHMICS 


sotalol 

X 

MULTAQ X amiodarone,other antiarrhyth 

4.8.1 HYPOLIPOPROTEINEMICS 

cholestyramine 

X 

colestipol hcl 

X 

fenofibrate 

X 

gemfibrozil 

X 

ANTARA X fenofibrate, TRICOR 

FENOGLIDE X fenofibrate, TRICOR 

LIPOFEN X fenofibrate, TRICOR 

LOVAZA X OTC omega 3 products 

NIASPAN 

X 

TRICOR 

X 

TRIGLIDE X fenofibrate, TRICOR 

TRILIPIX X fenofibrate, TRICOR 

WELCHOL X cholestyramine 

ZETIA 

X 

4.8.2 HMG‐COA REDUCTASE INHIBITORS 

lovastatin 

X 

pravastatin sodium 

X 

simvastatin 

X 

ALTOPREV X lovastatin,simvastatin, LIPITOR 

CRESTOR 

X 

LESCOL, ‐XL X lovastatin,simvastatin, LIPITOR 

LIPITOR 

X 

LIVALO X lovastatin,simvastatin, LIPITOR 

4.8.2.1 HMG‐COA COMBINATIONS 

ADVICOR 

X 

CADUET X amlodipine plus LIPITOR 

SIMCOR X simvastatin + niacin, NIASPAN 

VYTORIN X simvastatin, LIPITOR 


Page 14 of 50

DRUG NAME 

4.9 OTHER CARDIOVASCULAR DRUGS 

TIER 

1 2 3 4 


pentoxifylline 

X 

RANEXA X generic beta blocker, ccb, nitrate 

CHAPTER 5: AUTONOMIC AND CNS MEDICATIONS 

5.1.1 ANALGESICS 

butorphanol tartrate 

X 

tramadol hcl, ‐acetaminophen 

X 

ULTRAM ER X tramadol ir 

5.1.1.1 CLASS II NARCOTICS 

endocet 

X 

fentanyl 

X 

hydromorphone hcl 

X 

methadone hcl 

X 

morphine sulfate 

X 

oxycodone, ‐ hcl, ‐ 

acetaminophen 

X 

roxicet tablet 

X 

ROXICET ORAL SOLUTION X oxycodone solution 

AVINZA X morphine sulf; OXYCONTIN 

EMBEDA X morphine sulfate er 

EXALGO, ‐ER X morphine sulf; OXYCONTIN 

KADIAN X morphine sulf; OXYCONTIN 

NUCYNTA X oxycodone, tramadol 

ONSOLIS PA X fentanyl citrate otfc 

OPANA, ‐ER X morphine sulf; OXYCONTIN 

OXYCONTIN 

X 

5.1.1.2 CLASS III NARCOTICS 

acetaminophen‐codeine 

hydrocodone bit‐ibuprofen 

hydrocodone‐acetaminophen 

reprexain 

zamicet 

SUBOXONE 

5.1.2 DRUGS TO PREVENT AND TREAT HEADACHES 

X 

X 

X 

X 

X 

X 

butalbital compound‐codeine 

X 

butalbital‐apap‐caffeine 

X 

butalbital‐aspirin‐caffeine 

X 

butalbital‐caff‐apap‐codeine 

X 

isometh‐d‐chloralphenaz‐apap 

X 

sumatriptan 

X 

AMERGE X sumatriptan, ZOMIG/ZMT,MAXALT/MLT 

AXERT X sumatriptan, ZOMIG/ZMT,MAXALT/MLT 

FROVA X sumatriptan, ZOMIG/ZMT,MAXALT/MLT 

Page 15 of 50 

PA=prior authorization ST=step therapy QLL=quantity level limit

TIER 

DRUG NAME 


IMITREX X sumatriptan 

MAXALT, ‐MLT 

X 

MIGRANAL 

X 

RELPAX X sumatriptan, ZOMIG/ZMT,MAXALT/MLT 

TREXIMET X sumatriptan tab/naproxen 

ZOMIG, ‐ZMT 

X 

5.2.1 ANXIOLYTICS 

alprazolam, ‐er, ‐xr 

buspirone hcl 

chlordiazepoxide hcl 

clorazepate dipotassium 

diazepam 

lorazepam 

oxazepam 

5.2.2 SEDATIVE/HYPNOTIC DRUGS 

estazolam 

X 

flurazepam hcl 

X 

temazepam 

X 

triazolam 

X 

zaleplon 

X 

zolpidem tartrate 

X 

AMBIEN, ‐CR X zolpidem tartrate 

EDLUAR X zolpidem tartrate 

LUNESTA 

X 

ROZEREM 

X 

SILENOR 

X 

5.3 ANTIMANIA DRUGS 

lithium carbonate 

5.4.1 CARBAMAZEPINES 

carbamazepine 

X 

oxcarbazepine 

X 

CARBATROL X carbamazepine 

TEGRETOL XR 

X 

5.4.2 ANTICONVULSANT BENZODIAZEPINES 

clonazepam 

5.4.3 HYDANTOINS 

X 

X 

X 

X 

X 

X 

X 

X 

X 

phenytoin sodium extended 

X 

DILANTIN X phenytoin sodium extended 

PHENYTEK X phenytoin sodium extended release 

5.4.4 VALPROIC ACID AND DERIVATIVES 

divalproex sodium, ‐er 

valproic acid 

X 

X 


Page 16 of 50

TIER 

DRUG NAME 


DEPAKOTE ER X divalproex 

5.4.5 SUCCINIMIDES 

ethosuximide 

CELONTIN 

5.4.6 ANTICONVULSANT BARBITURATES 

phenobarbital 

primidone 

5.4.7 OTHER ANTICONVULSANTS 

gabapentin 

X 

lamotrigine 

X 

levetiracetam 

X 

topiramate PA X 

zonisamide PA X 

KEPPRA, ‐XR X levetiracetam 

LAMICTAL, ‐XR, ‐ODT X lamotrigine 

LYRICA 

X 

TOPAMAX PA X topiramate 

VIMPAT 

X 

5.5.1.1 TERTIARY AMINES 

amitriptyline hcl 

clomipramine hcl 

doxepin hcl 

imipramine hcl 

5.5.1.2 SECONDARY AMINES 

desipramine hcl 

X 

nortriptyline hcl 

X 

5.5.1.3 SELECTIVE SEROTONIN REUPTAKE INHIBITORS 

citalopram 

X 

citalopram hbr 

X 

fluoxetine hcl 

X 

fluvoxamine maleate 

X 

paroxetine hcl 

X 

sertraline hcl 

X 

CELEXA ST X citalopram 

LEXAPRO ST X generic ssri 

LUVOX CR ST X generic ssri 

PAXIL, ‐CR ST X paroxetine 

PEXEVA ST X paroxetine 

PROZAC ST X fluoxetine 

PROZAC WEEKLY ST X fluoxetine (daily) 

SARAFEM ST X fluoxetine 

ZOLOFT ST X sertraline 

X 

X 

X 

X 

X 

X 

X 

X 


Page 17 of 50

DRUG NAME 

5.5.1.4 OTHER ANTIDEPRESSANTS 

TIER 

1 2 3 4 

bupropion hcl, ‐sr, ‐xl 

X 

mirtazapine 

X 

nefazodone hcl 

X 

trazodone hcl 

X 

venlafaxine hcl 

X 

APLENZIN ST X bupropion xl 

CYMBALTA ST X venlafaxine 

EFFEXOR, ‐XR ST X venlafaxine 

PRISTIQ ST X venlafaxine 

SAVELLA ST X 

VENLAFAXINE HCL ER X venlafaxine 

WELLBUTRIN SR ST X bupropion sr 

WELLBUTRIN XL ST X bupropion xl 

5.5.2 MAO INHIBITORS 

phenelzine 

X 

tranylcypromine sulfate 

X 

NARDIL X phenelzine 

5.6 ANTIVERTIGO AND ANTIEMETIC DRUGS 

granisetron hcl 

X 

meclizine hcl 

X 

ondansetron hcl, ‐odt 

X 

prochlorperazine maleate 

X 

promethazine hcl 

X 

promethegan 

X 

trimethobenzamide hcl 

X 

ANZEMET X granisetron, ondansetron 

EMEND 

X 

SANCUSO 

X 

TRANSDERM‐SCOP X meclizine hcl 

5.7.1 ANTIPARKINSON ANTICHOLINERGIC DRUGS 

benztropine mesylate 

trihexyphenidyl hcl 

5.7.2 OTHER ANTIPARKINSON DRUGS 

bromocriptine mesylate 

X 

carbidopa‐levodopa 

X 

pramipexole 

X 

ropinirole hcl 

X 

AZILECT X selegiline 

COMTAN 

X 

MIRAPEX, ‐ER X pramipexole 

REQUIP XL X ropinirole 

X 

X 



Page 18 of 50

DRUG NAME 

STALEVO 

5.8 ANTIPSYCHOTIC DRUGS 

TIER 

1 2 3 4 

X 


clozapine 

X 

fluphenazine hcl 

X 

haloperidol 

X 

perphenazine 

X 

risperidone 

X 

thioridazine hcl 

X 

thiothixene 

X 

trifluoperazine hcl 

X 

ABILIFY, ‐DISCMELT X risperdone, SEROQUEL, ZYPREXA 

FANAPT X risperdone, SEROQUEL, ZYPREXA 

GEODON X risperdone, SEROQUEL, ZYPREXA 

INVEGA X risperdone, SEROQUEL, ZYPREXA 

LATUDA X risperdone, SEROQUEL, ZYPREXA 

RISPERDAL X risperidone tab 

RISPERDAL M‐TAB X risperidone regular tab 

SAPHRIS X risperdone, SEROQUEL, ZYPREXA 

SEROQUEL 

X 

SEROQUEL XR X risperdone, SEROQUEL, ZYPREXA 

ZYPREXA, ‐ZYDIS 

X 

ZYPREXA RELPREVV 

X 

5.8.1 ALIPHATIC PHENOTHIAZINES 

chlorpromazine hcl 

5.8.1.1 PSYCHOTHERAPEUTIC COMBINATIONS 

X 

SYMBYAX X fluoxetine + ZYPREXA (NON‐ZYDIS) 

5.9.1 CNS STIMULANT DRUGS 

amphetamine salt combo 

X 

dexmethylphenidate hcl, ‐ 

sulfate 

X 

dextroamphetamineamphetamine 

X 

methylin, ‐er 

X 

methylphenidate hcl, ‐sr 

X 

ADDERALL XR X dextroamphetamne‐amphetamne er 

CONCERTA X methylphenidate 

DAYTRANA X methylphenidate hcl 

FOCALIN XR X dexmethylphenidate 

METADATE CD X methylphenidate 

NUVIGIL X PROVIGIL 

PROVIGIL 

X 

RITALIN LA X methylphenidate 

VYVANSE X methylphenidate 


Page 19 of 50

DRUG NAME 

5.9.2 OTHER CNS/AUTONOMIC DRUGS 

TIER 

1 2 3 4 

atropine sulfate 

X 

naltrexone hcl 

X 

NUEDEXTA PA X 

XYREM PA X specialty 

5.9.2.1 ALCOHOL ANTAGONIST 

disulfiram 

X 

ANTABUSE X disulfiram 

5.9.3 ANTIDEMENTIA DRUGS 

donepezil, ‐odt 

X 

galantamine hbr 

X 

ARICEPT, ‐ ODT X donepezil, ‐odt 

EXELON X galantamine er, ARICEPT 

NAMENDA X galantamine er, ARICEPT 

RAZADYNE ER X galantamine er 

5.9.5 SMOKING CESSATION PRODUCTS 


bupropion hcl sr 

X 

$10 copay/30 day supply with dr prescription (only 

applies to generics); Can be dispensed up to 120 

nicotine gum (OTC) 

days per calendar year 



nicotine lozenge (OTC) 




nicotine patch (OTC) 


CHANTIX X Can be dispensed up to 120 days per calendar year 

NICOTROL INHALER X Can be dispensed up to 120 days per calendar year 

5.9.6 OTHER DRUGS FOR ADHD 

KAPVAY 

X 

STRATTERA 

X 

CHAPTER 6: DERMATOLOGICAL MEDICATIONS 

6.1 TOPICAL CORTICOSTEROID DRUGS 

alclometasone dipropionate 

betamethasone dipropionate 

betamethasone valerate 

clobetasol propionate 

desonide 

desoximetasone 

fluocinolone acetonide 

fluocinonide 

fluticasone propionate 

halobetasol propionate 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 


Page 20 of 50

TIER 

DRUG NAME 


hydrocortisone, ‐butyrate, ‐ 

valerate 

X 

mometasone furoate 

X 

triamcinolone acetonide 

X 

CAPEX SHAMPOO X fluocinolone cream,oint,sol 

CLOBEX X clobetasol solution 

HALOG 

X 

KENALOG X triamcinolone (non aerosol) 

OLUX X clobetasol propionate 

OLUX‐E X clobetasol(non foam) 

OLUX‐OLUX‐E X clobetasol(non foam) 

PRAMOSONE X lidocaine‐hc cream 

PRAMOSONE E 

X 

ULTRAVATE PAC X halobetasol propionate 

6.2 ANTIPRURITIC DRUGS 

hydroxyzine 

6.3 ANTIACNE DRUGS 

X 

benzoyl peroxide 

X 


X 

erythromycin 

X 

erythromycin‐benzoyl peroxide 

X 

metronidazole 

X 

sodium sulfacetamide‐sulfur 

X 


ACANYA X otc benzoyl peroxide+topical antibiotic 

ATRALIN PA X tretinoin 

AZELEX X tretinoin 

BENZACLIN X otc benzoyl peroxide+topical antibiotic 

BENZAMYCINPAK X erythromycin/benzoyl peroxide 

DIFFERIN X tretinoin 

DUAC CS X otc benzoyl peroxide+topical antibiotic 

EPIDUO X tretinoin 

FINACEA, ‐PLUS X tretinoin 

METROGEL X metronidazole 0.75% cream 

NORITATE X metronidazole cream 

RETIN‐A MICRO, ‐PUMP PA X tretinoin 

ZIANA PA X otc benzoyl peroxide+topical antibiotic 

6.3.1 ACCUTANES 

isotretinoin 

6.7 KERATOLYTIC DRUGS 

CONDYLOX X generic podofilox solution 

6.8 ANTIPSORIASIS AND ANTIECZEMA DRUGS 

calcipotriene 

X 

X 


Page 21 of 50

DRUG NAME 

selenium sulfide 

sulfacetamide sodium 

TAZORAC 

VECTICAL 

6.9.1 ORAL DERMATOLOGICAL DRUGS 

PROPECIA 

6.9.2 TOPICAL DERMATOLOGICAL DRUGS 

TIER 

1 2 3 4 

fluorouracil PA X 


ALDARA X imiquimod 

CARAC 

X 

ELIDEL X PROTOPIC 

PROTOPIC 

X 

QUTENZA X specialty 

SANTYL 

X 

SOLARAZE X fluorouracil 

VEREGEN X podofilox 

ZYCLARA 

X 

6.9.3 SCABICIDES 

permethrin 

X 

EURAX 

X 

ULESFIA X permethrin 

6.9.5 TOPICAL ANTI‐INFLAMMATORY DRUG 

PENNSAID SOLUTION 

7.1 DRUGS AFFECTING THE EAR 

X 

X 

X 

X 

X 

X 

CHAPTER 7: EAR‐NOSE‐THROAT MEDICATIONS 

acetic acid‐hydrocortisone 

X 

antipyrine‐benzocaine 

X 

neomycin‐polymyxin‐hc 

X 

ofloxacin 

X 

CETRAXAL X generics 

CIPRO HC X generics 

CIPRODEX X generics 

7.2 DRUGS AFFECTING THE NOSE 

azelastine 

X 

flunisolide, ‐propionate 

X 

ipratropium bromide 

X 

triamcinolone 

X 

ASTELIN 

X 

ASTEPRO X azelastine 

BECONASE AQ X generic, NASONEX 

NASACORT AQ X triamcinolone 



Page 22 of 50

TIER 

DRUG NAME 


NASONEX 

X 

OMNARIS X generic, NASONEX 

PATANASE X azelastine 

RHINOCORT AQUA 

X 

VERAMYST X generic, NASACORT,NASONEX 

7.3 DRUGS AFFECTING THE THROAT AND MOUTH 

pilocarpine hcl 


8.1.1 INSULIN 

X 

X 

CHAPTER 8: ENDOCRINE MEDICATIONS 

APIDRA X HUMALOG, NOVOLOG 

APIDRA SOLOSTAR X HUMALOG, NOVOLOG 

HUMALOG, ‐MIX 

X 

HUMULIN 50‐50, 

X 

HUMULIN 70‐30 

X 

HUMULIN N, ‐R 

X 

LANTUS, ‐SOLOSTAR 

X 

LEVEMIR X LANTUS 

NOVOLIN 70‐30, ‐INNOLET 

X 

NOVOLIN N, ‐INNOLET, ‐R 

X 

NOVOLOG, ‐MIX 

X 

8.1.2 ORAL HYPOGLYCEMIC DRUGS 

acarbose 

X 

glimepiride 

X 

glipizide/er, ‐metformin 

X 

glyburide, ‐micronized, ‐ 

metformin hcl 

X 

metformin hcl, ‐er 

X 

CYCLOSET 

X 

FORTAMET X metformin er 

PRANDIMET X nateglinide plus metformin 

PRANDIN X nateglinide 

RIOMET 

X 

STARLIX X nateglinide 

8.1.3 INSULIN SENSITIZERS 

ACTOPLUS MET 

X 

ACTOPLUS MET XR X ACTOS + metformin 

ACTOS 

X 

AVANDAMET 

X 

AVANDARYL 

X 

AVANDIA 

X 

DUETACT X ACTOS + glimepiride 


Page 23 of 50

DRUG NAME 

8.1.4 AMYLIN ANALOGUES 

SYMLIN, ‐ 120, ‐ 60 

8.1.5.1 INCRETIN MIMETICS 

BYETTA 

VICTOZA 

8.1.5.2 DIPEPTIDYL PEPTIDASE‐IV INHIBITORS 

JANUMET 

JANUVIA 

ONGLYZA 

8.2 GLUCOSE ELEVATING DRUGS 

GLUCAGEN 

8.3.1 GLUCOCORTICOID DRUGS 

dexamethasone 

dexamethasone sodium 

phosphate 

hydrocortisone 

methylprednisolone 

prednisolone 

prednisolone sodium phosphate 

prednisone 


8.3.2 MINERALOCORTICOID DRUGS 

fludrocortisone acetate 

8.4.1 THYROID SUPPLEMENTS 

TIER 

1 2 3 4 

levothyroxine sodium 

X 

levoxyl 

X 

NP thyroid 

X 

ARMOUR THYROID X NP thyroid 

CYTOMEL X liothyronine 

SYNTHROID X levothyroxine sodium 

8.4.2 ANTITHYROID DRUGS 

methimazole 

propylthiouracil 

8.6 OTHER ENDOCRINE DRUGS 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 


alendronate sodium 

X 

calcitonin nasal spray 

X 

desmopressin acetate PA X 

etidronate disodium 

X 

ACTONEL X alendronate 

ACTONEL WITH CALCIUM X alendronate tab plus calcium 

BONIVA PA X alendronate 

FORTEO PA X specialty 

FOSAMAX X alendronate 


Page 24 of 50

TIER 

DRUG NAME 


FOSAMAX PLUS D X alendronate tab plus calcium 

LUMIZYME X specialty 

PROLIA PA X specialty 

SENSIPAR 

X 

XGEVA PA X specialty 

CHAPTER 9: GASTROINTESTINAL MEDICATIONS 

9.2 ANTIDIARRHEAL DRUGS 

diphenoxylate‐atropine 

loperamide 

9.3 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY 

chlordiazepoxide‐clidinium 

X 

dicyclomine hcl 

X 

hyoscyamine sulfate 

X 

metoclopramide hcl 

X 

BENTYL X dicyclomine hcl 

CUVPOSA 

X 

NULEV X hyoscyamine sulfate 

9.4 ANTIULCER DRUGS 

cimetidine 

X 

famotidine 

X 

nizatidine 

X 

ranitidine hcl 

X 

AXID X nizatidine 

ZANTAC 25 X ranitidine hcl 

9.4.1 OTHER ANTIULCER DRUGS 

misoprostol 

X 

sucralfate 

X 

CARAFATE X sucralfate 

9.4.2 PROTON PUMP INHIBITORS ‐ OTC 

omeprazole 

PREVACID 24HR 

PRILOSEC OTC 

ZEGERID OTC 

9.4.2.1 PROTON PUMP INHIBITORS 

omeprazole 

pantoprazole sodium 

ACIPHEX 

DEXILANT 

NEXIUM X 

X 

X 

X 

$5 copay/30 day supply with dr. prescription 




Not covered, please use OTC omeprazole, 

pantoprazole/tier 2 or Nexium/tier 3 






Page 25 of 50

PREVACID 

PROTONIX 

DRUG NAME 

ZEGERID 

9.4.3 HELICOBACTER PYLORI DRUGS 

TIER 

1 2 3 4 

HELIDAC 

X 

PREVPAC X HELIDAC 

PYLERA X HELIDAC 

9.5 LAXATIVES AND CATHARTICS 

OSMOPREP 

9.6 OTHER GI DRUGS 

X 








anucort‐hc 

X 

balsalazide disodium 

X 

hydrocortisone, ‐acetate 

X 

peg 3350‐electrolyte 

X 

proctosol‐hc 

X 

proctozone‐hc 

X 

sulfasalazine 

X 

trilyte with flavor packets 

X 

ursodiol 

X 

ANALPRAM E, ‐HC X hc pramoxine 2.5% rectal cream 

APRISO X balsalazide, PENTASA 

ASACOL 

X 

ASACOL HD X balsalazide, PENTASA 

CANASA 

X 

CREON, ‐10, ‐20, ‐5 

X 

DIPENTUM 

X 

GOLYTELY X peg electrolyte 

HALFLYTELY‐BISACODYL X peg electrolyte 

LIALDA X balsalazide, PENTASA 

MOVIPREP X peg electrolyte 

NULYTELY WITH FLAVOR PACKS X peg electrolyte 

PENTASA 

X 

ULTRASE, ‐MT 

X 

URSO 

X 

URSO FORTE X ursodiol 

VIOKASE 

X 

ZENPEP 

X 

9.7 IRRITABLE BOWEL DRUGS 

AMITIZA 

X 


Page 26 of 50

TIER 

DRUG NAME 


CHAPTER 10: IMMUNOLOGICALS AND VACCINES 

10.0 IMMUNOLOGICALS AND VACCINES 

HYPERHEP B S‐D PA X specialty 

MICRHOGAM, ‐PLUS PA X specialty 

NABI‐HB PA X specialty 

RHOGAM PA X specialty 

RHOPHYLAC PA X specialty 

SYNAGIS PA X specialty 

WINRHO SDF PA X specialty 

10.2.1 MYELOID STIMULANTS 

NEULASTA PA X specialty 

NEUPOGEN PA X specialty 

10.2.2 ERYTHROID STIMULANTS 

ARANESP PA X specialty ‐ PROCRIT preferred 

PROCRIT PA X specialty 

10.2.3 INTERFERONS 

AMPYRA ER PA X specialty 

AVONEX, ‐ADMINISTRATION 

PACK PA X specialty 

BETASERON PA X specialty ‐ COPAXONE, REBIF preferred 

COPAXONE PA X specialty 

EXTAVIA PA X specialty ‐ COPAXONE, REBIF preferred 

GILENYA PA X specialty 

PEGASYS PA X specialty 

PEGINTRON PA X specialty 

PEGINTRON REDIPEN PA X specialty 

REBIF PA X specialty 

10.2.4 GROWTH HORMONES AND RELATED DRUGS 

EGRIFTA PA X specialty ‐ SAIZEN preferred 

GENOTROPIN PA X specialty ‐ SAIZEN preferred 

HUMATROPE PA X specialty ‐ SAIZEN preferred 

NORDITROPIN, ‐FLEXPRO, ‐ 

X 

NORDIFLEX 

PA 

specialty ‐ SAIZEN preferred 

NUTROPIN, ‐AQ, ‐AQ NUSPIN PA X specialty ‐ SAIZEN preferred 

OMNITROPE PA X specialty ‐ SAIZEN preferred 

SAIZEN PA X 

TEV‐TROPIN PA X specialty ‐ SAIZEN preferred 

10.2.6 INTERLEUKIN RECEPTOR ANTAGONIST 

KINERET PA X 

10.2.7 IMMUNOGLOBULIN ANTIBODIES 

XOLAIR PA X 


Page 27 of 50

TIER 

DRUG NAME 


CHAPTER 11: MUSCULOSKELETAL MEDICATIONS 

11.1.1 SALICYLATES AND RELATED DRUGS 

aspirin, ‐ ec 

X 

choline mag trisalicylate 

X 

diflunisal 

X 

salsalate 

X 

11.1.2 NON‐STEROIDAL ANTIINFLAMMATORY AGENTS 

diclofenac potassium, sodium 

X 

etodolac 

X 

flurbiprofen 

X 

ibuprofen 

X 

indomethacin 

X 

ketoprofen 

X 

ketorolac tromethamine 

X 

meloxicam 

X 

nabumetone 

X 

naproxen, sodium 

X 

oxaprozin 

X 

piroxicam 

X 

sulindac 

X 

CELEBREX 

X 

NAPRELAN X naproxen sodium 

11.1.4 OTHER DRUGS FOR ARTHRITIS 

SYNVISC PA X 

11.2 DRUGS TO PREVENT AND TREAT GOUT 

allopurinol 

X 

colchicine 

X 

probenecid 

X 

COLCRYS X colchicine 

KRYSTEXXA PA X specialty 

ULORIC X allopurinol 

11.3.1 DIRECT MUSCLE RELAXANTS 

baclofen 

X 

tizanidine hcl 

X 

XEOMIN PA X specialty 

11.3.2 CNS MUSCLE RELAXANTS 

carisoprodol 

X 

chlorzoxazone 

X 

cyclobenzaprine hcl 

X 

methocarbamol 

X 

orphenadrine citrate 

X 

AMRIX X cyclobenzaprine hcl 


Page 28 of 50

TIER 

DRUG NAME 


SKELAXIN 

X 

SOMA X carisoprodol 

CHAPTER 12: NUTRITION,BLOOD 

12.1.2 VITAMINS & MINERALS & RELATED PRODUCTS 

CEREFOLIN, ‐NAC X generic vitamin supplement 

FOLTX X generic vitamin supplement 

METANX X generic vitamin supplement 

REPLIVA 21‐7 X pruvate 21‐7 

12.1.3 THERAPEUTIC VITAMINS & MINERALS 

calcitriol 

X 

calcium acetate 

X 

eliphos 

X 

folic acid 

X 

levocarnitine 

X 

vitamin d 

X 

DEPLIN 

X 

HECTOROL CAPSULE X calcitriol 

HECTOROL INJECTABLE X cyanocobalamin inj 

PHOSLO X calcium acetate 667 mg capsule 

ZEMPLAR X calcitriol 

12.1.4 FLUORIDE PRODUCTS 

fluor‐a‐day 

sodium fluoride 

12.2 POTASSIUM SUPPLEMENTS 

potassium chloride 

12.3.1 ORAL ANTICOAGULANTS, VITAMIN K 

warfarin sodium 

X 

COUMADIN X warfarin sodium 

12.3.2 HEPARIN AND HEPARIN ANTAGONISTS 

enoxaparin 

heparin sodium 

X 

X 

X 

X 

X 

specialty – XARELTO preferred for hip/knee 

replacement 

ARIXTRA PA X specialty ‐ enoxaparin preferred 

FRAGMIN PA X specialty ‐ enoxaparin preferred 

LOVENOX PA X 

12.3.3 OTHER DRUGS AFFECTING COAGULATION 

XARELTO X Preferred product for hip/knee replacement 

12.3.5 THROMLAN INHIBITORS 

PRADAXA 

12.4 ANTIPLATELET DRUGS 

cilostazol 

X 

dipyridamole 

X 

AGGRENOX X aspirin + dipyridamole 

X 


Page 29 of 50

TIER 

DRUG NAME 


EFFIENT X PLAVIX 

PLAVIX 

X 

12.5 HEMOSTATICS 

LYSTEDA 

12.7 BLOOD DETOXICANTS 

enulose 

X 

lactulose 

X 

FOSRENOL X calcium acetate 

KRISTALOSE X lactulose 

RENAGEL X calcium acetate 

RENVELA X calcium acetate 

CHAPTER 13: OBSTETRICAL & GYNECOLOGICAL MEDICATIONS 

13.1.1 PRENATAL VITAMINS 

advanced natalcare 

multi‐nate 

prenate plus 

natalcare 

prenatal rx 

13.1.2 SPECIALIZED OB/GYN DRUGS 

X 

$0 copay 

$0 copay 

$0 copay 

$0 copay 

$0 copay 

chorionic gonadotropin PA X specialty 

leuprolide acetate PA X specialty 

novarel PA X specialty 

CETROTIDE PA X specialty 

GANIRELIX ACETATE PA X specialty 

LUPRON DEPOT PA X specialty 

LUPRON DEPOT‐PED PA X specialty 

specialty ‐ chronic gonadotropin, NOVAREL 

X 

OVIDREL 

PA 

preferred 

specialty ‐chronic gonadotropin, NOVAREL 

X 

PREGNYL 

PA 

preferred 

13.1.3 OB/GYN TOPICAL ANTIINFECTIVES 


X 

metronidazole 

X 

vandazole 

X 

CLINDESSE X clindamycin phosphate 

13.2 OVULATORY STIMULANTS 

clomiphene citrate 

X 

BRAVELLE PA X specialty 

FERTINEX X specialty 

FOLLISTIM AQ PA X specialty 

GONAL‐F, ‐RFF PA X specialty 

MENOPUR PA X specialty 

REPRONEX PA X specialty 


Page 30 of 50

TIER 

DRUG NAME 


jolivette 

X 

medroxyprogesterone acetate 

X 

nora‐be 

X 

norethindrone acetate 

X 

progesterone in oil PA X 

CRINONE 

X 

ENDOMETRIN 

X 

MAKENA X specialty 

PROCHIEVE 

X 

PROMETRIUM 

X 

13.7 CONTRACEPTIVES 

apri 

aranelle 

aviane 

balziva 

cesia 

cryselle 

enpresse 

jolessa 

junel, ‐ fe 

kariva 

kelnor 1‐35 

leena 

lessina 

levora‐28 

low‐ogestrel 

lutera 

microgestin , ‐fe 

mononessa 

necon 

nortrel 

ocella 

ogestrel 

portia 

previfem 

quasense 

reclipsen 

solia 

sprintec 

sronyx 

tilia fe 

tri‐legest fe 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 


Page 32 of 50

TIER 

DRUG NAME 


trinessa 

X 

tri‐previfem 

X 

tri‐sprintec 

X 

trivora‐28 

X 

velivet 

X 

zenchent 

X 

zovia 

X 

CYCLESSA X cesia, velivet 

ELLA 

X 

FEMCON FE X generic oral contraceptives 

LOESTRIN 24 FE X junel fe, microgestin fe 

LOSEASONIQUE X generic oral contraceptives 

LYBREL X generic oral contraceptives 

NATAZIA 

X 

NUVARING 

X 

ORTHO EVRA 

X 

ORTHO TRI‐CYCLEN X trinessa, tri‐previfem 

ORTHO TRI‐CYCLEN LO X generic oral contraceptives 

SEASONIQUE X generic oral contraceptives 

YASMIN 28 X ocella 

YAZ X generic oral contraceptives 

13.9 OXYTOCICS 

methylergonovine 

X 

METHERGINE X methylergonovine 

CHAPTER 14: OPHTHALMIC MEDICATIONS 

14.1.1 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS 

bacitracin 

X 

bacitracin‐polymyxin 

X 

ciprofloxacin hcl 

X 

erythromycin 

X 


X 

neomycin‐bacitracin‐polymyxin 

X 

ofloxacin 

X 

polymyxin b sul‐trimethoprim 

X 

sulfacetamide sodium 

X 

tobramycin sulfate 

X 

AZASITE X ciprofloxacin 

BESIVANCE X ciprofloxacin 

IQUIX X ciprofloxacin 

QUIXIN X ciprofloxacin 

VIGAMOX X ciprofloxacin 

ZYMAR X ciprofloxacin 


Page 33 of 50

DRUG NAME 

14.1.2 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS 

trifluridine 

14.2 OPHTHALMIC CORTICOSTEROID DRUGS 

TIER 

1 2 3 4 

X 


fluorometholone 

X 

prednisolone acetate 

X 

ALREX X generic opht. steroid 

DUREZOL X generic steroids, LOTEMAX 

FML FORTE X generic steroids, LOTEMAX 

LOTEMAX 

X 

VEXOL X generic steroids, LOTEMAX 

14.3 OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS 

neomycin‐polymyxin‐dexameth 

X 

tobramycin‐dexamethasone 

X 

TOBRADEX 

X 

ZYLET X generic, Tobradex 

14.5 ANTIGLAUCOMA DRUGS 

acetazolamide 

X 

brimonidine tartrate 

X 

dorzolamide hcl 

X 

dorzolamide‐timolol 

X 

latanoprost 

X 

levobunolol hcl 

X 

pilocarpine hcl 

X 

timolol maleate 

X 

ALPHAGAN P 

X 

AZOPT X brimonidine tartrate 

BETIMOL 

X 

BETOPTIC S X betaxolol 

COMBIGAN X brimonidine tartrate 

COSOPT X dorzolamide‐timolol 

IOPIDINE X generics 

ISTALOL X timolol maleate 

LUMIGAN 

X 

TRAVATAN Z X LUMIGAN, XALATAN 

TRUSOPT X dorzolamide 

XALATAN X latanoprost 

14.6 OTHER OPHTHALMIC DRUGS 

atropine sulfate 

X 

cromolyn sodium 

X 

diclofenac sodium 

X 

ketotifen fumarate 

X 

ACULAR, ‐ LS X ketorolac ophth 


Page 34 of 50

TIER 

DRUG NAME 


ACUVAIL X diclofenac, ketorolac ophth 

ALAMAST X cromolyn sodium 

ALOCRIL X cromolyn sodium 

ALOMIDE X cromolyn sodium 

BEPREVE X cromolyn sodium 

BOTOX PA X 

ELESTAT X cromolyn sodium 

EMADINE X cromolyn sodium 

NEVANAC X diclofenac sodium eye drops 

OPTIVAR X azalastine ophth 

PATADAY X otc ketotifen fumerate 

PATANOL X otc ketotifen fumerate 

RESTASIS 

X 

VOLTAREN X diclofenac sodium eye drops 

XIBROM X diclofenac sodium eye drops 

CHAPTER 15: RESPIRATORY MEDICATIONS 

15.1.1 BETA‐2 ADRENERGIC DRUGS 

albuterol sulfate 

X 

metaproterenol sulfate 

X 

terbutaline sulfate 

X 

BROVANA X albuterol 

FORADIL X SEREVENT 

MAXAIR AUTOHALER X PROAIR HFA,PROVENT HFA, XOPENEX HFA 

PERFOROMIST X albuterol 

PROAIR HFA 

X 

PROVENTIL HFA 

X 

SEREVENT DISKUS 

X 

VENTOLIN HFA X PROAIR HFA,PROVENT HFA, XOPENEX HFA 

XOPENEX X albuterol 

XOPENEX HFA 

X 

15.1.2 METHYL XANTHINE DRUGS 

aminophylline 

theophylline, ‐anhydrous 

15.1.3 OTHER DRUGS FOR ASTHMA 

budesonide 

X 

cromolyn sodium 

X 

epinephrine auto injector, ‐jr 

X 

ipratropium, ‐albuterol, ‐ 

bromide 

X 

ADVAIR DISKUS 

X 

ADVAIR HFA 

X 

AEROBID, ‐M X QVAR, FLOVENT HFA 

ALVESCO X QVAR, FLOVENT HFA 

X 

X 


Page 35 of 50

TIER 

DRUG NAME 


ASMANEX X QVAR, FLOVENT HFA 

ATROVENT HFA 

X 

COMBIVENT 

X 

DULERA 

X 

EPIPEN; ‐JR X epinephrine auto injector, ‐jr 

FLOVENT, ‐DISKUS, ‐HFA 

X 

PULMICORT X budesonide 

PULMICORT FLEXHALER X QVAR, FLOVENT HFA 

QVAR 

X 

SPIRIVA 

X 

SYMBICORT 

X 

TWINJECT X epinephrine auto injector, ‐jr 

15.1.4 LEUKOTRIENE MODIFIERS 

zafirlukast tabs 

X 

ACCOLATE X zafirlukast tabs 

SINGULAIR 

X 

15.2.1 ANTIHISTAMINES 

cetirizine 

cyproheptadine hcl 

diphenhydramine hcl 

fexofenadine hcl 

loratadine 

promethazine hcl 

ALLEGRA, ‐ODT 

CLARINEX 

XYZAL 

ZYRTEC 

15.2.3 ANTIHISTAMINE/DECONGESTANT COMBINATIONS 

X 

X 

X 

Not covered, please use over the counter 

medication* 


medication* 


medication* 


medication* 


medication* 


medication* 


medication* 

ALLEGRA‐D 


medication* 

CLARINEX‐D 


medication* 

RYNATAN PEDIATRIC X ceron syrup, c‐phen syrup 

SEMPREX‐D 

X 

ZYRTEC‐D 

X 

15.3 ANTITUSSIVE AND EXPECTORANT DRUGS 

benzonatate 

X 


Page 36 of 50

DRUG NAME 

guaifenesin/codiene 

guaifenesin‐codeine 

promethazine vc‐codeine 

promethazine‐codeine 

promethazine‐dm 

15.4 OTHER RESPIRATORY DRUGS 

TIER 

1 2 3 4 

PULMOZYME PA X specialty 

CHAPTER 16: UROLOGICAL MEDICATIONS 

16.1.1 ANTICHOLINERGIC ANTISPASMODICS 

X 

X 

X 

X 

X 


oxybutynin chloride 

X 

oxybutynin chloride er 

X 

DETROL, ‐LA 

X 

ENABLEX 

X 

GELNIQUE X oxybutynin er 

OXYTROL X oxybutynin er 

SANCTURA X oxybutynin er,ENABLEX,VESICARE,DETROL/LA 

SANCTURA XR X oxybutynin er,ENABLEX,VESICARE,DETROL/LA 

TOVIAZ X oxybutynin er,ENABLEX,VESICARE,DETROL/LA 

VESICARE 

X 

16.1.2 CHOLINERGIC STIMULANTS 

bethanechol chloride 

16.1.3 URINARY ANESTHETICS 

phenazopyridine hcl 

16.1.4 OTHER GENITOURINARY PRODUCTS 

finasteride 

X 

potassium citrate 

X 

tamsulosin hcl 

X 

AVODART X finasteride 

CIALIS X VIAGRA 

FLOMAX 

X 

LEVITRA X VIAGRA 

MUSE 

X 

RAPAFLO X doxazosn,tamsulosn 

UROXATRAL X doxazosn,tamsulosn 

VIAGRA 

X 

CHAPTER 17: DIAGNOSTIC & MISCELLANEOUS MEDICATIONS 

17.1 DIAGNOSTIC PRODUCTS 

MINILINK REAL‐TIME 

TRANSMITTER 

X 

PARADIGM REAL‐TIME 

X 

PRECISION XTRA 

X 

SOF‐SENSOR PA X 

THYROGEN PA X 

X 

X 


Page 37 of 50

DRUG NAME 

17.2 MISCELLANEOUS DRUGS 

TIER 

1 2 3 4 

CARBAGLU PA X specialty 

THALOMID PA X specialty 

17.3.1 APPETITE SUPPRESSANTS 

phentermine hcl PA X 

17.3.2 OTHER WEIGHT LOSS PRODUCTS 

XENICAL PA X OTC ALLI 

CHAPTER 18: MEDICAL (MISCELLANEOUS) SUPPLIES 

18.0 MEDICAL (MISCELLANEOUS) SUPPLIES 

AEROCHAMBER 

MINIMED, ‐RESERVOIR 

OPTICHAMBER 

QUICK RELEASE SOFT TEFLON 

SILHOUETTE 

18.1 DIABETIC SUPPLIES 

ACCU‐CHEK 

X 

ACCU‐CHEK ACTIVE 

X 

ACCU‐CHEK AVIVA 

X 

ACCU‐CHEK COMFORT CURVE 

X 

ACCU‐CHEK COMPACT 

X 

ACCU‐CHEK INSTANT 

X 

ASCENSIA AUTODISC X ACCU‐CHEK, ONE TOUCH 

AUTODISC NORMAL X ACCU‐CHEK, ONE TOUCH 

BREEZE 2 X ACCU‐CHEK, ONE TOUCH 

CONTOUR X ACCU‐CHEK, ONE TOUCH 

FAST TAKE 

X 

FREESTYLE FREEDOM LITE X ACCU‐CHEK, ONE TOUCH 

FREESTYLE LITE METER X ACCU‐CHEK, ONE TOUCH 

FREESTYLE LITE STRIPS X ACCU‐CHEK, ONE TOUCH 

FREESTYLE TEST STRIPS X ACCU‐CHEK, ONE TOUCH 

ONE TOUCH BASIC SYSTEM 

X 

ONE TOUCH TEST STRIPS 

X 

ONE TOUCH ULTRA 2 

X 

ONE TOUCH ULTRA SMART 

X 

ONE TOUCH ULTRA SYSTEM 

X 

ONE TOUCH ULTRA TEST STRIPS 

X 

ONE TOUCH ULTRAMINI 

X 

PRODIGY PEN NEEDLE X ACCU‐CHEK, ONE TOUCH 

SURESTEP 

X 

TRUETRACK SMART SYSTEM X ACCU‐CHEK, ONE TOUCH 

TRUETRACK TEST STRIP X ACCU‐CHEK, ONE TOUCH 

X 

X 

X 

X 

X 



Page 38 of 50

INDEX 

ABILIFY, ‐DISCMELT, 19 

ACANYA, 21 

acarbose, 23 

ACCOLATE, 36 

ACCU‐CHEK, 38 

ACCU‐CHEK ACTIVE, 38 

ACCU‐CHEK AVIVA, 38 

ACCU‐CHEK COMFORT CURVE, 38 

ACCU‐CHEK COMPACT, 38 

ACCU‐CHEK INSTANT, 38 

acebutolol hcl, 12 

ACEON, 13 

acetaminophen‐codeine, 15 

acetazolamide, 34 

acetic acid‐hydrocortisone, 22 

ACIPHEX, 25 

ACTEMRA, 10 

ACTIVELLA, 31 

ACTONEL, 24 

ACTONEL WITH CALCIUM, 24 

ACTOPLUS MET, 23 

ACTOPLUS MET XR, 23 

ACTOS, 23 

ACULAR, ‐ LS, 34 

ACUVAIL, 35 

acyclovir, 9 

ADCIRCA, 13 

ADDERALL XR, 19 

ADVAIR DISKUS, 35 

ADVAIR HFA, 35 

advanced natalcare, 30 

ADVICOR, 14 

AEROBID, ‐M, 35 

AEROCHAMBER, 38 

AGGRENOX, 29 

ALAMAST, 35 

albuterol sulfate, 35 

alclometasone dipropionate, 20 

ALDARA, 22 

alendronate sodium, 24 

ALLEGRA, ‐ODT, 36 

ALLEGRA‐D, 36 

allopurinol, 28 

ALOCRIL, 35 

ALOMIDE, 35 

ALORA, 31 

ALPHAGAN P, 34 

alprazolam, ‐er, ‐xr, 16 

ALREX, 34 

ALTABAX, 8 

ALTOPREV, 14 

ALVESCO, 35 

amantadine, 9 

AMBIEN, ‐cr, 16 

AMERGE, 15 

amiloride hcl, 12 

aminophylline, 35 

amiodarone hcl, 14 

AMITIZA, 26 

amitriptyline hcl, 17 

amlodipine ‐benazepril, 13 

amlodipine besylate, 11, 13 

amlodipine besylate‐benazepril, 13 

amox tr‐potassium clavulanate, 7 

amoxicillin, 7 

amphetamine salt combo, 19 

AMPYRA ER, 27 

AMRIX, 28 

anagrelide hcl, 10 

ANALPRAM E, ‐HC, 26 

anastrozole, 10 

ANDRODERM, 31 

ANDROGEL, 31 

ANGELIQ, 31 

ANTABUSE, 20 

ANTARA, 14 

antipyrine‐benzocaine, 22 

anucort‐hc, 26 

ANZEMET, 18 

APIDRA, 23 

APIDRA SOLOSTAR, 23 

APLENZIN, 18 

apri, 32 

APRISO, 26 

aranelle, 32 

ARANESP, 27 

ARICEPT, ‐ ODT, 20 

ARIMIDEX, 10 

ARIXTRA, 29 

ARMOUR THYROID, 24 

ASACOL, 26 

ASACOL HD, 26 

ASCENSIA AUTODISC, 38 

ASMANEX, 36 

aspirin, ‐ ec, 28 

ASTELIN, 22 

ASTEPRO, 22 

ATACAND, ‐HCT, 13 

atenolol, 12, 13 

atenolol‐chlorthalidone, 13 

ATRALIN, 21 

ATRIPLA, 9 

atropine sulfate, 20, 34 

ATROVENT HFA, 36 

AUGMENTIN XR, 7 

AUTODISC NORMAL, 38 

AVALIDE, 13 

AVANDAMET, 23 

AVANDARYL, 23 

AVANDIA, 23 

AVAPRO, 13 

AVELOX, ‐ABC PACK, 8

aviane, 32 

AVINZA, 15 

AVODART, 37 

AVONEX, ‐ADMINISTRATION PACK, 27 

AXERT, 15 

AXID, 25 

AZASITE, 33 

azathioprine, 10 

azelastine, 22, 23 

AZELEX, 21 

AZILECT, 18 

azithromycin, 7 

AZOPT, 34 

AZOR, 13 

bacitracin, 10, 33 

bacitracin‐polymyxin, 33 

baclofen, 28 

balsalazide disodium, 26 

balziva, 32 

BECONASE AQ, 22 

benazepril hcl, 12 

BENICAR, ‐HCT, 13 

BENTYL, 25 

BENZACLIN, 21 

BENZAMYCINPAK, 21 

benzonatate, 36 

benzoyl peroxide, 21 

benztropine mesylate, 18 

BEPREVE, 35 

BESIVANCE, 33 

betamethasone dipropionate, 20 

betamethasone valerate, 20 

BETASERON, 27 

bethanechol chloride, 37 

BETIMOL, 34 

BETOPTIC S, 34 

BIDIL, 13 

bisoprolol fumarate, 12 

BONIVA, 24 

BOTOX, 35 

BRAVELLE, 30 

BREEZE 2, 38 

brimonidine tartrate, 34 

bromocriptine mesylate, 18 

BROVANA, 35 

budesonide, 35, 36 

bumetanide, 11 

bupropion hcl sr, 20 

bupropion hcl, ‐sr, ‐xl, 18 

buspirone hcl, 16 

butalbital compound‐codeine, 15 

butalbital‐apap‐caffeine, 15 

butalbital‐aspirin‐caffeine, 15 

butalbital‐caff‐apap‐codeine, 15 

butorphanol tartrate, 15 

BYETTA, 24 

BYSTOLIC, 12 

CADUET, 14 

calcipotriene, 21 

calcitonin nasal spray, 24 

calcitriol, 29 

calcium acetate, 29, 30 

camila, 31 

CANASA, 26 

CAPEX SHAMPOO, 21 

captopril, 12, 13 

captopril‐hydrochlorothiazide, 13 

CARAC, 22 

CARAFATE, 25 

CARBAGLU, 38 

carbamazepine, 16 

CARBATROL, 16 

carbidopa‐levodopa, 18 

CARDENE SR, 11 

CARDIZEM LA, 11 

CARDURA XL, 12 

carisoprodol, 28, 29 

cartia xt, 11 

carvedilol, 12 

CEDAX, 7 

cefaclor, ‐er, 7 

cefadroxil, 7 

cefdinir, 7 

CEFDITOREN PIVOXIL, 7 

cefpodoxime proxetil, 7 

cefprozil, 7 

cefuroxime, 7 

CELEBREX, 28 

CELEXA, 17 

CELLCEPT, 10 

CELONTIN, 17 

CENESTIN, 31 

CENTANY, 8 

cephalexin, 7 

CEREFOLIN, ‐NAC, 29 

cesia, 32, 33 

cetirizine, 36 

CETRAXAL, 22 

CETROTIDE, 30 

CHANTIX, 20 

chlordiazepoxide hcl, 16 

chlordiazepoxide‐clidinium, 25 

chloroquine phosphate, 9 

chlorpromazine hcl, 19 

chlorthalidone, 12 

chlorzoxazone, 28 

cholestyramine, 14 

choline mag trisalicylate, 28 

chorionic gonadotropin, 30 

CIALIS, 37 

ciclopirox, 8 

cilostazol, 29 

cimetidine, 25 

CIMZIA, 10 

CIPRO HC, 22 

CIPRODEX, 22

ciprofloxacin hcl, 33 

ciprofloxacin, ‐er, ‐hcl, 8 

citalopram, 17 

citalopram hbr, 17 

CLARINEX, 36 

CLARINEX‐D, 36 

clarithromycin, ‐er, 7 

CLIMARA PRO, 31 

clindamycin phosphate, 7, 21, 30 

clindamycin, ‐ hcl, ‐phosphate, 7 

CLINDESSE, 30 

clobetasol propionate, 20, 21 

CLOBEX, 21 

clomiphene citrate, 30 

clomipramine hcl, 17 

clonazepam, 16 

clonidine hcl, 12 

clorazepate dipotassium, 16 

clotrimazole, 8, 9 

clotrimazole‐betamethasone, 9 

clozapine, 19 

colchicine, 28 

COLCRYS, 28 

colestipol hcl, 14 

COMBIGAN, 34 

COMBIPATCH, 31 

COMBIVENT, 36 

COMBIVIR, 9 

COMTAN, 18 

CONCERTA, 19 

CONDYLOX, 21 

CONTOUR, 38 

COPAXONE, 27 

COREG CR, 12 

COSOPT, 34 

COUMADIN, 29 

COVERA‐HS, 11 

COZAAR, 13 

CREON, ‐10, ‐20, ‐5, 26 

CRESTOR, 14 

CRINONE, 32 

cromolyn sodium, 34, 35 

cryselle, 32 

CUVPOSA, 25 

CYCLESSA, 33 

cyclobenzaprine hcl, 28 

CYCLOSET, 23 

cyclosporine, 10 

CYMBALTA, 18 

cyproheptadine hcl, 36 

CYTOMEL, 24 

DAPSONE, 10 

DAYTRANA, 19 

DENAVIR, 9 

DEPAKOTE ER, 17 

DEPLIN, 29 

desipramine hcl, 17 

desmopressin acetate, 24 

desonide, 20 

desoximetasone, 20 

DETROL, ‐LA, 37 

dexamethasone, 24 

dexamethasone sodium phosphate, 24 

DEXILANT, 25 

dexmethylphenidate hcl, ‐sulfate, 19 

dextroamphetamine‐amphetamine, 19 

diazepam, 16 

diclofenac potassium, sodium, 28 

diclofenac sodium, 34, 35 

dicloxacillin sodium, 7 

dicyclomine hcl, 25 

DIFFERIN, 21 

diflunisal, 28 

digoxin, 11 

DILANTIN, 16 

diltiazem/er, 11 

DIOVAN, ‐HCT, 13 

DIPENTUM, 26 

diphenhydramine hcl, 36 

diphenoxylate‐atropine, 25 

dipyridamole, 29 

disulfiram, 20 

divalproex sodium, ‐er, 16 

DIVIGEL, 31 

donepezil, 20 

DORYX, 8 

dorzolamide hcl, 34 

dorzolamide‐timolol, 34 

doxazosin mesylate, 12 

doxepin hcl, 17 

doxycycline hyclate, 7 

doxycycline monohydrate, 7 

DUAC CS, 21 

DUETACT, 23 

DULERA, 36 

DUREZOL, 34 

DYNACIRC CR, 11 

econazole nitrate, 8 

EDLUAR, 16 

EFFEXOR XR, 18 

EFFEXOR, ‐ XR, 18 

EFFIENT, 30 

EGRIFTA, 27 

ELESTAT, 35 

ELESTRIN, 31 

ELIDEL, 22 

ELIGARD, 10 

eliphos, 29 

ELLA, 33 

EMADINE, 35 

EMBEDA, 15 

EMEND, 18 

ENABLEX, 37 

enalapril maleate, 12 

ENBREL, 10 

endocet, 15

ENDOMETRIN, 32 

ENJUVIA, 31 

enpresse, 32 

enulose, 30 

EPIDUO, 21 

epinephrine auto injector, ‐jr, 35 

EPIVIR, 9 

EPIVIR HBV, 9 

eplerenone, 12 

EPZICOM, 9 

errin, 31 

ERTACZO, 8 

erythromycin, 7, 21, 33 

erythromycin‐benzoyl peroxide, 21 

estazolam, 16 

ESTRACE, 31 

ESTRADERM, 31 

estradiol, 31 

ESTRASORB, 31 

ESTRING, 31 

ESTROGEL, 31 

estrogen & methyltestosterone, 31 

estropipate, 31 

ethambutol hcl, 9 

ethosuximide, 17 

etidronate disodium, 24 

etodolac, 28 

EURAX, 22 

EVAMIST, 31 

EVISTA, 31 

EXALGO, ‐ER, 15 

EXELDERM, 8 

EXELON, 20 

EXFORGE, 13 

EXFORGE HCT, 13 

EXTAVIA, 27 

FACTIVE, 8 

famciclovir, 9 

famotidine, 25 

FANAPT, 19 

FAST TAKE, 38 

felodipine er, 11 

FEMARA, 10 

FEMCON FE, 33 

FEMHRT, 31 

FEMTRACE, 31 

fenofibrate, 14 

FENOGLIDE, 14 

fentanyl, 15 

FERTINEX, 30 

fexofenadine hcl, 36 

FINACEA, ‐PLUS, 21 

finasteride, 37 

FIRMAGON, 10 

flecainide acetate, 14 

FLOMAX, 37 

FLOVENT, ‐DISKUS, ‐HFA, 36 

fluconazole, 8 

fludrocortisone acetate, 24 

flunisolide, ‐propionate, 22 

fluocinolone acetonide, 20 

fluocinonide, 20 

fluor‐a‐day, 29 

fluorometholone, 34 

fluorouracil, 22 

fluoxetine hcl, 17 

fluphenazine hcl, 19 

flurazepam hcl, 16 

flurbiprofen, 28 

fluticasone propionate, 20 

fluvoxamine maleate, 17 

FML FORTE, 34 

FOCALIN XR, 19 

folic acid, 29 

FOLLISTIM AQ, 30 

FOLTX, 29 

FORADIL, 35 

FORTAMET, 23 

FORTEO, 24 

FOSAMAX, 24, 25 

FOSAMAX PLUS D, 25 

fosinopril sodium, 12 

fosinopril‐hydrochlorothiazide, 13 

FOSRENOL, 30 

FRAGMIN, 29 

FREESTYLE FREEDOM LITE, 38 

FREESTYLE LITE METER, 38 

FREESTYLE LITE STRIPS, 38 

FREESTYLE TEST STRIPS, 38 

FROVA, 15 

furosemide, 11 

gabapentin, 17 

galantamine hbr, 20 

GANIRELIX ACETATE, 30 

GELNIQUE, 37 

gemfibrozil, 14 

GENOTROPIN, 27 

gentamicin sulfate, 8, 10, 33 

GEODON, 19 

GILENYA, 27 

GLEEVEC, 10 

glimepiride, 23 

glipizide/er, ‐metformin, 23 

GLUCAGEN, 24 

glyburide, ‐micronized, ‐metformin hcl, 23 

GOLYTELY, 26 

GONAL‐F, ‐RFF, 30 

granisetron hcl, 18 

guaifenesin/codiene, 37 

guaifenesin‐codeine, 37 

guanfacine hcl, 12 

HALFLYTELY‐BISACODYL, 26 

halobetasol propionate, 20, 21 

HALOG, 21 

haloperidol, 19 

HECTOROL CAPSULE, 29

HECTOROL INJECTABLE, 29 

HELIDAC, 26 

heparin sodium, 29 

HUMALOG, ‐MIX, 23 

HUMATROPE, 27 

HUMIRA, 10 

HUMULIN 50‐50,, 23 

HUMULIN 70‐30, 23 

HUMULIN N, ‐R, 23 

hydrochlorothiazide, 12 

hydrocodone bit‐ibuprofen, 15 

hydrocodone‐acetaminophen, 15 

hydrocortisone, 21, 24, 26 

hydrocortisone, ‐acetate, 26 

hydrocortisone, ‐butyrate, ‐valerate, 21 

hydromorphone hcl, 15 

hydroxychloroquine sulfate, 9 

hydroxyurea, 10 

hydroxyzine, 21 

hyoscyamine sulfate, 25 

HYPERHEP B S‐D, 27 

HYZAAR, 13 

ibuprofen, 28 

imipramine hcl, 17 

IMITREX, 16 

INCIVEK, 9 

indapamide, 12 

indomethacin, 28 

INNOPRAN XL, 12 

INVEGA, 19 

IOPIDINE, 34 

ipratropium bromide, 22 

ipratropium, ‐albuterol, ‐bromide, 35 

IQUIX, 33 

ISENTRESS, 9 

isometh‐d‐chloralphenaz‐apap, 15 

isoniazid, 9 

isosorbide, ‐dinitrate, 13 

isotretinoin, 21 

ISTALOL, 34 

itraconazole, 8 

JANUMET, 24 

JANUVIA, 24 

jinteli, 31 

jolessa, 32 

jolivette, 32 

EPIPEN, 36 

junel, ‐ fe, 32 

KADIAN, 15 

KALETRA, 9 

KAPVAY, 20 

kariva, 32 

kelnor 1‐35, 32 

KENALOG, 21 

KEPPRA, ‐XR, 17 

ketoconazole, 8 

ketoprofen, 28 

ketorolac tromethamine, 28 

ketotifen fumarate, 34 

KINERET, 11, 27 

KRISTALOSE, 30 

KRYSTEXXA, 28 

labetalol hcl, 12 

lactulose, 30 

LAMICTAL, ‐XR, ‐ODT, 17 

LAMISIL, 8 

lamotrigine, 17 

LANOXIN, 11 

LANTUS, ‐SOLOSTAR, 23 

latanoprost, 34 

LATUDA, 19 

leena, 32 

leflunomide, 10 

LESCOL, ‐XL, 14 

lessina, 32 

LETAIRIS, 14 

letrozole, 10 

leucovorin calcium, 10 

leuprolide acetate, 30 

LEVAQUIN, 8 

LEVEMIR, 23 

levetiracetam, 17 

LEVITRA, 37 

levobunolol hcl, 34 

levocarnitine, 29 

levofloxacin, 8 

levora‐28, 32 

levothyroxine sodium, 24 

levoxyl, 24 

LEXAPRO, 17 

LIALDA, 26 

lidocaine hcl, 7 

lidocaine‐prilocaine, 7 

LIDODERM, 7 

LIPITOR, 14 

LIPOFEN, 14 

lisinopril, 12 

lithium carbonate, 16 

LIVALO, 14 

LOESTRIN 24 FE, 33 

loperamide, 25 

LOPROX, 8 

loratadine, 36 

lorazepam, 16 

losartan, 13 

losartan‐hydrochlorothiazide, 13 

LOSEASONIQUE, 33 

LOTEMAX, 34 

LOTREL, 13 

lovastatin, 14 

LOVAZA, 14 

LOVENOX, 29 

low‐ogestrel, 32 

LUMIGAN, 34 

LUMIZYME, 25 

LUNESTA, 16

LUPRON DEPOT, 30 

LUPRON DEPOT‐PED, 30 

lutera, 32 

LUVOX CR, 17 

LYBREL, 33 

LYRICA, 17 

LYSTEDA, 30 

MAKENA, 32 

MALARONE, 9 

MAXAIR AUTOHALER, 35 

MAXALT, ‐MLT, 16 

meclizine hcl, 18 

medroxyprogesterone acetate, 32 

mefloquine hcl, 9 

MEGACE ES, 11 

megestrol acetate, 10, 11 

meloxicam, 28 

MENEST, 31 

MENOPUR, 30 

MENOSTAR, 31 

MENTAX, 8 

MEPRON, 10 

mercaptopurine, 10 

METADATE CD, 19 

METANX, 29 

metaproterenol sulfate, 35 

metformin hcl, ‐er, 23 

methadone hcl, 15 

METHERGINE, 33 

methimazole, 24 

methocarbamol, 28 

methotrexate, 10 

methyldopa, 12 

methylergonovine, 33 

methylin, ‐er, 19 

methylphenidate hcl, ‐sr, 19 

methylprednisolone, 24 

metoclopramide hcl, 25 

metolazone, 12 

metoprolol, ‐succinate, ‐tartrate, 12 

metoprolol‐hydrochlorothiazide, 13 

METROGEL, 21 

metronidazole, 10, 21, 30 

MICARDIS, ‐HCT, 13 

MICRHOGAM, ‐PLUS, 27 

microgestin , ‐fe, 32 

MIGRANAL, 16 

MINILINK REAL‐TIME TRANSMITTER, 37 

MINIMED, ‐RESERVOIR, 38 

minocycline hcl, 7 

minoxidil, 12 

MIRAPEX, ‐ER, 18 

mirtazapine, 18 

misoprostol, 25 

moexipril hcl, 13 

moexipril‐hydrochlorothiazide, 13 

mometasone furoate, 21 

mononessa, 32 

morphine sulfate, 15 

MOVIPREP, 26 

MOXATAG, 7 

MULTAQ, 14 

multi‐nate, 30 

mupirocin, 8 

MUSE, 37 

MYCOBUTIN, 9 

MYFORTIC, 11 

NABI‐HB, 27 

nabumetone, 28 

nadolol, 12 

naltrexone hcl, 20 

NAMENDA, 20 

NAPRELAN, 28 

naproxen, sodium, 28 

NARDIL, 18 

NASACORT AQ, 22 

NASONEX, 22, 23 

natalcare, 30 

NATAZIA, 33 

NEBUPENT, 10 

necon, 32 

nefazodone hcl, 18 

neomycin‐bacitracin‐polymyxin, 33 

neomycin‐polymyxin‐dexameth, 34 

neomycin‐polymyxin‐hc, 22 

NEULASTA, 27 

NEUPOGEN, 27 

NEVANAC, 35 

NEXIUM, 25 

NIASPAN, 14 

nicotine gum (OTC), 20 

nicotine lozenge (OTC), 20 

nicotine patch (OTC), 20 

NICOTROL INHALER, 20 

nifediac cc, 11 

nifedical xl, 11 

nifedipine er, 11 

nisoldipine, 11 

nitrofurantoin, ‐mono‐macro, 8 

nitroglycerin, ‐patch, 13 

nizatidine, 25 

nora‐be, 32 

NORDITROPIN, ‐FLEXPRO, ‐NORDIFLEX, 27 

norethindrone acetate, 32 

NORITATE, 21 

NOROXIN, 8 

nortrel, 32 

nortriptyline hcl, 17 

NORVIR, 9 

novarel, 30 

NOVOLIN 70‐30, ‐INNOLET, 23 

NOVOLIN N, ‐INNOLET, ‐R, 23 

NOVOLOG, ‐MIX, 23 

NP thyroid, 24 

NUCYNTA, 15 

NUEDEXTA, 20

NULEV, 25 

NULYTELY WITH FLAVOR PACKS, 26 

NUTROPIN, ‐AQ, ‐AQ NUSPIN, 27 

NUVARING, 33 

NUVIGIL, 19 

nystatin, 8, 9 

nystatin‐triamcinolone, 9 

ocella, 32, 33 

ofloxacin, 8, 22, 33 

ogestrel, 32 

OLUX, 21 

OLUX‐E, 21 

OLUX‐OLUX‐E, 21 

omeprazole, 25 

OMNARIS, 23 

OMNITROPE, 27 

ondansetron hcl, ‐odt, 18 

ONE TOUCH BASIC SYSTEM, 38 

ONE TOUCH TEST STRIPS, 38 

ONE TOUCH ULTRA 2, 38 

ONE TOUCH ULTRA SMART, 38 

ONE TOUCH ULTRA SYSTEM, 38 

ONE TOUCH ULTRA TEST STRIPS, 38 

ONE TOUCH ULTRAMINI, 38 

ONGLYZA, 24 

ONSOLIS, 15 

OPANA, ‐ER, 15 

OPTICHAMBER, 38 

OPTIVAR, 35 

ORACEA, 8 

ORAVIG, 8 

orphenadrine citrate, 28 

ORTHO EVRA, 33 

ORTHO TRI‐CYCLEN, 33 

ORTHO TRI‐CYCLEN LO, 33 

OSMOPREP, 26 

OVIDREL, 30 

oxaprozin, 28 

oxazepam, 16 

oxcarbazepine, 16 

OXISTAT, 9 

oxybutynin chloride, 37 

oxybutynin chloride er, 37 

oxycodone, ‐ hcl, ‐acetaminophen, 15 

OXYCONTIN, 15 

OXYTROL, 37 

PACERONE, 14 

pantoprazole sodium, 25 

PARADIGM REAL‐TIME, 37 

paroxetine hcl, 17 

PATADAY, 35 

PATANASE, 23 

PATANOL, 35 

PAXIL, ‐CR, 17 

peg 3350‐electrolyte, 26 

PEGASYS, 27 

PEGINTRON, 27 

PEGINTRON REDIPEN, 27 

penicillin v potassium, 7 

PENNSAID SOLUTION, 22 

PENTASA, 26 

pentoxifylline, 15 

PERFOROMIST, 35 

permethrin, 22 

perphenazine, 19 

PEXEVA, 17 

phenazopyridine hcl, 37 

phenelzine, 18 

phenobarbital, 17 

phentermine hcl, 38 

PHENYTEK, 16 

phenytoin sodium extended, 16 

PHOSLO, 29 

pilocarpine hcl, 23, 34 

pindolol, 12 

piroxicam, 28 

PLAVIX, 29, 30 

polymyxin b sulfate, 10 

polymyxin b sul‐trimethoprim, 33 

portia, 32 

potassium chloride, 29 

potassium citrate, 37 

PRADAXA, 29 

pramipexole, 18 

PRAMOSONE, 21 

PRAMOSONE E, 21 

PRANDIMET, 23 

PRANDIN, 23 

pravastatin sodium, 14 

prazosin hcl, 12 

PRECISION XTRA, 37 

prednisolone, 24, 34 

prednisolone acetate, 34 

prednisolone sodium phosphate, 24 

prednisone, 24 

PREFEST, 31 

PREGNYL, 30 

PREMARIN, 31 

PREMPHASE, 31 

PREMPRO, 31 

prenatal rx, 30 

prenate plus, 30 

PREVACID, 25, 26 

PREVACID 24HR, 25 

previfem, 32 

PREVPAC, 26 

PREZISTA, 9 

PRILOSEC OTC, 25 

primidone, 17 

PRISTIQ, 18 

PROAIR HFA, 35 

probenecid, 28 

PROCHIEVE, 32 

prochlorperazine maleate, 18 

PROCRIT, 27 

proctosol‐hc, 26

proctozone‐hc, 26 

PRODIGY PEN NEEDLE, 38 

progesterone in oil, 32 

PROGRAF, 11 

PROLIA, 25 

promethazine hcl, 18, 36 

promethazine vc‐codeine, 37 

promethazine‐codeine, 37 

promethazine‐dm, 37 

promethegan, 18 

PROMETRIUM, 32 

propafenone hcl, 14 

PROPECIA, 22 

propranolol hcl, 12 

propylthiouracil, 24 

PROQUIN XR, 8 

PROTONIX, 26 

PROTOPIC, 22 

PROVENTIL HFA, 35 

PROVIGIL, 19 

PROZAC, 17 

PROZAC WEEKLY, 17 

PULMICORT, 36 

PULMICORT FLEXHALER, 36 

PULMOZYME, 37 

PYLERA, 26 

QUALAQUIN, 10 

quasense, 32 

QUICK RELEASE SOFT TEFLON, 38 

quinapril hcl, 13 

quinapril‐hydrochlorothiazide, 13 

QUIXIN, 33 

QUTENZA, 22 

QVAR, 35, 36 

ramipril, 13 

RANEXA, 15 

ranitidine hcl, 25 

RAPAFLO, 37 

RAPAMUNE, 11 

RAZADYNE ER, 20 

REBIF, 27 

reclipsen, 32 

RELENZA, 9 

RELPAX, 16 

REMICADE, 11 

RENAGEL, 30 

RENVELA, 30 

REPLIVA 21‐7, 29 

reprexain, 15 

REPRONEX, 30 

REQUIP XL, 18 

RESTASIS, 35 

RETIN‐A MICRO, ‐PUMP, 21 

REVATIO, 13 

REVLIMID, 11 

REYATAZ, 9 

RHINOCORT AQUA, 23 

RHOGAM, 27 

RHOPHYLAC, 27 

ribapak, 9 

ribavirin, 9 

rifampin, 9 

RIOMET, 23 

RISPERDAL, 19 

RISPERDAL M‐TAB, 19 

risperidone, 19 

RITALIN LA, 19 

ropinirole hcl, 18 

ROXICET ORAL SOLUTION, 15 

roxicet tablet, 15 

ROZEREM, 16 

RYNATAN PEDIATRIC, 36 

RYTHMOL SR, 14 

SAIZEN, 27 

salsalate, 28 

SANCTURA, 37 

SANCTURA XR, 37 

SANCUSO, 18 

SANDOSTATIN LAR, 11 

SANTYL, 22 

SAPHRIS, 19 

SARAFEM, 17 

SAVELLA, 18 

SEASONIQUE, 33 

selenium sulfide, 22 

SEMPREX‐D, 36 

SENSIPAR, 25 

SEREVENT DISKUS, 35 

SEROQUEL, 19 

SEROQUEL XR, 19 

sertraline hcl, 17 

SILENOR, 16 

SILHOUETTE, 38 

silver sulfadiazine, 8 

SIMCOR, 14 

SIMPONI, 11 

simvastatin, 14 

SINGULAIR, 36 

SKELAXIN, 29 

sodium fluoride, 29 

sodium sulfacetamide‐sulfur, 21 

SOF‐SENSOR, 37 

SOLARAZE, 22 

solia, 32 

SOLODYN, 8 

SOMA, 29 

SOMATULINE DEPOT, 11 

sotalol, 14 

SPIRIVA, 36 

spironolactone, ‐hctz, 12 

sprintec, 32 

SPRYCEL, 11 

sronyx, 32 

STALEVO, 19 

STARLIX, 23 

STRATTERA, 20

STRIANT, 31 

SUBOXONE, 15 

sucralfate, 25 

SULAR, 11 

sulfacetamide sodium, 22, 33 

sulfamethoxazole‐trimethoprim, 7 

sulfasalazine, 26 

sulindac, 28 

sumatriptan, 15, 16 

SUPRAX, 7 

SURESTEP, 38 

SUSTIVA, 9 

SUTENT, 11 

SYMBICORT, 36 

SYMBYAX, 19 

SYMLIN, ‐ 120, ‐ 60, 24 

SYNAGIS, 27 

SYNTHROID, 24 

SYNVISC, 28 

TAMIFLU, 9 

tamoxifen citrate, 10 

tamsulosin hcl, 37 

TARCEVA, 11 

TARKA, 13 

TAZORAC, 22 

TEGRETOL XR, 16 

TEKTURNA, 13 

TEKTURNA HCT, 13 

temazepam, 16 

TEMODAR, 11 

terazosin hcl, 12 

terbinafine hcl, 8 

terbutaline sulfate, 35 

TESTIM, 31 

testosterone cypionate, 31 

tetracycline hcl, 7 

TEVETEN, 13 

TEVETEN HCT, 13 

TEV‐TROPIN, 27 

THALOMID, 38 

theophylline, ‐anhydrous, 35 

thioridazine hcl, 19 

thiothixene, 19 

THYROGEN, 37 

tilia fe, 32 

timolol maleate, 12, 34 

tizanidine hcl, 28 

TOBI, 10 

TOBRADEX, 34 

tobramycin sulfate, 10, 33 

tobramycin‐dexamethasone, 34 

TOPAMAX, 17 

topiramate, 17 

TOPROL XL, 12 

torsemide, 12 

TOVIAZ, 37 

TRACLEER, 14 

tramadol hcl, ‐acetaminophen, 15 

trandolapril, 13 

TRANSDERM‐SCOP, 18 

tranylcypromine sulfate, 18 

TRAVATAN Z, 34 

trazodone hcl, 18 

TRELSTAR, ‐ DEPOT, ‐LA, 11 

tretinoin, 10, 21, 22 

TREXIMET, 16 

triamcinolone, 22 

triamcinolone acetonide, 21, 23, 24 

triamterene‐hctz, 12 

triazolam, 16 

TRICOR, 14 

trifluoperazine hcl, 19 

trifluridine, 34 

TRIGLIDE, 14 

trihexyphenidyl hcl, 18 

tri‐legest fe, 32 

TRILIPIX, 14 

trilyte with flavor packets, 26 

trimethobenzamide hcl, 18 

trimethoprim, 8 

trinessa, 33 

tri‐previfem, 33 

tri‐sprintec, 33 

trivora‐28, 33 

TRUETRACK SMART SYSTEM, 38 

TRUETRACK TEST STRIP, 38 

TRUSOPT, 34 

TRUVADA, 9 

TWINJECT, 36 

TWYNSTA, 13 

TYKERB, 11 

TYSABRI, 11 

ULESFIA, 22 

ULORIC, 28 

ULTRAM ER, 15 

ULTRASE, ‐MT, 26 

ULTRAVATE PAC, 21 

UROXATRAL, 37 

URSO, 26 

URSO FORTE, 26 

ursodiol, 26 

VAGIFEM, 31 

valproic acid, 16 

VALTREX, 9 

VALTURNA, 13 

VANCOCIN HCL, 10 

vandazole, 30 

VECTICAL, 22 

velivet, 33 

venlafaxine hcl, 18 

VENLAFAXINE HCL ER, 18 

VENTOLIN HFA, 35 

VERAMYST, 23 

verapamil, 11, 13 

VEREGEN, 22 

VESICARE, 37

VEXOL, 34 

VIAGRA, 37 

VICTOZA, 24 

VIGAMOX, 33 

VIMPAT, 17 

VIOKASE, 26 

VIRAMUNE, 9 

VIREAD, 9 

vitamin d, 29 

VIVELLE‐DOT, 31 

VOLTAREN, 35 

VYTORIN, 14 

VYVANSE, 19 

warfarin sodium, 29 

WELCHOL, 14 

WELLBUTRIN SR, 18 

WELLBUTRIN XL, 18 

WINRHO SDF, 27 

XALATAN, 34 

XELODA, 11 

XENICAL, 38 

XEOMIN, 28 

XGEVA, 25 

XIBROM, 35 

XIFAXAN, 10 

XOLAIR, 27 

XOPENEX, 35 

XOPENEX HFA, 35 

XYREM, 20 

XYZAL, 36 

YASMIN 28, 33 

YAZ, 33 

zafirlukast, 36 

zaleplon, 16 

zamicet, 15 

ZANTAC 25, 25 

ZEGERID, 25, 26 

ZEGERID OTC, 25 

ZEMPLAR, 29 

zenchent, 33 

ZENPEP, 26 

ZETIA, 14 

ZIANA, 21 

ZOLADEX, 11 

ZOLOFT, 17 

zolpidem tartrate, 16 

ZOMIG, ‐ZMT, 16 

zonisamide, 17 

ZORTRESS, 11 

zovia, 33 

ZOVIRAX, 9 

ZYCLARA, 22 

ZYLET, 34 

ZYMAR, 33 

ZYPREXA, 19 

ZYPREXA RELPREVV, 19 

ZYPREXA, ‐ZYDIS, 19 

ZYRTEC, 36 

ZYRTEC‐D, 36 

ZYVOX, 10

New West Health Services 

130 Neill Avenue

Helena, MT 59601 

Copyright 2009 

Express Scripts Inc. All Rights Reserved.

Prescribing Guide and 4-Tier Drug Formulary 2012

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