Select Drug List - fm.formularynavigator.com · A brand-name drug is FDA-approved and usually...

Select Drug List Drug list — NH Premium Assistance Program (PAP) Plan

Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). Here are a few things to remember about the list:

o You and your doctor can use it as a guide to choose drugs that are best for you. Drugs that aren’t on this list may not be covered by your plan and may cost you more out of pocket.

o Your coverage has limitations and exclusions, which means there are certain rules about what’s covered by your plan and what isn’t. To find out more, read your Certificate or Evidence of Coverage or your Summary Plan Description. To download those documents, log in to anthem.com and select Plan Information from the menu.

o To help you see how the drug list works with your drug benefit, we've included some frequently asked questions (FAQ) about how the list is set up and what to do if a drug you take isn't on it.

o The most up-to-date drug list for your plan - including drugs that have been added, generic drugs and more - is available at anthem.com/pharmacyinformation. Select the New Hampshire Premium Assistance Program (PAP) Select Drug List.

If you have questions about your pharmacy benefits, we're here to help. Just call us at the Member Services number on your ID card.

05267NHMENABS IND

What is a drug list? The drug list, also called a formulary, is a list of prescription medicines your plan covers. It includes hundreds of brand-name and generic drugs approved by the U.S. Food & Drug Administration (FDA). Is this a complete listing of all covered drugs? Yes, this is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design. Your coverage has limitations and exclusions, which means there are certain conditions that determine what’s covered by your plan and what isn’t. To find out more, read your Certificate/Evidence of Coverage or your Summary Plan Description, which you got when you signed up for your plan. How can I find a drug on the list? The drugs are listed in alphabetical order based on the name of their drug class, also called therapeutic class. You can search the PDF drug list by:

o Drug name, using Ctrl + F on your keyboard, then type in the name of the drug you’re looking for. o Drug class, using the categories listed in alphabetical order.

The Notes column will tell you if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST). When I search the list, I see that each drug is on a tier. What are the tiers for? The drug list is set up in tiers or levels. We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. Your share of the drug cost will depend on what tier a drug is on. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:

o Preferred Tier drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions.

o Non Preferred Tier drugs have a higher cost share. They may be preferred brand drugs, based on how well they work and their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may cost more because they're newer to the market.

How will I know how much my drug will cost? You can go online to estimate your share of a drug’s cost and compare prices at different pharmacies. Here’s how:

o At the top right of the anthem.com home page, select Manage Prescriptions from the Popular Tasks icon, then log in using your user name and password. If you haven’t signed up on the site, you’ll need to do that first.

o On your personal Pharmacy Overview page, select Price a Medication, then select one or more pharmacies and enter the name of the drug you’d like to price.

Please note: This tool will provide you with an estimate of your cost, but may not reflect the actual amount you pay at the pharmacy. Actual prices are based on your plan design and also include sales tax where applicable.

Select Drug List

If my medicine isn’t on the drug list, what are my options? Here are a few things to think about:

o If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it.

o You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just as well, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.

o You can search for generic drugs at anthem.com. OTC drugs aren’t shown on the list.

o If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapproval

or prior authorization. Your doctor can get the process started by calling the Member Services number on the back of your member ID card or by downloading a prior authorization form from our website and submitting it. If your request is approved, the amount you pay for the drug will depend on your plan’s benefit.

Who decides what drugs are on the list? The drugs on the list are reviewed through our Pharmacy and Therapeutics (P&T) process. In this process, a group of independent doctors, pharmacists and other health care professionals decides which drugs we include on our lists. This group meets regularly to look at new and existing drugs and recommends drugs based on how safe they are, how well they work and the value they offer our members. What’s the difference between brand-name and generic drugs? A brand-name drug is FDA-approved and usually available from only one manufacturer. It may be protected by a patent, which means it can only be made or sold by the company that has the patent. A generic drug is also FDA-approved and has the same active ingredients as the brand-name drug. But a generic drug is usually available only after the patent on the brand-name drug ends. It may look different, but a generic drug works the same as the brand-name drug.

Does the drug list change, and how will I know if it does? Drugs on our list are reviewed on a regular basis. Sometimes, drugs are added, removed or moved to a different tier. We’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier. You can always check the drug list to make sure medicines you take are still on it. You’ll find the most up-to-date drug list when you log in at anthem.com. Does my plan cover preventive drugs? We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA). A note about opioid analgesics. The member cost share for certain abuse-deterrent opioid analgesics may be lower in some states because of laws in those states. Opioid analgesics are a type of painkiller. In response to the global opioid epidemic, the U.S. Food and Drug Administration (FDA) has encouraged drug manufacturers to develop opioids with properties that help deter their misuse and abuse.

Drug(s) may be excluded from the list based on your plan's benefit design.

Search for a drug online

The most up-to-date drug list — including drugs that have been added, generic drugs and more — is always

available online when you log in at anthem.com. At the top right of the home page, choose Manage Prescriptions

from the Popular Tasks icon, then log in. On your personal Pharmacy Overview page, choose Search Your Drug

List and you can easily look up drugs by name, class or brand versus generic.

KEY Here are some terms and notes you’ll find on the drug list.

Brand name drugs are in UPPER CASE, bold type.

Generic drugs are in lower case, plain type.

$0 = preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a prescription

from your provider if specified criteria are met.

DO = dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once

a day at a higher strength.

LD = limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on

what the manufacturer decides.

PA = prior authorization. You may need to get benefits approved before certain prescr iptions can be filled.

QL = quantity limits. There are limits on the amount of medicine covered within a certain amount of time.

SP = specialty drugs. Specialty drugs are used to treat difficult, long -term conditions. You may need to get this drug

through a specialty pharmacy.

ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered.

2018 New Hampshire PAP Select Drug List

New Hampshire Select PAP Drug List

ANALGESICS ...........................................................................................................................................................................7ANESTHETICS .........................................................................................................................................................................8ANTIARTHRITICS .................................................................................................................................................................... 9ANTIASTHMATICS .................................................................................................................................................................. 9ANTIBIOTICS ......................................................................................................................................................................... 11ANTICOAGULANTS .............................................................................................................................................................. 14ANTIDOTES ........................................................................................................................................................................... 15ANTIFUNGALS ...................................................................................................................................................................... 15ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................. 16ANTIHISTAMINES ..................................................................................................................................................................16ANTIHYPERGLYCEMICS ...................................................................................................................................................... 17ANTIINFECTIVES/MISCELLANEOUS ...................................................................................................................................19ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS ....................................................................................19ANTINEOPLASTICS .............................................................................................................................................................. 19ANTIPARKINSON DRUGS .................................................................................................................................................... 21ANTIPLATELET DRUGS ....................................................................................................................................................... 22ANTIVIRALS ...........................................................................................................................................................................22AUTONOMIC DRUGS ............................................................................................................................................................ 24BIOLOGICALS ....................................................................................................................................................................... 24BLOOD ................................................................................................................................................................................... 27CARDIAC DRUGS ..................................................................................................................................................................27CARDIOVASCULAR .............................................................................................................................................................. 29CNS DRUGS ...........................................................................................................................................................................31COLONY STIMULATING FACTORS .....................................................................................................................................33CONTRACEPTIVES ............................................................................................................................................................... 33COUGH/COLD PREPARATIONS .......................................................................................................................................... 36DIAGNOSTIC ..........................................................................................................................................................................37DIURETICS .............................................................................................................................................................................37EENT PREPS ......................................................................................................................................................................... 37ELECT/CALORIC/H2O ...........................................................................................................................................................39GASTROINTESTINAL ............................................................................................................................................................40HORMONES ........................................................................................................................................................................... 42IMMUNOSUPPRESSANTS ....................................................................................................................................................44MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ..................................................................................... 44MUSCLE RELAXANTS .......................................................................................................................................................... 45PRE-NATAL VITAMINS ......................................................................................................................................................... 45PSYCHOTHERAPEUTIC DRUGS ..........................................................................................................................................46SEDATIVE/HYPNOTICS ........................................................................................................................................................ 49SKIN PREPS .......................................................................................................................................................................... 49SMOKING DETERRENTS ......................................................................................................................................................52THYROID PREPS ...................................................................................................................................................................52UNCLASSIFIED DRUG PRODUCTS .....................................................................................................................................53VITAMINS ............................................................................................................................................................................... 54

5

6

2018 New Hampshire PAP Select Drug List

CURRENT AS OF 7/1/2018

Drug Name Tier Notes

ANALGESICS

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml

Preferred QL

acetaminophen-codeine oral tablet

Preferred QL

almotriptan malate oral tablet

Preferred QL

asa-butalb-caff-cod #3 capsule

Preferred QL

ascomp with codeine oral capsule

Preferred QL

bayer aspirin 500 mg caplet

Preferred

butalbital compound w/codeine oral capsule

Preferred QL

butalbital compound-codeine oral capsule

Preferred QL

butalbital-acetaminop-caf-cod oral capsule

Preferred QL

butalbital-acetaminophen oral tablet

Preferred

butalbital-acetaminophen-caff oral capsule

Preferred

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

Preferred

butalbital-aspirin-caffeine oral capsule

Preferred

butalbital-aspirin-caffeine oral tablet

Preferred

butorphanol tartrate nasal spray,non-aerosol

Preferred PA; QL

capacet oral capsule Preferred

codeine sulfate oral tabletNon-

PreferredQL

diclofenac potassium oral tablet

Preferred

diflunisal oral tablet Preferred

dihydroergotamine nasal spray,non-aerosol

Non-Preferred

QL


diskets oral tablet,soluble Preferred PA; QL

eletriptan oral tabletNon-

PreferredQL

ELMIRON ORAL CAPSULE

Non-Preferred

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL

Non-Preferred

PA; QL

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Non-Preferred

QL

ergotamine-caffeine oral tablet

Preferred

fentanyl transdermal patch 72 hour

Non-Preferred

PA; QL

frovatriptan oral tabletNon-

PreferredQL

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

Preferred QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

Preferred QL

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

Preferred QL

hydromorphone oral liquid Preferred QL

hydromorphone oral tablet Preferred QL

hydromorphone rectal suppository

Non-Preferred

QL

ibuprofen-oxycodone oral tablet

Preferred QL

isometh-dichloral-acetaminophn oral capsule

Preferred

ketorolac oral tablet Preferred QL

levorphanol tartrate oral tablet

Non-Preferred

PA; QL

mefenamic acid oral capsule

Preferred QL

meperidine oral solution Preferred QL

meperidine oral tablet Preferred QL

methadone intensol oral concentrate

Preferred PA; QL

Effective 7/1/2018

7


methadone oral concentrate

Preferred PA; QL

methadone oral solution Preferred PA; QL

methadone oral tablet Preferred PA; QL

methadone oral tablet,soluble

Preferred PA; QL

methadose oral concentrate

Preferred PA; QL

methadose oral tablet,soluble

Preferred PA; QL

migergot rectal suppository

Preferred

morphine concentrate oral solution

Preferred QL

morphine oral capsule,extend.release pellets

Non-Preferred

PA; QL

morphine oral solution Preferred QL

morphine oral tablet Preferred QL

morphine oral tablet extended release

Non-Preferred

PA; QL

morphine rectal suppository

Preferred QL

naratriptan oral tablet Preferred QL

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR

Non-Preferred

PA; QL

NUCYNTA ORAL TABLET

Non-Preferred

QL

oxycodone oral capsuleNon-

PreferredQL

oxycodone oral concentrate

Non-Preferred

QL

oxycodone oral solutionNon-

PreferredQL

oxycodone oral syringeNon-

PreferredQL

oxycodone oral tabletNon-

PreferredQL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Preferred QL

oxycodone-aspirin oral tablet

Preferred QL

oxymorphone oral tabletNon-

PreferredQL


oxymorphone oral tablet extended release 12 hr

Non-Preferred

PA; QL

pentazocine-naloxone oral tablet

Preferred QL

rizatriptan oral tablet Preferred QL

rizatriptan oral tablet,disintegrating

Preferred QL

sumatriptan succinate oral tablet

Preferred QL

sumatriptan succinate subcutaneous cartridge

Non-Preferred

QL

sumatriptan succinate subcutaneous pen injector

Non-Preferred

QL

sumatriptan succinate subcutaneous solution

Non-Preferred

QL

tencon oral tablet 50-325 mg

Preferred

tramadol oral tablet Preferred QL

tramadol oral tablet extended release 24 hr

Non-Preferred

PA; QL

tramadol oral tablet, er multiphase 24 hr

Non-Preferred

PA; QL

tramadol-acetaminophen oral tablet

Preferred QL

vicodin es oral tabletNon-

PreferredQL

vicodin hp oral tabletNon-

PreferredQL

vicodin oral tabletNon-

PreferredQL

zebutal oral capsule 50-325-40 mg

Non-Preferred

ZIPSOR ORAL CAPSULENon-

PreferredQL

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR

Non-Preferred

PA; QL

zolmitriptan oral tablet Preferred QL

zolmitriptan oral tablet,disintegrating

Preferred QL

ANESTHETICS

lidocaine viscous mucous membrane solution

Preferred QL

lidocaine-prilocaine topical cream

Preferred QL

Effective 7/1/2018

8


lidocaine-prilocaine topical kit

Preferred

phenazopyridine oral tablet 100 mg, 200 mg

Preferred

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

Non-Preferred

ANTIARTHRITICS

allopurinol oral tablet Preferred

celecoxib oral capsuleNon-

PreferredST; QL

COLCRYS ORAL TABLET

Non-Preferred

PA; QL

CUPRIMINE ORAL CAPSULE

Non-Preferred

diclofenac sodium oral tablet extended release 24 hr

Preferred

diclofenac sodium oral tablet,delayed release (dr/ec)

Preferred

etodolac oral capsule Preferred

etodolac oral tablet Preferred

etodolac oral tablet extended release 24 hr

Preferred

fenoprofen oral tablet Preferred QL

flurbiprofen oral tablet Preferred

ibu oral tablet Preferred

ibuprofen oral suspension Preferred QL

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

Preferred

indomethacin oral capsule Preferred QL

indomethacin oral capsule, extended release

Preferred QL

ketoprofen oral capsule Preferred

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

Preferred QL

leflunomide oral tabletNon-

Preferred

meclofenamate oral capsule

Preferred

meloxicam oral suspension

Preferred QL

meloxicam oral tablet Preferred QL

nabumetone oral tablet Preferred


naproxen oral suspension Preferred

naproxen oral tablet Preferred

naproxen oral tablet,delayed release (dr/ec)

Preferred

naproxen sodium oral tablet 275 mg, 550 mg

Preferred

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN

Non-Preferred

PA; SP; QL

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR

Non-Preferred

PA; SP; QL

ORENCIA SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP; QL

oxaprozin oral tablet Preferred

piroxicam oral capsule Preferred

probenecid oral tablet Preferred

probenecid-colchicine oral tablet

Preferred

RIDAURA ORAL CAPSULE

Non-Preferred

sulindac oral tablet Preferred

tolmetin oral capsuleNon-

Preferred

tolmetin oral tabletNon-

Preferred

ULORIC ORAL TABLETNon-

PreferredST

ANTIASTHMATICS

acetylcysteine solutionNon-

Preferred

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Non-Preferred

QL

ADVAIR HFA INHALATION HFA AEROSOL INHALER

Non-Preferred

QL

albuterol sulfate inhalation solution for nebulization

Preferred

albuterol sulfate oral syrup Preferred

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Non-Preferred

QL

Effective 7/1/2018

9


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

Non-Preferred

QL

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)

Non-Preferred

BROVANA INHALATION SOLUTION FOR NEBULIZATION

Non-Preferred

QL

budesonide inhalation suspension for nebulization

Preferred QL

cromolyn inhalation solution for nebulization

Non-Preferred

DALIRESP ORAL TABLET

Non-Preferred

QL

DULERA INHALATION HFA AEROSOL INHALER

Non-Preferred

QL

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

Non-Preferred

QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER

Non-Preferred

QL

ipratropium bromide inhalation solution

Preferred QL

ipratropium-albuterol inhalation solution for nebulization

Non-Preferred

levalbuterol hcl inhalation solution for nebulization

Non-Preferred

metaproterenol oral syrup Preferred

metaproterenol oral tablet Preferred

montelukast oral granules in packet

Preferred QL

montelukast oral tablet Preferred QL

montelukast oral tablet,chewable

Preferred QL


PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

Non-Preferred

QL

PROAIR HFA INHALATION HFA AEROSOL INHALER

Non-Preferred

QL

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

Non-Preferred

QL

PROVENTIL HFA INHALATION HFA AEROSOL INHALER

Non-Preferred

QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Non-Preferred

QL

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

Non-Preferred

QL

SPIRIVA RESPIMAT INHALATION MIST

Non-Preferred

QL

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Non-Preferred

QL

SYMBICORT INHALATION HFA AEROSOL INHALER

Non-Preferred

QL

terbutaline oral tabletNon-

Preferred

theochron oral tablet extended release 12 hr

Preferred

theophylline oral elixir Preferred

theophylline oral solution Preferred

theophylline oral tablet extended release 12 hr

Preferred

theophylline oral tablet extended release 24 hr

Preferred

VENTOLIN HFA INHALATION HFA AEROSOL INHALER

Non-Preferred

QL

XOPENEX HFA INHALATION HFA AEROSOL INHALER

Non-Preferred

QL

zafirlukast oral tablet Preferred

zileuton oral tablet, er multiphase 12 hr

Non-Preferred

PA

Effective 7/1/2018

10


ANTIBIOTICS

amoxicillin oral capsule Preferred

amoxicillin oral suspension for reconstitution

Preferred

amoxicillin oral tablet Preferred

amoxicillin oral tablet,chewable 125 mg, 250 mg

Preferred

amoxicillin-pot clavulanate oral suspension for reconstitution

Preferred

amoxicillin-pot clavulanate oral tablet

Preferred

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Preferred

amoxicillin-pot clavulanate oral tablet,chewable

Preferred

ampicillin oral capsule Preferred

avidoxy oral tablet Preferred

AZASITE OPHTHALMIC (EYE) DROPS

Non-Preferred

azithromycin oral packet Preferred QL

azithromycin oral suspension for reconstitution

Preferred QL

azithromycin oral tablet Preferred QL

bacitracin ophthalmic (eye) ointment

Preferred

bacitracin-polymyxin b ophthalmic (eye) ointment

Preferred

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION

Non-Preferred

bp 10-1 topical cleanser Preferred

cefaclor oral capsule Preferred

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

Preferred

cefaclor oral tablet extended release 12 hr

Non-Preferred

cefadroxil oral capsule Preferred

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

Preferred


cefadroxil oral tablet Preferred

cefdinir oral capsule Preferred

cefdinir oral suspension for reconstitution

Preferred

cefditoren pivoxil oral tablet

Non-Preferred

cefpodoxime oral suspension for reconstitution

Non-Preferred

cefpodoxime oral tabletNon-

Preferred

cefprozil oral suspension for reconstitution

Preferred

cefprozil oral tablet Preferred

cefuroxime axetil oral tablet

Preferred

cephalexin oral capsule Preferred

cephalexin oral suspension for reconstitution

Preferred

cephalexin oral tablet Preferred

CIPRO HC OTIC (EAR) DROPS,SUSPENSION

Non-Preferred

CIPRODEX OTIC (EAR) DROPS,SUSPENSION

Non-Preferred

PA

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

Preferred QL

ciprofloxacin hcl ophthalmic (eye) drops

Preferred

ciprofloxacin hcl oral tablet Preferred QL

ciprofloxacin hcl otic (ear) dropperette

Preferred

clarithromycin oral suspension for reconstitution

Preferred

clarithromycin oral tablet Preferred

clarithromycin oral tablet extended release 24 hr

Preferred

cleansing wash topical cleanser

Preferred

clindamycin hcl oral capsule

Preferred

clindamycin palmitate hcl oral recon soln

Preferred

clindamycin pediatric oral recon soln

Preferred

Effective 7/1/2018

11


clindamycin phosphate topical foam

Preferred

clindamycin phosphate topical gel

Preferred

clindamycin phosphate topical lotion

Preferred

clindamycin phosphate topical solution

Preferred

clindamycin phosphate topical swab

Preferred

clindamycin phosphate vaginal cream

Preferred

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION

Non-Preferred

CORTISPORIN TOPICAL CREAM

Non-Preferred

CORTISPORIN TOPICAL OINTMENT

Non-Preferred

CYCLOSERINE ORAL CAPSULE

Non-Preferred

DAPSONE ORAL TABLET

Non-Preferred

demeclocycline oral tabletNon-

Preferred

dicloxacillin oral capsule Preferred

DIFICID ORAL TABLETNon-

PreferredPA

doxycycline hyclate oral capsule

Preferred

doxycycline hyclate oral tablet 100 mg, 50 mg

Preferred

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg

Preferred PA

doxycycline monohydrate oral capsule

Preferred

doxycycline monohydrate oral suspension for reconstitution

Preferred

doxycycline monohydrate oral tablet

Preferred

e.e.s. 400 oral tabletNon-

Preferred

ery pads topical swab Preferred

erygel topical gel Preferred


ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

Preferred

erythrocin (as stearate) oral tablet 250 mg

Preferred

erythromycin ethylsuccinate oral tablet

Non-Preferred

erythromycin ophthalmic (eye) ointment

Preferred

erythromycin oral capsule,delayed release(dr/ec)

Non-Preferred

erythromycin oral tabletNon-

Preferred

erythromycin with ethanol topical gel

Preferred

erythromycin with ethanol topical solution

Preferred

erythromycin with ethanol topical swab

Preferred

erythromycin-benzoyl peroxide topical gel

Preferred

ethambutol oral tabletNon-

Preferred

FACTIVE ORAL TABLETNon-

PreferredQL

gatifloxacin ophthalmic (eye) drops

Preferred

gentak ophthalmic (eye) ointment

Preferred

gentamicin ophthalmic (eye) drops

Preferred

gentamicin ophthalmic (eye) ointment

Preferred

INVANZ INJECTION RECON SOLN

Non-Preferred

INVANZ INTRAVENOUS RECON SOLN

Non-Preferred

isoniazid oral solution Preferred

isoniazid oral tablet Preferred

levofloxacin oral tabletNon-

PreferredQL

linezolid oral suspension for reconstitution

Non-Preferred

PA; QL

linezolid oral tabletNon-

PreferredPA; QL

Effective 7/1/2018

12


mafenide acetate topical packet

Non-Preferred

methenamine hippurate oral tablet

Non-Preferred

methenamine mandelate oral tablet

Non-Preferred

metronidazole oral capsule

Preferred

metronidazole oral tablet Preferred

metronidazole vaginal gel Preferred

minocycline oral capsule Preferred

minocycline oral tablet Preferred

minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg

Preferred PA

MONUROL ORAL PACKET

Non-Preferred

morgidox oral capsule 100 mg

Preferred

MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR

Non-Preferred

moxifloxacin ophthalmic (eye) drops

Preferred

mupirocin topical ointment Preferred

neomycin oral tablet Preferred

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment

Preferred

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

Preferred

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension

Preferred

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

Preferred

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

Preferred

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension

Preferred

neomycin-polymyxin-hc otic (ear) drops,suspension

Preferred


neomycin-polymyxin-hc otic (ear) solution

Preferred

neo-polycin hc ophthalmic (eye) ointment

Preferred

neo-polycin ophthalmic (eye) ointment

Preferred

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

Preferred

nitrofurantoin monohyd/m-cryst oral capsule

Preferred

nitrofurantoin oral suspension

Preferred

ofloxacin ophthalmic (eye) drops

Preferred

ofloxacin oral tablet 300 mg, 400 mg

Preferred QL

ofloxacin otic (ear) drops Preferred

ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE

Non-Preferred

penicillin v potassium oral recon soln

Preferred

penicillin v potassium oral tablet

Preferred

polycin ophthalmic (eye) ointment

Preferred

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

Preferred

PRIFTIN ORAL TABLETNon-

Preferred

PRIMSOL ORAL SOLUTION

Non-Preferred

pyrazinamide oral tabletNon-

Preferred

rifabutin oral capsuleNon-

Preferred

rifampin oral capsuleNon-

Preferred

RIFATER ORAL TABLETNon-

Preferred

silver sulfadiazine topical cream

Preferred

ssd topical cream Preferred

sss 10-5 topical cream Preferred

sss 10-5 topical foam Preferred

Effective 7/1/2018

13


sulfacetamide sodium ophthalmic (eye) drops

Preferred

sulfacetamide sodium ophthalmic (eye) ointment

Preferred

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %

Preferred

sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w)

Preferred

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)

Preferred

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

Preferred

sulfacetamide sodium-sulfur topical suspension

Preferred

sulfacetamide sod-sulfur-urea topical cleanser

Preferred

sulfacetamide-prednisolone ophthalmic (eye) drops

Preferred

sulfacetamide-sulfur-cleansr23 topical kit

Preferred

sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream

Preferred

sulfadiazine oral tabletNon-

Preferred

sulfamethoxazole-trimethoprim oral suspension

Preferred

sulfamethoxazole-trimethoprim oral tablet

Preferred

SULFAMYLON TOPICAL CREAM

Non-Preferred

sulfatrim oral suspension Preferred

SUPRAX ORAL CAPSULE

Non-Preferred

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

Non-Preferred

tetracycline oral capsule Preferred

THALOMID ORAL CAPSULE

Non-Preferred

PA; SP; QL


tigecycline intravenous recon soln

Non-Preferred

TOBRADEX OPHTHALMIC (EYE) OINTMENT

Non-Preferred

tobramycin in 0.225 % nacl inhalation solution for nebulization

Non-Preferred

SP

tobramycin ophthalmic (eye) drops

Preferred

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

Preferred

TRECATOR ORAL TABLET

Non-Preferred

trimethoprim oral tablet Preferred

vancomycin oral capsuleNon-

PreferredPA

vandazole vaginal gel Preferred

XIFAXAN ORAL TABLETNon-

PreferredPA; QL

ANTICOAGULANTS

enoxaparin subcutaneous solution

Non-Preferred

QL

enoxaparin subcutaneous syringe

Non-Preferred

QL

fondaparinux subcutaneous syringe

Non-Preferred

PA; QL

FRAGMIN SUBCUTANEOUS SOLUTION

Non-Preferred

QL

FRAGMIN SUBCUTANEOUS SYRINGE

Non-Preferred

QL

hep flush-10 (pf) intravenous solution

Preferred

heparin (porcine) in 0.9% nacl intravenous parenteral solution 5,000 unit/1,000 ml

Preferred

heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

Preferred

Effective 7/1/2018

14


heparin (porcine) in nacl (pf) intravenous parenteral solution

Preferred

heparin (porcine) injection cartridge

Preferred

heparin (porcine) injection solution

Preferred

heparin flush(porcine)-0.9nacl intravenous kit

Preferred

heparin lock flush (porcine) intravenous solution

Preferred

heparin lock flush (porcine) intravenous syringe

Preferred

heparin lock flush intravenous solution

Preferred

heparin lock flush intravenous syringe

Preferred

heparin lock intravenous solution

Preferred

heparin lockflush(porcine)(pf) intravenous syringe

Preferred

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

Preferred

heparin, porcine (pf) injection solution

Preferred

heparin, porcine (pf) injection syringe

Preferred

heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)

Preferred

heparin, porcine (pf) intravenous syringe

Preferred

jantoven oral tablet Preferred

PRADAXA ORAL CAPSULE

Non-Preferred

QL

warfarin oral tablet Preferred

XARELTO ORAL TABLET

Non-Preferred

QL

XARELTO ORAL TABLETS,DOSE PACK

Non-Preferred

QL


ANTIDOTES

naloxone injection solutionNon-

PreferredQL

naloxone injection syringeNon-

PreferredQL

naltrexone oral tablet Preferred

ANTIFUNGALS

ciclopirox topical cream Preferred

ciclopirox topical gel Preferred

ciclopirox topical shampoo Preferred

ciclopirox topical solution Preferred

ciclopirox topical suspension

Preferred

clotrimazole mucous membrane troche

Non-Preferred

QL

clotrimazole topical cream Preferred

clotrimazole topical solution

Preferred

clotrimazole-betamethasone topical cream

Preferred

clotrimazole-betamethasone topical lotion

Preferred

econazole topical cream Preferred

ERTACZO TOPICAL CREAM

Non-Preferred

EXELDERM TOPICAL CREAM

Non-Preferred

EXELDERM TOPICAL SOLUTION

Non-Preferred

fluconazole oral suspension for reconstitution

Preferred QL

fluconazole oral tablet Preferred QL

flucytosine oral capsuleNon-

Preferred

griseofulvin microsize oral suspension

Preferred

griseofulvin microsize oral tablet

Preferred

griseofulvin ultramicrosize oral tablet

Preferred

GYNAZOLE-1 VAGINAL CREAM

Non-Preferred

Effective 7/1/2018

15


itraconazole oral capsuleNon-

PreferredPA; QL

ketoconazole oral tablet Preferred QL

ketoconazole topical cream

Preferred

ketoconazole topical foam Preferred

ketoconazole topical shampoo

Preferred

MENTAX TOPICAL CREAM

Non-Preferred

miconazole-3 vaginal suppository

Preferred

NAFTIFINE TOPICAL CREAM 1 %

Non-Preferred

naftifine topical cream 2 %Non-

Preferred

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION

Non-Preferred

NOXAFIL ORAL SUSPENSION

Non-Preferred

QL

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC)

Non-Preferred

QL

nyamyc topical powder Preferred

nystatin oral powder 150 million unit, 500 million unit

Preferred

nystatin oral suspension Preferred

nystatin oral tablet Preferred

nystatin topical cream Preferred

nystatin topical ointment Preferred

nystatin topical powder Preferred

nystatin-triamcinolone topical cream

Preferred

nystatin-triamcinolone topical ointment

Preferred

nystop topical powder Preferred

oxiconazole topical creamNon-

Preferred

OXISTAT TOPICAL LOTION

Non-Preferred

terbinafine hcl oral tablet Preferred PA; QL

terconazole vaginal cream Preferred

terconazole vaginal suppository

Preferred


voriconazole oral suspension for reconstitution

Non-Preferred

PA; QL

voriconazole oral tabletNon-

PreferredPA; QL

ANTIHISTAMINE AND DECONGESTANT COMBINATION

promethazine vc oral syrup

Preferred

promethazine-phenylephrine oral syrup

Preferred

ANTIHISTAMINES

azelastine ophthalmic (eye) drops

Preferred QL

BEPREVE OPHTHALMIC (EYE) DROPS

Non-Preferred

PA; QL

carbinoxamine maleate oral liquid

Preferred

carbinoxamine maleate oral tablet

Preferred

cetirizine oral solution 1 mg/ml

Preferred

clemastine oral tablet 2.68 mg

Preferred

cyproheptadine oral syrup Preferred

cyproheptadine oral tablet Preferred

desloratadine oral tablet Preferred

desloratadine oral tablet,disintegrating

Preferred

diphenhydramine hcl injection solution 50 mg/ml

Non-Preferred

diphenhydramine hcl injection syringe

Non-Preferred

diphenhydramine hcl oral capsule 50 mg

Preferred

EMADINE OPHTHALMIC (EYE) DROPS

Non-Preferred

PA; QL

epinastine ophthalmic (eye) drops

Preferred QL

fexofenadine oral tablet 180 mg

Preferred

hydroxyzine hcl oral solution 10 mg/5 ml

Preferred

hydroxyzine hcl oral tablet Preferred

Effective 7/1/2018

16


hydroxyzine pamoate oral capsule

Preferred

LASTACAFT OPHTHALMIC (EYE) DROPS

Non-Preferred

PA; QL

levocetirizine oral solution Preferred

levocetirizine oral tablet Preferred

olopatadine ophthalmic (eye) drops

Non-Preferred

PA; QL

promethazine oral syrup Preferred

promethazine oral tablet Preferred

ANTIHYPERGLYCEMICS

acarbose oral tablet Preferred

AVANDIA ORAL TABLET2 MG, 4 MG

Non-Preferred

ST; QL

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR

Non-Preferred

ST; QL

BYDUREON SUBCUTANEOUS PEN INJECTOR

Non-Preferred

ST; QL

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

Non-Preferred

ST; QL

chlorpropamide oral tablet Preferred

CYCLOSET ORAL TABLET

Non-Preferred

FARXIGA ORAL TABLETNon-

PreferredST; QL

glimepiride oral tablet Preferred

glipizide oral tablet Preferred

glipizide oral tablet extended release 24hr

Preferred

glipizide-metformin oral tablet

Preferred

glyburide micronized oral tablet

Preferred

glyburide oral tablet Preferred

glyburide-metformin oral tablet

Preferred

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT

Non-Preferred


HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN

Non-Preferred

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION

Non-Preferred

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

Non-Preferred

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

Non-Preferred

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION

Non-Preferred

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Non-Preferred

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION

Non-Preferred

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Non-Preferred

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN

Non-Preferred

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN

Non-Preferred

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Non-Preferred

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION

Non-Preferred

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION

Non-Preferred

Effective 7/1/2018

17


HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

Non-Preferred

INVOKAMET ORAL TABLET

Non-Preferred

ST; QL

INVOKANA ORAL TABLET

Non-Preferred

ST; QL

JANUMET ORAL TABLET

Non-Preferred

ST; QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

Non-Preferred

ST; QL

JANUVIA ORAL TABLETNon-

PreferredST; QL

JARDIANCE ORAL TABLET

Non-Preferred

ST; QL

JENTADUETO ORAL TABLET

Non-Preferred

ST; QL

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Non-Preferred

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION

Non-Preferred

metformin oral tablet Preferred

metformin oral tablet extended release 24 hr

Preferred

metformin oral tablet extended release 24hr

Preferred

miglitol oral tabletNon-

Preferred

nateglinide oral tabletNon-

PreferredPA

NESINA ORAL TABLETNon-

PreferredST; QL

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Non-Preferred

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Non-Preferred

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION

Non-Preferred


NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Non-Preferred

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION

Non-Preferred

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN

Non-Preferred

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Non-Preferred

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION

Non-Preferred

ONGLYZA ORAL TABLET 2.5 MG

Non-Preferred

ST; DO

ONGLYZA ORAL TABLET 5 MG

Non-Preferred

ST; QL

pioglitazone oral tablet Preferred QL

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA

SYNJARDY ORAL TABLET

Non-Preferred

ST; QL

tolazamide oral tablet Preferred

tolbutamide oral tabletNon-

Preferred

TRADJENTA ORAL TABLET

Non-Preferred

ST; DO

TRULICITY SUBCUTANEOUS PEN INJECTOR

Non-Preferred

ST; QL

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

Non-Preferred

ST; QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

Non-Preferred

ST; QL

Effective 7/1/2018

18


XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Non-Preferred

ST; QL

ANTIINFECTIVES/MISCELLANEOUS

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

Non-Preferred

ALINIA ORAL TABLETNon-

Preferred

atovaquone oral suspension

Non-Preferred

atovaquone-proguanil oral tablet

Preferred

chloroquine phosphate oral tablet

Preferred

COARTEM ORAL TABLET

Non-Preferred

DARAPRIM ORAL TABLET

Non-Preferred

PA; LD; QL

hydroxychloroquine oral tablet

Preferred

ivermectin oral tablet Preferred

mefloquine oral tablet Preferred

NEBUPENT INHALATION RECON SOLN

Non-Preferred

paromomycin oral capsule Preferred

praziquantel oral tabletNon-

Preferred

PRIMAQUINE ORAL TABLET

Non-Preferred

quinine sulfate oral capsule

Non-Preferred

PA; QL

ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

Non-Preferred

PA; SP; LD; QL

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT

Non-Preferred

PA; SP; LD; QL

CIMZIA SUBCUTANEOUS SYRINGE KIT

Non-Preferred

PA; SP; LD; QL


ENBREL MINI SUBCUTANEOUS CARTRIDGE

Non-Preferred

PA; SP; QL

ENBREL SUBCUTANEOUS RECON SOLN

Non-Preferred

PA; SP; QL

ENBREL SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP; QL

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA; SP; QL

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

Non-Preferred

PA; SP; QL

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT

Non-Preferred

PA; SP; QL

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT

Non-Preferred

PA; SP; QL

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

Non-Preferred

PA; SP; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT

Non-Preferred

PA; SP; QL

SIMPONI ARIA INTRAVENOUS SOLUTION

Non-Preferred

PA; SP

SIMPONI SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA; SP; QL

SIMPONI SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP; QL

ANTINEOPLASTICS

ACTIMMUNE SUBCUTANEOUS SOLUTION

Non-Preferred

PA; SP; LD

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

Non-Preferred

PA; SP

AFINITOR ORAL TABLET

Non-Preferred

PA; SP

Effective 7/1/2018

19


anastrozole oral tabletNon-

PreferredQL

bexarotene oral capsuleNon-

PreferredPA; SP

bicalutamide oral tabletNon-

Preferred

BOSULIF ORAL TABLETNon-

PreferredPA; SP; QL

capecitabine oral tabletNon-

PreferredPA; SP

CAPRELSA ORAL TABLET

Non-Preferred

PA; QL

COMETRIQ ORAL CAPSULE

Non-Preferred

PA; LD; QL

CYCLOPHOSPHAMIDE ORAL CAPSULE

Non-Preferred

SP

diclofenac sodium topical gel 3 %

Non-Preferred

QL

EMCYT ORAL CAPSULENon-

PreferredPA

ERIVEDGE ORAL CAPSULE

Non-Preferred

PA; SP; QL

etoposide oral capsuleNon-

PreferredSP

exemestane oral tabletNon-

PreferredPA; QL

FARESTON ORAL TABLET

Non-Preferred

QL

FARYDAK ORAL CAPSULE

Non-Preferred

PA; SP; QL

FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG

Non-Preferred

PA; SP; QL

fluorouracil topical cream 5 %

Preferred QL

fluorouracil topical solution Preferred QL

flutamide oral capsuleNon-

Preferred

GILOTRIF ORAL TABLET

Non-Preferred

PA; SP; LD; QL

GLEOSTINE ORAL CAPSULE

Non-Preferred

PA

HEXALEN ORAL CAPSULE

Non-Preferred

HYCAMTIN ORAL CAPSULE

Non-Preferred

SP


hydroxyurea oral capsuleNon-

Preferred

IBRANCE ORAL CAPSULE

Non-Preferred

PA; SP; QL

ICLUSIG ORAL TABLETNon-

PreferredPA; QL

imatinib oral tabletNon-

PreferredPA; SP; QL

IMBRUVICA ORAL CAPSULE

Non-Preferred

PA; LD; QL

IMBRUVICA ORAL TABLET

Non-Preferred

PA; LD; QL

INLYTA ORAL TABLETNon-

PreferredPA; SP; QL

INTRON A INJECTION RECON SOLN

Non-Preferred

SP

INTRON A INJECTION SOLUTION

Non-Preferred

SP

JAKAFI ORAL TABLETNon-

PreferredPA; SP; LD; QL

LENVIMA ORAL CAPSULE

Non-Preferred

PA; SP; LD; QL

letrozole oral tabletNon-

PreferredQL

LEUKERAN ORAL TABLET

Non-Preferred

leuprolide subcutaneous kit

Non-Preferred

PA; SP

LYNPARZA ORAL CAPSULE

Non-Preferred

PA; SP; LD; QL

LYNPARZA ORAL TABLET

Non-Preferred

PA; SP; LD; QL

LYSODREN ORAL TABLET

Non-Preferred

QL

MATULANE ORAL CAPSULE

Non-Preferred

LD

MEKINIST ORAL TABLET

Non-Preferred

PA; SP; QL

melphalan oral tabletNon-

PreferredSP

mercaptopurine oral tabletNon-

Preferred

methotrexate sodium oral tablet

Non-Preferred

MYLERAN ORAL TABLET

Non-Preferred

Effective 7/1/2018

20


NEXAVAR ORAL TABLET

Non-Preferred

PA; SP; QL

nilutamide oral tabletNon-

PreferredQL

ODOMZO ORAL CAPSULE

Non-Preferred

PA; SP; QL

PICATO TOPICAL GELNon-

PreferredPA; QL

POMALYST ORAL CAPSULE

Non-Preferred

PA; SP; QL

REVLIMID ORAL CAPSULE

Non-Preferred

PA; SP; QL

SPRYCEL ORAL TABLET

Non-Preferred

PA; SP; QL

STIVARGA ORAL TABLET

Non-Preferred

PA; SP; QL

SUTENT ORAL CAPSULE

Non-Preferred

PA; SP; QL

TABLOID ORAL TABLETNon-

Preferred

TAFINLAR ORAL CAPSULE

Non-Preferred

PA; SP; QL

tamoxifen oral tabletNon-

Preferred$0

TARCEVA ORAL TABLET

Non-Preferred

PA; SP; QL

TARGRETIN TOPICAL GEL

Non-Preferred

PA; SP

TASIGNA ORAL CAPSULE

Non-Preferred

PA; SP; QL

temozolomide oral capsuleNon-

PreferredPA; SP; QL

tretinoin (chemotherapy) oral capsule

Non-Preferred

TYKERB ORAL TABLETNon-

PreferredPA; SP; QL

VOTRIENT ORAL TABLET

Non-Preferred

PA; SP; QL

XALKORI ORAL CAPSULE

Non-Preferred

PA; SP; QL

XTANDI ORAL CAPSULENon-

PreferredPA; SP; QL

ZELBORAF ORAL TABLET

Non-Preferred

PA; SP; QL

ZOLINZA ORAL CAPSULE

Non-Preferred

PA; SP; QL


ZYDELIG ORAL TABLETNon-


ZYKADIA ORAL CAPSULE

Non-Preferred

PA; SP; QL

ZYTIGA ORAL TABLETNon-

PreferredPA; SP; QL

ANTIPARKINSON DRUGS

amantadine hcl oral capsule

Non-Preferred

QL

amantadine hcl oral solution

Non-Preferred

amantadine hcl oral tabletNon-

PreferredQL

APOKYN SUBCUTANEOUS CARTRIDGE

Non-Preferred

SP; LD; QL

benztropine oral tablet Preferred

bromocriptine oral capsule Preferred

bromocriptine oral tablet Preferred

carbidopa oral tabletNon-

Preferred

carbidopa-levodopa oral tablet

Preferred

carbidopa-levodopa oral tablet extended release

Non-Preferred

carbidopa-levodopa oral tablet,disintegrating

Non-Preferred

entacapone oral tabletNon-

PreferredQL

pramipexole oral tabletNon-

PreferredQL

rasagiline oral tabletNon-

Preferred

ropinirole oral tablet Preferred

ropinirole oral tablet extended release 24 hr

Non-Preferred

selegiline hcl oral capsuleNon-

Preferred

selegiline hcl oral tabletNon-

Preferred

tolcapone oral tabletNon-

PreferredQL

trihexyphenidyl oral elixir Preferred

trihexyphenidyl oral tablet Preferred

Effective 7/1/2018

21


ANTIPLATELET DRUGS

anagrelide oral capsuleNon-

Preferred

aspirin-dipyridamole oral capsule, er multiphase 12 hr

Non-Preferred

QL

BRILINTA ORAL TABLET

Non-Preferred

QL

cilostazol oral tabletNon-

Preferred

clopidogrel oral tablet 300 mg

Non-Preferred

clopidogrel oral tablet 75 mg

Non-Preferred

QL

dipyridamole oral tabletNon-

Preferred

prasugrel oral tablet 10 mgNon-

PreferredQL

prasugrel oral tablet 5 mgNon-

PreferredDO

ANTIVIRALS

abacavir oral solutionNon-

Preferred

abacavir oral tabletNon-

Preferred

abacavir-lamivudine oral tablet

Non-Preferred

abacavir-lamivudine-zidovudine oral tablet

Non-Preferred

acyclovir oral capsule Preferred

acyclovir oral suspension 200 mg/5 ml

Preferred

acyclovir oral tablet Preferred

adefovir oral tabletNon-

PreferredSP

APTIVUS ORAL CAPSULE

Non-Preferred

APTIVUS ORAL SOLUTION

Non-Preferred

atazanavir oral capsuleNon-

Preferred

BARACLUDE ORAL SOLUTION

Non-Preferred

SP

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

Non-Preferred


DENAVIR TOPICAL CREAM

Non-Preferred

QL

didanosine oral capsule,delayed release(dr/ec)

Non-Preferred

EDURANT ORAL TABLET

Non-Preferred

efavirenz oral capsuleNon-

Preferred

efavirenz oral tabletNon-

Preferred

EMTRIVA ORAL CAPSULE

Non-Preferred

EMTRIVA ORAL SOLUTION

Non-Preferred

entecavir oral tabletNon-

PreferredSP

EPCLUSA ORAL TABLET

Non-Preferred

PA; SP; QL

EPIVIR HBV ORAL SOLUTION

Non-Preferred

SP

EVOTAZ ORAL TABLETNon-

Preferred

famciclovir oral tablet Preferred

GENVOYA ORAL TABLET

Non-Preferred

HARVONI ORAL TABLET

Non-Preferred

PA; SP; QL

INTELENCE ORAL TABLET

Non-Preferred

INVIRASE ORAL CAPSULE

Non-Preferred

INVIRASE ORAL TABLET

Non-Preferred

ISENTRESS ORAL TABLET

Non-Preferred

ISENTRESS ORAL TABLET,CHEWABLE

Non-Preferred

KALETRA ORAL TABLET

Non-Preferred

lamivudine oral tablet 150 mg, 300 mg

Non-Preferred

lamivudine-zidovudine oral tablet

Non-Preferred

lopinavir-ritonavir oral solution

Non-Preferred

Effective 7/1/2018

22


MAVYRET ORAL TABLET

Non-Preferred

PA; SP; QL

MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 200 MG (28)- 400 MG (28), 400-400 MG (28)-MG (28), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)

Non-Preferred

SP

moderiba dose pack oral tablets,dose pack 200 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7)

Non-Preferred

SP

moderiba oral tabletNon-

PreferredSP

nevirapine oral suspensionNon-

Preferred

nevirapine oral tabletNon-

Preferred

NORVIR ORAL CAPSULE

Non-Preferred

NORVIR ORAL SOLUTION

Non-Preferred

oseltamivir oral capsuleNon-

PreferredQL

oseltamivir oral suspension for reconstitution

Non-Preferred

QL

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

Non-Preferred

SP; QL

PEGASYS SUBCUTANEOUS SOLUTION

Non-Preferred

SP; QL

PEGASYS SUBCUTANEOUS SYRINGE

Non-Preferred

SP; QL

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML

Non-Preferred

SP

PREZISTA ORAL SUSPENSION

Non-Preferred

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

Non-Preferred


RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

Non-Preferred

QL

RESCRIPTOR ORAL TABLET

Non-Preferred

RESCRIPTOR ORAL TABLET, DISPERSIBLE

Non-Preferred

ribasphere oral capsuleNon-

PreferredSP

ribasphere oral tabletNon-

PreferredSP

ribasphere ribapak oral tablets,dose pack

Non-Preferred

SP

ribavirin oral capsuleNon-

PreferredSP

ribavirin oral tablet 200 mgNon-

PreferredSP

rimantadine oral tablet Preferred

ritonavir oral tabletNon-

Preferred

SELZENTRY ORAL TABLET

Non-Preferred

stavudine oral capsuleNon-

Preferred

STRIBILD ORAL TABLET

Non-Preferred

tenofovir disoproxil fumarate oral tablet

Non-Preferred

TIVICAY ORAL TABLETNon-

Preferred

trifluridine ophthalmic (eye) drops

Preferred

TRIUMEQ ORAL TABLET

Non-Preferred

TRUVADA ORAL TABLET

Non-Preferred

valacyclovir oral tablet Preferred

valganciclovir oral recon soln

Non-Preferred

SP

valganciclovir oral tabletNon-

PreferredSP

VEREGEN TOPICAL OINTMENT

Non-Preferred

VIRACEPT ORAL TABLET

Non-Preferred

VIREAD ORAL TABLET150 MG, 200 MG, 250 MG

Non-Preferred

Effective 7/1/2018

23


ZEPATIER ORAL TABLET

Non-Preferred

PA; SP; QL

zidovudine oral capsuleNon-

Preferred

zidovudine oral syrupNon-

Preferred

zidovudine oral tabletNon-

Preferred

ZIRGAN OPHTHALMIC (EYE) GEL

Non-Preferred

AUTONOMIC DRUGS

bethanechol chloride oral tablet

Non-Preferred

cevimeline oral capsuleNon-

Preferred

dextroamphetamine oral capsule, extended release

Preferred PA

dextroamphetamine oral solution

Preferred PA

dextroamphetamine oral tablet

Preferred PA

dextroamphetamine-amphetamine oral capsule,extended release 24hr

Preferred PA

dextroamphetamine-amphetamine oral tablet

Preferred PA

donepezil oral tabletNon-

Preferred

donepezil oral tablet,disintegrating

Non-Preferred

epinephrine 0.3 mg auto-inject

Preferred QL

epinephrine 0.3 mg auto-inject inner, suv

Preferred QL

epinephrine 0.3 mg auto-inject latex-free, sdv

Preferred QL

epinephrine 0.3 mg auto-inject latex-free, suv

Preferred QL

epinephrine 0.3 mg auto-inject no latex, auto-injct

Preferred QL

epinephrine 0.3 mg auto-inject no latex, two-pack

Preferred QL

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml

Preferred QL


EPIPEN 2-PAK INJECTION AUTO-INJECTOR

Non-Preferred

QL

EPIPEN INJECTION AUTO-INJECTOR

Non-Preferred

QL

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR

Non-Preferred

QL

EPIPEN JR INJECTION AUTO-INJECTOR

Non-Preferred

QL

galantamine oral capsule,ext rel. pellets 24 hr

Non-Preferred

galantamine oral solutionNon-

Preferred

galantamine oral tabletNon-

Preferred

guanidine oral tablet Preferred

methamphetamine oral tablet

Non-Preferred

PA

midodrine oral tabletNon-

Preferred

phenoxybenzamine oral capsule

Non-Preferred

pilocarpine hcl oral tabletNon-

Preferred

procentra oral solution Preferred PA

pyridostigmine bromide oral tablet

Non-Preferred

rivastigmine tartrate oral capsule

Non-Preferred

zenzedi oral tablet 10 mg, 5 mg

Preferred PA

BIOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON SOLN

Non-Preferred

$0

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

Effective 7/1/2018

24


AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION

Preferred $0; QL

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Preferred $0; QL

BEXSERO INTRAMUSCULAR SYRINGE

Non-Preferred

$0

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

Non-Preferred

$0

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

FLUBLOK 2017-2018 (PF) INTRAMUSCULAR SOLUTION

Preferred $0; QL

FLUBLOK QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL


FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Preferred $0; QL

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Preferred $0; QL

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION

Preferred $0; QL

FLUZONE HIGH-DOSE 2017-18 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE

Preferred $0; QL

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION

Preferred $0; QL

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION

Preferred $0; QL

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE

Preferred $0; QL

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

Effective 7/1/2018

25


HAVRIX (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

HAVRIX (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

HIBERIX (PF) INTRAMUSCULAR RECON SOLN

Non-Preferred

$0

HYQVIA SUBCUTANEOUS SOLUTION

Non-Preferred

PA; SP

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

Non-Preferred

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

IPOL INJECTION SUSPENSION

Non-Preferred

$0

IXIARO (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

KINRIX (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

KINRIX (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

MENACTRA (PF) INTRAMUSCULAR SOLUTION

Non-Preferred

$0

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT

Non-Preferred

$0

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

Non-Preferred

$0

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

Non-Preferred

$0


PENTACEL (PF) INTRAMUSCULAR KIT

Non-Preferred

$0

PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN

Non-Preferred

$0

PNEUMOVAX 23 INJECTION SOLUTION

Non-Preferred

$0

PNEUMOVAX 23 INJECTION SYRINGE

Non-Preferred

$0

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Non-Preferred

$0

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Non-Preferred

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

Non-Preferred

$0

ROTATEQ VACCINE ORAL SOLUTION

Non-Preferred

$0

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Non-Preferred

$0

SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Non-Preferred

$0

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

TENIVAC (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

Effective 7/1/2018

26


TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

TRUMENBA INTRAMUSCULAR SYRINGE

Non-Preferred

$0

TWINRIX (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

TYPHIM VI INTRAMUSCULAR SOLUTION

Non-Preferred

TYPHIM VI INTRAMUSCULAR SYRINGE

Non-Preferred

VAQTA (PF) INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

VAQTA (PF) INTRAMUSCULAR SYRINGE

Non-Preferred

$0

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Non-Preferred

$0

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Non-Preferred

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Non-Preferred

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Non-Preferred

$0

BLOOD

DROXIA ORAL CAPSULE

Non-Preferred

pentoxifylline oral tablet extended release

Preferred

tranexamic acid oral tablet Preferred


CARDIAC DRUGS

afeditab cr oral tablet extended release 30 mg

Non-Preferred

DO

afeditab cr oral tablet extended release 60 mg

Non-Preferred

QL

amiodarone oral tablet Preferred

amlodipine oral tablet 10 mg

Preferred QL

amlodipine oral tablet 2.5 mg, 5 mg

Preferred DO

cartia xt oral capsule,extended release 24hr 120 mg, 180 mg

Preferred DO

cartia xt oral capsule,extended release 24hr 240 mg, 300 mg

Preferred QL

digox oral tablet Preferred

digoxin oral solution 50 mcg/ml

Preferred

digoxin oral tablet Preferred

diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg

Preferred DO

diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg

Preferred QL

diltiazem hcl oral capsule,extended release 12 hr

Non-Preferred

QL

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg

Preferred DO

diltiazem hcl oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

Preferred QL

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg

Preferred DO

diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg

Preferred QL

diltiazem hcl oral tablet Preferred QL

diltiazem hcl oral tablet extended release 24 hr 180 mg

Preferred DO

Effective 7/1/2018

27


diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

Preferred QL

dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg

Preferred DO

dilt-xr oral capsule,ext.rel 24h degradable 240 mg

Preferred QL

disopyramide phosphate oral capsule

Non-Preferred

dofetilide oral capsuleNon-

Preferred

felodipine oral tablet extended release 24 hr 10 mg

Preferred QL

felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg

Preferred DO

flecainide oral tabletNon-

Preferred

isosorbide dinitrate oral tablet

Preferred

isosorbide dinitrate oral tablet extended release

Preferred

isosorbide mononitrate oral tablet

Preferred

isosorbide mononitrate oral tablet extended release 24 hr

Preferred

isradipine oral capsule Preferred QL

LANOXIN ORAL TABLETNon-

Preferred

matzim la oral tablet extended release 24 hr 180 mg

Preferred DO

matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

Preferred QL

mexiletine oral capsuleNon-

Preferred

MULTAQ ORAL TABLETNon-

Preferred

nicardipine oral capsuleNon-

PreferredQL

nifedipine oral capsuleNon-

PreferredQL


nifedipine oral tablet extended release 24hr 30 mg

Non-Preferred

DO

nifedipine oral tablet extended release 24hr 60 mg, 90 mg

Non-Preferred

QL

nifedipine oral tablet extended release 30 mg

Non-Preferred

DO

nifedipine oral tablet extended release 60 mg, 90 mg

Non-Preferred

QL

nimodipine oral capsuleNon-

PreferredQL

nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg

Preferred DO

nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg

Preferred QL

nitro-bid transdermal ointment

Preferred

nitroglycerin oral capsule, extended release

Non-Preferred

nitroglycerin sublingual tablet

Preferred

nitroglycerin translingual spray,non-aerosol

Non-Preferred

nitro-time oral capsule, extended release

Preferred

pacerone oral tablet 100 mg, 200 mg, 400 mg

Non-Preferred

propafenone oral capsule,extended release 12 hr

Non-Preferred

propafenone oral tabletNon-

Preferred

quinidine sulfate oral tablet Preferred

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

Non-Preferred

taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg

Preferred DO

taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg

Preferred QL

Effective 7/1/2018

28


verapamil oral capsule, 24 hr er pellet ct 100 mg

Preferred DO

verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg

Preferred QL

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg

Preferred DO

verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg

Preferred QL

verapamil oral tablet Preferred QL

verapamil oral tablet extended release

Preferred QL

CARDIOVASCULAR

acebutolol oral capsule Preferred

ADCIRCA ORAL TABLET

Non-Preferred

PA; SP; QL

amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg

Preferred QL

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg

Preferred DO

amlodipine-benazepril oral capsule

Preferred

atenolol oral tablet Preferred

atenolol-chlorthalidone oral tablet

Preferred

atorvastatin oral tablet 10 mg, 20 mg

Preferred DO; $0

atorvastatin oral tablet 40 mg

Preferred DO

atorvastatin oral tablet 80 mg

Preferred QL

benazepril oral tablet Preferred

benazepril-hydrochlorothiazide oral tablet

Preferred

betaxolol oral tablet Preferred

bisoprolol fumarate oral tablet

Preferred

bisoprolol-hydrochlorothiazide oral tablet

Preferred


BYSTOLIC ORAL TABLET

Non-Preferred

candesartan oral tablet Preferred QL

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg

Preferred QL

candesartan-hydrochlorothiazid oral tablet 32-25 mg

Preferred

captopril oral tabletNon-

Preferred

captopril-hydrochlorothiazide oral tablet

Non-Preferred

carvedilol oral tablet Preferred

cholestyramine (with sugar) oral powder

Non-Preferred

QL

cholestyramine (with sugar) oral powder in packet

Non-Preferred

QL

cholestyramine light oral powder

Non-Preferred

QL

cholestyramine light oral powder in packet

Non-Preferred

clonidine hcl oral tablet Preferred

colesevelam oral tabletNon-

Preferred

colestipol oral granules Preferred

colestipol oral packet Preferred

colestipol oral tablet Preferred

doxazosin oral tablet Preferred

EDARBI ORAL TABLET40 MG

Non-Preferred

DO

EDARBI ORAL TABLET80 MG

Non-Preferred

QL

enalapril maleate oral tablet

Preferred

enalapril-hydrochlorothiazide oral tablet

Preferred

eprosartan oral tablet Preferred QL

ergoloid oral tabletNon-

Preferred

ezetimibe oral tabletNon-

PreferredPA; QL

Effective 7/1/2018

29


fenofibrate micronized oral capsule 130 mg, 43 mg

Preferred

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

Preferred QL

fenofibrate nanocrystallized oral tablet

Preferred QL

fenofibrate oral tablet 160 mg, 54 mg

Preferred QL

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

Preferred QL

fenofibric acid oral tablet Preferred QL

fluvastatin oral capsule Preferred DO; $0

fluvastatin oral tablet extended release 24 hr

Preferred $0

fosinopril oral tablet Preferred

fosinopril-hydrochlorothiazide oral tablet

Preferred

gemfibrozil oral tablet Preferred

guanfacine oral tablet Preferred

hydralazine oral tablet Preferred

irbesartan oral tablet 150 mg, 75 mg

Preferred DO

irbesartan oral tablet 300 mg

Preferred QL

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg

Preferred QL

irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg

Preferred

labetalol oral tablet Preferred

LETAIRIS ORAL TABLETNon-


LEVATOL ORAL TABLET

Non-Preferred

lisinopril oral tablet Preferred

lisinopril-hydrochlorothiazide oral tablet

Preferred

LIVALO ORAL TABLET 1 MG, 2 MG

Non-Preferred

ST; DO

LIVALO ORAL TABLET 4 MG

Non-Preferred

ST; QL


losartan oral tablet Preferred QL

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

Preferred QL

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

Preferred DO

lovastatin oral tablet 10 mg, 20 mg

Preferred DO; $0

lovastatin oral tablet 40 mg

Preferred $0; QL

methyldopa oral tablet Preferred

methyldopa-hydrochlorothiazide oral tablet

Preferred

metoprolol succinate oral tablet extended release 24 hr

Preferred

metoprolol ta-hydrochlorothiaz oral tablet

Preferred

metoprolol tartrate oral tablet

Preferred

minoxidil oral tablet Preferred

moexipril oral tablet Preferred

moexipril-hydrochlorothiazide oral tablet

Preferred

nadolol oral tabletNon-

Preferred

nadolol-bendroflumethiazide oral tablet

Preferred

niacin oral tablet extended release 24 hr

Preferred QL

olmesartan oral tablet 20 mg

Non-Preferred

DO

olmesartan oral tablet 40 mg, 5 mg

Non-Preferred

QL

perindopril erbumine oral tablet

Preferred

pindolol oral tabletNon-

Preferred

pravastatin oral tablet 10 mg, 20 mg

Preferred DO; $0

Effective 7/1/2018

30


pravastatin oral tablet 40 mg

Preferred $0

pravastatin oral tablet 80 mg

Preferred $0; QL

prazosin oral capsule Preferred

prevalite oral powderNon-

PreferredQL

prevalite oral powder in packet

Non-Preferred

propranolol oral capsule,extended release 24 hr

Preferred

propranolol oral solution Preferred

propranolol oral tablet Preferred

propranolol-hydrochlorothiazid oral tablet

Preferred

quinapril oral tablet Preferred

quinapril-hydrochlorothiazide oral tablet

Preferred

ramipril oral capsule Preferred

REMODULIN INJECTION SOLUTION

Non-Preferred

PA; SP; LD

rosuvastatin oral tablet 10 mg, 5 mg

Non-Preferred

DO; $0

rosuvastatin oral tablet 20 mg

Non-Preferred

DO

rosuvastatin oral tablet 40 mg

Non-Preferred

QL

sildenafil (antihypertensive) oral tablet

Non-Preferred

PA; SP; QL

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Preferred DO; $0

simvastatin oral tablet 80 mg

Preferred PA; QL

sorine oral tabletNon-

Preferred

sotalol af oral tabletNon-

Preferred

sotalol oral tabletNon-

Preferred

TEKTURNA ORAL TABLET 150 MG

Non-Preferred

DO

TEKTURNA ORAL TABLET 300 MG

Non-Preferred

QL


telmisartan oral tablet 20 mg, 40 mg

Preferred DO

telmisartan oral tablet 80 mg

Preferred QL

terazosin oral capsule Preferred

timolol maleate oral tablet Preferred

TRACLEER ORAL TABLET

Non-Preferred

PA; SP; QL

trandolapril oral tablet Preferred

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg

Preferred DO

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg

Preferred QL

valsartan oral tablet Preferred QL

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg

Preferred DO

valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg

Preferred QL

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

Non-Preferred

PA; SP; LD; QL

WELCHOL ORAL POWDER IN PACKET

Non-Preferred

CNS DRUGS

AUBAGIO ORAL TABLET

Non-Preferred

PA; SP; QL

BANZEL ORAL SUSPENSION

Non-Preferred

BANZEL ORAL TABLETNon-

Preferred

carbamazepine oral capsule, er multiphase 12 hr

Preferred

carbamazepine oral suspension 100 mg/5 ml

Preferred

carbamazepine oral tablet Preferred

carbamazepine oral tablet extended release 12 hr

Preferred

carbamazepine oral tablet,chewable

Preferred

Effective 7/1/2018

31


CELONTIN ORAL CAPSULE 300 MG

Non-Preferred

clonazepam oral tablet Preferred

clonazepam oral tablet,disintegrating

Preferred

divalproex oral capsule, delayed rel sprinkle

Non-Preferred

divalproex oral tablet extended release 24 hr

Non-Preferred

divalproex oral tablet,delayed release (dr/ec)

Non-Preferred

epitol oral tablet Preferred

ethosuximide oral capsule Preferred

ethosuximide oral solution Preferred

EXTAVIA SUBCUTANEOUS KIT

Non-Preferred

PA; SP

EXTAVIA SUBCUTANEOUS RECON SOLN

Non-Preferred

PA; SP

felbamate oral suspensionNon-

Preferred

felbamate oral tabletNon-

Preferred

gabapentin oral capsuleNon-

Preferred

gabapentin oral solutionNon-

Preferred

gabapentin oral tablet 600 mg, 800 mg

Non-Preferred

glatiramer subcutaneous syringe 20 mg/ml

Non-Preferred

PA; SP

glatopa subcutaneous syringe 20 mg/ml

Non-Preferred

PA; SP

HORIZANT ORAL TABLET EXTENDED RELEASE

Non-Preferred

PA; QL

lamotrigine oral tablet Preferred

lamotrigine oral tablet, chewable dispersible

Preferred

levetiracetam oral solutionNon-

Preferred

levetiracetam oral tabletNon-

Preferred

levetiracetam oral tablet extended release 24 hr

Non-Preferred

PA


LYRICA ORAL CAPSULENon-

PreferredPA; QL

LYRICA ORAL SOLUTION

Non-Preferred

PA; QL

memantine oral solutionNon-

Preferred

memantine oral tabletNon-

Preferred

memantine oral tablets,dose pack

Non-Preferred

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

Non-Preferred

oxcarbazepine oral suspension

Non-Preferred

oxcarbazepine oral tabletNon-

Preferred

PEGANONE ORAL TABLET

Non-Preferred

phenytoin sodium extended oral capsule

Preferred

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA; SP

PLEGRIDY SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP

primidone oral tablet Preferred

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA; SP

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP

riluzole oral tabletNon-

PreferredSP

SABRIL ORAL TABLETNon-

PreferredSP; LD

tiagabine oral tabletNon-

Preferred

topiramate oral capsule, sprinkle

Preferred

topiramate oral tablet Preferred

Effective 7/1/2018

32


valproic acid (as sodium salt) oral solution

Preferred

valproic acid oral capsule Preferred

vigabatrin oral powder in packet

Non-Preferred

SP; LD

VIMPAT ORAL SOLUTION

Non-Preferred

VIMPAT ORAL TABLETNon-

Preferred

zonisamide oral capsuleNon-

Preferred

COLONY STIMULATING FACTORS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION

Non-Preferred

PA; SP

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

Non-Preferred

PA; SP

NEULASTA SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP; QL

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

Non-Preferred

PA; SP; QL

NEUPOGEN INJECTION SOLUTION

Non-Preferred

PA; SP

NEUPOGEN INJECTION SYRINGE

Non-Preferred

PA; SP

PROCRIT INJECTION SOLUTION

Non-Preferred

PA; SP

PROMACTA ORAL TABLET

Non-Preferred

PA; SP

CONTRACEPTIVES

AFTERA ORAL TABLET Preferred $0; QL

altavera (28) oral tablet Preferred $0

alyacen 1/35 (28) oral tablet

Preferred $0

alyacen 7/7/7 (28) oral tablet

Preferred $0

amethia lo oral tablets,dose pack,3 month

Preferred $0

amethia oral tablets,dose pack,3 month

Preferred $0

amethyst oral tablet Preferred $0

apri oral tablet Preferred $0


aranelle (28) oral tablet Preferred $0

ashlyna oral tablets,dose pack,3 month

Preferred $0

aubra oral tablet Preferred $0

aviane oral tablet Preferred $0

azurette (28) oral tablet Preferred $0

BALCOLTRA ORAL TABLET

Non-Preferred

$0

balziva (28) oral tablet Preferred $0

BEKYREE (28) ORAL TABLET

Preferred $0

BLISOVI 24 FE ORAL TABLET

Preferred $0

BLISOVI FE 1.5/30 (28) ORAL TABLET

Preferred $0

BLISOVI FE 1/20 (28) ORAL TABLET

Preferred $0

briellyn oral tablet Preferred $0

camila oral tablet Preferred $0

camrese lo oral tablets,dose pack,3 month

Preferred $0

camrese oral tablets,dose pack,3 month

Preferred $0

CAYA CONTOURED VAGINAL DIAPHRAGM

Non-Preferred

$0

caziant (28) oral tablet Preferred $0

chateal oral tablet Preferred $0

cryselle (28) oral tablet Preferred $0

cyclafem 1/35 (28) oral tablet

Preferred $0

cyclafem 7/7/7 (28) oral tablet

Preferred $0

cyred oral tablet Preferred $0

dasetta 1/35 (28) oral tablet

Preferred $0

dasetta 7/7/7 (28) oral tablet

Preferred $0

daysee oral tablets,dose pack,3 month

Preferred $0

deblitane oral tablet Preferred $0

delyla (28) oral tablet Preferred $0

desog-e.estradiol/e.estradiol oral tablet

Preferred $0

Effective 7/1/2018

33


desogestrel-ethinyl estradiol oral tablet

Preferred $0

drospirenone-e.estradiol-lm.fa oral tablet

Preferred $0

drospirenone-ethinyl estradiol oral tablet

Preferred $0

econtra ez oral tablet Preferred $0; QL

elinest oral tablet Preferred $0

ELLA ORAL TABLETNon-

Preferred$0

emoquette oral tablet Preferred $0

enpresse oral tablet Preferred $0

enskyce oral tablet Preferred $0

errin oral tablet Preferred $0

estarylla oral tablet Preferred $0

ethynodiol diac-eth estradiol oral tablet

Preferred $0

falmina (28) oral tablet Preferred $0

FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH

Preferred $0

FEMCAP VAGINAL DEVICE

Non-Preferred

$0

femynor oral tablet Preferred $0

gianvi (28) oral tablet Preferred $0

heather oral tablet Preferred $0

introvale oral tablets,dose pack,3 month

Preferred $0

isibloom oral tablet Preferred $0

jencycla oral tablet Preferred $0

jolessa oral tablets,dose pack,3 month

Preferred $0

jolivette oral tablet Preferred $0

JULEBER ORAL TABLET

Preferred $0

junel 1.5/30 (21) oral tablet Preferred $0

junel 1/20 (21) oral tablet Preferred $0

junel fe 1.5/30 (28) oral tablet

Preferred $0

junel fe 1/20 (28) oral tablet

Preferred $0

junel fe 24 oral tablet Preferred $0

KAITLIB FE ORAL TABLET,CHEWABLE

Preferred $0


kariva (28) oral tablet Preferred $0

kelnor 1/35 (28) oral tablet Preferred $0

kelnor 1-50 oral tablet Preferred $0

kimidess (28) oral tablet Preferred $0

kurvelo oral tablet Preferred $0

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month

Preferred $0

larin 1.5/30 (21) oral tablet Preferred $0

larin 1/20 (21) oral tablet Preferred $0

larin 24 fe oral tablet Preferred $0

larin fe 1.5/30 (28) oral tablet

Preferred $0

larin fe 1/20 (28) oral tablet

Preferred $0

LARISSIA ORAL TABLET

Preferred $0

layolis fe oral tablet,chewable

Preferred $0

leena 28 oral tablet Preferred $0

lessina oral tablet Preferred $0

levonest (28) oral tablet Preferred $0

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg

Preferred $0

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

Preferred $0

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

Preferred $0

levonorg-eth estrad triphasic oral tablet

Preferred $0

levora-28 oral tablet Preferred $0

lillow oral tablet Preferred $0

LO LOESTRIN FE ORAL TABLET

Non-Preferred

$0

loryna (28) oral tablet Preferred $0

low-ogestrel (28) oral tablet

Preferred $0

lutera (28) oral tablet Preferred $0

lyza oral tablet Preferred $0

marlissa oral tablet Preferred $0

medroxyprogesterone intramuscular suspension

Preferred $0

Effective 7/1/2018

34


medroxyprogesterone intramuscular syringe

Preferred $0

MELODETTA 24 FE ORAL TABLET,CHEWABLE

Preferred $0

MIBELAS 24 FE ORAL TABLET,CHEWABLE

Preferred $0

microgestin 1.5/30 (21) oral tablet

Preferred $0

microgestin 1/20 (21) oral tablet

Preferred $0

microgestin fe 1.5/30 (28) oral tablet

Preferred $0

microgestin fe 1/20 (28) oral tablet

Preferred $0

mili oral tablet Preferred $0

mono-linyah oral tablet Preferred $0

mononessa (28) oral tablet Preferred $0

my way oral tablet Preferred $0; QL

myzilra oral tablet Preferred $0

NATAZIA ORAL TABLETNon-

Preferred$0

necon 0.5/35 (28) oral tablet

Preferred $0

necon 7/7/7 (28) oral tablet

Preferred $0

next choice one dose oral tablet

Preferred $0; QL

nikki (28) oral tablet Preferred $0

nora-be oral tablet Preferred $0

noreth-ethinyl estradiol-iron oral tablet,chewable

Preferred $0

norethindrone (contraceptive) oral tablet

Preferred $0

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

Preferred $0

norethindrone-e.estradiol-iron oral tablet

Preferred $0

norethindrone-e.estradiol-iron oral tablet,chewable

Preferred $0

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)

Preferred $0


norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg

Preferred $0

NORLYDA ORAL TABLET

Preferred $0

norlyroc oral tablet Preferred $0

nortrel 0.5/35 (28) oral tablet

Preferred $0

nortrel 1/35 (21) oral tablet Preferred $0

nortrel 1/35 (28) oral tablet Preferred $0

nortrel 7/7/7 (28) oral tablet

Preferred $0

NUVARING VAGINAL RING

Non-Preferred

$0

ocella oral tablet Preferred $0

ogestrel (28) oral tablet Preferred $0

opcicon one-step oral tablet

Preferred $0; QL

option-2 oral tabletNon-

Preferred$0; QL

orsythia oral tablet Preferred $0

philith oral tablet Preferred $0

pimtrea (28) oral tablet Preferred $0

pirmella oral tablet Preferred $0

PLAN B ONE-STEP ORAL TABLET

Preferred $0; QL

portia oral tablet Preferred $0

previfem oral tablet Preferred $0

quasense oral tablets,dose pack,3 month

Preferred $0

RAJANI ORAL TABLET Preferred $0

reclipsen (28) oral tablet Preferred $0

RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH

Preferred $0

setlakin oral tablets,dose pack,3 month

Preferred $0

sharobel oral tablet Preferred $0

sprintec (28) oral tablet Preferred $0

sronyx oral tablet Preferred $0

syeda oral tablet Preferred $0

TAKE ACTION ORAL TABLET

Preferred $0; QL

Effective 7/1/2018

35


tarina fe 1/20 (28) oral tablet

Preferred $0

TAYTULLA ORAL CAPSULE

Non-Preferred

$0

tilia fe oral tablet Preferred $0

TRI FEMYNOR ORAL TABLET

Preferred $0

tri-estarylla oral tablet Preferred $0

tri-legest fe oral tablet Preferred $0

tri-linyah oral tablet Preferred $0

TRI-LO-ESTARYLLA ORAL TABLET

Preferred $0

tri-lo-marzia oral tablet Preferred $0

TRI-LO-SPRINTEC ORAL TABLET

Preferred $0

tri-mili oral tablet Preferred $0

trinessa (28) oral tablet Preferred $0

TRINESSA LO ORAL TABLET

Preferred $0

tri-previfem (28) oral tablet Preferred $0

tri-sprintec (28) oral tablet Preferred $0

trivora (28) oral tablet Preferred $0

tri-vylibra oral tablet Preferred $0

tulana oral tablet Preferred $0

tydemy oral tablet Preferred $0

velivet triphasic regimen (28) oral tablet

Preferred $0

VIENVA ORAL TABLET Preferred $0

viorele (28) oral tablet Preferred $0

vyfemla (28) oral tablet Preferred $0

vylibra oral tablet Preferred $0

wera (28) oral tablet Preferred $0

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM

Non-Preferred

$0


Non-Preferred

$0


Non-Preferred

$0


Non-Preferred

$0



Non-Preferred

$0


Non-Preferred

$0


Non-Preferred

$0


Non-Preferred

$0

wymzya fe oral tablet,chewable

Preferred $0

xulane transdermal patch weekly

Preferred $0

zarah oral tablet Preferred $0

zenchent (28) oral tablet Preferred $0

zovia 1/35e (28) oral tablet Preferred $0

COUGH/COLD PREPARATIONS

benzonatate oral capsule 100 mg, 200 mg

Preferred

cheratussin ac oral liquid Preferred

codeine-guaifen 10-100 mg/5 ml (otc)

Preferred

codeine-guaifen 10-100 mg/5 ml a/f,d/f,s/f (otc)

Preferred

g tussin ac oral liquid Preferred

guaiatussin ac oral liquid Preferred

guaifen-codeine 100-10 mg/5 ml (otc)

Preferred

guaifen-codeine 100-10 mg/5 ml inner (otc)

Preferred

guaifen-codeine 100-10 mg/5 ml outer (otc)

Preferred

guaifen-codeine 200-20 mg/10 ml inner (otc)

Preferred

guaifen-codeine 200-20 mg/10 ml outer (otc)

Preferred

guaifenesin ac oral liquid Preferred

guaifenesin-codeine syrup (otc)

Preferred

guaifenesin-codeine syrup (otc)

Preferred

Effective 7/1/2018

36


hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

Preferred

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

Preferred

promethazine vc-codeine oral syrup

Preferred

promethazine-codeine oral syrup

Preferred

promethazine-dm oral syrup

Preferred

promethazine-phenyleph-codeine oral syrup

Preferred

TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR

Non-Preferred

virtussin ac oral liquid Preferred

VITUZ ORAL SOLUTIONNon-

Preferred

DIAGNOSTIC

ACCU-CHEK AVIVA PLUS TEST STRP STRIP

Non-Preferred

QL

ACCU-CHEK COMPACT PLUS TEST STRIP

Non-Preferred

QL

ACCU-CHEK GUIDE STRIP

Non-Preferred

QL

ACCU-CHEK SMARTVIEW TEST STRIP STRIP

Non-Preferred

QL

ACCUTREND GLUCOSE STRIP

Non-Preferred

QL

GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

Non-Preferred

GLUCAGON HCL INJECTION RECON SOLN

Non-Preferred

ONETOUCH VERIO STRIP

Non-Preferred

QL

DIURETICS

acetazolamide oral capsule, extended release

Preferred

acetazolamide oral tablet Preferred

amiloride oral tabletNon-

Preferred


AMMONIUM CHLORIDE INTRAVENOUS SOLUTION

Non-Preferred

bumetanide oral tablet Preferred

chlorothiazide oral tablet Preferred

chlorthalidone oral tablet 25 mg, 50 mg

Preferred

DYRENIUM ORAL CAPSULE

Non-Preferred

eplerenone oral tabletNon-

Preferred

ethacrynic acid oral tabletNon-

Preferred

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

Preferred

furosemide oral tablet Preferred

hydrochlorothiazide oral capsule

Preferred

hydrochlorothiazide oral tablet

Preferred

indapamide oral tablet Preferred

methazolamide oral tabletNon-

Preferred

methyclothiazide oral tablet

Preferred

metolazone oral tablet Preferred

SAMSCA ORAL TABLETNon-

PreferredSP; LD

spironolactone oral tablet Preferred

spironolacton-hydrochlorothiaz oral tablet

Preferred

torsemide oral tablet Preferred

triamterene-hydrochlorothiazid oral capsule

Preferred

triamterene-hydrochlorothiazid oral tablet

Preferred

EENT PREPS

acetic acid otic (ear) solution

Preferred

ALOCRIL OPHTHALMIC (EYE) DROPS

Non-Preferred

PA; QL

Effective 7/1/2018

37


ALOMIDE OPHTHALMIC (EYE) DROPS

Non-Preferred

PA; QL

apraclonidine ophthalmic (eye) drops

Preferred

azelastine nasal aerosol,spray

Preferred QL

AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION

Non-Preferred

betaxolol ophthalmic (eye) drops

Preferred

bimatoprost ophthalmic (eye) drops

Non-Preferred

brimonidine ophthalmic (eye) drops

Preferred

bromfenac ophthalmic (eye) drops

Non-Preferred

carteolol ophthalmic (eye) drops

Preferred

COMBIGAN OPHTHALMIC (EYE) DROPS

Non-Preferred

cromolyn ophthalmic (eye) drops

Preferred QL

dexamethasone sodium phosphate ophthalmic (eye) drops

Preferred

diclofenac sodium ophthalmic (eye) drops

Preferred

dorzolamide ophthalmic (eye) drops

Preferred

dorzolamide-timolol ophthalmic (eye) drops

Preferred

DUREZOL OPHTHALMIC (EYE) DROPS

Non-Preferred

QL

DYMISTA NASAL SPRAY,NON-AEROSOL

Non-Preferred

QL

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

Preferred ST; QL

fluocinolone acetonide oil otic (ear) drops

Preferred

fluorometholone ophthalmic (eye) drops,suspension

Preferred

flurbiprofen sodium ophthalmic (eye) drops

Preferred


fluticasone nasal spray,suspension

Preferred QL

FML S.O.P. OPHTHALMIC (EYE) OINTMENT

Non-Preferred

hydrocortisone-acetic acid otic (ear) drops

Preferred

ketorolac ophthalmic (eye) drops

Preferred

LACRISERT OPHTHALMIC (EYE) INSERT

Non-Preferred

latanoprost ophthalmic (eye) drops

Preferred

levobunolol ophthalmic (eye) drops 0.5 %

Preferred

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL

Non-Preferred

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION

Non-Preferred

LOTEMAX OPHTHALMIC (EYE) OINTMENT

Non-Preferred

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

Non-Preferred

metipranolol ophthalmic (eye) drops

Preferred

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION

Non-Preferred

olopatadine nasal spray,non-aerosol

Preferred QL

OMNARIS NASAL SPRAY,NON-AEROSOL

Non-Preferred

ST; QL

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS

Non-Preferred

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

Preferred

prednisolone acetate ophthalmic (eye) drops,suspension

Preferred

prednisolone sodium phosphate ophthalmic (eye) drops

Preferred

RESTASIS OPHTHALMIC (EYE) DROPPERETTE

Non-Preferred

Effective 7/1/2018

38


timolol maleate ophthalmic (eye) drops

Preferred

timolol maleate ophthalmic (eye) gel forming solution

Preferred

TRAVATAN Z OPHTHALMIC (EYE) DROPS

Non-Preferred

tropicamide ophthalmic (eye) drops

Preferred

TYZINE NASAL DROPS0.05 %

Non-Preferred

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE

Non-Preferred

ELECT/CALORIC/H2O

calcium acetate oral tablet 667 mg

Non-Preferred

cytra k crystals oral packet Preferred

cytra-k oral solution Preferred

dentagel dental gel Preferred

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

Non-Preferred

effer-k oral tablet, effervescent 25 meq

Preferred

eliphos oral tabletNon-

PreferredPA

fe c plus tablet Preferred

fluoride (sodium) oral drops

Preferred $0

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Preferred $0

fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Preferred

fluoridex daily defense dental paste

Preferred

fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

Preferred $0

fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Preferred


FOSRENOL ORAL POWDER IN PACKET

Non-Preferred

PA

GLUCAGEN HYPOKIT INJECTION RECON SOLN

Non-Preferred

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

Non-Preferred

k-effervescent oral tablet, effervescent

Preferred

kionex (with sorbitol) oral suspension

Non-Preferred

kionex oral powderNon-

Preferred

klor-con 10 oral tablet extended release

Preferred

klor-con 8 oral tablet extended release

Preferred

klor-con m10 oral tablet,er particles/crystals

Preferred


Preferred


Preferred

klor-con/ef oral tablet, effervescent

Preferred

lanthanum oral tablet,chewable

Non-Preferred

PA

ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Preferred $0

ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Preferred

magnesium sulfate in 0.9 %nacl intravenous solution 40 gram/1,000ml (40 mg/ml)

Non-Preferred

NUTRAMINE ORAL POWDER

Non-Preferred

potassium bicarb and chloride oral tablet, effervescent

Preferred

potassium bicarb-citric acid oral tablet, effervescent

Preferred

Effective 7/1/2018

39


potassium chloride oral capsule, extended release

Preferred

potassium chloride oral tablet extended release

Preferred

potassium chloride oral tablet,er particles/crystals

Preferred

potassium citrate oral tablet extended release

Non-Preferred

potassium citrate-citric acid oral solution

Preferred

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

Non-Preferred

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

Non-Preferred

PREVIDENT DENTAL GEL

Non-Preferred

sevelamer carbonate oral powder in packet

Preferred

sevelamer carbonate oral tablet

Preferred

sf dental gel Preferred

SHOHL'S MODIFIED ORAL SOLUTION

Non-Preferred

sodium chloride 0.45 % intravenous parenteral solution

Preferred

sodium chloride 0.45 % intravenous piggyback

Preferred

sodium chloride 0.9 % injection solution

Preferred

sodium chloride 0.9 % intravenous parenteral solution

Preferred

sodium chloride 0.9 % intravenous piggyback

Preferred

sodium chloride 3 % intravenous parenteral solution

Preferred

sodium chloride 5 % intravenous parenteral solution

Preferred

sodium chloride intravenous parenteral solution 2.5 meq/ml

Preferred

sodium polystyrene (sorb free) oral suspension

Non-Preferred


sodium polystyrene sulfonate oral powder

Non-Preferred

sodium polystyrene sulfonate oral suspension

Non-Preferred

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

Preferred

sps (with sorbitol) oral suspension

Non-Preferred

sps (with sorbitol) rectal enema

Preferred

GASTROINTESTINAL

alosetron oral tabletNon-

PreferredQL

AMITIZA ORAL CAPSULE

Non-Preferred

anaspaz oral tablet,disintegrating

Non-Preferred

anucort-hc rectal suppository

Preferred

ANZEMET ORAL TABLET

Non-Preferred

QL

aprepitant oral capsuleNon-

PreferredQL

aprepitant oral capsule,dose pack

Non-Preferred

QL

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

Non-Preferred

QL

balsalazide oral capsule Preferred QL

carafate oral suspension Preferred

CESAMET ORAL CAPSULE

Non-Preferred

cimetidine hcl oral solution Preferred

cimetidine oral tablet Preferred

COMPAZINE ORAL TABLET

Preferred

constulose oral solution Preferred

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

Non-Preferred

PA; QL

dicyclomine oral capsule Preferred

dicyclomine oral solution Preferred

dicyclomine oral tablet Preferred

DIPENTUM ORAL CAPSULE

Non-Preferred

QL

Effective 7/1/2018

40


diphenoxylate-atropine oral liquid

Preferred

diphenoxylate-atropine oral tablet

Preferred

dronabinol oral capsuleNon-

Preferred

enulose oral solution Preferred

famotidine oral suspension Preferred

famotidine oral tablet 20 mg, 40 mg

Preferred

gavilyte-c oral recon soln Preferred $0

gavilyte-g oral recon soln Preferred $0

gavilyte-n oral recon soln Preferred $0

generlac oral solution Preferred

glycopyrrolate oral tablet 1 mg, 2 mg

Preferred

granisetron hcl oral tabletNon-

PreferredQL

hydrocortisone acetate rectal suppository

Preferred

hydrocortisone-pramoxine rectal cream

Preferred

hyoscyamine sulfate oral tablet

Preferred

hyoscyamine sulfate oral tablet extended release 12 hr

Preferred

hyoscyamine sulfate oral tablet,disintegrating

Preferred

hyoscyamine sulfate sublingual tablet

Preferred

lactulose oral solution Preferred

lansoprazole oral capsule,delayed release(dr/ec)

Preferred QL

meclizine oral tablet 12.5 mg, 25 mg

Preferred

methscopolamine oral tablet

Preferred

metoclopramide hcl oral solution

Preferred

metoclopramide hcl oral tablet

Preferred

metoclopramide hcl oral tablet,disintegrating

Preferred

misoprostol oral tablet Preferred


MOTOFEN ORAL TABLET

Non-Preferred

MOVIPREP ORAL POWDER IN PACKET

Non-Preferred

nizatidine oral capsule Preferred

nizatidine oral solution Preferred

omega-3 acid ethyl esters oral capsule

Preferred QL

omeprazole oral capsule,delayed release(dr/ec)

Preferred QL

ondansetron hcl oral solution

Non-Preferred

QL

ondansetron hcl oral tabletNon-

PreferredQL

ondansetron oral tablet,disintegrating

Non-Preferred

QL

OSMOPREP ORAL TABLET

Non-Preferred

pantoprazole oral tablet,delayed release (dr/ec)

Non-Preferred

QL

peg 3350-electrolytes oral recon soln

Preferred $0

peg-3350 with flavor packs oral recon soln

Preferred $0

peg-electrolyte soln oral recon soln

Preferred $0

peg-prep oral kitNon-

Preferred$0

phenadoz rectal suppository

Non-Preferred

phenobarb-hyoscy-atropine-scop oral elixir

Preferred

polyethylene glycol 3350 oral powder

Non-Preferred

$0

polyethylene glycol 3350 oral powder in packet

Preferred $0

pramcort rectal cream Preferred

prochlorperazine maleate oral tablet

Preferred

promethazine rectal suppository

Non-Preferred

promethegan rectal suppository

Non-Preferred

Effective 7/1/2018

41


rabeprazole oral tablet,delayed release (dr/ec)

Non-Preferred

QL

ranitidine hcl oral capsule Preferred

ranitidine hcl oral syrup Preferred

ranitidine hcl oral tablet 150 mg, 300 mg

Preferred

RECTIV RECTAL OINTMENT

Non-Preferred

scopolamine base transdermal patch 3 day

Non-Preferred

sodium phenylbutyrate oral tablet

Non-Preferred

PA; QL

sucralfate oral tablet Preferred

sulfasalazine oral tablet Preferred QL

sulfasalazine oral tablet,delayed release (dr/ec)

Preferred QL

SUPREP BOWEL PREP KIT ORAL RECON SOLN

Non-Preferred

trilyte with flavor packets oral recon soln

Preferred $0

trimethobenzamide oral capsule

Preferred

ursodiol oral capsuleNon-

Preferred

ursodiol oral tabletNon-

Preferred

VIBERZI ORAL TABLETNon-

PreferredPA; QL

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

Non-Preferred

HORMONES

AMABELZ ORAL TABLET

Preferred

ANADROL-50 ORAL TABLET

Non-Preferred


ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP20.25 MG/1.25 GRAM (1.62 %)

Non-Preferred

PA; QL

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

Non-Preferred

PA; QL

budesonide oral capsule,delayed,extend.release

Non-Preferred

QL

cabergoline oral tablet Preferred

calcitonin (salmon) nasal spray,non-aerosol

Non-Preferred

QL

chorionic gonadotropin, human intramuscular recon soln

Non-Preferred

PA; SP

cortisone oral tablet Preferred

covaryx h.s. oral tablet Preferred

covaryx oral tablet Preferred

danazol oral capsuleNon-

Preferred

decadron oral elixir Preferred

DELTASONE ORAL TABLET 20 MG

Preferred

desmopressin nasal spray with pump

Non-Preferred

desmopressin nasal spray,non-aerosol

Non-Preferred

desmopressin oral tablet Preferred

dexamethasone intensol oral drops

Preferred

dexamethasone oral elixir Preferred

dexamethasone oral solution

Preferred

dexamethasone oral tablet Preferred

eemt hs oral tablet Preferred

eemt oral tablet Preferred

estradiol oral tablet Preferred

estradiol transdermal patch semiweekly

Preferred QL

estradiol transdermal patch weekly

Preferred

Effective 7/1/2018

42


estradiol vaginal creamNon-

Preferred

estradiol vaginal tabletNon-

PreferredQL

estradiol-norethindrone acet oral tablet

Preferred

ESTRING VAGINAL RING

Non-Preferred

QL

estrogens-methyltestosterone oral tablet

Preferred

estropipate oral tablet 0.75 mg

Preferred

fludrocortisone oral tablet Preferred

hydrocortisone oral tablet Preferred

hydrocortisone rectal enema

Non-Preferred

jinteli oral tablet Preferred

LOPREEZA ORAL TABLET

Preferred

medroxyprogesterone oral tablet

Preferred QL

MENEST ORAL TABLET0.3 MG, 0.625 MG, 1.25 MG

Non-Preferred

METHITEST ORAL TABLET

Non-Preferred

methylergonovine oral tablet

Preferred

methylprednisolone oral tablet

Preferred

methylprednisolone oral tablets,dose pack

Preferred

millipred dp oral tablets,dose pack

Preferred

millipred oral tablet Preferred

mimvey lo oral tablet Preferred

mimvey oral tablet Preferred

MYALEPT SUBCUTANEOUS RECON SOLN

Non-Preferred

SP; LD

norethindrone acetate oral tablet

Preferred

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA; SP


oxandrolone oral tabletNon-

PreferredPA

prednisolone oral solution 15 mg/5 ml

Preferred

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

Preferred

prednisone intensol oral concentrate

Preferred

prednisone oral solution Preferred

prednisone oral tablet Preferred

prednisone oral tablets,dose pack

Preferred

PREMARIN ORAL TABLET

Non-Preferred

QL

PREMARIN VAGINAL CREAM

Non-Preferred

QL

PREMPHASE ORAL TABLET

Non-Preferred

PREMPRO ORAL TABLET

Non-Preferred

progesterone micronized oral capsule

Preferred QL

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

Non-Preferred

PA; SP; QL

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP; QL

SYNAREL NASAL SPRAY,NON-AEROSOL

Non-Preferred

PA; SP; QL

testosterone cypionate intramuscular oil

Preferred

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

Non-Preferred

PA; QL

testosterone transdermal gel in packet

Non-Preferred

PA; QL

veripred 20 oral solution Preferred

YUVAFEM VAGINAL TABLET

Non-Preferred

QL

Effective 7/1/2018

43


IMMUNOSUPPRESSANTS

ACTEMRA INTRAVENOUS SOLUTION

Non-Preferred

PA; SP; QL

ACTEMRA SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP; QL

azathioprine oral tabletNon-

Preferred

cyclosporine modified oral capsule

Non-Preferred

SP

cyclosporine modified oral solution

Non-Preferred

SP

cyclosporine oral capsuleNon-

PreferredSP

ELIDEL TOPICAL CREAM

Non-Preferred

PA

gengraf oral capsule 100 mg, 25 mg

Non-Preferred

SP

gengraf oral solutionNon-

PreferredSP

mycophenolate mofetil oral capsule

Non-Preferred

SP

mycophenolate mofetil oral tablet

Non-Preferred

SP

mycophenolate sodium oral tablet,delayed release (dr/ec)

Non-Preferred

SP

RAPAMUNE ORAL SOLUTION

Non-Preferred

SP

sirolimus oral tabletNon-

PreferredSP

tacrolimus oral capsuleNon-

PreferredSP

tacrolimus topical ointment Preferred PA

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG

ACCU-CHEK AVIVA CONTROL SOLN SOLUTION

Non-Preferred

ACCU-CHEK AVIVA PLUS METER

Non-Preferred

ACCU-CHEK COMP BLUE CONT, M-H SOLUTION

Non-Preferred


ACCU-CHEK COMPACT PLUS CARE KIT

Non-Preferred

ACCU-CHEK COMPACT PLUS CONTROL SOLUTION

Non-Preferred

ACCU-CHEK FASTCLIX LANCING DEV KIT

Non-Preferred

ACCU-CHEK GUIDE GLUCOSE METER

Non-Preferred

ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION

Non-Preferred

ACCU-CHEK MULTICLIX LANCET

Non-Preferred

ACCU-CHEK MULTICLIX LANCET KIT

Non-Preferred

ACCU-CHEK NANONon-

Preferred

ACCU-CHEK SAFE-T-PRO PLUS

Non-Preferred

ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION

Non-Preferred

ACCU-CHEK SOFT DEV LANCETS KIT

Non-Preferred

ACCU-CHEK SOFTCLIX LANCET DEV

Non-Preferred

ACCU-CHEK SOFTCLIX LANCETS

Non-Preferred

ACCU-CHEK VOICEMATE KIT

Non-Preferred

ACCUTREND GLUCOSE CONTROL SOLUTION

Non-Preferred

acti-lance lancets 17 gauge, 28 gauge

Preferred

CHEMSTRIP BG LOG BOOK

Non-Preferred

e-z ject lancets Preferred

E-Z JECT THIN LANCETS

Preferred

insulin syringe-needle u-100 syringe 1 ml 30 gauge x 3/8"

Preferred

ONETOUCH DELICA LANC DEVICE KIT

Non-Preferred

ONETOUCH DELICA LANCETS

Non-Preferred

Effective 7/1/2018

44


ONETOUCH ULTRA CONTROL SOLUTION

Non-Preferred

ONETOUCH ULTRA2 KITNon-

Preferred

ONETOUCH ULTRAMINI KIT

Non-Preferred

ONETOUCH ULTRASOFT LANCETS

Non-Preferred

ONETOUCH VERIO FLEX

Non-Preferred

ONETOUCH VERIO HIGH CONTROL SOLUTION

Non-Preferred

ONETOUCH VERIO IQ METER

Non-Preferred

ONETOUCH VERIO MID CONTROL SOLUTION

Non-Preferred

ONETOUCH VERIO SYSTEM

Non-Preferred

thinpro insulin syringe syringe 0.3 ml 29 gauge x 1/2", 0.5 ml 29 gauge x 1/2", 1 ml 29 gauge x 1/2"

Preferred

MUSCLE RELAXANTS

baclofen oral tablet 10 mg, 20 mg

Non-Preferred

carisoprodol oral tablet Preferred

chlorzoxazone oral tablet Preferred

cyclobenzaprine oral tablet Preferred

dantrolene oral capsuleNon-

Preferred

metaxalone oral tablet Preferred

methocarbamol oral tablet Preferred

orphenadrine citrate oral tablet extended release

Preferred

tizanidine oral capsule Preferred

tizanidine oral tablet Preferred

PRE-NATAL VITAMINS

bal-care dha oral combo pack,tablet and cap,dr

Preferred

c-nate dha oral capsule Preferred

complete natal dha oral combo pack

Preferred

completenate oral tablet,chewable

Preferred

elite ob with dha oral capsule

Preferred


elite-ob 400 oral capsule Preferred

ELITE-OB ORAL TABLET

Preferred

folivane-ob oral capsule Preferred

hemenatal ob + dha oral combo pack

Preferred

hemenatal ob oral tablet Preferred

mynatal advance oral tablet

Preferred

mynatal oral capsule Preferred

mynatal oral tablet Preferred

mynatal plus oral tablet Preferred

mynatal-z oral tablet Preferred

mynate 90 plus oral tablet extended release

Preferred

obstetrix dha oral combo pack,tablet and cap,dr

Preferred

pnv ob+dha oral combo pack 27-1-50-250 mg

Preferred

pnv-dha + docusate oral capsule

Preferred

pnv-dha oral capsule Preferred

pnv-ferrous fumarate-docu-fa oral tablet

Preferred

pnv-omega oral capsule Preferred

pnv-select oral tablet Preferred

pr natal 400 ec oral combo pack,tablet and cap,dr

Preferred

pr natal 400 oral combo pack

Preferred

pr natal 430 ec oral combo pack,tablet and cap,dr

Preferred

pr natal 430 oral combo pack

Preferred

prenaissance oral capsule Preferred

prenaissance plus oral capsule

Preferred

prenatabs fa oral tablet Preferred

prenatabs rx oral tablet Preferred

prenatal 19 (with docusate) oral tablet

Preferred

prenatal low iron oral tablet

Preferred

prenatal multivitamin tablet Preferred $0

Effective 7/1/2018

45


PRENATAL ONE DAILY ORAL TABLET

Preferred $0

prenatal plus (calcium carb) oral tablet

Preferred

prenatal plus oral tablet Preferred

prenatal vitamin oral tablet 27 mg iron- 0.8 mg

Preferred $0

PRENATAL VITAMIN PLUS LOW IRON

Preferred

prenatal-u oral capsule Preferred

preplus oral tablet Preferred

relnate dha oral capsule Preferred

se-natal 19 (with docusate) oral tablet

Preferred

se-natal 19 oral tablet,chewable

Preferred

taron-c dha oral capsule Preferred

taron-prex prenatal-dha oral capsule

Preferred

tl-select oral capsule Preferred

triadvance oral tablet Preferred

trinatal gt oral tablet Preferred

trinatal rx 1 oral tablet Preferred

trinate oral tablet Preferred

tri-tabs dha oral combo pack

Preferred

triveen-duo dha oral combo pack

Preferred

triveen-one oral capsule Preferred

triveen-prx rnf oral capsule Preferred

trust natal dha oral combo pack

Preferred

ultimatecare one oral capsule

Preferred

vemavite-prx-2 oral capsule

Preferred

vena-bal dha oral combo pack,tablet and cap,dr

Preferred

vinacal oral tablet Preferred

vinate care oral tablet,chewable

Preferred

vinate gt oral tablet Preferred

vinate ii oral tablet Preferred

vinate m oral tablet Preferred


vinate one oral tablet Preferred

vinate pn care oral tablet Preferred

vinate ultra oral tablet Preferred

VIRT-NATE DHA ORAL CAPSULE

Preferred

virt-pn dha oral capsule Preferred

virt-pn oral tablet Preferred

virt-pn plus oral capsule Preferred

virt-select oral capsule Preferred

vitafol-ob oral tablet Preferred

vol-nate oral tablet Preferred

vol-plus oral tablet Preferred

vol-tab rx oral tablet Preferred

vp-ch plus oral capsule Preferred

vp-ch-pnv oral capsule Preferred

vp-ggr-b6 oral tablet Preferred

vp-heme ob oral tablet Preferred

vp-heme one oral capsule Preferred

zatean-ch oral capsule Preferred

zatean-pn dha oral capsule

Preferred

zatean-pn plus oral capsule

Preferred

zingiber oral tablet Preferred

PSYCHOTHERAPEUTIC DRUGS

alprazolam oral tablet Preferred

amitriptyline oral tablet Preferred

amoxapine oral tablet Preferred

aripiprazole oral solutionNon-

Preferred

aripiprazole oral tabletNon-

Preferred

armodafinil oral tablet 150 mg, 250 mg, 50 mg

Non-Preferred

PA; QL

armodafinil oral tablet 200 mg

Non-Preferred

PA

atomoxetine oral capsuleNon-

PreferredPA

bupropion hcl oral tablet 100 mg

Preferred QL

bupropion hcl oral tablet 75 mg

Preferred DO

Effective 7/1/2018

46


bupropion hcl oral tablet extended release 12 hr 100 mg

Preferred DO


Preferred $0


Preferred


Preferred DO


Preferred QL

buspirone oral tablet Preferred

chlorpromazine oral tabletNon-

Preferred

citalopram oral solution Preferred QL

citalopram oral tablet 10 mg, 20 mg

Preferred DO

citalopram oral tablet 40 mg

Preferred QL

clomipramine oral capsuleNon-

Preferred

clonidine hcl oral tablet extended release 12 hr

Preferred PA

clozapine oral tabletNon-

Preferred

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

Non-Preferred

desipramine oral tabletNon-

Preferred

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg

Preferred QL

desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg

Preferred DO

dexmethylphenidate oral capsule,er biphasic 50-50

Preferred PA

dexmethylphenidate oral tablet

Preferred PA

diazepam intensol oral concentrate

Preferred

diazepam oral concentrate Preferred


diazepam oral solution Preferred

diazepam oral tablet Preferred

doxepin oral capsule Preferred

doxepin oral concentrate Preferred

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg

Non-Preferred

PA; QL

duloxetine oral capsule,delayed release(dr/ec) 30 mg

Non-Preferred

PA; DO

EMSAM TRANSDERMAL PATCH 24 HOUR

Non-Preferred

escitalopram oxalate oral solution

Preferred QL

escitalopram oxalate oral tablet 10 mg, 5 mg

Preferred DO

escitalopram oxalate oral tablet 20 mg

Preferred QL

FANAPT ORAL TABLETNon-

Preferred

FANAPT ORAL TABLETS,DOSE PACK

Non-Preferred

fluoxetine oral capsule 10 mg, 20 mg

Preferred DO

fluoxetine oral capsule 40 mg

Preferred QL

fluoxetine oral capsule,delayed release(dr/ec)

Preferred QL

fluoxetine oral solution Preferred QL

fluoxetine oral tablet 10 mg

Preferred DO

fluoxetine oral tablet 20 mg

Preferred

fluphenazine hcl oral concentrate

Preferred

fluphenazine hcl oral elixir Preferred

fluphenazine hcl oral tablet Preferred

fluvoxamine oral tablet 100 mg

Preferred QL

fluvoxamine oral tablet 25 mg, 50 mg

Preferred DO

guanfacine oral tablet extended release 24 hr

Preferred PA

haloperidol oral tablet Preferred

Effective 7/1/2018

47


imipramine hcl oral tablet Preferred

LATUDA ORAL TABLETNon-

Preferred

lithium carbonate oral capsule

Preferred

lithium carbonate oral tablet

Preferred

lithium carbonate oral tablet extended release

Preferred

lithium citrate oral solution Preferred

loxapine succinate oral capsule

Preferred

maprotiline oral tablet Preferred

MARPLAN ORAL TABLET

Non-Preferred

meprobamate oral tablet Preferred

metadate er oral tablet extended release

Preferred PA

methylphenidate hcl oral capsule, er biphasic 30-70

Preferred PA

methylphenidate hcl oral capsule,er biphasic 50-50

Preferred PA

methylphenidate hcl oral solution

Preferred PA

methylphenidate hcl oral tablet

Preferred PA

methylphenidate hcl oral tablet extended release

Preferred PA

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

Preferred PA

mirtazapine oral tablet Preferred

mirtazapine oral tablet,disintegrating

Preferred

modafinil oral tablet 100 mg

Non-Preferred

PA; DO

modafinil oral tablet 200 mg

Non-Preferred

PA; QL

nefazodone oral tablet Preferred

nortriptyline oral capsule Preferred

nortriptyline oral solution Preferred

olanzapine oral tabletNon-

Preferred

olanzapine oral tablet,disintegrating

Non-Preferred


paliperidone oral tablet extended release 24hr

Non-Preferred

paroxetine hcl oral tablet 10 mg, 20 mg

Preferred DO

paroxetine hcl oral tablet 30 mg, 40 mg

Preferred QL

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

Preferred DO

paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

Preferred QL

perphenazine oral tablet Preferred

phenelzine oral tablet Preferred

pimozide oral tabletNon-

Preferred

protriptyline oral tabletNon-

Preferred

quetiapine oral tabletNon-

Preferred

quetiapine oral tablet extended release 24 hr

Non-Preferred

risperidone oral solution Preferred

risperidone oral tablet Preferred

risperidone oral tablet,disintegrating

Non-Preferred

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

Non-Preferred

sertraline oral concentrate Preferred QL

sertraline oral tablet 100 mg

Preferred QL

sertraline oral tablet 25 mg, 50 mg

Preferred DO

thioridazine oral tablet Preferred

thiothixene oral capsule Preferred

tranylcypromine oral tablet Preferred

trazodone oral tablet Preferred

trifluoperazine oral tablet Preferred

trimipramine oral capsule Preferred

venlafaxine oral capsule,extended release 24hr 150 mg

Preferred QL

venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg

Preferred DO

Effective 7/1/2018

48


venlafaxine oral tablet Preferred QL

VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 150 MG, 225 MG

Preferred QL

VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 37.5 MG, 75 MG

Preferred DO

VIIBRYD ORAL TABLET10 MG, 20 MG

Non-Preferred

ST; DO

VIIBRYD ORAL TABLET40 MG

Non-Preferred

ST; QL

VIIBRYD ORAL TABLETS,DOSE PACK10 MG (7)- 20 MG (23)

Non-Preferred

ST; QL

VYVANSE ORAL CAPSULE

Non-Preferred

PA

ziprasidone hcl oral capsule

Non-Preferred

SEDATIVE/HYPNOTICS

estazolam oral tablet Preferred

eszopiclone oral tablet 1 mg, 2 mg

Preferred QL

eszopiclone oral tablet 3 mg

Preferred PA; QL

phenobarbital oral elixir Preferred

phenobarbital oral tablet Preferred

ROZEREM ORAL TABLET

Non-Preferred

ST; QL

SILENOR ORAL TABLETNon-

PreferredQL

XYREM ORAL SOLUTION

Non-Preferred

PA; SP; LD; QL

zaleplon oral capsule Preferred QL

zolpidem oral tablet Preferred QL

SKIN PREPS

acitretin oral capsuleNon-

Preferred

adapalene topical cream Preferred

adapalene topical gel Preferred

adapalene topical gel with pump

Preferred

adapalene-benzoyl peroxide topical gel with pump

Non-Preferred


alclometasone topical cream

Preferred

alclometasone topical ointment

Preferred

ALTABAX TOPICAL OINTMENT

Non-Preferred

amcinonide topical cream Preferred

amcinonide topical lotion Preferred

amcinonide topical ointment

Preferred

ammonium lactate topical cream

Preferred

ammonium lactate topical lotion

Preferred

amnesteem oral capsuleNon-

PreferredPA

avita topical cream Preferred PA

AZELEX TOPICAL CREAM

Non-Preferred

PA

benzoyl peroxide 9.8% foam emollient foam (otc)

Preferred

benzoyl peroxide topical cleanser 3 %, 6 %, 9 %

Preferred

benzoyl peroxide topical foam 5.3 %

Preferred

betamethasone dipropionate topical cream

Preferred

betamethasone dipropionate topical lotion

Preferred

betamethasone dipropionate topical ointment

Preferred

betamethasone valerate topical cream

Preferred

betamethasone valerate topical foam

Preferred

betamethasone valerate topical lotion

Preferred

betamethasone valerate topical ointment

Preferred

betamethasone, augmented topical cream

Preferred

betamethasone, augmented topical gel

Preferred

betamethasone, augmented topical lotion

Preferred

Effective 7/1/2018

49


betamethasone, augmented topical ointment

Preferred

bpo topical gel Preferred

bpo topical towelette 6 % Preferred

calcipotriene scalp solution

Preferred

calcipotriene topical cream Preferred

calcipotriene topical ointment

Preferred

calcipotriene-betamethasone topical ointment

Preferred

calcitrene topical ointmentNon-

Preferred

calcitriol topical ointment Preferred

claravis oral capsuleNon-

PreferredPA

clindamycin-benzoyl peroxide topical gel

Preferred

clindamycin-benzoyl peroxide topical gel with pump

Preferred

clindamycin-tretinoin topical gel

Non-Preferred

clobetasol scalp solution Preferred

clobetasol topical cream Preferred

clobetasol topical foam Preferred

clobetasol topical gel Preferred

clobetasol topical lotion Preferred

clobetasol topical ointment Preferred

clobetasol topical shampoo

Preferred

clobetasol-emollient topical cream

Preferred

clobetasol-emollient topical foam

Preferred

CLODERM TOPICAL CREAM

Non-Preferred

CORDRAN TAPE LARGE ROLL TOPICAL TAPE

Non-Preferred

cormax scalp solution Preferred

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP; QL


COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA; SP; QL

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA; SP; QL

COSENTYX SUBCUTANEOUS SYRINGE

Non-Preferred

PA; SP; QL

dapsone topical gelNon-

Preferred

desonide topical cream Preferred

desonide topical lotion Preferred

desonide topical ointment Preferred

desoximetasone topical cream

Preferred

desoximetasone topical gel

Preferred

desoximetasone topical ointment

Preferred

diclofenac sodium topical gel 1 %

Non-Preferred

QL

diflorasone topical cream Preferred

diflorasone topical ointment

Preferred

EURAX TOPICAL CREAM

Non-Preferred

EURAX TOPICAL LOTION

Non-Preferred

FINACEA TOPICAL GELNon-

Preferred

FLECTOR TRANSDERMAL PATCH 12 HOUR

Non-Preferred

QL

fluocinolone and shower cap scalp oil

Preferred

fluocinolone topical cream Preferred

fluocinolone topical oil Preferred

fluocinolone topical ointment

Preferred

fluocinolone topical solution

Preferred

fluocinonide topical cream Preferred

fluocinonide topical gel Preferred

fluocinonide topical ointment

Preferred

Effective 7/1/2018

50


fluocinonide topical solution

Preferred

fluocinonide-e topical cream

Preferred

fluocinonide-emollient topical cream

Preferred

flurandrenolide topical cream

Non-Preferred

flurandrenolide topical lotion

Non-Preferred

fluticasone topical cream Preferred

fluticasone topical lotion Preferred

fluticasone topical ointment

Preferred

halobetasol propionate topical cream

Preferred

halobetasol propionate topical ointment

Preferred

HALOG TOPICAL CREAM

Non-Preferred

HALOG TOPICAL OINTMENT

Non-Preferred

hydrocortisone butyrate topical cream

Preferred

hydrocortisone butyrate topical lotion

Preferred

hydrocortisone butyrate topical ointment

Preferred

hydrocortisone butyrate topical solution

Preferred

hydrocortisone butyr-emollient topical cream

Preferred

hydrocortisone topical cream 2.5 %

Preferred

hydrocortisone topical cream with perineal applicator

Preferred

hydrocortisone topical lotion 2.5 %

Preferred

hydrocortisone topical ointment 2.5 %

Preferred

hydrocortisone valerate topical cream

Preferred

hydrocortisone valerate topical ointment

Preferred

hydrocortisone-pramoxine topical cream

Preferred


imiquimod topical cream in packet

Preferred PA; QL

iodoquinol-hc topical cream

Preferred

lindane topical shampoo Preferred

malathion topical lotion Preferred

methoxsalen oral capsule,liqd-filled,rapid rel

Non-Preferred

PA; SP

metronidazole topical cream

Preferred

metronidazole topical gel Preferred

metronidazole topical gel with pump

Preferred

metronidazole topical lotion

Preferred

mometasone topical cream

Preferred

mometasone topical ointment

Preferred

mometasone topical solution

Preferred

permethrin topical cream Preferred

PHYSIOLYTE IRRIGATION SOLUTION

Non-Preferred

podofilox topical solution Preferred

prednicarbate topical cream

Preferred

prednicarbate topical ointment

Preferred

proctosol hc topical cream with perineal applicator

Preferred

proctozone-hc topical cream with perineal applicator

Preferred

prudoxin topical creamNon-

Preferred

REGRANEX TOPICAL GEL

Non-Preferred

rosadan topical cream Preferred

ROSADAN TOPICAL GEL

Preferred

salicylic acid topical cream Preferred

salicylic acid topical cream,extended release

Preferred

salicylic acid topical foam Preferred

salicylic acid topical gel Preferred

Effective 7/1/2018

51


salicylic acid topical lotion Preferred

salicylic acid topical lotion,extended release

Preferred

salicylic acid topical shampoo

Preferred

salvax topical foam Preferred

SANTYL TOPICAL OINTMENT

Non-Preferred

seb-prev topical cleanser Preferred

selenium sulfide topical lotion

Preferred

selenium sulfide topical shampoo 2.25 %

Preferred

sodium chloride irrigation solution

Preferred

spinosad topical suspension

Preferred

sulfacetamide sodium (acne) topical suspension

Preferred

sulfacetamide sodium topical cleanser

Preferred

sulfacetamide sodium topical cleanser, gel

Preferred

sulfacetamide sodium topical shampoo

Preferred

tazarotene topical creamNon-

Preferred

TAZORAC TOPICAL CREAM 0.05 %

Non-Preferred

TAZORAC TOPICAL GELNon-

Preferred

tretinoin (emollient) topical cream

Preferred PA

tretinoin topical cream Preferred PA

tretinoin topical gel 0.01 %, 0.025 %

Preferred PA

triamcinolone acetonide topical cream

Preferred

triamcinolone acetonide topical lotion

Preferred

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

Preferred

trianex topical ointment Preferred

triderm topical cream 0.1 %

Preferred


TRIDERM TOPICAL CREAM 0.5 %

Preferred

ULESFIA TOPICAL LOTION

Non-Preferred

zenatane oral capsuleNon-

PreferredPA

SMOKING DETERRENTS

bupropion hcl (smoking deter) oral tablet extended release 12 hr

Preferred $0; QL

CHANTIX CONTINUING MONTH BOX ORAL TABLET

Non-Preferred

$0; QL

CHANTIX ORAL TABLETNon-

Preferred$0; QL

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

Non-Preferred

$0; QL

NICOTROL INHALATION CARTRIDGE

Non-Preferred

$0

NICOTROL NS NASAL SPRAY,NON-AEROSOL

Non-Preferred

$0

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR

Non-Preferred

$0; QL

THYROID PREPS

ARMOUR THYROID ORAL TABLET

Preferred

levothyroxine oral tablet Preferred

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Preferred

liothyronine oral tablet Preferred

methimazole oral tablet 10 mg, 5 mg

Preferred

nature-throid oral tablet Preferred

NP THYROID ORAL TABLET 120 MG, 15 MG

Preferred

np thyroid oral tablet 30 mg, 60 mg, 90 mg

Preferred

propylthiouracil oral tablet Preferred

SYNTHROID ORAL TABLET

Preferred

THYROLAR-1 ORAL TABLET

Non-Preferred

Effective 7/1/2018

52


THYROLAR-1/2 ORAL TABLET

Non-Preferred

THYROLAR-1/4 ORAL TABLET

Non-Preferred


Non-Preferred


Non-Preferred

unithroid oral tablet Preferred

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

Preferred

WP THYROID ORAL TABLET

Preferred

UNCLASSIFIED DRUG PRODUCTS

acamprosate oral tablet,delayed release (dr/ec)

Non-Preferred

QL

alendronate oral solution Preferred

alendronate oral tablet Preferred QL

alfuzosin oral tablet extended release 24 hr

Preferred

BERINERT INTRAVENOUS KIT

Non-Preferred

PA; LD

BERINERT INTRAVENOUS RECON SOLN

Non-Preferred

PA; LD

buprenorphine hcl sublingual tablet

Non-Preferred

QL

buprenorphine-naloxone sublingual tablet

Preferred QL

CARBAGLU ORAL TABLET, DISPERSIBLE

Non-Preferred

LD

CHEMET ORAL CAPSULE

Non-Preferred

chlorhexidine gluconate mucous membrane mouthwash

Preferred

CIALIS ORAL TABLET2.5 MG, 5 MG

Non-Preferred

PA; QL

CYSTADANE ORAL POWDER

Non-Preferred

LD

darifenacin oral tablet extended release 24 hr

Non-Preferred

ST

disulfiram oral tablet Preferred


doxercalciferol oral capsule

Non-Preferred

doxycycline hyclate oral tablet 20 mg

Preferred

dutasteride oral capsuleNon-

Preferred

etidronate disodium oral tablet

Non-Preferred

FERRIPROX ORAL TABLET

Non-Preferred

PA; LD

finasteride oral tablet 5 mg Preferred

flavoxate oral tablet Preferred

FORTEO SUBCUTANEOUS PEN INJECTOR

Non-Preferred

PA; SP; QL

FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT

Non-Preferred

ST; QL

FOSAMAX PLUS D ORAL TABLET 70 MG- 5,600 UNIT

Non-Preferred

ST

ibandronate oral tablet Preferred QL

KUVAN ORAL TABLET,SOLUBLE

Non-Preferred

PA; SP; LD

leucovorin calcium oral tablet

Non-Preferred

levocarnitine (with sugar) oral solution

Preferred

levocarnitine oral tabletNon-

Preferred

miglustat oral capsuleNon-

PreferredPA; SP

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

Non-Preferred

oralone dental paste Preferred

oxybutynin chloride oral syrup

Preferred

oxybutynin chloride oral tablet

Preferred

oxybutynin chloride oral tablet extended release 24hr

Preferred

paricalcitol oral capsuleNon-

Preferred

paroex oral rinse mucous membrane mouthwash

Preferred

Effective 7/1/2018

53


periogard mucous membrane mouthwash

Preferred

raloxifene oral tablet Preferred $0

RAPAFLO ORAL CAPSULE

Non-Preferred

risedronate oral tablet Preferred QL

SAVELLA ORAL TABLET

Non-Preferred

QL

SAVELLA ORAL TABLETS,DOSE PACK

Non-Preferred

QL

SENSIPAR ORAL TABLET 30 MG, 60 MG

Non-Preferred

QL

SENSIPAR ORAL TABLET 90 MG

Non-Preferred

SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION

Non-Preferred

$0

tamsulosin oral capsule Preferred

tolterodine oral tablet Preferred

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR

Non-Preferred

triamcinolone acetonide dental paste

Preferred

trientine oral capsuleNon-

PreferredSP

trospium oral capsule,extended release 24hr

Non-Preferred

VESICARE ORAL TABLET

Non-Preferred

VITAMINS

calcitriol oral capsule Preferred

calcitriol oral solutionNon-

Preferred

cyanocobalamin (vitamin b-12) injection solution

Preferred

ergocalciferol (vitamin d2) oral capsule

Preferred

folic acid oral tablet 1 mg Preferred

multi-vitamin with fluoride oral drops

Non-Preferred

$0

multivitamin with fluoride oral tablet,chewable

Non-Preferred

$0


multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Non-Preferred

$0

multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Non-Preferred

$0

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Non-Preferred

$0

tl gard rx oral tablet Preferred

triple vitamin with fluoride oral drops

Non-Preferred

$0

tri-vitamin with fluoride oral drops

Non-Preferred

$0

vitamin d2 oral capsule Preferred

vitamins a,c,d and fluoride oral drops

Non-Preferred

$0

Effective 7/1/2018

54

Most plans include our home delivery program at no extra cost to you. Find out more by going online to anthem.com or call 866-217-2657.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 03/18

For information about your pharmacy benefit, log in at anthem.com. You’ll find the most up-to-date drug list and details about your benefits. If you still have questions, we’re here. Just call the Member Services number on your ID card.

Speech and hearing impaired (TDD/TTY) users Call 1-800-221-6915, Monday through Friday, 8:30 a.m. to 5 p.m.ET.

Date post:	19-Jul-2018
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