Standard Formulary

Introduction Utilization Management

The EnvisionRx Pharmacy and Therapeutics Committee is
responsible for the development and maintenance of the
Standard Formulary. The Committee is comprised of
independent practicing physicians and pharmacists from a
wide variety of medical specialties. The formulary is
reviewed and updated from time to time as new drugs or
new prescribing information becomes available. Factors
which affect decisions regarding the formulary include safe
use, clinical efficacy, and therapeutic need. Only after those
factors are assessed is cost considered. Compliance with
the formulary is important for improving quality of care and
restraining health care costs.
How to Use the Standard Formulary
The EnvisionRx Standard Formulary is a reference tool for
identifying preferred medications within certain therapeutic
categories. Preferred brand medications are listed to help
identify products that are clinically appropriate and cost
effective. Generics are considered first line and are available
for generic copayment. Only the most commonly prescribed
generics are listed on the formulary for reference purposes.
The formulary is not all inclusive and does not guarantee
coverage of any medication.
Generics are listed in lowercase letters
Brands are listed in UPPERCASE letters
Non-Preferred products are listed with an [NP] symbol
Specialty products are listed with an [SP] symbol
The EnvisionRx Standard Formulary features a set of
Utilization Management protocols for certain drug
categories. Within these drug categories, there are clinically
interchangeable alternatives available with significant
deviations in economic value. In order to maintain the
highest quality of care, EnvisionRx has selected the most
clinically and economically valuable agents in each class to
be included on the formulary. Please see the Utilization
Management section to reference the preferred agents
within each drug category. Certain agents within these
categories may be considered formulary exclusions, or may
require the use of primary treatment options prior to
secondary treatment options.
Prior Authorizations and Quantity Limits may be in place for
certain medications and will vary by plan.
New-to-Market Drugs
Any medication approved to enter the market will not be
covered under the Standard Formulary until a clinical review
and tier placement decision has been made by the
EnvisionRx Pharmacy and Therapeutics Committee. The
committee will review safety, efficacy and cost information
in order to determine coverage on a quarterly basis at
minimum. Please be aware that any new-to-market drug
which has not yet been reviewed by the EnvisionRx
Pharmacy and Therapeutics committee will be considered a
formulary exclusion.

Products subject to clinical review are listed with

Therapeutic Listing

ADHD / ANTI-NARCOLEPSY / Methylphenidate HCl *Soluble Tumor Necrosis HYSINGLA ER

ANTI-OBESITY / Modafinil Factor Receptor Agents** NUCYNTA
ANOREXIANTS ENBREL
NUVIGIL NUCYNTA ER
*Amphetamines** ANALGESICS - ANTI- ANALGESICS - NonNarcotic OPANA ER
Amphetamine- INFLAMMATORY *Analgesic Combinations** OXYCONTIN
Dextroamphetamine *Anti-TNF-alpha - Monoclonal Butalbital-Acetaminophen- ZOHYDRO ER
Dextroamphetamine Sulfate Antibodies** Caffeine *Opioid Combinations**
VYVANSE HUMIRA Butalbital-Aspirin-Caffeine Acetaminophen w/ Codeine
*Anorexiants Non- *Nonsteroidal Anti- *Analgesics Other** Hydrocodone-Acetaminophen
Amphetamine** inflammatory Agents
Acetaminophen Oxycodone w/ Acetaminophen
(NSAIDs)**
Phentermine HCl *Salicylates**
Ibuprofen *Opioid Partial Agonists**
*Anti-Obesity Agents** Aspirin
Meloxicam Buprenorphine HCl
BELVIQ ANALGESICS - OPIOID
Naproxen Buprenorphine HCl-Naloxone
BELVIQ XR *Opioid Agonists** HCl Dihydrate
*Pyrimidine Synthesis
CONTRAVE Inhibitors** Morphine Sulfate BUTRANS
*Stimulants - Misc.** Oxycodone HCl SUBOXONE
Leflunomide
Dexmethylphenidate HCl Tramadol HCl ANDROGENS-ANABOLIC

[NP] = Non-Preferred [SP] = Specialty October 2016

*Androgens** Levalbuterol HCl *Tricyclic Agents** ANTIDIARRHEALS
Testosterone Cypionate ADVAIR DISKUS/HFA Amitriptyline HCl *Antiperistaltic Agents**
ANDROGEL 1.62% BREO ELLIPTA Doxepin HCl Diphenoxylate w/ Atropine
ANORECTAL AGENTS COMBIVENT RESPIMAT Nortriptyline HCl Loperamide HCl
*Rectal Combinations** FORADIL ANTIDIABETICS ANTIDOTES
Hydrocortisone Acetate w/ PROAIR *Antidiabetic Combinations** *Opioid Antagonists**
Pramoxine SEREVENT DISKUS Glyburide-Metformin Naltrexone HCl
PROCTOFOAM HC 1% SYMBICORT Pioglitazone HCl-Metformin HCl ANTIEMETICS
*Rectal Steroids** VENTOLIN INVOKAMET *5-HT3 Receptor Antagonists**
Hydrocortisone (Rectal) ANTICOAGULANTS JANUMET Ondansetron
Hydrocortisone Acetate (Rectal) *Coumarin Anticoagulants** JANUMET XR Ondansetron HCl
ANTIANGINAL AGENTS Warfarin Sodium KAZANO ANZEMET
*Antianginals-Other** *Direct Factor Xa Inhibitors** KOMBIGLYZE *Antiemetics -
RANEXA Anticholinergic**
ELIQUIS OSENI
*Nitrates** Meclizine HCl
SAVAYSA PRANDIMET
ANTIFUNGALS
Isosorbide Mononitrate XARELTO *Biguanides**
*Antifungals**
Nitroglycerin *Heparins And Heparinoid-Like Metformin HCl
ANTIANXIETY AGENTS Agents** Terbinafine HCl
*Diabetic Other**
*Imidazole-Related
*Benzodiazepines** Enoxaparin Sodium GLUCAGEN Antifungals**
Alprazolam *Thrombin Inhibitors** GLUCAGON Fluconazole
Diazepam PRADAXA *Dipeptidyl Peptidase-4 (DPP- Ketoconazole
Lorazepam ANTICONVULSANTS 4) Inhibitors** ANTIHISTAMINES
ANTIARRHYTHMICS *Anticonvulsants - JANUVIA *Antihistamines -
*Antiarrhythmics Type I-C** Benzodiazepines** NESINA Ethanolamines**
Flecainide Acetate Clonazepam ONGLYZA Diphenhydramine HCl
Propafenone HCl *Anticonvulsants - Misc.** *Incretin Mimetic Agents (GLP- *Antihistamines - Non-
*Antiarrhythmics Type III** Gabapentin 1 Receptor Agonists)** Sedating**
Lamotrigine BYDUREON Cetirizine HCl
Amiodarone HCl
Topiramate BYETTA Levocetirizine Dihydrochloride
MULTAQ
LYRICA Loratadine
TIKOSYN VICTOZA
*Valproic Acid** *Insulin Sensitizing Agents** *Antihistamines -
ANTIASTHMATIC AND
Phenothiazines**
BRONCHODILATOR AGENTS Divalproex Sodium Pioglitazone HCl
Promethazine HCl
*Bronchodilators - ANTIDEPRESSANTS *Insulin**
Anticholinergics** *Antihistamines - Piperidines**
*Alpha-2 Receptor Antagonists LANTUS
Ipratropium Bromide (Tetracyclics)** Cyproheptadine HCl
LEVEMIR
ANORO Mirtazapine ANTIHYPERLIPIDEMICS
NOVOLIN
INCRUSE *Antidepressants - Misc.** *Antihyperlipidemics - Misc.**
NOVOLIN MIX
SPIRIVA Bupropion HCl Omega-3-acid Ethyl Esters
NOVOLIN N
STIOLTO VASCEPA
*Selective Serotonin Reuptake NOVOLIN R
*Leukotriene Modulators** Inhibitors (SSRIs)** *Bile Acid Sequestrants**
NOVOLOG
Montelukast Sodium Citalopram Hydrobromide Cholestyramine
NOVOLOG MIX
Escitalopram Oxalate Colestipol HCl
*Selective Phosphodiesterase TOUJEO
4 (PDE4) Inhibitors** Sertraline HCl WELCHOL
TRESIBA
*Serotonin Modulators** *Fibric Acid Derivatives**
DALIRESP *Meglitinide Analogues**
*Steroid Inhalants** Trazodone HCl Choline Fenofibrate
Repaglinide
Budesonide (Inhalation) BRINTELLIX Fenofibrate
*Sodium-Glucose Co-
ARNUITY ELLIPTA VIIBRYD Transporter 2 (SGLT2) Gemfibrozil
ASMANEX Inhibitors** LIPOFEN
*Serotonin-Norepinephrine
FLOVENT Reuptake Inhibitors (SNRIs)** FARXIGA *HMG CoA Reductase
Inhibitors**
PULMICORT FLEXHALER Duloxetine HCl INVOKANA
*Sulfonylureas** Atorvastatin Calcium
QVAR Venlafaxine HCl
Pravastatin Sodium
*Sympathomimetics** FETZIMA Glimepiride
Simvastatin
Albuterol Sulfate KHEDEZLA ER Glipizide
CRESTOR
Ipratropium-Albuterol PRISTIQ Glyburide

[NP] = Non-Preferred [SP] = Specialty October 2016

LIVALO ANTIPARKINSON AGENTS COREG CR YAZ
*Intestinal Cholesterol *Antiparkinson *Beta Blockers Cardio- *Combination Contraceptives -
Absorption Inhibitors** Anticholinergics** Selective** Transdermal**
ZETIA Benztropine Mesylate Atenolol Norelgestromin-Ethinyl Estradiol
*Proprotein Convertase *Antiparkinson BYSTOLIC *Combination Contraceptives -
Subtilisin/Kevin Type 9 Dopaminergics** Vaginal**
*Beta Blockers Cardio-
Inhibitors** Carbidopa-Levodopa Selective** NUVARING
PRALUENT Pramipexole Dihydrochloride *Progestin Contraceptives -
Metoprolol Succinate
Ropinirole Hydrochloride Injectable**
REPATHA Metoprolol Tartrate
*Antiparkinson Monoamine *Beta Blockers Non- Medroxyprogesterone Acetate
ANTIHYPERTENSIVES
Oxidase Inhibitors** Selective** (Contraceptive)
*ACE Inhibitors**
AZILECT Nadolol *Progestin Contraceptives -
Enalapril Maleate
ANTIPSYCHOTICS/ANTIMANIC Propranolol HCl Oral**
Lisinopril AGENTS Sotalol HCl Norethindrone (Contraceptive)
Ramipril *Antimanic Agents** CALCIUM CHANNEL CORTICOSTEROIDS
*Angiotensin II Receptor Lithium Carbonate BLOCKERS
Antagonists** *Glucocorticosteroids**
*Calcium Channel Blockers**
*Antipsychotics - Misc.** Dexamethasone
Irbesartan Amlodipine Besylate
Ziprasidone HCl Methylprednisolone
Losartan Potassium Diltiazem HCl Coated Beads
*Benzisoxazoles** Prednisone
Telmisartan Nifedipine
Risperidone UCERIS
BENICAR CARDIOTONICS
*Butyrophenones** *Mineralocorticoids**
*Antiadrenergic *Cardiac Glycosides**
Haloperidol Fludrocortisone Acetate
Antihypertensives**
Haloperidol Lactate Digoxin
Clonidine HCl COUGH/COLD/ALLERGY
*Dibenzapines** CARDIOVASCULAR AGENTS -
Doxazosin Mesylate *Antitussives**
MISC.
Olanzapine Benzonatate
Terazosin HCl *Cardiovascular Agents Misc. -
Quetiapine Fumarate Hydrocodone w/ Homatropine
*Antihypertensive Combinations**
Combinations** SEROQUEL XR *Cough/Cold/Allergy
Amlodipine Besylate-Atorvastatin
AMTURNIDE *Phenothiazines** Calcium Combinations**
AZOR Prochlorperazine Hydrocodone Polistirex-
ENTRESTO
Prochlorperazine Maleate Chlorpheniramine Polistirex
BENICAR HCT *Impotence Agents**
*Quinolinone Derivatives** Promethazine w/Codeine
TEKAMLO LEVITRA
ABILIFY MAINTENA Promethazine-DM
TEKTURNA HCT VIAGRA
ANTIVIRALS *Expectorants**
TRIBENZOR *Pulmonary Hypertension -
*CMV Agents** Guaifenesin
*Direct Renin Inhibitors** Endothelin Receptor
Ganciclovir Antagonists** DERMATOLOGICALS
Lisinopril & Hydrochlorothiazide
*Hepatitis Agents** OPSUMIT *Acne Products**
Losartan Potassium &
Hydrochlorothiazide HARVONI LETAIRIS Clindamycin Phosphate (Topical)
Valsartan-Hydrochlorothiazide PEG-INTRON TRACLEER Clindamycin Phosphate-Benzoyl
PEGASYS Peroxide
TEKTURNA *Pulmonary Hypertension - Sol
Ribavirin Guanylate Cyclase Tretinoin
*Vasodilators**
Stimulator** ACANYA
Hydralazine HCl SOVALDI
ADEMPAS ATRALIN
ANTI-INFECTIVE AGENTS - *Herpes Agents**
*Sinus Node Inhibitors** AZELEX
MISC. Acyclovir
Famciclovir CORLANOR ONEXTON
*Anti-Infective Agents - Misc.**
Valacyclovir HCl CONTRACEPTIVES RETIN-A MICR GEL 0.08%
XIFAXAN *Combination Contraceptives - ZIANA
ZOVIRAX CRE 5%
ANTINEOPLASTICS AND Oral** *Agents for
*Immunosuppressive Agents**
ADJUNCTIVE THERAPIES Norethin Acet & Estrad-Fe Wrinkles/Lipoatrophy/Other
Azathioprine
*Antineoplastic - Hormonal Norgestimate-Ethinyl Estradiol Aesthetic Uses**
and Related Agents* Mycophenolate Mofetil
Norgestimate-Ethinyl Estradiol RENOVA
Tacrolimus
XTANDI (Triphasic) *Antibiotics - Topical**
BETA BLOCKERS
ZYTIGA BEYAZ Mupirocin
*Alpha-Beta Blockers**
*Antineoplastic Enzyme NATAZIA Mupirocin Calcium (Topical)
Inhibitors** Carvedilol
SAFYRAL *Antifungals - Topical**
TASIGNA Labetalol HCl
YASMIN Clotrimazole w/ Betamethasone

[NP] = Non-Preferred [SP] = Specialty October 2016

Ketoconazole (Topical) Spironolactone APRISO SILENOR
Nystatin (Topical) *Thiazides and Thiazide-Like LIALDA *Non-Barbiturate Hypnotics**
JUBLIA Diuretics** *Intestinal Acidifiers** Eszopiclone
LUZU Chlorthalidone Lactulose (Encephalopathy) Temazepam
MENTAX Hydrochlorothiazide *Irritable Bowel Syndrome Zolpidem Tartrate
*Anti-inflammatory Agents - Metolazone (IBS) Agents** LAXATIVES
Topical** ENDOCRINE AND METABOLIC LINZESS *Laxative Combinations**
FLECTOR AGENTS - MISC. *Phosphate Binder Agents** SUPREP
*Antineoplastic or *Bone Density Regulators** FOSRENOL *Laxatives - Miscellaneous**
Premalignant Lesion Agents - Alendronate Sodium RENAGEL Lactulose
Topical**
Ibandronate Sodium RENVELA Polyethylene Glycol 3350
Fluorouracil (Topical)
*Fertility Regulators** *Peripheral Opioid Receptor KRISTALOSE
PICATO
FOLLISTIM AQ Antagonists** *Stimulant Laxatives**
*Burn Products**
*Growth Hormones** MOVANTIK Bisacodyl
Silver Sulfadiazine
*Emollient/Keratolytic GENOTROPIN GENITOURINARY AGENTS - Sennosides
Agents** NORDITROPIN MISCELLANEOUS
*Surfactant Laxatives**
Urea *Hormone Receptor *Alkalinizers**
Docusate Sodium
*Emollients** Modulators** Potassium Citrate (Alkalinizer)
MACROLIDES
Lactic Acid (Ammonium Lactate) Raloxifene HCl *Prostatic Hypertrophy
Agents** *Azithromycin**
*Immunomodulating Agents - *Posterior Pituitary
Hormones** Alfuzosin HCl Azithromycin
Topical**
Desmopressin Acetate Finasteride *Clarithromycin**
Imiquimod
*Prolactin Inhibitors** Tamsulosin HCl Clarithromycin
ZYCLARA
Cabergoline JALYN *Erythromycins**
*Immunosuppressive Agents -
ESTROGENS RAPAFLO Erythromycin Base
Topical**
*Estrogen Combinations** *Urinary Analgesics** MEDICAL DEVICES
ELIDEL
Esterified Estrogens & Phenazopyridine HCl *Diabetic Supplies**
*Local Anesthetics - Topical**
Methyltestosterone GOUT AGENTS FREESTYLE
Lidocaine-Prilocaine
Estradiol & Norethindrone *Gout Agents** PRECISION
*Misc. Topical** Acetate
Allopurinol ONETOUCH
Aluminum Chloride CLIMARA PRO
COLCRYS *Parenteral Therapy Supplies**
DIAGNOSTIC PRODUCTS COMBIPATCH
ULORIC NOVOFINE
*Diagnostic Tests** PREMPHASE
HEMATOLOGICAL AGENTS - NOVOTWIST
FREESTYLE PREMPRO
MISC. ULTICARE LANCETS
PRECISION *Estrogens**
*Platelet Aggregation ULTICARE PEN NEEDLES
ONETOUCH Estradiol Inhibitors** ULTICARE SYRINGES
DIGESTIVE AIDS MENEST Cilostazol
MIGRAINE PRODUCTS
*Digestive Enzymes** MENOSTAR Clopidogrel Bisulfate
*Migraine Combinations**
CREON PREMARIN BRILINTA
Acetaminophen-Isometheptene-
SUCRAID FLUOROQUINOLONES HEMATOPOIETIC AGENTS Dichloralphenazone
ZENPEP *Fluoroquinolones** *Folic Acid/Folates** TREXIMET
DIURETICS Ciprofloxacin HCl Folic Acid *Serotonin Agonists**
*Carbonic Anhydrase Levofloxacin *Hematopoietic Growth
Inhibitors** Rizatriptan Benzoate
Moxifloxacin HCl Factors**
Acetazolamide Sumatriptan Succinate
GASTROINTESTINAL AGENTS EPOGEN
*Diuretic Combinations** Zolmitriptan
- MISC. NEULASTA
Spironolactone & RELPAX
*Gallstone Solubilizing NEUPOGEN
Hydrochlorothiazide Agents** MOUTH/THROAT/DENTAL
PROCRIT AGENTS
Triamterene & Ursodiol
Hydrochlorothiazide HEMOSTATICS *Anesthetics Topical Oral**
*Gastrointestinal Chloride
*Loop Diuretics** *Hemostatics - Systemic** Lidocaine HCl (Mouth-Throat)
Channel Activators**
Bumetanide Tranexamic Acid *Anti-infectives - Throat**
AMITIZA
Furosemide HYPNOTICS Clotrimazole
*Gastrointestinal Stimulants**
Torsemide *Barbiturate Hypnotics** Nystatin (Mouth-Throat)
Metoclopramide HCl
*Potassium Sparing Phenobarbital *Antiseptics - Mouth/Throat**
*Inflammatory Bowel Agents**
Diuretics** *Hypnotics - Tricyclic Agents**
Sulfasalazine

[NP] = Non-Preferred [SP] = Specialty October 2016

Chlorhexidine Gluconate (Mouth- MOXEZA Donepezil Hydrochloride Nitrofurantoin Macrocrystal
Throat) VIGAMOX NAMENDA XR Nitrofurantoin Monohyd Macro
*Dental Products** *Ophthalmic *Fibromyalgia Agents** URINARY ANTISPASMODICS
Sodium Fluoride (Dental) Immunomodulators** SAVELLA *Urinary Antispasmodic -
*Steroids - Mouth/Throat** RESTASIS *Multiple Sclerosis Agents** Antimuscarinics
Triamcinolone Acetonide *Ophthalmic Steroids** (Anticholinergic)**
AVONEX
(Mouth) Oxybutynin Chloride
ALREX COPAXONE
MULTIVITAMINS
DUREZOL GILENYA Tolterodine Tartrate
*Ped MV w/ Fluoride**
LOTEMAX PLEGRIDY VESICARE
Pediatric Multivitamins w/Fl
*Ophthalmics - Misc.** TECFIDERA *Urinary Antispasmodics -
*Prenatal Vitamins** Beta-3 Adrenergic Agonists**
Azelastine HCl (Ophth) *Smoking Deterrents**
Prenatal Vit w/ Ferrous
Dorzolamide HCl Nicotine MYRBETRIQ
Fumarate-Folic Acid
Ketorolac Tromethamine (Ophth) CHANTIX VAGINAL PRODUCTS
PRENATE DHA
ACUVAIL TETRACYCLINES *Vaginal Anti-infectives**
PRENATE ELITE
ALOMIDE *Tetracyclines** Metronidazole Vaginal
PRENATE ESSENTIAL
AZOPT Doxycycline (Monohydrate) Terconazole Vaginal
MUSCULOSKELETAL
THERAPY AGENTS NEVANAC Doxycycline Hyclate AVC
*Central Muscle Relaxants** PATADAY Minocycline HCl *Vaginal Estrogens**
Carisoprodol PAZEO SOLODYN ESTRING
Cyclobenzaprine HCl PROLENSA THYROID AGENTS PREMARIN
*Prostaglandins - *Antithyroid Agents** PREMARIN VAGINAL CREAM
Tizanidine HCl
Ophthalmic** VAGIFEM
NASAL AGENTS - SYSTEMIC Methimazole
Latanoprost
AND TOPICAL *Thyroid Hormones** VASOPRESSORS
Travoprost *Anaphylaxis Therapy
*Nasal Agent Cominations** Levothyroxine Sodium
LUMIGAN Agents**
DYMISTA Levoxyl
TRAVATAN Z AUVI-Q
*Nasal Antiallergy** Liothyronine Sodium
OTIC AGENTS EPIPEN
Azelastine HCl SYNTHROID
*Otic Anti-infectives** EPIPEN-JR
*Nasal Anticholinergics** ULCER DRUGS
Ofloxacin (Otic) *Vasopressors**
Ipratropium Bromide (Nasal) *Antispasmodics**
*Otic Combinations** Midodrine HCl
*Nasal Steroids** Dicyclomine HCl
Antipyrine-Benzocaine ADHD / ANTI-NARCOLEPSY /
Fluticasone Propionate (Nasal) Glycopyrrolate ANTI-OBESITY /
Neomycin-Polymyxin-HC (Otic)
Triamcinolone Acetonide (Nasal) Hyoscyamine Sulfate ANOREXIANTS
CIPRO HC
NASONEX CANTIL *Amphetamines**
CIPRODEX
QNASL *H-2 Antagonists** Amphetamine-
PENICILLINS
VERAMYST Cimetidine Dextroamphetamine
*Aminopenicillins**
OPHTHALMIC AGENTS Famotidine Dextroamphetamine Sulfate
Amoxicillin
*Beta-blockers - Ophthalmic** Ranitidine HCl VYVANSE
Ampicillin
Dorzolamide HCl-Timolol *Misc. Anti-Ulcer** *Anorexiants Non-
Maleate *Natural Penicillins**
Sucralfate Amphetamine**
Timolol Maleate (Ophth) Penicillin V Potassium
CARAFATE SUS 1GM/10ML Phentermine HCl
BETIMOL *Penicillin Combinations**
*Proton Pump Inhibitors** *Anti-Obesity Agents**
BETOPTIC-S Amoxicillin & Pot Clavulanate
Lansoprazole BELVIQ
COMBIGAN *Penicillinase-Resistant
Penicillins** Omeprazole CONTRAVE
*Cycloplegic Mydriatics**
Pantoprazole Sodium *Stimulants - Misc.**
Atropine Sulfate (Ophthalmic) Dicloxacillin Sodium
DEXILANT Dexmethylphenidate HCl
*Ophthalmic Adrenergic PROGESTINS
NEXIUM GRANULES Methylphenidate HCl
Agents** *Progestins**
*Ulcer Drugs - Modafinil
Brimonidine Tartrate Medroxyprogesterone Acetate Prostaglandins** NUVIGIL
ALPHAGAN P SOL 0.1% Norethindrone Acetate Misoprostol
Progesterone Micronized ANALGESICS - ANTI-
*Ophthalmic Anti-infectives** *Ulcer Therapy
INFLAMMATORY
Erythromycin (Ophth) PSYCHOTHERAPEUTIC AND Combinations**
Omeprazole-Sodium *Anti-TNF-alpha - Monoclonal
Polymyxin B-Trimethoprim NEUROLOGICAL AGENTS -
Bicarbonate Antibodies**
MISC.
Tobramycin (Ophth) URINARY ANTI-INFECTIVES HUMIRA [SP]
BESIVANCE *Antidementia Agents**
*Urinary Anti-infectives**

[NP] = Non-Preferred [SP] = Specialty October 2016

*Nonsteroidal Anti- *Antianginals-Other** *Direct Factor Xa Inhibitors** KAZANO [NP]
inflammatory Agents
RANEXA ELIQUIS KOMBIGLYZE
(NSAIDs)**
Ibuprofen *Nitrates** SAVAYSA [NP] OSENI [NP]
Isosorbide Mononitrate XARELTO PRANDIMET
Meloxicam
XIGDUO XR
Naproxen Nitroglycerin *Heparins And Heparinoid-Like
Agents** *Biguanides**
ANTIANXIETY AGENTS
*Pyrimidine Synthesis Metformin HCl
Inhibitors** *Benzodiazepines** Enoxaparin Sodium
*Diabetic Other**
Leflunomide Alprazolam *Thrombin Inhibitors**
GLUCAGEN
Diazepam PRADAXA
*Soluble Tumor Necrosis GLUCAGON
Factor Receptor Agents** Lorazepam ANTICONVULSANTS
*Dipeptidyl Peptidase-4 (DPP-
ENBREL [SP] ANTIARRHYTHMICS *Anticonvulsants -
4) Inhibitors**
*Antiarrhythmics Type I-C** Benzodiazepines**
ANALGESICS - NonNarcotic
JANUVIA
*Analgesic Combinations** Flecainide Acetate Clonazepam
NESINA [NP]
Propafenone HCl *Anticonvulsants - Misc.**
Butalbital-Acetaminophen- ONGLYZA
Caffeine *Antiarrhythmics Type III** Gabapentin
Lamotrigine *Incretin Mimetic Agents (GLP-
Butalbital-Aspirin-Caffeine Amiodarone HCl 1 Receptor Agonists)**
*Analgesics Other** MULTAQ Topiramate
BYDUREON
Acetaminophen TIKOSYN LYRICA
BYETTA
*Salicylates** ANTIASTHMATIC AND *Valproic Acid**
VICTOZA
Aspirin BRONCHODILATOR AGENTS Divalproex Sodium
*Insulin Sensitizing Agents**
ANALGESICS - OPIOID *Bronchodilators - ANTIDEPRESSANTS
Pioglitazone HCl
*Opioid Agonists** Anticholinergics** *Alpha-2 Receptor Antagonists
(Tetracyclics)** *Insulin**
Morphine Sulfate Ipratropium Bromide
Mirtazapine LANTUS
Oxycodone HCl ANORO
*Antidepressants - Misc.** LEVEMIR
Tramadol HCl INCRUSE
Bupropion HCl NOVOLIN
HYSINGLA ER SPIRIVA
NOVOLIN MIX
NUCYNTA STIOLTO *Selective Serotonin Reuptake
Inhibitors (SSRIs)** NOVOLIN N
NUCYNTA ER *Leukotriene Modulators**
Citalopram Hydrobromide NOVOLIN R
OPANA ER Montelukast Sodium
Escitalopram Oxalate NOVOLOG
OXYCONTIN *Selective Phosphodiesterase
4 (PDE4) Inhibitors** Sertraline HCl NOVOLOG MIX
ZOHYDRO ER [NP]
*Serotonin Modulators** TOUJEO
*Opioid Combinations** DALIRESP
Trazodone HCl *Meglitinide Analogues**
Acetaminophen w/ Codeine *Steroid Inhalants**
BRINTELLIX Repaglinide
Hydrocodone-Acetaminophen Budesonide (Inhalation)
TRINTELLIX *Sodium-Glucose Co-
Oxycodone w/ Acetaminophen ARNUITY ELLIPTA
VIIBRYD Transporter 2 (SGLT2)
*Opioid Partial Agonists** ASMANEX Inhibitors**
*Serotonin-Norepinephrine
Buprenorphine HCl FLOVENT Reuptake Inhibitors (SNRIs)** FARXIGA
Buprenorphine HCl-Naloxone PULMICORT FLEXHALER INVOKANA
Duloxetine HCl
HCl Dihydrate QVAR *Sulfonylureas**
Venlafaxine HCl
BUTRANS *Sympathomimetics** Glimepiride
FETZIMA
SUBOXONE Albuterol Sulfate Glipizide
KHEDEZLA ER
ANDROGENS-ANABOLIC Ipratropium-Albuterol Glyburide
PRISTIQ
*Androgens** Levalbuterol HCl ANTIDIARRHEALS
*Tricyclic Agents**
Testosterone Cypionate ADVAIR DISKUS/HFA *Antiperistaltic Agents**
Amitriptyline HCl
ANDROGEL 1.62% BREO ELLIPTA Diphenoxylate w/ Atropine
Doxepin HCl
ANORECTAL AGENTS COMBIVENT RESPIMAT Loperamide HCl
Nortriptyline HCl
*Rectal Combinations** FORADIL ANTIDOTES
ANTIDIABETICS
Hydrocortisone Acetate w/ PROAIR *Opioid Antagonists**
*Antidiabetic Combinations**
Pramoxine SEREVENT DISKUS
Glyburide-Metformin Naltrexone HCl
PROCTOFOAM HC 1% SYMBICORT
Pioglitazone HCl-Metformin HCl ANTIEMETICS
*Rectal Steroids** VENTOLIN
INVOKAMET *5-HT3 Receptor Antagonists**
Hydrocortisone (Rectal) ANTICOAGULANTS
JANUMET Ondansetron
Hydrocortisone Acetate (Rectal) *Coumarin Anticoagulants**
JANUMET XR Ondansetron HCl
ANTIANGINAL AGENTS Warfarin Sodium

[NP] = Non-Preferred [SP] = Specialty October 2016

ANZEMET [SP] Lisinopril ANTIPSYCHOTICS/ANTIMANIC Nadolol
*Antiemetics - Ramipril AGENTS Propranolol HCl
Anticholinergic** *Antimanic Agents**
*Angiotensin II Receptor Sotalol HCl
Meclizine HCl Antagonists** Lithium Carbonate CALCIUM CHANNEL
ANTIFUNGALS BLOCKERS
Irbesartan *Antipsychotics - Misc.**
*Antifungals** *Calcium Channel Blockers**
Losartan Potassium Ziprasidone HCl
Terbinafine HCl *Benzisoxazoles** Amlodipine Besylate
Telmisartan
*Imidazole-Related Diltiazem HCl Coated Beads
Antifungals** BENICAR Risperidone
*Butyrophenones** Nifedipine
Fluconazole *Antiadrenergic
Antihypertensives** CARDIOTONICS
Ketoconazole Haloperidol
Clonidine HCl *Cardiac Glycosides**
ANTIHISTAMINES Haloperidol Lactate
Doxazosin Mesylate *Dibenzapines** Digoxin
*Antihistamines -
Ethanolamines** Terazosin HCl Olanzapine CARDIOVASCULAR AGENTS -
MISC.
Diphenhydramine HCl *Antihypertensive Quetiapine Fumarate
*Antihistamines - Non- Combinations** *Cardiovascular Agents Misc. -
SEROQUEL XR
Sedating** Combinations**
AMTURNIDE *Phenothiazines**
Cetirizine HCl AZOR Amlodipine Besylate-Atorvastatin
Prochlorperazine Calcium
Levocetirizine Dihydrochloride BENICAR HCT Prochlorperazine Maleate
Loratadine *Impotence Agents**
TEKAMLO *Quinolinone Derivatives**
*Antihistamines - LEVITRA
TEKTURNA HCT ABILIFY MAINTENA
Phenothiazines** VIAGRA
TRIBENZOR ANTIVIRALS
Promethazine HCl *Direct Renin Inhibitors** *Pulmonary Hypertension -
*CMV Agents** Endothelin Receptor
*Antihistamines - Piperidines** Lisinopril & Hydrochlorothiazide Ganciclovir Antagonists**
Cyproheptadine HCl Losartan Potassium & *Hepatitis Agents** OPSUMIT [SP]
ANTIHYPERLIPIDEMICS Hydrochlorothiazide
DAKLINZA [SP] LETAIRIS [SP]
*Antihyperlipidemics - Misc.** Valsartan-Hydrochlorothiazide
HARVONI [SP] TRACLEER [SP]
Omega-3-acid Ethyl Esters TEKTURNA
PEG-INTRON [SP] *Pulmonary Hypertension - Sol
VASCEPA *Vasodilators** Guanylate Cyclase
PEGASYS [SP]
*Bile Acid Sequestrants** Hydralazine HCl Stimulator**
Ribavirin [SP]
Cholestyramine ANTI-INFECTIVE AGENTS - ADEMPAS [SP]
SOVALDI [SP]
Colestipol HCl MISC. CONTRACEPTIVES
*Herpes Agents**
WELCHOL *Anti-Infective Agents - Misc.** *Combination Contraceptives -
Acyclovir
*Fibric Acid Derivatives** Oral**
XIFAXAN Famciclovir
Choline Fenofibrate Norethin Acet & Estrad-Fe
ANTINEOPLASTICS AND Valacyclovir HCl
Fenofibrate Norgestimate-Ethinyl Estradiol
ADJUNCTIVE THERAPIES ZOVIRAX CRE 5%
Gemfibrozil Norgestimate-Ethinyl Estradiol
*Antineoplastic - Hormonal *Immunosuppressive Agents**
LIPOFEN (Triphasic)
and Related Agents* Azathioprine
*HMG CoA Reductase BEYAZ
XTANDI [SP] Mycophenolate Mofetil [SP]
Inhibitors** NATAZIA
ZYTIGA [SP] Tacrolimus
Atorvastatin Calcium SAFYRAL
*Antineoplastic Enzyme BETA BLOCKERS
Pravastatin Sodium YASMIN
Inhibitors**
Rosuvastatin Calcium *Alpha-Beta Blockers**
TASIGNA [SP] YAZ
Simvastatin Carvedilol
ANTIPARKINSON AGENTS *Combination Contraceptives -
LIVALO Labetalol HCl Transdermal**
*Intestinal Cholesterol *Antiparkinson COREG CR
Anticholinergics** Norelgestromin-Ethinyl Estradiol
Absorption Inhibitors**
*Beta Blockers Cardio- *Combination Contraceptives -
ZETIA Benztropine Mesylate Selective** Vaginal**
*Antiparkinson
*Proprotein Convertase Dopaminergics** Atenolol NUVARING
Subtilisin/Kevin Type 9 BYSTOLIC
Inhibitors** Carbidopa-Levodopa *Progestin Contraceptives -
Pramipexole Dihydrochloride *Beta Blockers Cardio- Injectable**
PRALUENT [SP] Selective**
Ropinirole Hydrochloride Medroxyprogesterone Acetate
REPATHA [SP] Metoprolol Succinate (Contraceptive)
*Antiparkinson Monoamine
ANTIHYPERTENSIVES Oxidase Inhibitors** Metoprolol Tartrate *Progestin Contraceptives -
*ACE Inhibitors** *Beta Blockers Non- Oral**
AZILECT
Enalapril Maleate Selective** Norethindrone (Contraceptive)

[NP] = Non-Preferred [SP] = Specialty October 2016

 CORTICOSTEROIDS Silver Sulfadiazine GENOTROPIN [SP] GENITOURINARY AGENTS -
*Glucocorticosteroids** *Emollient/Keratolytic NORDITROPIN [SP] MISCELLANEOUS
Agents** *Alkalinizers**
Dexamethasone *Hormone Receptor
Urea Modulators**
Methylprednisolone Potassium Citrate (Alkalinizer)
*Emollients** *Prostatic Hypertrophy
Prednisone Raloxifene HCl
Lactic Acid (Ammonium Lactate) *Posterior Pituitary Agents**
UCERIS [NP]
*Immunomodulating Agents - Hormones** Alfuzosin HCl
*Mineralocorticoids**
Topical** Desmopressin Acetate [SP] Finasteride
Fludrocortisone Acetate
Imiquimod *Prolactin Inhibitors** Tamsulosin HCl
COUGH/COLD/ALLERGY
ZYCLARA [NP] Cabergoline JALYN
*Antitussives**
*Immunosuppressive Agents - ESTROGENS RAPAFLO
Benzonatate Topical** *Estrogen Combinations** *Urinary Analgesics**
Hydrocodone w/ Homatropine ELIDEL Esterified Estrogens & Phenazopyridine HCl
*Cough/Cold/Allergy *Local Anesthetics - Topical** Methyltestosterone GOUT AGENTS
Combinations**
Lidocaine-Prilocaine Estradiol & Norethindrone *Gout Agents**
Hydrocodone Polistirex- Acetate
*Misc. Topical** Allopurinol
Chlorpheniramine Polistirex CLIMARA PRO
Aluminum Chloride COLCRYS
Promethazine w/Codeine COMBIPATCH
DIAGNOSTIC PRODUCTS ULORIC
Promethazine-DM PREMPHASE
*Diagnostic Tests** HEMATOLOGICAL AGENTS -
*Expectorants** PREMPRO
FREESTYLE MISC.
Guaifenesin *Estrogens**
PRECISION *Platelet Aggregation
DERMATOLOGICALS Estradiol Inhibitors**
ONETOUCH
*Acne Products** MENEST Cilostazol
DIGESTIVE AIDS
Clindamycin Phosphate (Topical) MENOSTAR Clopidogrel Bisulfate
*Digestive Enzymes**
Clindamycin Phosphate-Benzoyl PREMARIN BRILINTA
Peroxide CREON
FLUOROQUINOLONES HEMATOPOIETIC AGENTS
SUCRAID
Tretinoin *Fluoroquinolones** *Folic Acid/Folates**
ZENPEP
ACANYA Ciprofloxacin HCl Folic Acid
DIURETICS
ATRALIN Levofloxacin *Hematopoietic Growth
*Carbonic Anhydrase
AZELEX Inhibitors** Moxifloxacin HCl Factors**
ONEXTON Acetazolamide GASTROINTESTINAL AGENTS EPOGEN [SP]
RETIN-A MICR GEL 0.08% *Diuretic Combinations** - MISC. NEULASTA [SP]
ZIANA Spironolactone & *Gallstone Solubilizing NEUPOGEN [SP]
Hydrochlorothiazide Agents**
*Agents for PROCRIT
Wrinkles/Lipoatrophy/Other Ursodiol
Triamterene & HEMOSTATICS
Aesthetic Uses** Hydrochlorothiazide *Gastrointestinal Chloride
*Hemostatics - Systemic**
Channel Activators**
RENOVA [NP] *Loop Diuretics** Tranexamic Acid
*Antibiotics - Topical** AMITIZA
Bumetanide HYPNOTICS
*Gastrointestinal Stimulants**
Mupirocin Furosemide *Barbiturate Hypnotics**
Mupirocin Calcium (Topical) Metoclopramide HCl
Torsemide Phenobarbital
*Antifungals - Topical** *Inflammatory Bowel Agents**
*Potassium Sparing *Hypnotics - Tricyclic Agents**
Clotrimazole w/ Betamethasone Diuretics** Sulfasalazine
SILENOR [NP]
Ketoconazole (Topical) Spironolactone APRISO
*Non-Barbiturate Hypnotics**
Nystatin (Topical) *Thiazides and Thiazide-Like LIALDA
Diuretics** Eszopiclone
*Intestinal Acidifiers**
JUBLIA [NP] Temazepam
Chlorthalidone Lactulose (Encephalopathy)
LUZU [NP] Zolpidem Tartrate
Hydrochlorothiazide *Irritable Bowel Syndrome
MENTAX LAXATIVES
Metolazone (IBS) Agents**
*Anti-inflammatory Agents - *Laxative Combinations**
Topical** ENDOCRINE AND METABOLIC LINZESS
AGENTS - MISC. *Phosphate Binder Agents** SUPREP
FLECTOR
*Bone Density Regulators** FOSRENOL *Laxatives - Miscellaneous**
*Antineoplastic or
Premalignant Lesion Agents - Alendronate Sodium RENAGEL Lactulose
Topical** Ibandronate Sodium RENVELA Polyethylene Glycol 3350
Fluorouracil (Topical) *Fertility Regulators** KRISTALOSE
*Peripheral Opioid Receptor
PICATO [NP] FOLLISTIM AQ [SP] Antagonists** *Stimulant Laxatives**
*Burn Products** *Growth Hormones** MOVANTIK Bisacodyl

[NP] = Non-Preferred [SP] = Specialty October 2016

Sennosides PRENATE ESSENTIAL ALOMIDE TETRACYCLINES
*Surfactant Laxatives** MUSCULOSKELETAL AZOPT *Tetracyclines**
Docusate Sodium THERAPY AGENTS NEVANAC Doxycycline (Monohydrate)
MACROLIDES *Central Muscle Relaxants** PATADAY Doxycycline Hyclate
*Azithromycin** Carisoprodol PAZEO Minocycline HCl
Azithromycin Cyclobenzaprine HCl PROLENSA SOLODYN [NP]
*Clarithromycin** Tizanidine HCl *Prostaglandins - THYROID AGENTS
NASAL AGENTS - SYSTEMIC Ophthalmic**
Clarithromycin *Antithyroid Agents**
AND TOPICAL Latanoprost
*Erythromycins** Methimazole
*Nasal Agent Cominations** Travoprost
Erythromycin Base *Thyroid Hormones**
DYMISTA [NP] LUMIGAN
MEDICAL DEVICES Levothyroxine Sodium
*Nasal Antiallergy** TRAVATAN Z
*Diabetic Supplies** Levoxyl
Azelastine HCl OTIC AGENTS
FREESTYLE Liothyronine Sodium
*Nasal Anticholinergics** *Otic Anti-infectives**
PRECISION SYNTHROID
Ipratropium Bromide (Nasal) Ofloxacin (Otic)
ONETOUCH ULCER DRUGS
*Nasal Steroids** *Otic Combinations**
*Parenteral Therapy Supplies** *Antispasmodics**
Fluticasone Propionate (Nasal) Antipyrine-Benzocaine
NOVOFINE Dicyclomine HCl
Triamcinolone Acetonide (Nasal) Neomycin-Polymyxin-HC (Otic)
NOVOTWIST Glycopyrrolate
NASONEX CIPRO HC
ULTICARE LANCETS Hyoscyamine Sulfate
QNASL CIPRODEX
ULTICARE PEN NEEDLES CANTIL
VERAMYST PENICILLINS
ULTICARE SYRINGES *H-2 Antagonists**
OPHTHALMIC AGENTS *Aminopenicillins**
MIGRAINE PRODUCTS Cimetidine
*Beta-blockers - Ophthalmic** Amoxicillin
*Migraine Combinations** Famotidine
Dorzolamide HCl-Timolol Ampicillin
Acetaminophen-Isometheptene- Ranitidine HCl
Maleate *Natural Penicillins**
Dichloralphenazone *Misc. Anti-Ulcer**
Timolol Maleate (Ophth) Penicillin V Potassium
TREXIMET [NP] Sucralfate
BETIMOL *Penicillin Combinations**
*Serotonin Agonists** CARAFATE SUS 1GM/10ML
BETOPTIC-S Amoxicillin & Pot Clavulanate
Rizatriptan Benzoate *Proton Pump Inhibitors**
COMBIGAN *Penicillinase-Resistant
Sumatriptan Succinate Lansoprazole
*Cycloplegic Mydriatics** Penicillins**
Zolmitriptan Omeprazole
Atropine Sulfate (Ophthalmic) Dicloxacillin Sodium
RELPAX Pantoprazole Sodium
*Ophthalmic Adrenergic PROGESTINS
MOUTH/THROAT/DENTAL Agents** DEXILANT
AGENTS *Progestins**
Brimonidine Tartrate *Ulcer Drugs -
Medroxyprogesterone Acetate Prostaglandins**
*Anesthetics Topical Oral**
ALPHAGAN P SOL 0.1% Norethindrone Acetate
Lidocaine HCl (Mouth-Throat) Misoprostol
*Ophthalmic Anti-infectives** Progesterone Micronized *Ulcer Therapy
*Anti-infectives - Throat**
Erythromycin (Ophth) Combinations**
Clotrimazole PSYCHOTHERAPEUTIC AND
Polymyxin B-Trimethoprim Omeprazole-Sodium
NEUROLOGICAL AGENTS -
Nystatin (Mouth-Throat) Bicarbonate
Tobramycin (Ophth) MISC.
*Antiseptics - Mouth/Throat** URINARY ANTI-INFECTIVES
BESIVANCE *Antidementia Agents**
Chlorhexidine Gluconate (Mouth- *Urinary Anti-infectives**
MOXEZA Donepezil Hydrochloride
Throat) Nitrofurantoin Macrocrystal
VIGAMOX NAMENDA XR
*Dental Products** Nitrofurantoin Monohyd Macro
*Ophthalmic NAMZARIC
Sodium Fluoride (Dental) URINARY ANTISPASMODICS
Immunomodulators** *Fibromyalgia Agents**
*Steroids - Mouth/Throat** *Urinary Antispasmodic -
RESTASIS SAVELLA
Triamcinolone Acetonide Antimuscarinics
(Mouth) *Ophthalmic Steroids** *Multiple Sclerosis Agents** (Anticholinergic)**
MULTIVITAMINS ALREX AVONEX [SP] Oxybutynin Chloride
*Ped MV w/ Fluoride** DUREZOL COPAXONE [SP] Tolterodine Tartrate
Pediatric Multivitamins w/Fl LOTEMAX GILENYA [SP] VESICARE
*Prenatal Vitamins** *Ophthalmics - Misc.** PLEGRIDY [SP] *Urinary Antispasmodics -
Prenatal Vit w/ Ferrous Azelastine HCl (Ophth) TECFIDERA [SP] Beta-3 Adrenergic Agonists**
Fumarate-Folic Acid Dorzolamide HCl *Smoking Deterrents** MYRBETRIQ
PRENATE DHA Ketorolac Tromethamine (Ophth) Nicotine VAGINAL PRODUCTS
PRENATE ELITE ACUVAIL CHANTIX *Vaginal Anti-infectives**

[NP] = Non-Preferred [SP] = Specialty October 2016

Metronidazole Vaginal PREMARIN *Anaphylaxis Therapy *Vasopressors**
Agents**
Terconazole Vaginal PREMARIN VAGINAL CREAM Midodrine HCl
AUVI-Q
AVC VAGIFEM
EPIPEN
*Vaginal Estrogens** VASOPRESSORS
EPIPEN-JR
ESTRING

[NP] = Non-Preferred [SP] = Specialty October 2016

Standard Formulary
Alphabetical Listing

A ATRALIN Cabergoline Desmopressin Acetate [SP]

ABILIFY MAINTENA Atropine Sulfate (Ophthalmic) CANTIL Dexamethasone
ACANYA AUVI-Q CARAFATE SUS 1GM/10ML DEXILANT
Acetaminophen AVC Carbidopa-Levodopa Dexmethylphenidate HCl
Acetaminophen w/ Codeine AVONEX [SP] Carisoprodol Dextroamphetamine Sulfate
Acetaminophen-Isometheptene- Azathioprine Carvedilol Diazepam
Dichloralphenazone Azelastine HCl Cetirizine HCl Dicloxacillin Sodium
Acetazolamide Azelastine HCl (Ophth) CHANTIX Dicyclomine HCl
ACUVAIL AZELEX Chlorhexidine Gluconate Digoxin
Acyclovir AZILECT (Mouth-Throat) Diltiazem HCl Coated Beads
ADEMPAS [SP] Azithromycin Chlorthalidone Diphenhydramine HCl
ADVAIR DISKUS/HFA AZOPT Cholestyramine Diphenoxylate w/ Atropine
Albuterol Sulfate AZOR Choline Fenofibrate Divalproex Sodium
Alendronate Sodium Cilostazol Docusate Sodium
B
Alfuzosin HCl Cimetidine Donepezil Hydrochloride
BELVIQ
Allopurinol CIPRO HC Dorzolamide HCl
BENICAR
ALOMIDE CIPRODEX Dorzolamide HCl-Timolol
BENICAR HCT
Ciprofloxacin HCl Maleate
ALPHAGAN P SOL 0.1% Benzonatate Doxazosin Mesylate
Alprazolam Citalopram Hydrobromide
Benztropine Mesylate Doxepin HCl
ALREX Clarithromycin
BESIVANCE Doxycycline (Monohydrate)
Aluminum Chloride CLIMARA PRO
BETIMOL Doxycycline Hyclate
Clindamycin Phosphate
Amiodarone HCl BETOPTIC-S (Topical) Duloxetine HCl
AMITIZA BEYAZ Clindamycin Phosphate- DUREZOL
Amitriptyline HCl Bisacodyl Benzoyl Peroxide
DYMISTA [NP]
Amlodipine Besylate BREO ELLIPTA Clonazepam
Amlodipine Besylate- Clonidine HCl E
BRILINTA
Atorvastatin Calcium Clopidogrel Bisulfate ELIDEL
Brimonidine Tartrate
Amoxicillin Clotrimazole ELIQUIS
BRINTELLIX
Amoxicillin & Pot Clavulanate Clotrimazole w/ Betamethasone Enalapril Maleate
Budesonide (Inhalation)
Amphetamine- COLCRYS ENBREL [SP]
Dextroamphetamine Bumetanide
Colestipol HCl Enoxaparin Sodium
Ampicillin Buprenorphine HCl
COMBIGAN EPIPEN
AMTURNIDE Buprenorphine HCl-Naloxone
HCl Dihydrate COMBIPATCH EPIPEN-JR
ANDROGEL 1.62% EPOGEN [SP]
Bupropion HCl COMBIVENT RESPIMAT
Antipyrine-Benzocaine Erythromycin (Ophth)
Butalbital-Acetaminophen- CONTRAVE
ANORO Caffeine Erythromycin Base
COPAXONE [SP]
ANZEMET [SP] Butalbital-Aspirin-Caffeine Escitalopram Oxalate
COREG CR
APRISO BUTRANS Esterified Estrogens &
CREON
ARNUITY ELLIPTA Methyltestosterone
BYDUREON Cyclobenzaprine HCl
ASMANEX Estradiol
BYETTA Cyproheptadine HCl
Aspirin BYSTOLIC Estradiol & Norethindrone
Atenolol
D Acetate
DAKLINZA [SP] ESTRING
Atorvastatin Calcium
C DALIRESP Eszopiclone

[NP] = Non-Preferred [SP] = Specialty October 2016

 F Ibandronate Sodium Lithium Carbonate Neomycin-Polymyxin-HC (Otic)
Famciclovir Ibuprofen LIVALO NESINA [NP]
Famotidine Imiquimod Loperamide HCl NEULASTA [SP]
FARXIGA INCRUSE Loratadine NEUPOGEN [SP]
Fenofibrate INVOKAMET Lorazepam NEVANAC
FETZIMA INVOKANA Losartan Potassium NEXIUM GRANULES
Finasteride Ipratropium Bromide Losartan Potassium & Nicotine
Ipratropium Bromide (Nasal) Hydrochlorothiazide Nifedipine
Flecainide Acetate
Ipratropium-Albuterol LOTEMAX Nitrofurantoin Macrocrystal
FLECTOR
Irbesartan LUMIGAN Nitrofurantoin Monohyd Macro
FLOVENT
Isosorbide Mononitrate LUZU [NP] Nitroglycerin
Fluconazole
LYRICA NORDITROPIN [SP]
Fludrocortisone Acetate J
Fluorouracil (Topical) JALYN M Norelgestromin-Ethinyl
Estradiol
Fluticasone Propionate (Nasal) JANUMET Meclizine HCl
Norethin Acet & Estrad-Fe
Folic Acid JANUMET XR Medroxyprogesterone Acetate
Norethindrone (Contraceptive)
FOLLISTIM AQ [SP] JANUVIA Medroxyprogesterone Acetate
(Contraceptive) Norethindrone Acetate
FORADIL JUBLIA [NP] Norgestimate-Ethinyl Estradiol
Meloxicam
FOSRENOL K Norgestimate-Ethinyl Estradiol
MENEST
FREESTYLE KAZANO [NP] (Triphasic)
MENOSTAR
Furosemide Ketoconazole Nortriptyline HCl
MENTAX
G Ketoconazole (Topical) NOVOFINE
Metformin HCl
Gabapentin Ketorolac Tromethamine NOVOLIN
(Ophth) Methimazole
Ganciclovir NOVOLIN MIX
KHEDEZLA ER Methylphenidate HCl
Gemfibrozil NOVOLIN N
KOMBIGLYZE Methylprednisolone
GENOTROPIN [SP] NOVOLIN R
KRISTALOSE Metoclopramide HCl
NOVOLOG
GILENYA [SP] Metolazone
Glimepiride
L NOVOLOG MIX
Metoprolol Succinate
Labetalol HCl NOVOTWIST
Glipizide Metoprolol Tartrate
Lactic Acid (Ammonium NUCYNTA
GLUCAGEN Lactate) Metronidazole Vaginal
GLUCAGON NUCYNTA ER
Lactulose Midodrine HCl
Glyburide NUVARING
Lactulose (Encephalopathy) Minocycline HCl
Glyburide-Metformin NUVIGIL
Lamotrigine Mirtazapine
Glycopyrrolate Nystatin (Mouth-Throat)
Lansoprazole Misoprostol
Guaifenesin Nystatin (Topical)
LANTUS Modafinil
H Latanoprost Montelukast Sodium
O
Haloperidol Leflunomide Ofloxacin (Otic)
Morphine Sulfate
Haloperidol Lactate LETAIRIS [SP] Olanzapine
MOVANTIK
HARVONI [SP] Levalbuterol HCl Omega-3-acid Ethyl Esters
MOXEZA
HUMIRA [SP] LEVEMIR Omeprazole
Moxifloxacin HCl
LEVITRA Omeprazole-Sodium
Hydralazine HCl MULTAQ Bicarbonate
Hydrochlorothiazide Levocetirizine Dihydrochloride Mupirocin Ondansetron
Hydrocodone Polistirex- Levofloxacin Mupirocin Calcium (Topical) Ondansetron HCl
Chlorpheniramine Polistirex Levothyroxine Sodium Mycophenolate Mofetil [SP] ONETOUCH
Hydrocodone w/ Homatropine Levoxyl MYRBETRIQ ONEXTON
Hydrocodone-Acetaminophen LIALDA
N ONGLYZA
Hydrocortisone (Rectal) Lidocaine HCl (Mouth-Throat)
Nadolol OPANA ER
Hydrocortisone Acetate (Rectal) Lidocaine-Prilocaine
Naltrexone HCl OPSUMIT [SP]
Hydrocortisone Acetate w/ LINZESS
Pramoxine NAMENDA XR OSENI [NP]
Liothyronine Sodium
NAMZARIC Oxybutynin Chloride
Hyoscyamine Sulfate
LIPOFEN
Naproxen Oxycodone HCl
HYSINGLA ER
Lisinopril
NASONEX Oxycodone w/ Acetaminophen
I Lisinopril & Hydrochlorothiazide
OXYCONTIN
NATAZIA

[NP] = Non-Preferred [SP] = Specialty October 2016

 P Promethazine-DM STIOLTO UCERIS [NP]
Pantoprazole Sodium Propafenone HCl SUBOXONE ULORIC
PATADAY Propranolol HCl SUCRAID ULTICARE LANCETS
PAZEO PULMICORT FLEXHALER Sucralfate ULTICARE PEN NEEDLES
Pediatric Multivitamins w/Fl Q Sulfasalazine ULTICARE SYRINGES

PEG 3350-KCl-Sod Bicarb-Sod QNASL Sumatriptan Succinate Urea

Chloride-Sod Sulfate Quetiapine Fumarate SUPREP Ursodiol
PEG 3350-Potassium Chloride- QVAR SYMBICORT V
Sod Bicarbonate-Sod Chloride SYNTHROID
R VAGIFEM
PEGASYS [SP]
Raloxifene HCl T Valacyclovir HCl
PEG-INTRON [SP]
Ramipril Tacrolimus Valsartan-Hydrochlorothiazide
Penicillin V Potassium
RANEXA Tamsulosin HCl VASCEPA
Phenazopyridine HCl
Ranitidine HCl TASIGNA [SP] Venlafaxine HCl
Phenobarbital
RAPAFLO TECFIDERA [SP] VENTOLIN HFA
Phentermine HCl
RELPAX TEKAMLO VERAMYST
PICATO [NP]
RENAGEL TEKTURNA VESICARE
Pioglitazone HCl
RENOVA [NP] TEKTURNA HCT VIAGRA
Pioglitazone HCl-Metformin HCl
RENVELA Telmisartan VICTOZA
PLEGRIDY [SP]
Repaglinide Temazepam VIGAMOX
Polyethylene Glycol 3350
REPATHA [SP] Terazosin HCl VIIBRYD
Polymyxin B-Trimethoprim
RESTASIS Terbinafine HCl VYVANSE
Potassium Citrate (Alkalinizer)
RETIN-A MICR GEL 0.08% Terconazole Vaginal W
PRADAXA
Ribavirin [SP] Testosterone Cypionate Warfarin Sodium
PRALUENT [SP]
Risperidone TIKOSYN WELCHOL
Pramipexole Dihydrochloride
Rizatriptan Benzoate Timolol Maleate (Ophth)
PRANDIMET X
Ropinirole Hydrochloride Tizanidine HCl
Pravastatin Sodium XARELTO
Rosuvastatin Calcium Tobramycin (Ophth)
PRECISION XIFAXAN
S Tolterodine Tartrate XIGDUO XR
Prednisone
SAFYRAL Topiramate XTANDI [SP]
PREMARIN
SAVAYSA [NP] Torsemide Y
PREMARIN VAGINAL CREAM
SAVELLA TOUJEO YASMIN
PREMPHASE
Sennosides TRACLEER [SP] YAZ
PREMPRO
Sennosides-Docusate Sodium Tramadol HCl
Prenatal Vit w/ Ferrous Z
SEREVENT DISKUS Tranexamic Acid
Fumarate-Folic Acid ZENPEP
SEROQUEL XR TRAVATAN Z
PRENATE DHA ZETIA
Sertraline HCl Travoprost
PRENATE ELITE ZIANA
SILENOR [NP] Trazodone HCl
PRENATE ESSENTIAL Ziprasidone HCl
Silver Sulfadiazine Tretinoin
PRISTIQ ZOHYDRO ER [NP]
Simvastatin TREXIMET [NP]
PROAIR Zolmitriptan
Sodium Fluoride (Dental) Triamcinolone Acetonide
Prochlorperazine Zolpidem Tartrate
SOLODYN [NP] (Mouth)
Prochlorperazine Maleate ZOVIRAX CRE 5%
Sotalol HCl Triamcinolone Acetonide
PROCRIT (Nasal) ZYCLARA [NP]
SOVALDI [SP]
PROCTOFOAM HC 1% Triamterene & ZYTIGA [SP]
SPIRIVA Hydrochlorothiazide
Progesterone Micronized
Spironolactone TRIBENZOR
PROLENSA TRINTELLIX
Spironolactone &
Promethazine HCl
Hydrochlorothiazide U
Promethazine w/Codeine

[NP] = Non-Preferred [SP] = Specialty October 2016

Utilization Management
Formulary Exclusions
Preferred products for each drug category are listed in the table below. Agents listed as Excluded Products
are considered to be a formulary exclusion.

Drug Category Excluded Products Preferred Products

Amnesteen, Claravis, Myorisan,

Acne Absorica
Zenatane

Androderm, Axiron, Fortesta,

Androgens Androgel 1.62%, generic testosterone
Testim

Diabetes/Glucose Testing Accu-Chek, Breeze/Contour,

FreeStyle/Precision, OneTouch
Supplies Nipro

famotidine PLUS ibuprofen

Gastrointestinal Duexis, Vimovo or
omeprazole PLUS naproxen

Olysio, Technivie, Viekira,

Hepatitis C Harvoni, Sovaldi
Zepatier

Insulins Apidra, Humalog, Humulin Novolog, Novolin

Injectable Anti-Diabetics Tanzeum, Trulicity Bydureon, Byetta, Victoza

Oral Contraceptives drospirenone-ethinyl estradiol* Yasmin, Yaz

*drospirenone-ethinyl estradiol is commonly marketed as Gianvi, Loryna, Ocella, Syeda, Vestura, or Zarah

[NP] = Non-Preferred [SP] = Specialty October 2016

Utilization Management (continued)
Step Therapies
The Primary Products for each drug category is listed in the table below. At least one Primary Product must be
tried prior to use of a Secondary Product

Drug Category Secondary Products Primary Products

Vyvanse,
ADD/ADHD Daytrana, Focalin XR, Quillivant, Ritalin LA
generic ADD/AHDH medications

Asthma Proventil, Xopenex Proair, Ventolin

Janumet, Januvia, Kombiglyze,

Diabetes Jentadueto, Tradjenta
Onglyza

Erectile Dysfunction Cialis(1), Staxyn, Stendra Levitra, Viagra

Humatrope, Nutropin AQ, Omnitrope,

Growth Hormone Genotropin, Norditropin
Saizen, Zomacton

Inflammatory Bowel
Asacol HD, Delzicol, Pentasa Apriso, Lialda
Disease

Actemra, Cimzia, Cosentyx, Kineret,

Inflammatory Conditions Enbrel, Humira
Orencia, Otezla, Simponi, Stelara, Xeljanz

Avonex, Copaxone, Gilenya,

Multiple Sclerosis Aubagio(2), Betaseron, Extavia, Rebif
Plegridy, Tecfidera

Bunavail, buprenorphine/naloxone,
Opioid Abuse Suboxone Film
Zubsolv

(1) Managed by Prior Authorization to assess indication

(2) Requires trial and failure of only one Primary Product

[NP] = Non-Preferred [SP] = Specialty October 2016