Post on 30-Aug-2018
transcript
Revised: 6/28/2018
OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY
OPTIMA FAMILY CARE (FAMIS) (July September 2018)
Effective: July 1, 2018
Table of Contents
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PENICILLINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CEPHALOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
FIRST GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SECOND GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
THIRD GENERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
MACROLIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
TETRACYCLINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
QUINOLONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
AMINOGLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
SULFONAMIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ANTIMYCOBACTERIAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ANTIFUNGALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ANTIVIRALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ANTIMALARIALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTHELMINTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
MISC. ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTINEOPLASTICS, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ALKYLATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ANTIMETABOLITES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
HORMONAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
MITOTIC INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ENZYME INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
TOPOISOMERASE I INHIBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTINEOPLASTICS MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
CHEMOTHERAPY RESCUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTINEOPLASTIC COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CARDIOVASCULAR DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CARDIAC GLYCOSIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIANGINAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
BETA BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CALCIUM CHANNEL BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIARRHYTHMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ACE INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANGIOTENSIN RCPTR BLOCKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIHYPERTENSIVES MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ANTIHYPERTENSIVE COMBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DIURETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
VASOPRESSORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ANTIHYPERLIPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
CARDIOVASCULAR - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DERMATOLOGICALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ACNE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ROSACEA AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIBIOTICS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIFUNGALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ANTIVIRALS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTI-INFLAMMATORY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTIPSORIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ANTISEBORRHEIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CORTICOSTEROIDS - TOPICAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
IMMUNOMODULATING AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DERMATOLOGICALS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ENDOCRINE AND METABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CORTICOSTEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ANDROGENS-ANABOLIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ESTROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CONTRACEPTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
PROGESTINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTIDIABETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
INCRETIN MIMETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
SULFONYLUREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
BIGUANIDES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
MEGLITINIDE ANALOGUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
DIABETIC OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ALPHA-GLUCOSIDASE INHIBIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
DPP-4 INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
INSULIN SENSITIZING AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTIDIABETIC COMBINATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
BISPHOSPHONATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CALCITONINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PARATHYROID HORMONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
HORMONE RECEPTOR MDLTR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
FERTILITY REGULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
LHRH/GNRH AGONIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
GROWTH HORMONES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
SOMATOSTATIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
POSTERIOR PITUITARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PROLACTIN INHIBITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
METABOLIC MODIFIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
THYROID AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
GASTROINTESTINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
LAXATIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ANTIDIARRHEALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ANTACIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ULCER DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ANTIEMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
DIGESTIVE AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
GASTROINTESTINAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
GENITOURINARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
URINARY ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
URINARY ANTISPASMODICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
VAGINAL PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
GENITOURINARY - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
HEMATOLOGICAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
HEMATOPOIETIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ANTICOAGULANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
HEMOSTATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
HEMATOLOGICAL - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
MOUTH/THROAT/DENTAL AGENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
NEUROLOGY, CNS, PSYCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ANTIANXIETY AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ANTIDEPRESSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ANTIPSYCHOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
HYPNOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ADHD, NARCOLEPSY, ETC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ANTICONVULSANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ANTIPARKINSON AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
NEUROLOGY, PSYCH - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
NEUROMUSCULAR AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
MUSCULOSKELETAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
ANTIMYASTHENIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
OPHTHALMOLOGY AND OTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
ANTI-INFECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
BETA-BLOCKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
OPHTHALMIC STEROIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
PROSTAGLANDINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
CYCLOPLEGIC MYDRIATICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
DECONGESTANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
MIOTICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
ADRENERGIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
IMMUNOMODULATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
LOCAL ANESTHETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
OPHTHALMICS - MISC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
OTIC AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
OXYTOCICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
ANALGESICS - NONNARCOTIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
ANALGESICS - OPIOID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
ANTI-INFLAMMATORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
MIGRAINE PRODUCTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
GOUT AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
RESPIRATORY, ALLERGY, ETC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
ANTIHISTAMINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
NASAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
COUGH/COLD/ALLERGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
ANTIASTHMATIC/COPD AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
RESPIRATORY AGENTS - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
VACCINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
MULTIVITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
MEDICAL DEVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
DIABETIC SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
MEDICAL DEVICES - MISC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
MISCELLANEOUS AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
doxycycline
doxycycline hyclate
doxycycline hyclate DRST
doxycycline monohydrate
July 2018
minocycline hydrochloride
minocycline hydrochlorideerST
ANTI-INFECTIVES
minocycline HCL
minocycline HCL ERST
PENICILLINS
mondoxyne nl
FORMULARY FORMULARY
morgidox 1X100MG
amoxicillin
morgidox 1X50MG
amoxicillin/clavulanate potassium
morgidox 2X100MG
amoxicillin/clavulanate potassium ER
okebo
ampicillin
soloxideST
dicloxacillin sodium
tetracycline hydrochloride
penicillin v potassium
tetracycline HCL
Amoxicillin
Tetracycline HCL
Amoxicillin ER
Vibramycin
Amoxicillin/Clavulanate Potassium
Ampicillin
Augmentin
QUINOLONES
Penicillin V Potassium
FORMULARY FORMULARY
ciprofloxacin
CEPHALOSPORIN
ciprofloxacin ER
FIRST GENERATION
ciprofloxacin HCL
FORMULARY FORMULARY
levofloxacin
cefadroxil
moxifloxacin HCL
cephalexin
Ciprofloxacin HCL
Cephalexin
Levofloxacin
SECOND GENERATION
FORMULARY FORMULARY
AMINOGLYCOSIDES
cefaclor
FORMULARY FORMULARY
cefprozil
neomycin sulfate
cefuroxime axetil
paromomycin sulfate
Cefaclor
tobramycinQL
Ceftin
QL
THIRD GENERATION
FORMULARY FORMULARY
SULFONAMIDES
cefdinir
FORMULARY FORMULARY
cefixime
Sulfadiazine
cefpodoxime proxetil
Suprax
ANTIMYCOBACTERIAL AGENTS
FORMULARY FORMULARY
MACROLIDES
ethambutol HCL
isoniazid
FORMULARY FORMULARY
pyrazinamide
azithromycin
rifabutin
clarithromycin
rifampin
clarithromycin ER
Cycloserine
erythromycin
Isoniazid
erythromycin base
Rifamate
erythromycin ethylsuccinate
Azithromycin
ANTIFUNGALS
Clarithromycin
E.e.s. 400
FORMULARY FORMULARY
Ery-TAB
bio-statin
Eryped 400
fluconazole
Erythrocin Stearate
flucytosine
Erythromycin Ethylsuccinate
griseofulvin microsize
PCE
griseofulvin ultramicrosize
itraconazole
ketoconazole
TETRACYCLINES
nystatin
terbinafine HCL
FORMULARY FORMULARY
voriconazole
avidoxy
coreminoST
demeclocycline hydrochloride
ANTIVIRALS
demeclocycline HCL
FORMULARY FORMULARY
abacavir
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 1
abacavir sulfate/lamivudine/zidovudine
Truvada
abacavir/lamivudine
Tybost
acyclovir
Vemlidy
atazanavir
Videx Pediatric
atazanavir sulfate
Viekira PAKPA
didanosine
Viekira XRPA
efavirenz
Viracept
efavirnez
Viread
entecavir
Vitekta
famciclovir
VoseviPA
fosamprenavir calcium
ZepatierPA
lamivudine
lamivudine/zidovudine
lopinavir/ritonavir
ANTIMALARIALS
moderiba
FORMULARY FORMULARY
nevirapine
atovaquone/proguanil HCL
nevirapine ER
chloroquine phosphate
oseltamivir phosphateQL
hydroxychloroquine sulfate
ribasphere
mefloquine HCL
ribavirin
quinine sulfate
rimantadine HCL
Chloroquine Phosphate
ritonavir
DaraprimPA
stavudine
Mefloquine HCL
tenofovir disoproxil fumarate
Primaquine Phosphate
valacyclovir HCL
valganciclovir
valganciclovir hydrochlordeAL
ANTHELMINTICS
zidovudine
FORMULARY FORMULARY
Aptivus
ivermectin
Atripla
pinworm medicine
Biktarvy
reeses pinworm medicine
Complera
EmvermST
Crixivan
Reeses Pinworm Medicine
Descovy
Edurant
Emtriva
MISC. ANTI-INFECTIVES
EpclusaPA
FORMULARY FORMULARY
Evotaz
atovaquone
Fuzeon
clindamycin palmitate HCL
Genvoya
clindamycin HCL
HarvoniPA
dapsone
Intelence
linezolid
Invirase
metronidazole
Isentress
sulfamethoxazole/trimethoprim
Isentress HD
sulfamethoxazole/trimethoprim DS
Juluca
sulfatrim pediatric
Kaletra
tinidazole
Lexiva
trimethoprim
MavyretPA
vancomycin
Norvir
vancomycin HCL
Odefsey
Alinia
Peg-intron Redipen
Cayston
Peg-intron Redipen PAK 4
First-vancomycin 25
Pegasys
First-vancomycin 50
Pegasys Proclick
Firvanq
Pegintron
Linezolid
Prezcobix
Nebupent
Prezista
Rebetol
Relenza DiskhalerQL
ANTINEOPLASTICS, ETC.
Rescriptor
ALKYLATING AGENTS
Reyataz
FORMULARY FORMULARY
Ribasphere
cyclophosphamide
Ribasphere Ribapak
melphalanQL
Selzentry
temozolomide
SovaldiPA
Cyclophosphamide
Stribild
Gleostine
TamifluQL
Hexalen
Tivicay
Leukeran
Triumeq
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 2
Myleran
Alecensa
Valchlor
Bosulif
Yondelis
CabometyxQL
Caprelsa
Cometriq
ANTIMETABOLITES
Cotellic
Farydak
FORMULARY FORMULARY
Gilotrif
capecitabine
Ibrance
mercaptopurine
Iclusig
methotrexate
Idhifa
methotrexate sodium
Imbruvica
Methotrexate Sodium
Inlyta
Purixan
IressaPA
Tabloid
Jakafi
Trexall
KisqaliPA
Xatmep
Lenvima 10 MG Daily Dose
Lenvima 14 MG Daily Dose
HORMONAL AGENTS
Lenvima 18 MG Daily Dose
FORMULARY FORMULARY
Lenvima 20 MG Daily Dose
anastrozole
Lenvima 24 MG Daily Dose
bicalutamide
Lenvima 8 MG Daily Dose
exemestane
Lynparza
flutamide
Mekinist
letrozole
Nerlynx
leuprolide acetate
Nexavar
megestrol acetate
Ninlaro
nilutamide
RubracaQL,PA
tamoxifen citrate
Rydapt
Eligard
Sprycel
Emcyt
Stivarga
Fareston
Sutent
Firmagon
Tafinlar
Lupron Depot (1-month)
Tagrisso
Lupron Depot (3-month)
Tarceva
Lupron Depot (4-month)
Tasigna
Lupron Depot (6-month)
Tykerb
Lysodren
VerzenioPA
Soltamox
Votrient
Vantas
XalkoriPA
Xtandi
ZejulaPA
Zoladex
ZelborafPA
Zytiga
Zolinza
Zydelig
Zykadia
IMMUNOMODULATORS
FORMULARY FORMULARY
TOPOISOMERASE I INHIBITOR
azathioprine
FORMULARY FORMULARY
cyclosporine
Hycamtin
cyclosporine modified
Onivyde
gengraf
mycophenolate mofetil
ANTINEOPLASTICS MISC.
mycophenolic acid DR
FORMULARY FORMULARY
sirolimus
bexarotene
tacrolimus
hydroxyurea
Cyclosporine Modified
tretinoin
Pomalyst
ActimmunePA
Revlimid
Alferon N
Sandimmune
Intron A
Thalomid
Intron A W/Diluent
Matulane
MITOTIC INHIBITORS
Sylatron
FORMULARY FORMULARY
Etoposide
CHEMOTHERAPY RESCUE
FORMULARY FORMULARY
ENZYME INHIBITORS
leucovorin calcium
FORMULARY FORMULARY
Leucovorin Calcium
imatinib mesylate
Mesnex
Afinitor
Afinitor Disperz
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 3
ANTINEOPLASTIC COMBO
isradipine
nicardipine HCL
FORMULARY FORMULARY
nifedical XL
Kisqali Femara 200 Dose
nifedipine
Kisqali Femara 400 Dose
nifedipine ER
Kisqali Femara 600 Dose
nimodipine
Lonsurf
taztia XT
verapamil HCL
CARDIOVASCULAR DRUGS
verapamil HCL ER
CARDIAC GLYCOSIDES
verapamil HCL SR
FORMULARY FORMULARY
Cardizem LA
digitek
digox
ANTIARRHYTHMICS
digoxin
FORMULARY FORMULARY
Digoxin
amiodarone hydrochloride
amiodarone hydrocloride
ANTIANGINAL AGENTS
amiodarone HCL
FORMULARY FORMULARY
disopyramide phosphate
isosorbide dinitrate
dofetilide
isosorbide mononitrate
flecainide acetate
isosorbide mononitrate ER
mexiletine HCL
minitran
propafenone hydrochloride ER
nitro-time
propafenone hydrochlorideer
nitroglycerin
propafenone HCL
nitroglycerin lingual
propafenone HCL ER
nitroglycerin transdermal
quinidine gluconate CR
nitroglycerin ER
quinidine gluconate ER
Dilatrate SR
Multaq
Isosorbide Dinitrate ER
Norpace CR
Nitro-bid
Quinidine Sulfate
Nitro-dur
Nitroglycerin Lingual
ACE INHIBITORS
FORMULARY FORMULARY
BETA BLOCKERS
benazepril HCL
FORMULARY FORMULARY
captopril
acebutolol hydrochloride
enalapril maleate
acebutolol HCL
fosinopril sodium
atenolol
lisinopril
betaxolol HCL
quinapril hydrochloride
bisoprolol fumarate
quinapril HCL
carvedilol
ramipril
labetalol hydrochloride
trandolapril
labetalol HCL
Epaned
metoprolol succinate ER
metoprolol tartrate
ANGIOTENSIN RCPTR BLOCKER
nadolol
FORMULARY FORMULARY
pindolol
candesartan cilexetil
propranolol hydrochloride
irbesartan
propranolol HCL
losartan potassium
propranolol HCL ER
olmesartan medoxomil
sotalol hydrochloride
telmisartan
sotalol hydrochloride (AF)
valsartan
sotalol hydrocholride
Eprosartan Mesylate
sotalol HCL
sotalol HCL (AF)
ANTIHYPERTENSIVES MISC.
Metoprolol Tartrate
FORMULARY FORMULARY
Propranolol HCL
clonidine HCL
doxazosin
doxazosin mesylate
CALCIUM CHANNEL BLOCKERS
eplerenone
FORMULARY FORMULARY
guanfacine HCL
afeditab CR
hydralazine hydrochloride
amlodipine besylate
hydralazine HCL
cartia XT
methyldopa
dilt-XR
minoxidil
diltiazem CD
phenoxybenzamine hydrochloride
diltiazem HCL
prazosin HCL
diltiazem HCL CD
terazosin HCL
diltiazem HCL ER
felodipine ER
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 4
ANTIHYPERTENSIVE COMBO
ANTIHYPERLIPIDEMICS
FORMULARY FORMULARY
FORMULARY FORMULARY
amlodipine besylate/benazepril hydrochloride
atorvastatin calcium
amlodipine besylate/benazepril HCL
cholestyramine
amlodipine besylate/valsartan
cholestyramine light
amlodipine/olmesartan medoxomil
colestipol HCL
amlodipine/valsartan/hctz
fenofibrate
atenolol/chlorthalidone
fenofibrate micronized
benazepril HCL/hydrochlorothiazide
fenofibric acid DR
bisoprolol fumarate/hydrochlorothiazide
fluvastatin
candesartan cilexetil/hydrochlorothiazide
fluvastatin sodium ERST
enalapril maleate/hydrochlorothiazide
gemfibrozil
fosinopril sodium/hydrochlorothiazide
lovastatin
irbesartan/hydrochlorothiazide
niacin ER
lisinopril/hydrochlorothiazide
omega-3-acid ethyl estersPA
losartan potassium/hydrochlorothiazide
pravastatin sodium
metoprolol/hydrochlorothiazide
prevalite
moexipril/hydrochlorothiazide
rosuvastatin calcium
nadolol/bendroflumethiazide
simvastatin
olmesartan medoxomil/hydrochlorothiazide
trikloPA
quinapril/hydrochlorothiazide
Fenofibrate
telmisartan/amlodipine
Fenofibric Acid
telmisartan/hydrochlorothiazide
Niacor
trandolapril/verapamil HCL ER
RepathaQL,PA
valsartan/hydrochlorothiazide
Repatha Pushtronex SystemQL,PA
Captopril/Hydrochlorothiazide
Repatha SureclickQL,PA
Clorpres
Welchol
Methyldopa/Hydrochlorothiazide
Metoprolol/Hydrochlorothiazide
Propranolol/Hydrochlorothiazide
CARDIOVASCULAR - MISC.
Trandolapril/Verapamil HCL ER
FORMULARY FORMULARY
amlodipine besylate/atorvastatin calcium
sildenafilQL,PA
DIURETICS
sildenafil citrateQL,PA
FORMULARY FORMULARY
AdcircaPA
acetazolamide
Adempas
acetazolamide ER
Letairis
amiloride HCL
Opsumit
amiloride/hydrochlorothiazide
RevatioPA
bumetanide
Tracleer
chlorothiazide
Tyvaso
chlorthalidone
Tyvaso Refill
furosemide
Tyvaso Starter
hydrochlorothiazide
UptraviPA
indapamide
Ventavis
methazolamide
metolazone
DERMATOLOGICALS
spironolactone
ACNE PRODUCTS
spironolactone/hydrochlorothiazide
FORMULARY FORMULARY
torsemide
acne medication 5
triamterene/hydrochlorothiazide
adapalene
Aldactazide
adapalene P.M.
Chlorothiazide
amnesteem
Diuril
avar cleanser
Furosemide
avita
Methyclothiazide
benzoyl peroxide
Triamterene/Hydrochlorothiazide
bp gel
claravis
clearplex v
VASOPRESSORS
clindacin etz pledgets
FORMULARY FORMULARY
clindacin-p
midodrine HCL
clindamycin phosphate
AdrenaclickQL
clindamycin/benzoyl peroxide
Auvi-qQL
ery
EpinephrineQL
erythromycin
Epipen 2-PAKQL
erythromycin/benzoyl peroxide
Epipen-JR 2-PAKQL
isotretinoin
kp benzoyl peroxide
myorisan
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 5
neuac
HM bacitracin
rosanil cleanser
HM triple antibiotic
sodium sulfacetamide
HM triple antibiotic plus maximum strength
sodium sulfacetamide/sulfur
SB bacitracin
sodium sulfacetamide/sulfur cleanser
SB triple antibiotic
sulfacetamide sodium
sulfacetamide sodium/sulfur cleanser
tretinoin
ANTIFUNGALS - TOPICAL
tretinoin microsphereST
FORMULARY FORMULARY
tretinoin microsphere P.M.ST
anti-fungal
zenatane
antifungal
Clindacin Etz
antifungal foot
Clindacin PAC
athletes foot
CVS creamy acne face wash
athletes foot AF cream
DifferinAL
baza antifungal
Panoxyl-4 Creamy Wash
carrington antifungal
Sodium Sulfacetamide/Sulfur
cavilon
ciclodan
ciclopirox
ROSACEA AGENTS
ciclopirox nail lacquer
FORMULARY FORMULARY
ciclopirox olamine
metronidazole
clotrimazole
rosadan
clotrimazole anti-fungal
DoxycyclineST
clotrimazole antifungal
Metronidazole
clotrimazole grx
Mirvaso
clotrimazole AF
Rhofade
clotrimazole/betamethasone dipropionate
desenex
ANTIBIOTICS - TOPICAL
econazole nitrate
eq antifungal
FORMULARY FORMULARY
eq athletes foot
bacitracin
eq jock itch
bacitracin/neomycin/polymyxin
eql antifungal
bacitraycin plus
eql athletes foot
bactericin
fungicure intensive with nailguard
curad triple antibiotic
gnp athletes foot
eq triple antibiotic
gnp terbinafine hydrochloride
eql first aid antibiotic
jock itch
eql first aid antibiotic + pain relief maximum strength
jock itch relief
first aid antibiotic
ketoconazole
gentamicin sulfate
kp clotrimazole
gnp first aid antibiotic
kp miconazole nitrate
gnp triple antibiotic
kp terbinafine hydrochloride
gnp triple antibiotic plus
micaderm
lanabiotic
miconazole antifungal
medi-first triple antibiotic
miconazole nitrate
meijer triple antibiotic
nyamyc
mupirocin
nyata
neoporacin
nystatin
neosporin + pain relief maximum strength
nystatin/triamcinolone
neosporin pain/itch/scar
nystatin/triamcinolone acetonide
px triple ointment
nystop
qc bacitracin
podactin
ra antibiotic/pain relief maximum strength
pro-EX antifungal
ra triple antibiotic
px athletic foot
ra triple antibiotic plus
qc athletes foot
sm first aid antibiotic
qc clotrimazole
sm triple antibiotic
ra antifungal
sm triple antibiotic original strength
ra antifungal foot care
sm triple antibiotic plus maximum strength
ra athletes foot
tgt antibiotic
ra clotrimazole
tgt bacitracin
ra foot care antifungal
tri-biozene
ra jock itch
triple antibiotic
remedy antifungal
triple antibiotic plus
secura antifungal
triple antibiotic plus maximum strength
secura antifungal extra thick
triple antibiotic with pain relief maximum strength
shopko athletes foot
CVS antibiotic
sm antifungal clotrimazole
CVS triple antibiotic
sm antifungal miconazole
CVS triple antibiotic maximum strength
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 6
sm athletes foot
eql anti-itch maximum strength plus 10 healing moisturizers
soothe & cool inzo antifungal cream
fluocinolone acetonide
terbinafine HCL
fluocinolone acetonide body
tgt athletes foot
fluocinolone acetonide scalp
tgt clotrimazole
fluocinonide
tineacide
fluocinonide emulsified base
CVS athletes foot
fluticasone propionate
CVS clotrimazole
gnp hydrocortisone
CVS itch relief antifungal
gnp hydrocortisone maximum strength
CVS jock itch
gnp hydrocortisone plus
CVS ringworm
halobetasol propionate
Exoderm
hydrocortisone
SB clotrimazole foot
hydrocortisone butyrate
hydrocortisone butyrate (lipid)
hydrocortisone butyrate (lipophilic)
ANTIVIRALS - TOPICAL
hydrocortisone intensive healing
FORMULARY FORMULARY
hydrocortisone maximum strength
acyclovir
hydrocortisone maximum strength plus 10 moisturizers
hydrocortisone maximum strength plus 12 moisturizers
ANTI-INFLAMMATORY AGENTS
hydrocortisone plus
FORMULARY FORMULARY
hydrocortisone valerate
diclofenac sodium
hydrocortisone IN absorbase
hydrocortisone 1% IN absorbase
ANTIPSORIATICS
hydroskin
FORMULARY FORMULARY
instacort 5
acitretin
kericort 10
calcipotriene
kp hydrocortisone
calcitrene
kp hydrocortisone maximum strength
methoxsalen
lokara
Dritho-creme HP
meijer hydrocortisone
SiliqPA
mometasone furoate
TremfyaPA
neosporin eczema essentials maximum strength
8-mop
noble formula HC
prednicarbate
ANTISEBORRHEIC AGENTS
preparation h hydrocortisone
FORMULARY FORMULARY
px hydrocream
seb-prev wash
qc hydrocortisone
selenium sulfide
qc hydrocortisone maximumstrength
selenium sulfide shampoo
ra anti-itch maximum strength
sodium sulfacetamide
ra anti-itch/maximum strength
sodium sulfacetamide wash
ra hydrocortisone maximumstrength
ra hydrocortisone plus 12
CORTICOSTEROIDS - TOPICAL
recort plus
FORMULARY FORMULARY
scalacort
ala-cort
sm hydrocortisone
alclometasone dipropionate
sm hydrocortisone maximum strength
alphatrex
tgt anti-itch maximum strength
anti-itch maximum strength
tgt anti-itch plus oatmeal
augmented betamethasone dipropionate
tgt anti-itch/aloe/vitamin e
aveeno anti-itch maximum strength
triamcinolone acetonide
betamethasone dipropionate
triderm
betamethasone valerate
Amcinonide
calcipotriene/betamethasone dipropionateST
Augmented Betamethasone Dipropionate
clobetasol propionate
Clocortolone Pivalate
clobetasol propionate e
Clocortolone Pivalate P.M.
clobetasol propionate emollient
CVS anti-itch maximum strength
clodan
CVS cortisone intense healing anti-itch
cormax scalp application
CVS cortisone maximum strength
cortaid maximum strength
CVS eczema anti-itch maximum strength
cortizone-10
CVS hydrocortisone anti-itch
desonide
CVS hydrocortisone maximum strength
desoximetasone
Diflorasone Diacetate
eq anti-itch maximum strength
Lidosol-HC
eq hydrocortisone maximu m strength
MED-derm hydrocortisone
eq hydrocortisone plus
Pramosone
eq 1% hydrocortisone
Prednicarbate
eql anti-itch intensive healing formula
Synalar
eql anti-itch maximum strength
SB hydrocortisone
SB hydrocortisone maximum strength
SB hydrocortisone plus
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 7
podofilox
premium lidocaine
IMMUNOMODULATING AGENTS
ra calming daily moisturizing
ra capsicum hot patch
FORMULARY FORMULARY
ra diaper rash
imiquimod
ra hydrating healing
tacrolimus
ra lice maximum strength
Elidel
ra lice treatment
ra moisturizing therapy
ra renewal moisturizing
DERMATOLOGICALS - MISC.
rea LO 40
FORMULARY FORMULARY
rid lice killing shampoo
a-200 maximum strength
salacyn
advanced healing ointment/baby
salicylic acid
al12
salicylic acid wart remover
amlactin
salicylic acid ER
ammonium lactate
salimez
anecream
salisol forte
aspercreme w/lidocaine
salitech forte
boudreauxs butt paste maximum strength
saratoga
caprex
sm lice killing
caprex +
sm lice killing maximum strength
capsaicin
sm lice treatment
capsaicin hot patch
sodium hyaluronate
cerovel
stop lice maximum strength
cocoa butter skin cream
sure result SR relief
collagen
tgt lice killing maximum strength
cottontails diaper rash
tippy toes diaper rash
dermaphor
trixaicin HP
diaper rash
urea
dry skin treatment
urea hydrating
dry skin treatment advanced therapy
urea 40% nail film
e-ointment
urea-c40
eq diaper rash
uremez-40
eq lice killing maximum strength
zinc oxide
eql advanced healing ointment
Atopaderm
eql baby basics diaper rash
Atopiclair
eql lice killing maximum strength
Capsagel
ethyl chloride
Cerave
flanders buttocks
Cerave AM SPF 30
geri-hydrolac 12
Cerave PM
geri-hydrolac 5
Cerave Renewing SA
glydo
Cerave SA Renewing
gnp lice treatment
Cetaphil
hydrolatum
Cetaphil Daily Advance Ultra Hydrating
hydrophor
Cetaphil Daily Facial Moisturizer
lac-hydrin five
Cetaphil Dermacontrol Moisturizer/SPF 30
lactic acid
Cetaphil Moisturizing
lactic acid e
Cetaphil Restoraderm
lactic acid w/vitamin e
Cetaphil Therapeutic Hand
latrix
Cocaine HCL
lice killing maximum strength
CVS advanced healing ointment
lice killing shampoo
CVS diaper rash
lice treatment
CVS hydrating skin treatment
lice treatment creme rinse
CVS lice killing
licide
CVS lice treatment
licide maximum strength
CVS medicated heat patch
lido-k
CVS moisturizing cream
lidocaine
CVS moisturizing extra dry
lidocaine hydrochloride
CVS permethrin
lidocaine HCL
CVS skin treatment
lidocaine HCL jelly
CVS skin treatment body lotion
lidocaine PAK
Dexeryl
lidocaine-prilocaine-cream base
Dmae
lidocaine/prilocaine
Drysol
lidocream
DHEA
lindaneST
Eletone
malathion
Eletone Twinpack
moisturizing cream
Ethyl Chloride
permethrin
Ethyl Chloride/Fine Pinpoint
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 8
Ethyl Chloride/Fine Stream
ANDROGENS-ANABOLIC
Ethyl Chloride/Medium Jet Stream
FORMULARY FORMULARY
Ethyl Chloride/Medium Stream
danazol
Ethyl Chloride/Mist
methyltestosterone
Eucerin
oxandrolone
Eucerin Calming Daily Moisturizer
testosteronePA
Eucerin Daily Protection/SPF 30
testosterone cypionatePA
Eucerin Intensive Repair
testosterone enanthatePA
Eucerin Intensive Repair Hand
testosterone topical solutionPA
Eucerin Original Healing Soothing Repair
testosterone P.M.PA
Eucerin Plus
AndrodermPA
Eucerin Plus Intensive Repair
AndrogelPA
Eucerin Skin Calming Daily Moisturizing
Androgel P.M.PA
Eucerin Smoothing Repair Advanced Formula
Testosterone
Hylatopic Plus
Testosterone P.M.PA
Hylira
PA
Hypercare
HM lice killing maximum strength
ESTROGENS
HM lice treatment
FORMULARY FORMULARY
HPR Plus
amabelz
Latrix XM
estradiol
LindaneST
estradiol/norethindrone acetate
LC-4 lidocaine
jevantique LO
Neocera
jinteli
Neosalus
lopreeza
Neosalus CP
mimvey
Nivatopic Plus
mimvey LO
Ointment Base
norethindrone acetate/ethinyl estradiol
Oxsoralen
Combipatch
Podocon 25 IN Benzoin Tincture
Estropipate
Pruclair
Menest
Prumyx
Prefest
Pyrogallic Acid
Premarin
Salrix
Premphase
Salvax
Prempro
Spinosad
Sulfurated Lime
CONTRACEPTIVES
SB lice killing maximum strength
FORMULARY FORMULARY
SB lice treatment
aftera
Tetrix
altavera
Urea
alyacen 1/35
Urea Topical
alyacen 7/7/7
Vitamin E With Panthenol
amethia
Xeralux
amethia LO
amethyst
apri
ENDOCRINE AND METABOLIC
aranelle
CORTICOSTEROIDS
aubra
FORMULARY FORMULARY
aviane
budesonide
azurette
decadron
balziva
dexamethasone
bekyree
fludrocortisone acetate
blisovi FE 1.5/30
hydrocortisone
blisovi FE 1/20
methylprednisolone
blisovi 24 FE
methylprednisolone dose pack
briellyn
prednisolone
camila
prednisolone sodium phosphate
camrese
prednisolone sodium phosphate odt
camrese LO
prednisone
caziant
Cortisone Acetate
chateal
Dexamethasone
cryselle-28
Dexamethasone Intensol
cyclafem 1/35
Prednisolone Sodium Phosphate
cyclafem 7/7/7
Prednisone
cyred
Prednisone Intensol
dasetta 1/35
Solu-cortef
dasetta 7/7/7
deblitane
delyla
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 9
desogestrel/ethinyl estradiol
necon 1/35
drospirenone/ethinyl estradiol
necon 10/11-28
econtra one-step
necon 7/7/7
econtra EZ
next choice one dose
elinest
nikki
emoquette
nora-be
enpresse-28
norethindrone
enskyce
norethindrone & ethinyl estradiol ferrous fumarate
errin
norethindrone acetate/ethinyl estradiol
estarylla
norethindrone acetate/ethinyl estradiol/ferrous fumarate
ethynodiol diacetate/ethinyl estradiol
norethindrone/ethinyl estradiol/ferrous fumarate
fallback solo
norgestimate/ethinyl estradiol
falmina
norlyda
femynor
norlyroc
gianvi
nortrel 0.5/35 (28)
gildagia
nortrel 1/35
gildess FE 1.5/30
nortrel 7/7/7
gildess FE 1/20
ocella
gildess 1.5/30
opcicon one-step
gildess 1/20
option 2
heather
orsythia
introvale
philith
isibloom
pimtrea
jencycla
pirmella 1/35
jolessa
pirmella 7/7/7
jolivette
portia-28
juleber
previfem
junel FE 1.5/30
quasense
junel FE 1/20
react
junel FE 24
reclipsen
junel 1.5/30
setlakin
junel 1/20
sharobel
kaitlib FE
sprintec 28
kariva
sronyx
kelnor 1/35
syeda
kelnor 1/50
take action
kimidess
tarina FE 1/20
kurvelo
tilia FE
larin FE 1.5/30
tri femynor
larin FE 1/20
tri-estarylla
larin 1.5/30
tri-legest FE
larin 1/20
tri-linyah
larissia
tri-previfem
leena
tri-sprintec
lessina
tri-vylibra
levonest
tri-LO-estarylla
levonorgestrel
trinessa
levonorgestrel and ethinyl estradiol
trinessa LO
levonorgestrel/ethinyl estradiol
trivora-28
levora 0.15/30-28
velivet
lillow
vestura
loryna
vienva
low-ogestrel
viorele
lutera
vyfemla
lyza
vylibra
marlissa
wera
medroxyprogesterone acetate
wymzya FE
melodetta 24 FE
zarah
mibelas 24 FE
zenchent
microgestin FE
zenchent FE
microgestin FE 1.5/30
zovia 1/35e
microgestin 1.5/30
zovia 1/50e
microgestin 1/20
Ella
microgestin 24 FE
Necon 1/50-28
mono-linyah
Norinyl 1+50
mononessa
Nuvaring
my choice
Ogestrel
my way
Xulane
myzilra
necon 0.5/35-28
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 10
PROGESTINS
FORMULARY
pioglitazone HCL
FORMULARY FORMULARY
Avandia
medroxyprogesterone acetate
ANTIDIABETIC COMBINATIONS
megestrol acetate
FORMULARY FORMULARY
norethindrone acetate
glipizide/metformin HCL
progesterone
glyburide/metformin HCL
Janumet
ANTIDIABETIC AGENTS
Janumet XR
INSULIN
Jentadueto
FORMULARY FORMULARY
Jentadueto XR
Admelog
Soliqua 100/33QL,ST
Humalog
Humalog Junior Kwikpen
BISPHOSPHONATES
Humalog Kwikpen
FORMULARY FORMULARY
Humalog Mix 50/50
alendronate sodium
Humalog Mix 50/50 Kwikpen
ibandronate sodium
Humalog Mix 75/25
risedronate sodium
Humalog Mix 75/25 Kwikpen
risedronate sodium DR
Humulin N
Alendronate Sodium
Humulin N Kwikpen
Binosto
Humulin R
Etidronate Disodium
Humulin R U-500 (concentrated)
Fosamax Plus D
Humulin R U-500 Kwikpen
Humulin 70/30
Humulin 70/30 Kwikpen
CALCITONINS
Lantus
Lantus Solostar
FORMULARY FORMULARY
Toujeo Max Solostar
calcitonin salmon
Toujeo Solostar
calcitonin-salmon
INCRETIN MIMETIC AGENTS
FORMULARY FORMULARY
PARATHYROID HORMONE
AdlyxinST
FORMULARY FORMULARY
Adlyxin Starter PackST
ForteoQL
TanzeumST
Natpara
TrulicityST
TymlosQL
SULFONYLUREAS
FORMULARY FORMULARY
HORMONE RECEPTOR MDLTR
glimepiride
FORMULARY FORMULARY
glipizide
raloxifene hydrochloride
glipizide ER
Osphena
glipizide XL
glyburide
FERTILITY REGULATORS
glyburide micronized
FORMULARY FORMULARY
Chlorpropamide
Chorionic GonadotropinPA
Tolazamide
NovarelPA
Tolbutamide
Pregnyl W/Diluent Benzyl Alcohol/NACLPA
BIGUANIDES
FORMULARY FORMULARY
LHRH/GNRH AGONIST
metformin hydrochloride
FORMULARY FORMULARY
metformin HCL
Lupron Depot-PED (1-month)
metformin HCL ER
SynarelPA
MEGLITINIDE ANALOGUES
FORMULARY FORMULARY
GROWTH HORMONES
nateglinide
FORMULARY FORMULARY
repaglinide
Norditropin CartridgePA
DIABETIC OTHER
Norditropin FlexproPA
FORMULARY FORMULARY
Glucagen Hypokit
SOMATOSTATIC AGENTS
Glucagon Emergency Kit
FORMULARY FORMULARY
Proglycem
octreotide acetate
ALPHA-GLUCOSIDASE INHIBIT
Sandostatin Lar Depot
FORMULARY FORMULARY
acarbose
POSTERIOR PITUITARY
miglitol
FORMULARY FORMULARY
DPP-4 INHIBITORS
desmopressin acetate
FORMULARY FORMULARY
Stimate
Januvia
Tradjenta
INSULIN SENSITIZING AGENT
FORMULARY
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 11
PROLACTIN INHIBITORS
eq fiber laxative
eq fiber therapy
FORMULARY FORMULARY
eq gentle laxative
cabergoline
eq laxative maximum strength
eq magnesium citrate
METABOLIC MODIFIERS
eq milk of magnesia
FORMULARY FORMULARY
eq natural fiber laxative
calcitriol
eq natural laxative
doxercalciferol
eq natural vegetable laxative
levocarnitine
eq senna-s
paricalcitol
eq stool softener
Sensipar
eq stool softener/stimulant laxative
eq vegetable laxative
eq womans laxative
THYROID AGENTS
eq womens laxative
FORMULARY FORMULARY
eql clearlax
levo-t
eql fiber laxative
levothyroxine sodium
eql fiber therapy
levothyroxine sodium TAB 0.075MG
eql gentle laxative
levothyroxine/liothyronine
eql laxative
levoxyl
eql laxative maximum strength
liothyronine sodium
eql magnesium citrate
methimazole
eql milk of magnesia
propylthiouracil
eql natural fiber
Armour Thyroid
eql senna laxative
Cytomel
eql senna-s
NP thyroid 120
eql stool softener
Synthroid
eql stool softener/stimulant laxative
eql stool softener/stimulant laxative overnight relief
GASTROINTESTINAL
evac-u-gen
LAXATIVES
feenamint
FORMULARY FORMULARY
fiber
alophen
fiber laxative
bisac-evac
fiber therapy
bisacodyl
fiber TABS
bisacodyl laxative
fiber-CAPS
bisacodyl EC
fiber-LAX
biscolax
fibergen
calcium polycarbophil
fleet laxative
carters little pills
gavilax
citrate of magnesia
gavilyte-c
citrate of megnesia
gavilyte-h
citroma
gavilyte-n/flavor pack
clearlax
gavilyte-G
colace 2-IN-1
gentle laxative
constulose
gentle laxative for women
correct
gentle laxative overnightrelief
correctol
gentlelax
correctol extra gentle
geri-kot
diocto
glycerin children
doc-q-LAX
glycerin infants & children
docqlace
glycerin pediatric
docu
glycolax
docu soft
gnp bisa-LAX
docusate calcium
gnp clearlax
docusate sodium
gnp docusate calcium
docusate sodium & senna stimulant laxative/stool softener
gnp fiber-CAPS
docusate sodium/senna
gnp glycerin child
docusil
gnp glycerin infant
dok
gnp laxative
dok plus
gnp laxative pills
dss
gnp magnesium citrate
ducodyl
gnp milk of magnesia
dulcolax balance
gnp natural fiber
dulcolax milk of magnesia
gnp senna plus
dulcolax pink stool softener
gnp senna LAX
dulcolax stool softener
gnp senna-LAX
easy-LAX
gnp stool softener
easy-LAX plus
gnp stool softener/stimulant laxative
eq clearlax
gnp womens gentle laxative
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 12
gnp womens laxative
qc stool softener plus laxative
goodsense magnesium citrate
qc stool softener plus stimulant laxative
goodsense natural fiber
ra col-rite
goodsense senna laxative
ra fast relief laxative
goodsense stimulant laxative plus
ra fiber
kao-tin
ra fiber laxative
kls fiber-TABS
ra fiber supplement
kls laxaclear
ra fiber therapy
kls natural psyllium fiber
ra fiber-CAP
kls stool softener
ra fiber-TAB
konsyl
ra laxative
konsyl fiber
ra laxative & stool softener
kp bisacodyl
ra laxative extra strength
kp senna
ra laxative maximum strength
ks stool softener
ra magnesium citrate
lactulose
ra milk of magnesia
laxa basic
ra multihealth fiber supplement
laxacin
ra p col-rite
laxative
ra senna
laxative feminine
ra senna plus
laxative pills maximum strength
ra stimulant laxative
laxative pills regular strength
ra stool softener
laxative with senna
ra womens laxative
magnesium citrate
reguloid
medi-natural
sani-supp pediatric
medi-natural plus
senexon
medi-LAX
senexon-s
metamucil
senna
metamucil multihealth fiber
senna laxative
metamucil original texture
senna plus
metamucil smooth texture
senna s
metamucil smooth texture sugar free
senna smooth
milk of magnesia
senna LAX
natrul colon care
senna-grx
natural fiber
senna-plus
natural fiber laxative
senna-s
natural fiber therapy
senna-time
natural psyllium seed indian husks
senna-time s
natural senna laxative
senna-LAX
natural vegetable fiber
senna-TABS
peg 3350
senna/docusate sodium
peg 3350/electrolytes
sennacon
peg-prep
sennalax-s
peg-3350/electrolytes
sennazon
peg-3350/NACL/NA bicarbonate/KCL
senno
pegylax
sennosides/docusate sodium
peg3350
senokot extra strength
perdiem overnight relief
silace
peri-colace
sm clearlax
phillips milk of magnesia
sm docusate calcium
phillips stool softener
sm fiber
polyethylene glycol 3350
sm fiber laxative
psyldex
sm gentle laxative
psyllium H.S.
sm glycerin laxative pediatric
px docusate sodium
sm laxative
px fiber
sm laxative maximum strength
px laxative
sm magnesium citrate
px milk of magnesia
sm milk of magnesia
px vegetable laxative
sm natural laxative plus stool softener
qc docusate calcium
sm senna laxative
qc gentle laxative
sm senna laxative maximum strength
qc laxative
sm senna-s
qc magnesium citrate
sm stool softener
qc milk of magnesia
sm stool softener plus laxative
qc natura-LAX
sm womans laxative
qc natural vegetable
smooth LAX
qc natural vegetable laxative
sof-LAX
qc senna
sorbulax
qc senna-s
stimulant laxative
qc stool softener
stool softener
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 13
stool softener & stimulannt laxative
SB FIB LAX orange
stool softener extra strength
stool softener laxative
stool softener plus laxative
ANTIDIARRHEALS
stool softener plus stimulant laxative
FORMULARY FORMULARY
stool softener/laxative
anti-diarrheal
surfak
diamode
sw clearlax
diphenoxylate/atropine
tgt fiber laxative
eq anti-diarrheal
tgt fiber therapy
eq loperamide HCL
tgt gentle laxative
eql anti-diarrheal
tgt laxative pills maximum strength
eql loperamide HCL
tgt natural laxative pills maximum strength
flora assist
tgt powderlax
floranex
tgt senna
gnp anti-diarrheal
tgt senna laxative
gnp loperamide HCL
tgt senna laxative/stool softener
imperim
tgt stool softener
kls anti-diarrheal
tgt stool softener & stimulant laxative
lactinex
tgt womens laxative
lactobacillus
the magic bullet
loperamide a-d
trilyte
loperamide hydrochloride
veracolate
loperamide HCL
wal-mucil
meijer anti-diarrheal
womans laxative
probiotic chewable childrens
womens laxative
probiotic packets childrens
Cascara Sagrada
px anti-diarrheal
CVS bisacodyl
qc anti-diarrheal
CVS c-LAX laxative
ra anti-diarrheal
CVS citrate of magnesia
ra loperamide HCL
CVS fiber laxative
sm anti-diarrheal
CVS gentle laxative
sm loperamide HCL
CVS gentle laxative womens
tgt anti-diarrheal
CVS laxative pills
tgt loperamide HCL
CVS magnesium citrate
CVS anti-diarrheal
CVS milk of magnesia
CVS loperamide HCL
CVS natural daily fiber
Diphenoxylate/Atropine
CVS purelax
HM anti-diarrheal
CVS senna
HM loperamide HCL
CVS senna plus
Lactinex
CVS senna-extra
Paregoric
CVS stool softener
SB anti-diarrhea
CVS stool softener plus stimulant laxative
SR anti-diarrheal
DR edwards olive laxative
EX-LAX ultra
Golytely
ANTACIDS
HM clearlax
FORMULARY FORMULARY
HM fiber
almacone
HM laxative
antacid
HM magnesium citrate
antacid & antigas
HM milk of magnesia
antacid anti-gas
HM senna
antacid anti-gas regular strength
HM senna-s
antacid calcium extra ST rength
HM stool softener
antacid calcium regular strength
HM stool softener maximum strength
antacid extra strength
HM stool softener/laxative
antacid fast acting
Metamucil Multihealth Fiber
antacid fast relief
SB bisacodyl laxative EC
antacid flavor chews
SB docusate sodium
antacid i
SB docusate sodium/senna
antacid liquid
SB fiber laxative
antacid m
SB gentle laxative womens
antacid plus anti-gas fast acting
SB gentle LAX-women
antacid plus anti-gas relief
SB glycerin pediatric
antacid regular strength
SB laxative
antacid regular strength fast acting
SB magnesium citrate
calcium antacid
SB milk of magnesia
calcium antacid extra strength
SB polyethylene glycol 3 350
calcium carbonate
SB senna-LAX
calcium carbonate extra strength
SB stool softener
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 14
chewable antacid
SB antacid anti-gas
comfort gel
SB antacid extra strength
comfort gel antacid anti-gas
SB antacid/antigas
comfort gel antacid& anti-gas
Tums Lasting Effects
eq antacid
eq antacid extra strength
ULCER DRUGS
eq antacid/anti-gas
FORMULARY FORMULARY
eql antacid
acid control maximum strength
eql antacid extra strength
acid controller maximum strength
eql antacid/anti-gas
acid reducer
flanax heartburn relief
acid reducer maximum strength
geri-lanta
cimetidine
gnp antacid
cimetidine acid reducer
gnp antacid & anti-gas/regular strength
cimetidine 200
gnp antacid anti-gas
dicyclomine HCL
gnp antacid extra strength
ed-spaz
gnp antacid/regular strength
eq acid reducer
gnp masanti regular strength
eq acid reducer maximum strength
healthy mama tame the flame
eq heartburn relief
kls antacid
eq omeprazole magnesium
long lasting antacid
eq ranitidine
magnesium oxide
eql acid reducer
meijer antacid anti-gas
eql acid reducer maximum strength
mi-acid
eql heartburn prevention/maximum strength
milantex
eql heartburn relief maximum strength
mintox
esomeprazole magnesium
px antacid extra strength
famotidine
px antacid regular strength
glycopyrrolate
px calcium antacid regular strength
gnp acid control 150 maximum strength
qc antacid
gnp acid control 75
qc antacid extra strength
gnp acid reducer
qc antacid/anti-gas
gnp acid reducer maximum strength
ra antacid
gnp heartburn relief
ra antacid extra strength
gnp heartburn relief 200
ra antacid/anti-gas
gnp omeprazole
ra liquid antacid
goodsense acid reducer
ra smooth antacid extra strength
heartburn relief
rulox
heartburn relief maximum strength
sm antacid
heartburn relief 150 maximum strength
sm antacid advanced
hyoscyamine sulfate
sm antacid anti-gas
hyoscyamine sulfate odt
sm antacid/antigas
hyoscyamine sulfate ER
sm calcium antacid
hyoscyamine sulfate SR
sm calcium antacid extra strength
kls acid controller maximum strength
sm smooth antacid extra strength
kls acid reducer
sodium bicarbonate
kls acid reducer maximum strength
tgt antacid anti-gas regular strength
kp omeprazole magnesium
tgt antacid extra strength
lansoprazole
tums freshers
lansoprazole/amoxicillin/clarithromycin
tums smoothies
methscopolamine bromide
CAL-gest antacid
misoprostol
CVS antacid extra
nizatidine
CVS antacid extra strength
nulev
CVS antacid kids
omeprazole
CVS antacid liquid fast relief
omeprazole magnesium
CVS antacid/anti-gas
omeprazole DR
CVS antacid/anti-gas liq uid
oscimin
CVS antacid/simethicone
oscimin SR
CVS chewy not chalky flavor chews
pantoprazole sodium
CVS smooth antacid extra strength
pantoprazole sodium DR
Di-gel
pepcid ac maximum strength
HM antacid
phenobarbital/belladonna alkaloids
HM antacid/antigas
px acid reducer
HM calcium antacid
px acid reducer maximum strength
HM calcium antacid extra strength
px ranitidine
HM calcium antacid smoothdissolve
qc acid controller maximum strength
HM calcium antacid smoothdissolve extra strength
qc omeprazole magnesium
HM magnesium
ra acid reducer
MAG-al plus
ra acid reducer maximum strength
SB antacid
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 15
rabeprazole sodium
sm motion sickness
ranitidine acid reducer
travel-ease
ranitidine maximum strength
trimethobenzamide HCL
ranitidine HCL
wal-dram II
ranitidine 150 maximum strength
CVS motion sickness II
ranitidine 75
Granisetron HCL
sm acid reducer
HM motion relief
sm acid reducer maximum strength
HM motion sickness relief
sucralfate
SyndrosPA
sw acid reducer 150 maximum strength
Transderm-scop
symax-SR
tgt acid reducer
wal-zan 150 maximum strength
DIGESTIVE AIDS
wal-zan 75
FORMULARY FORMULARY
Belladonna & Opium
Creon
Belladonna Alkaloids & Opium
Zenpep
Carafate
Cimetidine HCL
CVS acid controller maximum strength
GASTROINTESTINAL - MISC.
CVS acid reducer maximum strength
FORMULARY FORMULARY
CVS heartburn relief
CVS omeprazole magnesium
alosetron hydrochloride
CVS ranitidine
ana-lex
CVS Omeprazole
balsalazide disodium
Eq Omeprazole
calcium acetateQL
Eql Omeprazole
colocort
First-lansoprazole
cromolyn sodium
First-omeprazole
drx choice gas relief
Gnp Omeprazole
enulose
HM acid reducer
eq gas relief
HM acid reducer maximum strength
eq infants gas relief
HM famotidine
eql gas relief
HM Omeprazole
eql gas relief extra strength
Kls Omeprazole
eql infants gas relief
Nizatidine
gas relief
Omeprazole
gas relief extra strength
Omeprazole + Syrspend SF Alka
gas relief infants
Pepcid Ac Maximum Strength
gas-x extra strength
Prilosec
gas-x infant drops
Prilosec OTC
generlac
Propantheline Bromide
gnp gas relief
Px Omeprazole
gnp gas relief extra strength
Ra Omeprazole
gnp infants gas relief
Sm Omeprazole
hydrocortisone
Sw Omeprazole
hydrocortisone acetate/pramoxine
Symax Duotab
infants gas relief
SB acid controller maximum strength
infants simethicone
SB acid reducer
lactulose
SB acid reducer ranitidine 75
lidocaine HCL/hydrocortisone acetate
SB cimetidine
little remedies for tummys gas relief
SB Omeprazole
little tummys gas relief
Tgt Omeprazole
mesalamine
mesalamine DR
metoclopramide HCL
ANTIEMETICS
mi-acid gas relief
FORMULARY FORMULARY
mommys bliss gas relief drops
dramamine less drowsy
mytab gas
dronabinol
pediacare gas relief drops infants
eq motion sickness relief
pediacare infants gas relief
eql motion sickness relief
pramcort
gnp motion sickness relief
procto-MED HC
granisetron hydrochloride
procto-PAK
granisetron HCLQL
proctosol HC
meclizine HCL
proctozone-HC
meclizine 25
px gas relief extra strength
ondansetron odt
px gas relief infants
ondansetron HCL
qc gas relief
ra motion sickness relief
ra gas relief
scopolamine
ra gas relief extra strength
Effective July 1, 2018
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; 16
ra gas relief/infants
trospium chloride
sevelamer carbonateQL
trospium chloride ER
simeped
Oxytrol For Women
simethicone
simethicone extra strength
VAGINAL PRODUCTS
sm gas relief
FORMULARY FORMULARY
sm gas relief drops infants
clindamycin phosphate
sm gas relief extra strength
clotrimazole
sm gas relief infants drops
clotrimazole-7
sulfasalazine
eq miconazole 1
tgt gas relief extra strength
eq miconazole 3 combo pack
tgt gas relief infants drops
eq miconazole 7
ursodiol
eq miconazole 7 day treatment
Apriso
eql miconazole 1
Canasa
eql miconazole 3
Cortifoam
eql miconazole 7
CVS gas relief
estradiol
CVS gas relief drops extra strength
gnp miconazole 1
CVS gas relief infants
gnp miconazole 3
CVS infants gas relief
gnp miconazole 3 combination pack
Gas-x
gnp miconazole 7
HM gas relief
goodsense miconazole 1
HM gas relief extra strengh
metronidazole vaginal
HM gas relief extra strength
miconazole
HM gas relief infants
miconazole nitrate
HM gas relief infants drops
miconazole 1
Lidocaine HCL-hydrocortisone Acetate With Aloe
miconazole 3 combination pack
Mesalamine DR
miconazole 3 combo pack
Metoclopramide Odt
miconazole 7
Pentasa
px miconazole 3-day combo pack
Proctofoam HC
qc miconazole 7
RenagelQL
ra clotrimazole 7
SB gas relief
ra miconazole 3 combination pack
QL
ra miconazole 7
sm clotrimazole vaginal
GENITOURINARY
sm miconazole 3
sm miconazole 7
URINARY ANTI-INFECTIVES
terconazole
FORMULARY FORMULARY
tgt miconazole 1
azuphen mb
tgt miconazole 3 combination pack
me/naphos/mb/hyo 1
tgt miconazole 7
methenamine hippurate
vagistat-3
methenamine mandelate
vandazole
nitrofurantoin