Post on 16-Apr-2020
2019 National Formulary
Effective 01/01/2019
The Formulary List is a guide providing tier designation for common medicines within select therapeutic categories. The Formulary List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing.
For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available. It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider.
Tier Definitions1 Generics2 Preferred Brands3 Non-Preferred Brands
(ST) Step Therapy(PA) Prior Authorization
Major Drug Class OverviewNon-Preferred Drugs With Preferred Options
2019
PreferredNon-PreferredDrug Class
ANALGESICSANTIARTHRITICS EUFLEXXA, GEL-ONE, HYALGAN,
MONOVISC, ORTHOVISC
DUROLANE, GELSYN-3, SUPARTZ,
SUPARTZ FX, SYNVISC, SYNVISC ONE
NARCOTICS ABSTRAL, EMBEDA, FENTORA, KADIAN fentanyl, fentanyl citrate oral transmucosal,
morphine sulfate er, oxycodone hcl,
HYSINGLA ER, NUCYNTA ER, OXYCONTIN,
ZOHYDRO ER
ANTI-INFECTIVESANTIVIRALS REBETOL moderiba, ribavirin, RIBASPHERE RIBAPAK
HEPATITIS C DAKLINZA, EPCLUSA, HARVONI, SOVALDI,
ZEPATIER
MAVYRET
TETRACYCLINES DOXYCYCLINE, ORACEA minocycline hcl, tetracycline hcl, SOLODYN
CARDIACANGIOTENSIN RECEPTOR BLOCKER BENICAR HCT, EDARBI, EDARBYCLOR candesartan cilexetil/hydrochlorothiazide,
irbesartan/hydrochlorothiazide, losartan
potassium/hydrochlorothiazide,
valsartan/hydrochlorothiazide
ANTICOAGULANTS PRADAXA clopidogrel, ELIQUIS, XARELTO
ANTI-HYPERLIPIDEMICS VYTORIN atorvastatin calcium, ezetimibe,
ezetimibe/simvastatin, rosuvastatin calcium,
simvastatin, LIVALO
CNSADHD ADDERALL XR amphetamine/dextroamphetamine er
ANTIDEPRESSANTS PEXEVA, SARAFEM citalopram hydrobromide, escitalopram
oxalate, fluoxetine hcl, fluvoxamine
maleate, paroxetine hcl, paroxetine hcl er,
sertraline hcl, trazodone hcl, VIIBRYD
ANTI-PSYCHOTIC FANAPT, REXULTI aripiprazole, olanzapine, olanzapine odt,
quetiapine fumarate, quetiapine fumarate
er, LATUDA, SAPHRIS
SLEEP ZOLPIMIST eszopiclone, zaleplon, zolpidem tartrate,
zolpidem tartrate er, BELSOMRA,
ROZEREM
DIABETESDPP-4 ALOGLIPTIN, KAZANO, KOMBIGLYZE XR,
NESINA, ONGLYZA, OSENI
JANUMET XR, JANUVIA, JENTADUETO,
TRADJENTA
INCRETINS BYDUREON PEN, BYETTA, TANZEUM OZEMPIC, TRULICITY, VICTOZA
INSULIN AFREZZA, APIDRA FIASP, FIASP FLEXTOUCH, HUMALOG,
HUMALOG MIX 50/50, HUMALOG MIX
75/25, HUMULIN 70/30, HUMULIN N,
HUMULIN R, NOVOLIN 70/30, NOVOLOG
FLEXPEN, NOVOLOG MIX 70/30,
NOVOLOG PENFILL
INSULIN: LONG ACTING BASAGLAR KWIKPEN LANTUS, LANTUS SOLOSTAR, LEVEMIR,
TOUJEO SOLOSTAR, TRESIBA
FLEXTOUCH
OTHER GLUMETZA, RIOMET metformin hcl er
SGLT-2 FARXIGA, INVOKAMET, INVOKANA,
JARDIANCE, SYNJARDY, XIGDUO XR
PreferredNon-PreferredDrug Class
DIABETESTESTING ACCU-CHEK AVIVA CONNECT,
ACCU-CHEK AVIVA PLUS, ADVOCATE
BLOOD GLUCOSE MONITORING SYSTEM,
BAYER BREEZE 2 TEST DISC, BAYER
CONTOUR BLOOD GLUCOSE TEST STRIPS,
EMBRACE BLOOD GLUCOSE TEST STRIPS,
PRODIGY AUTOCODE BLOOD GLUCOSE
MONITORING SYSTEM, TRUE METRIX
BLOOD GLUCOSETEST STRIPS, TRUE
METRIX SELF MONITORING BLOOD
GLUCOSE STRIPS, TRUETRACK SMART
SYSTEM, UNISTRIP1 GENERIC
FREESTYLE TEST STRIPS, ONETOUCH
ULTRA BLUE, ONETOUCH VERIO TEST
STRIPS
ENDOCRINEESTROGENS CLIMARA PRO, ESTRACE, ESTROGEL estradiol, DIVIGEL, ESTRING, PREMARIN
FERTILITY AGENTS BRAVELLE, FOLLISTIM AQ, GANIRELIX
ACETATE, PREGNYL W/DILUENT
BENZYLALCOHOL/NACL
clomiphene citrate, CETROTIDE, GONAL-F,
MENOPUR, NOVAREL
PROGESTINS CRINONE ENDOMETRIN
TESTOSTERONE AXIRON, FORTESTA, NATESTO, STRIANT,
TESTIM, VOGELXO
testosterone cypionate, ANDROGEL,
ANDROGEL PUMP
GASTROINTESTINALDIGESTIVE ENZYMES PANCREAZE, PERTZYE CREON, VIOKACE, ZENPEP
OTHER DIPENTUM, LIALDA balsalazide disodium, AMITIZA, APRISO,
DELZICOL, LINZESS, PENTASA
PROTON PUMP INHIBITORS DEXILANT lansoprazole, omeprazole, pantoprazole
sodium
GROWTH HORMONESGENOTROPIN, HUMATROPE, NUTROPIN AQ
NUSPIN 10, OMNITROPE, SAIZEN
CLICK.EASY, ZOMACTON, ZORBTIVE
NORDITROPIN FLEXPRO
HEMATOLOGYEPOGEN, MIRCERA ARANESP ALBUMIN FREE, PROCRIT
MUSCULOSKELETALANTI-INFLAMMATORY ** CIMZIA, ILUMYA, KEVZARA, KINERET,
ORENCIA, REMICADE, SILIQ, SIMPONI,
TALTZ, TREMFYA
ACTEMRA, COSENTYX, COSENTYX
SENSOREADY PEN, ENBREL SURECLICK,
ENTYVIO, HUMIRA PEN, OTEZLA,
STELARA, XELJANZ, XELJANZ XR
(1) Trial of TWO preferred products required [documentation required]
(2) Trial of ONE preferred product required
(3) Trial of Humira required / Other preferred products not requiring Humira first for Psoriasis are Cosentyx, Otezla & Stelara
Non-Preferred Products Preferred ProductsIndication
CIMZIA (1) or KEVZARA (1) or KINERET (1) or
ORENCIA (1) or SIMPONI 50mg (1)
ACTEMRA or ENBREL or HUMIRA or XELJANZ
or XELJANZ XRRheumatoid Arthritis
ORENCIA (2) ENBREL or HUMIRAJuvenille Idiopathic Arthritis
CIMZIA (1) or SIMPONI 50mg (1) COSENTYX or ENBREL or HUMIRAAnkylosing Spondylitis
CIMZIA (1) or ORENCIA (1) or OTEZLA (2) or
SIMPONI 50mg (1) or TALTZ (1) or XELJANZ (1) or
XELJANZ XR (1)
COSENTYX or ENBREL or HUMIRA or
STELARAPsoriatic Arthritis
CIMZIA (1) or ILUMYA (1) or SILIQ (1) or TALTZ (1)
or TREMFYA (1)
COSENTYX or HUMIRA or OTEZLA or STELARAPlaque Psoriasis
CIMZIA (1) HUMIRA or STELARACrohn's Disease
SIMPONI 100mg (2) or XELJANZ (2) or XELJANZ XR
(2)
HUMIRAUlcerative Colitis
PreferredNon-PreferredDrug Class
GLAUCOMA COSOPT PF, SIMBRINZA, ZIOPTAN dorzolamide hcl, latanoprost, AZOPT,
COMBIGAN, TRAVATAN Z
NSAIDS ACUVAIL bromfenac, diclofenac sodium, ketorolac
tromethamine, ILEVRO, NEVANAC,
PROLENSA
OTICMISCELLANEOUS CETRAXAL ciprofloxacin
RESPIRATORYASTHMA/COPD DULERA, TUDORZA PRESSAIR ADVAIR DISKUS, ANORO ELLIPTA, BREO
ELLIPTA, INCRUSE ELLIPTA, STIOLTO
RESPIMAT, SYMBICORT
BETA AGONISTS FORADIL AEROLIZER, PROVENTIL HFA,
XOPENEX HFA
ARCAPTA NEOHALER, PERFOROMIST,
PROAIR HFA, VENTOLIN HFA
INHALED STEROIDS ALVESCO, ASMANEX TWISTHALER 120
METERED DOSES
ARNUITY ELLIPTA, FLOVENT DISKUS,
FLOVENT HFA, PULMICORT FLEXHALER,
QVAR
NASAL STEROIDS BECONASE AQ, NASONEX, OMNARIS,
ZETONNA
flunisolide, fluticasone propionate,
DYMISTA, QNASL
TOPICALACNE ATRALIN, AVAGE, AZELEX, BENZACLIN
WITH PUMP, EPIDUO, VELTIN
adapalene, clindamycin phosphate/tretinoin,
clindamycin/benzoyl peroxide,
erythromycin, tretinoin, ACANYA,
TAZORAC
MISCELLANEOUS ALDARA, ZYCLARA PUMP fluorouracil, imiquimod, PICATO
ROSACEA NORITATE, SOOLANTRA metronidazole, FINACEA
UROLOGICALANTISPASMODICS ENABLEX, GELNIQUE oxybutynin chloride, oxybutynin chloride er,
tolterodine tartrate, trospium chloride,
MYRBETRIQ, TOVIAZ, VESICARE
ERECTILE DYSFUNCTION CIALIS, LEVITRA, STAXYN, STENDRA,
VIAGRA
sildenafil citrate, tadalafil
Additional covered alternatives m ay be available. Costs for covered alternatives m ay vary. Other
prescription benefit considerations m ay apply.
ANALGESICSANTIARTHRITICSDUROLANE 2Prefilled Syringe
GELSYN-3 2Solution Prefilled Syringe
SUPARTZ 2Solution Prefilled Syringe
SUPARTZ FX 2Solution Prefilled Syringe
SYNVISC 2Solution Prefilled Syringe
SYNVISC ONE 2Solution Prefilled Syringe
EUFLEXXA 3 (ST)Solution Prefilled Syringe
* Must try and fail Durolane, Gelsyn-3, Supartz FX, Synvisc and Synvisc One
GEL-ONE 3 (ST)Prefilled Syringe
* Must try and fail Durolane, Gelsyn-3, Supartz FX, Synvisc and Synvisc One
GENVISC 850 3 (ST)Solution Prefilled Syringe
* Must try and fail Durolane, Gelsyn-3, Supartz FX, Synvisc and Synvisc One
HYALGAN 3 (ST)Solution Prefilled Syringe
* Must try and fail Durolane, Gelsyn-3, Supartz FX, Synvisc and Synvisc One
HYMOVIS 3 (ST)Solution Prefilled Syringe
* Must try and fail Durolane, Gelsyn-3, Supartz FX, Synvisc and Synvisc One
MONOVISC 3 (ST)Solution Prefilled Syringe
* Must try and fail Durolane, Gelsyn-3, Supartz FX, Synvisc and Synvisc One
ORTHOVISC 3 (ST)Solution Prefilled Syringe
* Must try and fail Durolane, Gelsyn-3, Supartz FX, Synvisc and Synvisc One
HEADACHEdihydroergotamine mesylate 1Solution
isometheptene/dichloralphenazone/acetaminophen 1Capsule
naratriptan hcl 1Tablet
rizatriptan benzoate 1Tablet
sumatriptan 1Solution
sumatriptan succinate 1Tablet
sumatriptan succinate 1Solution Auto-injector
zolmitriptan 1Tablet
zolmitriptan odt 1Tablet Disintegrating
TREXIMET 2Tablet
ZOMIG 2Solution
AXERT 3Tablet
CAFERGOT 3Tablet
ERGOMAR 3Tablet Sublingual
FROVA 3Tablet
RELPAX 3Tablet
SUMAVEL DOSEPRO 3Solution Jet-injector
MISCELLANEOUSdiflunisal 1Tablet
salsalate 1Tablet
tramadol hcl 1Tablet
tramadol hcl er 1Tablet Extended Release 24 Hour
tramadol hydrochloride/acetaminophen 1Tablet
CONZIP 3Capsule Extended Release 24 Hour
NARCOTIC ANTAGONIST (NON-OPIOD)LUCEMYRA 2
NARCOTIC ANTAGONISTS (OPIOD)buprenorphine hcl/naloxone hcl 1Tablet Sublingual
naltrexone hcl 1Tablet
NARCAN 2Liquid
SUBOXONE 2Film
VIVITROL 2Suspension Reconstituted
ZUBSOLV 2Tablet Sublingual
EVZIO 3Solution Auto-injector
NARCOTICSacetaminophen/codeine 1Tablet
acetaminophen/codeine 1Solution
buprenorphine hcl 1Tablet Sublingual
butalbital/acetaminophen/caffeine 1Tablet
butalbital/acetaminophen/caffeine/codeine 1Capsule
Printed Date:12/6/2018
Page 5 | 2019 National FormularyData Last Updated:12/6/2018
NARCOTICSbutalbital/aspirin/caffeine 1Capsule
butalbital/aspirin/caffeine/codeine 1Capsule
codeine sulfate 1Tablet
fentanyl 1Patch 72 Hour
fentanyl citrate oral transmucosal 1Lozenge on a Handle
hydrocodone bitartrate/acetaminophen 1Solution
hydrocodone/acetaminophen 1Tablet
hydrocodone/ibuprofen 1Tablet
hydromorphone hcl 1Tablet
meperidine hcl 1Solution
methadone hcl 1Solution
methadone hcl 1Tablet Soluble
morphine sulfate 1Suppository
morphine sulfate er 1Tablet Extended Release
oxycodone hcl 1Solution
oxycodone/acetaminophen 1Tablet
oxycodone/aspirin 1Tablet
oxycodone/ibuprofen 1Tablet
oxymorphone hydrochloride 1Tablet
FLECTOR 2Patch
HYSINGLA ER 2Tablet ER 24 Hour Abuse-Deterrent
NUCYNTA 2Tablet
NUCYNTA ER 2Tablet Extended Release 12 Hour
OXYCONTIN 2Tablet ER 12 Hour Abuse-Deterrent
ZOHYDRO ER 2Capsule ER 12 Hour Abuse-Deterrent
ABSTRAL 3Tablet Sublingual
BUPRENORPHINE 3Patch Weekly
CAPITAL/CODEINE 3Suspension
EMBEDA 3Capsule Extended Release
FENTORA 3Tablet
KADIAN 3Capsule Extended Release 24 Hour
PRIMLEV 3Tablet
SUBSYS 3Liquid
NSAIDScelecoxib 1Capsule
diclofenac potassium 1Tablet
diclofenac sodium er 1Tablet Extended Release 24 Hour
diclofenac sodium/misoprostol 1Tablet Delayed Release
etodolac 1Tablet
fenoprofen calcium 1Tablet
flurbiprofen 1Tablet
indomethacin 1Capsule
ketoprofen 1Capsule
ketorolac tromethamine 1Tablet
meclofenamate sodium 1Capsule
mefenamic acid 1Capsule
meloxicam 1Suspension
meloxicam 1Tablet
nabumetone 1Tablet
naproxen 1Tablet
naproxen sodium 1Tablet
oxaprozin 1Tablet
piroxicam 1Capsule
sulindac 1Tablet
tolmetin sodium 1Capsule
CELEBREX 3Capsule
DUEXIS 3Tablet
Printed Date:12/6/2018
Page 6 | 2019 National FormularyData Last Updated:12/6/2018
NSAIDSINDOCIN 3Suppository
NALFON 3Capsule
SPRIX 3Solution
VIMOVO 3Tablet Delayed Release
VOLTAREN 3Gel
ZIPSOR 3Capsule
ZORVOLEX 3Capsule
ANTI-INFECTIVESANTIFUNGALclotrimazole 1Troche
fluconazole 1Tablet
fluconazole 1Suspension Reconstituted
flucytosine 1Capsule
griseofulvin microsize 1Suspension
griseofulvin microsize 1Tablet
griseofulvin ultramicrosize 1Tablet
itraconazole 1Capsule
ketoconazole 1Tablet
nystatin 1Suspension
nystatin 1Tablet
terbinafine hcl 1Tablet
voriconazole 1Suspension Reconstituted
voriconazole 1Tablet
NOXAFIL 2Suspension
SPORANOX 2Solution
LAMISIL 3Tablet
ONMEL 3Tablet
ANTIMALARIALSatovaquone/proguanil hcl 1Tablet
chloroquine phosphate 1Tablet
hydroxychloroquine sulfate 1Tablet
mefloquine hcl 1Tablet
quinine sulfate 1Capsule
COARTEM 2Tablet
DARAPRIM 2Tablet
PRIMAQUINE PHOSPHATE 2Tablet
ANTIMYCOBACTERIALScycloserine 1Capsule
ethambutol hcl 1Tablet
isoniazid 1Tablet
pyrazinamide 1Tablet
rifampin 1Capsule
SIRTURO 2Tablet
PASER 3Packet
RIFATER 3Tablet
TRECATOR 3Tablet
ANTIPARASITICSmetronidazole 1Tablet
paromomycin sulfate 1Capsule
tinidazole 1Tablet
ALBENZA 2Tablet
ALINIA 2Tablet
ALINIA 2Suspension Reconstituted
BILTRICIDE 3Tablet
FLAGYL ER 3Tablet Extended Release 24 Hour
MEPRON 3Suspension
STROMECTOL 3Tablet
ANTIVIRALSacyclovir 1Capsule
acyclovir 1Suspension
Printed Date:12/6/2018
Page 7 | 2019 National FormularyData Last Updated:12/6/2018
ANTIVIRALSacyclovir 1Tablet
amantadine hcl 1Capsule
amantadine hcl 1Syrup
famciclovir 1Tablet
lamivudine 1Tablet
moderiba 1Tablet
oseltamivir phosphate 1Capsule
ribasphere 1Capsule
ribavirin 1Capsule
rimantadine hcl 1Tablet
valacyclovir hcl 1Tablet
EPIVIR HBV 2Solution
RIBASPHERE RIBAPAK 2Tablet
BARACLUDE 3Tablet
REBETOL 3Solution
SITAVIG 3Tablet
TAMIFLU 3Suspension Reconstituted
VALCYTE 3Solution Reconstituted
VALCYTE 3Tablet
CEPHALOSPORINScefaclor 1Suspension Reconstituted
cefaclor 1Capsule
cefadroxil 1Suspension Reconstituted
cefadroxil 1Capsule
cefdinir 1Capsule
cefdinir 1Suspension Reconstituted
cefprozil 1Suspension Reconstituted
cefprozil 1Tablet
ceftibuten 1Capsule
ceftibuten 1Suspension Reconstituted
cephalexin 1Suspension Reconstituted
cephalexin 1Tablet
CEFTIN 3Suspension Reconstituted
SUPRAX 3Suspension Reconstituted
ERYTHROMYCINS/MACROLIDSazithromycin 1Suspension Reconstituted
clarithromycin 1Suspension Reconstituted
clarithromycin 1Tablet
clarithromycin er 1Tablet Extended Release 24 Hour
ery-tab 1Tablet Delayed Release
erythromycin base 1Tablet
erythromycin ethylsuccinate 1Tablet
DIFICID 3Tablet
HEPATITIS CMAVYRET 2 (PA)Tablet
* Based on Clinical Indications Only
DAKLINZA 3 (PA)Tablet
* Must try and fail Mavyret
EPCLUSA 3 (PA)Tablet
* Must try and fail Mavyret
HARVONI 3 (PA)Tablet
* Must try and fail Mavyret
OLYSIO 3 (PA)Capsule
* Must try and fail Mavyret
SOVALDI 3 (PA)Tablet
* Must try and fail Mavyret
ZEPATIER 3 (PA)Tablet
* Must try and fail Mavyret
HIVabacavir 1Tablet
abacavir sulfate/lamivudine/zidovudine 1Tablet
didanosine 1Capsule Delayed Release
lamivudine/zidovudine 1Tablet
Printed Date:12/6/2018
Page 8 | 2019 National FormularyData Last Updated:12/6/2018
HIVnevirapine 1Suspension
nevirapine 1Tablet
ritonavir 1
stavudine 1Solution Reconstituted
stavudine 1Capsule
zidovudine 1Capsule
zidovudine 1Syrup
zidovudine 1Tablet
APTIVUS 2Capsule
APTIVUS 2Solution
ATRIPLA 2Tablet
COMPLERA 2Tablet
CRIXIVAN 2Capsule
DESCOVY 2Tablet
EDURANT 2Tablet
EMTRIVA 2Solution
EMTRIVA 2Capsule
GENVOYA 2Tablet
INTELENCE 2Tablet
INVIRASE 2Tablet
ISENTRESS 2Tablet
KALETRA 2Tablet
LEXIVA 2Suspension
NORVIR 2Solution
NORVIR 2Tablet
ODEFSEY 2Tablet
PREZISTA 2Suspension
PREZISTA 2Tablet
RESCRIPTOR 2Tablet
SELZENTRY 2Tablet
STRIBILD 2Tablet
TIVICAY 2Tablet
TRUVADA 2Tablet
VIDEXPEDIATRIC 2Solution Reconstituted
VIRACEPT 2Tablet
EPIVIR 3Solution
EPZICOM 3Tablet
KALETRA 3Solution
LEXIVA 3Tablet
REYATAZ 3Capsule
SUSTIVA 3Capsule
VIREAD 3Tablet
ZIAGEN 3Solution
MISCELLANEOUSclindamycin hcl 1Capsule
clindamycin palmitate hcl 1Solution Reconstituted
dapsone 1Tablet
linezolid 1Tablet
methenamine hippurate 1Tablet
methenamine mandelate 1Tablet
nitrofurantoin macrocrystals 1Capsule
nitrofurantoin monohydrate 1Capsule
sulfadiazine 1Tablet
sulfamethoxazole/trimethoprim 1Tablet
sulfamethoxazole/trimethoprim 1Suspension
trimethoprim 1Tablet
vancomycin hcl 1Capsule
Printed Date:12/6/2018
Page 9 | 2019 National FormularyData Last Updated:12/6/2018
MISCELLANEOUSTOBI PODHALER 2Capsule
XIFAXAN 2Tablet
FIRVANQ 3
MONUROL 3Packet
PRIMSOL 3Solution
SIVEXTRO 3Tablet
ZYVOX 3Tablet
PENICILLINSamoxicillin 1Tablet
amoxicillin 1Suspension Reconstituted
amoxicillin/clavulanate potassium 1Suspension Reconstituted
amoxicillin/clavulanate potassium 1Tablet
amoxicillin/clavulanate potassium er 1Tablet Extended Release 12 Hour
ampicillin 1Suspension Reconstituted
ampicillin 1Capsule
dicloxacillin sodium 1Capsule
penicillin v potassium 1Tablet
penicillin v potassium 1Solution Reconstituted
QUINOLONESciprofloxacin er 1Tablet Extended Release 24 Hour
ciprofloxacin hcl 1Tablet
levofloxacin 1Solution
levofloxacin 1Tablet
TETRACYCLINESdemeclocycline hcl 1Tablet
doxycycline hyclate 1Tablet
doxycycline monohydrate 1Capsule
minocycline hcl 1Capsule
morgidox 1x100mg 1Capsule
tetracycline hcl 1Capsule
SOLODYN 2Tablet Extended Release 24 Hour
ACTICLATE 3Tablet
DORYX 3Tablet Delayed Release
DOXYCYCLINE 3Capsule Delayed Release
MINOCIN 3Capsule
MONODOX 3Capsule
ORACEA 3Capsule Delayed Release
VIBRAMYCIN 3Syrup
VAGINALclindamycin phosphate 1Cream
metronidazole vaginal 1Gel
miconazole 3 1Suppository
terconazole 1Suppository
terconazole 1Cream
AVC 3Cream
GYNAZOLE-1 3Cream
CANANTIDEPRESSANTSSAVELLA 2 (PA)Tablet
* Coverage based on indication.
CARDIACACE INHIBITORSamlodipine besylate/benazepril hydrochloride 1Capsule
benazepril hcl 1Tablet
benazepril hcl/hydrochlorothiazide 1Tablet
captopril 1Tablet
captopril/hydrochlorothiazide 1Tablet
enalapril maleate 1Tablet
fosinopril sodium 1Tablet
fosinopril sodium/hydrochlorothiazide 1Tablet
lisinopril 1Tablet
lisinopril/hydrochlorothiazide 1Tablet
Printed Date:12/6/2018
Page 10 | 2019 National FormularyData Last Updated:12/6/2018
ACE INHIBITORSmoexipril hcl 1Tablet
moexipril/hydrochlorothiazide 1Tablet
perindopril erbumine 1Tablet
quinapril hcl 1Tablet
quinapril/hydrochlorothiazide 1Tablet
ramipril 1Capsule
trandolapril 1Tablet
ACCUPRIL 3Tablet
ALTACE 3Capsule
EPANED 3Solution
LOTENSIN 3Tablet
MAVIK 3Tablet
PRINIVIL 3Tablet
QBRELIS 3Solution
TARKA 3Tablet Extended Release
VASOTEC 3Tablet
ZESTRIL 3Tablet
ANGIOTENSIN RECEPTOR BLOCKERcandesartan cilexetil 1Tablet
candesartan cilexetil/hydrochlorothiazide 1Tablet
eprosartan mesylate 1Tablet
irbesartan 1Tablet
irbesartan/hydrochlorothiazide 1Tablet
losartan potassium 1Tablet
losartan potassium/hydrochlorothiazide 1Tablet
olmesartan medoxomil 1Tablet
telmisartan 1Tablet
telmisartan/amlodipine 1Tablet
telmisartan/hydrochlorothiazide 1Tablet
valsartan 1Tablet
valsartan/hydrochlorothiazide 1Tablet
TEKAMLO 2Tablet
TEKTURNA 2Tablet
TEKTURNA HCT 2Tablet
ATACAND HCT 3Tablet
AZOR 3Tablet
BENICAR 3Tablet
BENICAR HCT 3Tablet
DIOVAN HCT 3Tablet
EDARBI 3Tablet
EDARBYCLOR 3Tablet
EXFORGE 3Tablet
EXFORGE HCT 3Tablet
TRIBENZOR 3Tablet
ANTIARRHYTHMICamiodarone hcl 1Tablet
digoxin 1Tablet
digoxin 1Solution
disopyramide phosphate 1Capsule
flecainide acetate 1Tablet
mexiletine hcl 1Capsule
pacerone 1Tablet
procainamide hcl 1Solution
propafenone hcl 1Tablet
quinidine gluconate 1Solution
quinidine sulfate 1Tablet
quinidine sulfate er 1Tablet Extended Release
sorine 1Tablet
Printed Date:12/6/2018
Page 11 | 2019 National FormularyData Last Updated:12/6/2018
ANTIARRHYTHMICsotalol hcl 1Tablet
sotalol hcl (af) 1Tablet
MULTAQ 2Tablet
NORPACE CR 2Capsule Extended Release 12 Hour
TIKOSYN 3Capsule
ANTICOAGULANTScilostazol 1Tablet
clopidogrel 1Tablet
dipyridamole 1Tablet
enoxaparin sodium 1Solution
fondaparinux sodium 1Solution
heparin sodium 1Solution
jantoven 1Tablet
pentoxifylline er 1Tablet Extended Release
ticlopidine hcl 1Tablet
warfarin sodium 1Tablet
BEVYXXA 2Capsule
BRILINTA 2Tablet
ELIQUIS 2Tablet
FRAGMIN 2Solution
MEPHYTON 2Tablet
XARELTO 2Tablet
XARELTO STARTER PACK 2Tablet Therapy Pack
AGGRENOX 3Capsule Extended Release 12 Hour
COUMADIN 3Tablet
EFFIENT 3Tablet
PRADAXA 3Capsule
ANTI-HYPERLIPIDEMICSamlodipine besylate/atorvastatin calcium 1Tablet
atorvastatin calcium 1Tablet
cholestyramine 1Packet
colestipol hcl 1Tablet
ezetimibe 1Tablet
ezetimibe/simvastatin 1Tablet
fenofibrate 1Tablet
fenofibric acid dr 1Capsule Delayed Release
fluvastatin 1Capsule
gemfibrozil 1Tablet
lovastatin 1Tablet
niacin er 1Tablet Extended Release
pravastatin sodium 1Tablet
prevalite 1Packet
rosuvastatin calcium 1Tablet
simvastatin 1Tablet
LIPOFEN 2Capsule
LIVALO 2Tablet
PRALUENT 2Solution Pen-injector
PRALUENT 2Solution Prefilled Syringe
REPATHA 2Solution Prefilled Syringe
REPATHA SURECLICK 2Solution Auto-injector
VASCEPA 2Capsule
ALTOPREV 3Tablet Extended Release 24 Hour
ANTARA 3Capsule
CRESTOR 3Tablet
FENOGLIDE 3Tablet
JUXTAPID 3Capsule
LESCOL XL 3Tablet Extended Release 24 Hour
LOVAZA 3Capsule
Printed Date:12/6/2018
Page 12 | 2019 National FormularyData Last Updated:12/6/2018
ANTI-HYPERLIPIDEMICSNIACOR 3Tablet
TRIGLIDE 3Tablet
VYTORIN 3Tablet
WELCHOL 3Packet
WELCHOL 3Tablet
ZETIA 3Tablet
BETA BLOCKERSacebutolol hcl 1Capsule
atenolol 1Tablet
atenolol/chlorthalidone 1Tablet
betaxolol hcl 1Tablet
bisoprolol fumarate 1Tablet
bisoprolol fumarate/hydrochlorothiazide 1Tablet
carvedilol 1Tablet
labetalol hcl 1Tablet
metoprolol tartrate 1Tablet
nadolol 1Tablet
nadolol/bendroflumethiazide 1Tablet
pindolol 1Tablet
propranolol hcl 1Solution
propranolol hcl 1Tablet
propranolol/hydrochlorothiazide 1Tablet
timolol maleate 1Tablet
BYSTOLIC 2Tablet
HEMANGEOL 2Solution
COREG CR 3Capsule Extended Release 24 Hour
LEVATOL 3Tablet
CALCIUM CHANNEL BLOCKERSafeditab cr 1Tablet Extended Release 24 Hour
amlodipine besylate 1Tablet
cartia xt 1Capsule Extended Release 24 Hour
diltiazem cd 1Capsule Extended Release 24 Hour
diltiazem hcl 1Tablet
diltiazem hcl er 1Capsule Extended Release 24 Hour
felodipine er 1Tablet Extended Release 24 Hour
isradipine 1Capsule
nifedipine 1Capsule
nifedipine er 1Tablet Extended Release 24 Hour
nimodipine 1Capsule
nisoldipine er 1Tablet Extended Release 24 Hour
taztia xt 1Capsule Extended Release 24 Hour
verapamil hcl 1Tablet
verapamil hcl er 1Capsule Extended Release 24 Hour
DIURETICSacetazolamide 1Tablet
amiloride hcl 1Tablet
amiloride/hydrochlorothiazide 1Tablet
bumetanide 1Tablet
chlorothiazide 1Tablet
eplerenone 1Tablet
furosemide 1Solution
hydrochlorothiazide 1Tablet
indapamide 1Tablet
methazolamide 1Tablet
methyclothiazide 1Tablet
metolazone 1Tablet
spironolactone 1Tablet
spironolactone/hydrochlorothiazide 1Tablet
Printed Date:12/6/2018
Page 13 | 2019 National FormularyData Last Updated:12/6/2018
DIURETICStorsemide 1Tablet
triamterene/hydrochlorothiazide 1Tablet
DYRENIUM 3Capsule
HEREDITARY ANGIOEDEMA (HAE)RUCONEST 2Solution Reconstituted
BERINERT 3Kit
CINRYZE 3Solution Reconstituted
HAEGARDA 3Solution Reconstituted
NITRATESisosorbide dinitrate 1Tablet
isosorbide mononitrate 1Tablet
minitran 1Patch 24 Hour
nitroglycerin lingual 1Aerosol Solution
nitroglycerin transdermal 1Patch 24 Hour
DILATRATE SR 2Capsule Extended Release
NITRO-BID 2Ointment
NITRO-DUR 2Patch 24 Hour
NITROSTAT 3Tablet Sublingual
OTHERENTRESTO 2Tablet
RANEXA 2Tablet Extended Release 12 Hour
VECAMYL 3Tablet
OTHER ANTI-HYPERTENSIVESclonidine hcl 1Tablet
clorpres 1Tablet
doxazosin mesylate 1Tablet
guanfacine hcl 1Tablet
hydralazine hcl 1Tablet
methyldopa 1Tablet
methyldopa/hydrochlorothiazide 1Tablet
minoxidil 1Tablet
prazosin hcl 1Capsule
reserpine 1Tablet
terazosin hcl 1Capsule
BIDIL 3Tablet
CARDURA XL 3Tablet Extended Release 24 Hour
CNSADHDamphetamine/dextroamphetamine 1Tablet
amphetamine/dextroamphetamine er 1Capsule Extended Release 24 Hour
dexmethylphenidate hcl 1Tablet
dexmethylphenidate hcl er 1Capsule Extended Release 24 Hour
dextroamphetamine sulfate 1Solution
dextroamphetamine sulfate 1Tablet
guanidine hcl 1Tablet
methylphenidate hcl 1Tablet
methylphenidate hcl cd 1Capsule Extended Release
methylphenidate hydrochloride 1Solution
DAYTRANA 2Patch
MYDAYIS 2Capsule Extended Release 24 Hour
QUILLICHEW ER 2Tablet Chewable Extended Release
QUILLIVANT XR 2Suspension Reconstituted
VYVANSE 2Tablet Chewable
VYVANSE 2Capsule
ADDERALL XR 3Capsule Extended Release 24 Hour
ADZENYS XR-ODT 3Tablet Extended Release Disintegrating
FOCALIN XR 3Capsule Extended Release 24 Hour
INTUNIV 3Tablet Extended Release 24 Hour
STRATTERA 3Capsule
ALZHEIMER'S
Printed Date:12/6/2018
Page 14 | 2019 National FormularyData Last Updated:12/6/2018
ALZHEIMER'Sgalantamine hydrobromide er 1Capsule Extended Release 24 Hour
memantine hcl 1Tablet
rivastigmine tartrate 1Capsule
NAMENDA XR 2Capsule Extended Release 24 Hour
NAMZARIC 2Capsule ER 24 Hour Therapy Pack
NAMZARIC 2Capsule Extended Release 24 Hour
EXELON 3Patch 24 Hour
NAMENDA 3Solution
ANTICONVULSANTScarbamazepine 1Suspension
carbamazepine 1Tablet
carbamazepine er 1Tablet Extended Release 12 Hour
clonazepam 1Tablet
clonazepam odt 1Tablet Disintegrating
diazepam 1Gel
divalproex sodium dr 1Tablet Delayed Release
divalproex sodium er 1Tablet Extended Release 24 Hour
epitol 1Tablet
ethosuximide 1Capsule
ethosuximide 1Solution
felbamate 1Tablet
felbamate 1Suspension
fosphenytoin sodium 1Solution
gabapentin 1Capsule
gabapentin 1Tablet
lamotrigine 1Tablet
levetiracetam 1Tablet
levetiracetam 1Solution
oxcarbazepine 1Tablet
oxcarbazepine 1Suspension
phenobarbital 1Elixir
phenobarbital 1Tablet
phenytoin 1Suspension
phenytoin sodium extended 1Capsule
primidone 1Tablet
tiagabine hydrochloride 1Tablet
topiramate 1Tablet
valproic acid 1Capsule
valproic acid 1Solution
zonisamide 1Capsule
BANZEL 2Tablet
FYCOMPA 2Tablet
LYRICA 2Capsule
ONFI 2Suspension
OXTELLAR XR 2Tablet Extended Release 24 Hour
PEGANONE 2Tablet
SABRIL 2Tablet
TROKENDI XR 2Capsule Extended Release 24 Hour
VIMPAT 2Solution
VIMPAT 2Tablet
DEPAKOTE ER 3Tablet Extended Release 24 Hour
EQUETRO 3Capsule Extended Release 12 Hour
GABITRIL 3Tablet
HORIZANT 3Tablet Extended Release
LAMICTAL ODT 3Tablet Disintegrating
LAMICTAL XR 3Kit
LYRICA CR 3Tablet Extended Release 24 Hour
POTIGA 3Tablet
Printed Date:12/6/2018
Page 15 | 2019 National FormularyData Last Updated:12/6/2018
ANTICONVULSANTSQUDEXY XR 3Capsule ER 24 Hour Sprinkle
ANTIDEPRESSANTSamitriptyline hcl 1Tablet
amoxapine 1Tablet
bupropion hcl 1Tablet
bupropion hcl xl 1Tablet Extended Release 24 Hour
chlordiazepoxide/amitriptyline 1Tablet
citalopram hydrobromide 1Solution
citalopram hydrobromide 1Tablet
clomipramine hcl 1Capsule
desipramine hcl 1Tablet
doxepin hcl 1Capsule
doxepin hcl 1Concentrate
duloxetine hcl 1Capsule Delayed Release Particles
escitalopram oxalate 1Tablet
fluoxetine hcl 1Capsule
fluoxetine hcl 1Solution
fluvoxamine maleate 1Tablet
imipramine hcl 1Tablet
imipramine pamoate 1Capsule
maprotiline hcl 1Tablet
mirtazapine 1Tablet
nefazodone hcl 1Tablet
nortriptyline hcl 1Capsule
nortriptyline hcl 1Solution
paroxetine hcl 1Tablet
paroxetine hcl er 1Tablet Extended Release 24 Hour
perphenazine/amitriptyline 1Tablet
phenelzine sulfate 1Tablet
protriptyline hcl 1Tablet
sertraline hcl 1Tablet
tranylcypromine sulfate 1Tablet
trazodone hcl 1Tablet
venlafaxine hcl 1Tablet
venlafaxine hcl er 1Capsule Extended Release 24 Hour
BRISDELLE 2Capsule
FETZIMA 2Capsule Extended Release 24 Hour
FETZIMA TITRATION PACK 2Capsule ER 24 Hour Therapy Pack
TRINTELLIX 2Tablet
VIIBRYD 2Kit
VIIBRYD 2Tablet
VIIBRYD STARTER PACK 2Kit
APLENZIN 3Tablet Extended Release 24 Hour
DESVENLAFAXINE ER 3Tablet Extended Release 24 Hour
EMSAM 3Patch 24 Hour
FORFIVO XL 3Tablet Extended Release 24 Hour
KHEDEZLA 3Tablet Extended Release 24 Hour
MARPLAN 3Tablet
PEXEVA 3Tablet
PRISTIQ 3Tablet Extended Release 24 Hour
SARAFEM 3Tablet
ANTIPARKINSONISMbenztropine mesylate 1Tablet
bromocriptine mesylate 1Tablet
carbidopa/levodopa 1Tablet
carbidopa/levodopa er 1Tablet Extended Release
carbidopa/levodopa/entacapone 1Tablet
entacapone 1Tablet
Printed Date:12/6/2018
Page 16 | 2019 National FormularyData Last Updated:12/6/2018
ANTIPARKINSONISMropinirole hcl 1Tablet
selegiline hcl 1Tablet
trihexyphenidyl hcl 1Elixir
trihexyphenidyl hcl 1Tablet
NEUPRO 2Patch 24 Hour
RYTARY 2Capsule Extended Release
AZILECT 3Tablet
MIRAPEX ER 3Tablet Extended Release 24 Hour
STALEVO 75 3Tablet
TASMAR 3Tablet
XADAGO 3Tablet
ZELAPAR 3Tablet Disintegrating
ANTI-PSYCHOTICaripiprazole 1Tablet
chlorpromazine hcl 1Tablet
clozapine 1Tablet
clozapine odt 1Tablet Disintegrating
fluphenazine hcl 1Concentrate
fluphenazine hcl 1Tablet
haloperidol 1Concentrate
haloperidol 1Tablet
haloperidol decanoate 1Solution
loxapine succinate 1Capsule
olanzapine 1Tablet
olanzapine odt 1Tablet Disintegrating
olanzapine/fluoxetine 1Capsule
perphenazine 1Tablet
quetiapine fumarate 1Tablet
quetiapine fumarate er 1Tablet Extended Release 24 Hour
risperidone 1Tablet
risperidone odt 1Tablet Disintegrating
thioridazine hcl 1Tablet
thiothixene 1Capsule
trifluoperazine hcl 1Tablet
ziprasidone hcl 1Capsule
ABILIFY MAINTENA 2Prefilled Syringe
INVEGA SUSTENNA 2Suspension
INVEGA TRINZA 2Suspension
LATUDA 2Tablet
RISPERDAL CONSTA 2Suspension Reconstituted
SAPHRIS 2Tablet Sublingual
VRAYLAR 2Capsule Therapy Pack
VRAYLAR 2Capsule
ABILIFY 3Tablet
FANAPT 3Tablet
FAZACLO 3Tablet Disintegrating
ORAP 3Tablet
REXULTI 3Tablet
SEROQUEL XR 3Tablet Extended Release 24 Hour
VERSACLOZ 3Suspension
ANXIOLYTICSalprazolam 1Tablet
alprazolam er 1Tablet Extended Release 24 Hour
alprazolam odt 1Tablet Disintegrating
buspirone hcl 1Tablet
chlordiazepoxide hcl 1Capsule
clorazepate dipotassium 1Tablet
diazepam 1Tablet
Printed Date:12/6/2018
Page 17 | 2019 National FormularyData Last Updated:12/6/2018
ANXIOLYTICSdiazepam intensol 1Concentrate
lorazepam 1Tablet
lorazepam intensol 1Concentrate
midazolam hcl 1Syrup
oxazepam 1Capsule
ALPRAZOLAM INTENSOL 3Concentrate
MISCELLANEOUSarmodafinil 1Tablet
lithium 1Solution
lithium carbonate 1Capsule
lithium carbonate er 1Tablet Extended Release
modafinil 1Tablet
BELVIQ 2Tablet
NUEDEXTA 2Capsule
QSYMIA 2Capsule Extended Release 24 Hour
SAXENDA 2Solution Pen-injector
CONTRAVE 3Tablet Extended Release 12 Hour
SOLIRIS 3Solution
XENAZINE 3Tablet
MULTIPLE SCLEROSISAMPYRA 2Tablet Extended Release 12 Hour
AUBAGIO 2Tablet
AVONEX 2Kit
BETASERON 2Kit
GILENYA 2Capsule
REBIF 2Solution Prefilled Syringe
REBIF REBIDOSE 2Solution Auto-injector
REBIF REBIDOSE TITRATIONPACK 2Solution Auto-injector
REBIF TITRATION PACK 2Solution Prefilled Syringe
TECFIDERA 2Capsule Delayed Release
COPAXONE 3Solution Prefilled Syringe
EXTAVIA 3 (ST)Kit
* Must try and fail Betaseron
SLEEPestazolam 1Tablet
eszopiclone 1Tablet
flurazepam hcl 1Capsule
quazepam 1Tablet
temazepam 1Capsule
zaleplon 1Capsule
zolpidem tartrate 1Tablet
zolpidem tartrate er 1Tablet Extended Release
BELSOMRA 2Tablet
ROZEREM 2Tablet
BUTISOL SODIUM 3Tablet
INTERMEZZO 3Tablet Sublingual
ZOLPIMIST 3Solution
DIABETESDPP-4JANUMET 2Tablet
JANUMET XR 2Tablet Extended Release 24 Hour
JANUVIA 2Tablet
JENTADUETO 2Tablet
TRADJENTA 2Tablet
ALOGLIPTIN 3Tablet
ALOGLIPTIN/METFORMIN HCL 3Tablet
KAZANO 3Tablet
KOMBIGLYZE XR 3Tablet Extended Release 24 Hour
NESINA 3Tablet
ONGLYZA 3Tablet
Printed Date:12/6/2018
Page 18 | 2019 National FormularyData Last Updated:12/6/2018
DPP-4OSENI 3Tablet
INCRETINSOZEMPIC 2Solution Pen-injector
TRULICITY 2Solution Pen-injector
VICTOZA 2Solution Pen-injector
BYDUREON 3Suspension Reconstituted ER
BYDUREON PEN 3Pen-injector
BYETTA 3Solution Pen-injector
TANZEUM 3Pen-injector
INSULINFIASP 2Solution
FIASP FLEXTOUCH 2Solution Pen-injector
HUMALOG 2Solution
HUMALOG MIX 50/50 2Suspension
HUMALOG MIX 75/25 2Suspension
HUMULIN 70/30 2Suspension
HUMULIN N 2Suspension
HUMULIN R 2Solution
HUMULIN R U-500 (CONCENTRATED) 2Solution
HUMULIN R U-500 KWIKPEN 2Solution Pen-injector
NOVOLIN 70/30 2Suspension
NOVOLIN N 2Suspension
NOVOLIN R 2Solution
NOVOLOG 2Solution
NOVOLOG FLEXPEN 2Solution Pen-injector
NOVOLOG MIX 70/30 2Suspension
NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2Suspension Pen-injector
NOVOLOG PENFILL 2Solution Cartridge
SOLIQUA 100/33 2Solution Pen-injector
XULTOPHY 100/3.6 2Solution Pen-injector
ADMELOG 3Solution
ADMELOG SOLOSTAR 3Solution Pen-injector
AFREZZA 3Powder
APIDRA 3Solution
APIDRA SOLOSTAR 3Solution Pen-injector
INSULIN: LONG ACTINGLANTUS 2Solution
LANTUS SOLOSTAR 2Solution Pen-injector
LEVEMIR 2Solution
LEVEMIR FLEXTOUCH 2Solution Pen-injector
TOUJEO SOLOSTAR 2Solution Pen-injector
TRESIBA FLEXTOUCH 2Solution Pen-injector
BASAGLAR KWIKPEN 3 (ST)Solution Pen-injector
* Must try and fail Lantus
OTHERacarbose 1Tablet
metformin hcl 1Tablet
metformin hcl er 1Tablet Extended Release 24 Hour
nateglinide 1Tablet
repaglinide 1Tablet
CYCLOSET 2Tablet
GLUCAGEN HYPOKIT 2Solution Reconstituted
GLUCAGON EMERGENCY KIT 2Kit
SYMLINPEN 120 2Solution Pen-injector
GLUMETZA 3Tablet Extended Release 24 Hour
GLYSET 3Tablet
RIOMET 3Solution
SGLT-2FARXIGA 2Tablet
INVOKAMET 2Tablet
Printed Date:12/6/2018
Page 19 | 2019 National FormularyData Last Updated:12/6/2018
SGLT-2INVOKANA 2Tablet
JARDIANCE 2Tablet
SYNJARDY 2Tablet
SYNJARDY XR 2Tablet Extended Release 24 Hour
XIGDUO XR 2Tablet Extended Release 24 Hour
SGLT-2 / DPP-4GLYXAMBI 2Tablet
QTERN 3Tablet
SULFONYLUREASglimepiride 1Tablet
glipizide er 1Tablet Extended Release 24 Hour
glipizide/metformin hcl 1Tablet
glyburide 1Tablet
glyburide micronized 1Tablet
glyburide/metformin hcl 1Tablet
TESTINGBD INSULIN SYRINGE MICROFINE IV/U-100/1ML/28G X 1/2" 2Miscellaneous
BD NEEDLE/27G X 1/2" 2Miscellaneous
BD PEN NEEDLE/MINI/ULTRAFINE/31G X 3/16" 2Miscellaneous
DEXCOM G4 PLATINUM RECEIVER KIT 2Device
DEXCOM G5 MOBILE RECEIVERKIT 2Device
FREESTYLE INSULINX BLOODGLUCOSE TEST 2Strip
FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS 2Strip
FREESTYLE LITE TEST STRIPS 2Strip
FREESTYLE TEST STRIPS 2Strip
ONETOUCH ULTRA 2 2Kit
ONETOUCH ULTRA BLUE 2Strip
ONETOUCH VERIO FLEX BLOODGLUCOSE MONITORING SYSTEM2Kit
ONETOUCH VERIO IQ BLOOD GLUCOSE MONITORING SYSTEM2Kit
ONETOUCH VERIO SYNC BLOODGLUCOSE MONITORING SYSTEM2Kit
ONETOUCH VERIO TEST STRIPS 2Strip
PRECISION PCX PLUS TEST STRIPS 2Strip
PRECISION QID TEST STRIPS 2Strip
PRECISION XTRA BLOOD GLUCOSE TEST STRIPS 2Strip
TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16" 2Miscellaneous
TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X 5/16" 2Miscellaneous
TRUEPLUS LANCETS 28G 2Miscellaneous
TRUEPLUS LANCETS 30G ULTRA THIN 2Miscellaneous
TRUEPLUS LANCETS 33G 2Miscellaneous
TRUEPLUS PEN NEEDLES 29GX12MM 2Miscellaneous
TRUEPLUS PEN NEEDLES 31GX5MM 2Miscellaneous
TRUEPLUS PEN NEEDLES 31GX6MM 2Miscellaneous
TRUEPLUS PEN NEEDLES 31GX8MM 2Miscellaneous
TRUEPLUS PEN NEEDLES 32GX4MM 2Miscellaneous
ACCU-CHEK AVIVA CONNECT 3 (ST)Kit
* Must try and fail Freestyle and OneTouch
ACCU-CHEK AVIVA PLUS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
ACCU-CHEK COMPACT PLUS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
ACCU-CHEK NANO SMARTVIEW 3 (ST)Kit
* Must try and fail Freestyle and OneTouch
Printed Date:12/6/2018
Page 20 | 2019 National FormularyData Last Updated:12/6/2018
TESTINGACCU-CHEK SMARTVIEW STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
ACCUTREND GLUCOSE 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
ADVOCATE BLOOD GLUCOSE MONITORING SYSTEM 3 (ST)Device
* Must try and fail Freestyle and OneTouch
AGAMATRIX PRESTO TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
ASSURE PLATINUM TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
ASSURE PRISM MULTI TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
BAYER BREEZE 2 TEST DISC 3 (ST)Disk
* Must try and fail Freestyle and OneTouch
BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
BAYER CONTOUR NEXT BLOODGLUCOSE TEST 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
CLEVER CHEK TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
EMBRACE BLOOD GLUCOSE TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
FORA GD20 TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
GE100 BLOOD GLUCOSE TESTSTRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
GLUCOCARD 01 SENSOR PLUS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
GLUCOCARD EXPRESSION BLOOD GLUCOSE TEST STRIPS3 (ST)Strip
* Must try and fail Freestyle and OneTouch
GLUCOCARD VITAL TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
IN TOUCH BLOOD GLUCOSE TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
NOVA MAX GLUCOSE TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
OPTIUM TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
OPTIUMEZ TEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
PRODIGY AUTOCODE BLOOD GLUCOSE MONITORING SYSTEM3 (ST)Device
* Must try and fail Freestyle and OneTouch
PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS3 (ST)Strip
* Must try and fail Freestyle and OneTouch
TRUE METRIX BLOOD GLUCOSETEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS3 (ST)Strip
* Must try and fail Freestyle and OneTouch
TRUETEST STRIPS 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
TRUETRACK SMART SYSTEM 3 (ST)Kit
* Must try and fail Freestyle and OneTouch
TRUETRACK TEST 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
UNISTRIP1 GENERIC 3 (ST)Strip
* Must try and fail Freestyle and OneTouch
TZDpioglitazone hcl 1Tablet
pioglitazone hcl/metformin hcl 1Tablet
pioglitazone hcl-glimepiride 1Tablet
ENDOCRINEADRENAL HORMONESdexamethasone 1Tablet
fludrocortisone acetate 1Tablet
hydrocortisone 1Tablet
methylprednisolone acetate 1Suspension
methylprednisolone dose pack 1Tablet Therapy Pack
prednisolone 1Solution
prednisone 1Tablet
SOLU-CORTEF 2Solution Reconstituted
H.P. ACTHAR 3Gel
ORAPRED ODT 3Tablet Disintegrating
RAYOS 3Tablet Delayed Release
Printed Date:12/6/2018
Page 21 | 2019 National FormularyData Last Updated:12/6/2018
CONTRACEPTIVESaltavera 1Tablet
alyacen 1/35 1Tablet
amethia 1Tablet
amethyst 1Tablet
apri 1Tablet
aranelle 1Tablet
aubra 1Tablet
aviane 1Tablet
azurette 1Tablet
balziva 1Tablet
briellyn 1Tablet
camrese 1Tablet
caziant 1Tablet
chateal 1Tablet
cryselle-28 1Tablet
cyclafem 1/35 1Tablet
dasetta 7/7/7 1Tablet
daysee 1Tablet
elinest 1Tablet
emoquette 1Tablet
enpresse-28 1Tablet
enskyce 1Tablet
estarylla 1Tablet
falmina 1Tablet
gianvi 1Tablet
gildagia 1Tablet
introvale 1Tablet
jolessa 1Tablet
junel 1.5/30 1Tablet
kariva 1Tablet
kelnor 1/35 1Tablet
kurvelo 1Tablet
larin fe 1.5/30 1Tablet
leena 1Tablet
lessina 1Tablet
levonest 1Tablet
levora 0.15/30-28 1Tablet
lomedia 24 fe 1Tablet
loryna 1Tablet
low-ogestrel 1Tablet
lutera 1Tablet
marlissa 1Tablet
microgestin 1/20 1Tablet
mono-linyah 1Tablet
mononessa 1Tablet
myzilra 1Tablet
necon 1/50-28 1Tablet
nortrel 1/35 1Tablet
ocella 1Tablet
orsythia 1Tablet
philith 1Tablet
pimtrea 1Tablet
pirmella 7/7/7 1Tablet
portia-28 1Tablet
previfem 1Tablet
quasense 1Tablet
reclipsen 1Tablet
Printed Date:12/6/2018
Page 22 | 2019 National FormularyData Last Updated:12/6/2018
CONTRACEPTIVESsprintec 28 1Tablet
sronyx 1Tablet
syeda 1Tablet
tilia fe 1Tablet
tri-estarylla 1Tablet
tri-linyah 1Tablet
trinessa 1Tablet
tri-previfem 1Tablet
tri-sprintec 1Tablet
trivora-28 1Tablet
velivet 1Tablet
vestura 1Tablet
viorele 1Tablet
wera 1Tablet
wymzya fe 1Tablet Chewable
zarah 1Tablet
zenchent 1Tablet
zovia 1/35e 1Tablet
LO LOESTRIN FE 2Tablet
NUVARING 2Ring
OGESTREL 2Tablet
SKYLA 2Intrauterine Device
TAYTULLA 2Capsule
BEYAZ 3Tablet
GENERESS FE 3Tablet Chewable
NATAZIA 3Tablet
ORTHO TRI-CYCLEN LO 3Tablet
QUARTETTE 3Tablet
SAFYRAL 3Tablet
ESTROGENSesterified estrogens/methyltestosterone hs 1Tablet
estradiol 1Patch Weekly
estradiol/norethindrone acetate 1Tablet
jinteli 1Tablet
COMBIPATCH 2Patch Twice Weekly
DIVIGEL 2Gel
DUAVEE 2Tablet
ESTRING 2Ring
MINIVELLE 2Patch Twice Weekly
PREMARIN 2Cream
PREMARIN 2Tablet
PREMPHASE 2Tablet
PREMPRO 2Tablet
ALORA 3Patch Twice Weekly
ANGELIQ 3Tablet
CLIMARA PRO 3Patch Weekly
ESTRACE 3Cream
ESTROGEL 3Gel
FEMHRT LOW DOSE 3Tablet
PREFEST 3Tablet
VAGIFEM 3Tablet
FERTILITY AGENTSclomiphene citrate 1Tablet
CETROTIDE 2Kit
MENOPUR 2Solution Reconstituted
NOVAREL 2Solution Reconstituted
GONAL-F 2 (PA)Solution Reconstituted
* Based on Clinical Indications Only
Printed Date:12/6/2018
Page 23 | 2019 National FormularyData Last Updated:12/6/2018
FERTILITY AGENTSGANIRELIX ACETATE 3Solution
HUMAN CHORIONIC GONADOTROPIN 3Powder
PREGNYL W/DILUENT BENZYLALCOHOL/NACL 3Solution Reconstituted
BRAVELLE 3 (PA)Solution Reconstituted
* Must try and fail Gonal-F
FOLLISTIM AQ 3 (PA)Solution
* Must try and fail Gonal-F
MISCELLANEOUScabergoline 1Tablet
calcitriol 1Capsule
desmopressin acetate 1Solution
desmopressin acetate 1Tablet
ADDYI 2Tablet
PROGESTINScamila 1Tablet
errin 1Tablet
heather 1Tablet
jencycla 1Tablet
jolivette 1Tablet
lyza 1Tablet
nora-be 1Tablet
norethindrone 1Tablet
progesterone 1Capsule
ENDOMETRIN 2Insert
CRINONE 3Gel
TESTOSTERONEandroxy 1Tablet
danazol 1Capsule
oxandrolone 1Tablet
testosterone cypionate 1Solution
ANDROGEL 2Gel
ANDROGEL PUMP 2Gel
ANDROID 3Capsule
DEPO-TESTOSTERONE 3Solution
STRIANT 3Miscellaneous
TESTOPEL 3Pellet
TESTRED 3Capsule
ANDRODERM 3 (ST)Patch 24 Hour
* Must try and fail Androgel 1.62%
AXIRON 3 (ST)Solution
* Must try and fail Androgel 1.62%
FORTESTA 3 (ST)Gel
* Must try and fail Androgel 1.62%
NATESTO 3 (ST)Gel
* Must try and fail Androgel 1.62%
TESTIM 3 (ST)Gel
* Must try and fail Androgel 1.62%
TESTOSTERONE 3 (ST)Gel
* Must try and fail Androgel 1.62%
TESTOSTERONE PUMP 3 (ST)Gel
* Must try and fail Androgel 1.62%
VOGELXO 3 (ST)Gel
* Must try and fail Androgel 1.62%
VOGELXO PUMP 3 (ST)Gel
* Must try and fail Androgel 1.62%
THYROIDlevothyroxine sodium 1Tablet
levoxyl 1Tablet
liothyronine sodium 1Tablet
methimazole 1Tablet
nature-throid 1Tablet
unithroid 1Tablet
ARMOUR THYROID 2Tablet
SSKI 3Solution
THYROLAR-1/4 3Tablet
Printed Date:12/6/2018
Page 24 | 2019 National FormularyData Last Updated:12/6/2018
THYROIDTIROSINT 3Capsule
GASTROINTESTINALANTIDIARRHEALSanaspaz 1Tablet Disintegrating
dicyclomine hcl 1Capsule
diphenoxylate/atropine 1Liquid
diphenoxylate/atropine 1Tablet
glycopyrrolate 1Tablet
hyoscyamine sulfate 1Solution
loperamide hcl 1Capsule
methscopolamine bromide 1Tablet
CUVPOSA 3Solution
ANTIEMETICdronabinol 1Capsule
granisetron hcl 1Tablet
meclizine hcl 1Tablet
ondansetron hcl 1Tablet
ondansetron hcl 1Solution
ondansetron odt 1Tablet Disintegrating
prochlorperazine 1Suppository
prochlorperazine maleate 1Tablet
trimethobenzamide hcl 1Capsule
BONJESTA 2Tablet Extended Release
DICLEGIS 2Tablet Delayed Release
SANCUSO 2Patch
ANZEMET 3Tablet
EMEND 3Capsule
TRANSDERM-SCOP 3Patch 72 Hour
ZUPLENZ 3Film
BOWEL EVACUANTS
CLENPIQ 2Solution
PREPOPIK 2Packet
COLYTE-FLAVOR PACKS 3Solution Reconstituted
OSMOPREP 3Tablet
SUCLEAR 3Kit
MOVIPREP 3 (ST)Solution Reconstituted
* Must try and fail Clenpiq
SUPREP BOWEL PREP KIT 3 (ST)Solution
* Must try and fail Clenpiq
DIGESTIVE ENZYMESCREON 2Capsule Delayed Release Particles
SUCRAID 2Solution
VIOKACE 2Tablet
ZENPEP 2Capsule Delayed Release Particles
PANCREAZE 3Capsule Delayed Release Particles
PERTZYE 3Capsule Delayed Release Particles
H2 ANTAGONISTScimetidine 1Tablet
cimetidine hcl 1Solution
famotidine 1Tablet
famotidine 1Suspension Reconstituted
nizatidine 1Capsule
ranitidine hcl 1Tablet
ranitidine hcl 1Syrup
OTHERbalsalazide disodium 1Capsule
budesonide 1Capsule Delayed Release Particles
chlordiazepoxide hcl/clidinium bromide 1Capsule
constulose 1Solution
lactulose 1Solution
metoclopramide hcl 1Solution
Printed Date:12/6/2018
Page 25 | 2019 National FormularyData Last Updated:12/6/2018
OTHERmetoclopramide hcl 1Tablet
misoprostol 1Tablet
sulfasalazine 1Tablet
sulfasalazine 1Tablet Delayed Release
ursodiol 1Capsule
AMITIZA 2Capsule
APRISO 2Capsule Extended Release 24 Hour
ASACOL HD 2Tablet Delayed Release
BELLADONNA 2Tincture
CHENODAL 2Tablet
DELZICOL 2Capsule Delayed Release
KINEVAC 2Solution Reconstituted
LINZESS 2Capsule
MOVANTIK 2Tablet
PENTASA 2Capsule Extended Release
RELISTOR 2Solution
UCERIS 2Tablet Extended Release 24 Hour
VIBERZI 2Tablet
DIPENTUM 3Capsule
ENTEREG 3Capsule
GIAZO 3Tablet
KRISTALOSE 3Packet
LIALDA 3Tablet Delayed Release
LOTRONEX 3Tablet
RELISTOR 3Tablet
TRULANCE 3Tablet
OTHER ULCER THERAPY
lansoprazole/amoxicillin/clarithromycin 1Miscellaneous
sucralfate 1Tablet
CARAFATE 2Suspension
PYLERA 2Capsule
PROTON PUMP INHIBITORSlansoprazole 1Capsule Delayed Release
omeprazole 1Capsule Delayed Release
omeprazole/sodium bicarbonate 1Capsule
pantoprazole sodium 1Tablet Delayed Release
rabeprazole sodium 1Tablet Delayed Release
DEXILANT 3Capsule Delayed Release
NEXIUM 3Capsule Delayed Release
NEXIUM 3Packet
RECTALanucort-hc 1Suppository
colocort 1Enema
mesalamine 1Enema
CANASA 2Suppository
UCERIS 2Foam
CORTIFOAM 3Foam
ROWASA 3Kit
GROWTH HORMONES
NORDITROPIN FLEXPRO 2 (PA)Solution
* Based on Clinical Indications Only
EGRIFTA 3 (PA)Solution Reconstituted
* Must try and fail Norditropin
GENOTROPIN 3 (PA)Solution Reconstituted
* Must try and fail Norditropin
HUMATROPE 3 (PA)Solution Reconstituted
* Must try and fail Norditropin
NUTROPIN AQ NUSPIN 10 3 (PA)Solution
* Must try and fail Norditropin
Printed Date:12/6/2018
Page 26 | 2019 National FormularyData Last Updated:12/6/2018
OMNITROPE 3 (PA)Solution
* Must try and fail Norditropin
SAIZEN CLICK.EASY 3 (PA)Solution Reconstituted
* Must try and fail Norditropin
SEROSTIM 3 (PA)Solution Reconstituted
* Must try and fail Norditropin
ZOMACTON 3 (PA)Solution Reconstituted
* Must try and fail Norditropin
ZORBTIVE 3 (PA)Solution Reconstituted
* Must try and fail Norditropin
HEMATOLOGY
ARANESP ALBUMIN FREE 2Solution Prefilled Syringe
ARANESP ALBUMIN FREE 2Solution
PROCRIT 2Solution
ZARXIO 2Solution Prefilled Syringe
NEULASTA 3Solution Prefilled Syringe
EPOGEN 3 (ST)Solution
* Must try and fail Aranesp and Procrit
GRANIX 3 (ST)Solution Prefilled Syringe
* Must try and fail Zarxio
MIRCERA 3 (ST)Solution Prefilled Syringe
* Must try and fail Aranesp and Procrit
NEUPOGEN 3 (ST)Solution Prefilled Syringe
* Must try and fail Zarxio
IMMUNOSUPPRESSANTS
azathioprine 1Tablet
cyclosporine modified 1Solution
cyclosporine modified 1Capsule
gengraf 1Solution
gengraf 1Capsule
mycophenolate mofetil 1Capsule
sirolimus 1Tablet
tacrolimus 1Capsule
AZASAN 2Tablet
RAPAMUNE 2Solution
SANDIMMUNE 2Solution
ZORTRESS 2Tablet
ASTAGRAF XL 3Capsule Extended Release 24 Hour
CELLCEPT 3Suspension Reconstituted
NEORAL 3Capsule
NEORAL 3Solution
RAPAMUNE 3Tablet
SANDIMMUNE 3Capsule
INTERFERONS
ACTIMMUNE 2Solution
ALFERON N 2Solution
INTRON A W/DILUENT 2Solution Reconstituted
PEGASYS 2Solution
PEGINTRON 2Kit
PEG-INTRON REDIPEN 2Kit
SYLATRON 2Kit
MISCELLANEOUS
bupropion hcl sr 1Tablet Extended Release 12 Hour
calcitonin salmon 1Solution
cevimeline hcl 1Capsule
disulfiram 1Tablet
epinephrine 1Solution Auto-injector
epipen 2-pak 1Solution Auto-injector
epipen-jr 2-pak 1Solution Auto-injector
etidronate disodium 1Tablet
midodrine hcl 1Tablet
riluzole 1Tablet
Printed Date:12/6/2018
Page 27 | 2019 National FormularyData Last Updated:12/6/2018
CARBAGLU 2Tablet
CHANTIX CONTINUING MONTHPAK 2Tablet
EXJADE 2Tablet Soluble
VELPHORO 2Tablet Chewable
ADRENACLICK 3Solution Auto-injector
AUVI-Q 3Solution Auto-injector
EPISNAP 3Kit
FOSRENOL 3Tablet Chewable
GELCLAIR 3Gel
RENAGEL 3Tablet
RENVELA 3Packet
SALIVAMAX 3Packet
MUSCULOSKELETALANTI-INFLAMMATORYOTREXUP 2Solution Auto-injector
RASUVO 2Solution Auto-injector
ACTEMRA 2 (PA)Solution Prefilled Syringe
* Coverage based on indication.
COSENTYX 2 (PA)Solution Prefilled Syringe
* Coverage based on indication.
COSENTYX SENSOREADY PEN 2 (PA)Solution Auto-injector
* Coverage based on indication.
ENBREL SURECLICK 2 (PA)Solution Auto-injector
* Coverage based on indication.
ENTYVIO 2 (PA)Solution Reconstituted
* Coverage based on indication.
HUMIRA PEN 2 (PA)Pen-injector Kit
* Coverage based on indication.
OTEZLA 2 (PA)Tablet
* Coverage based on indication.
STELARA 2 (PA)Solution Prefilled Syringe
* Coverage based on indication.
XELJANZ 2 (PA)Tablet
* Coverage based on indication.
XELJANZ XR 2 (PA)Tablet Extended Release 24 Hour
* Coverage based on indication.
CIMZIA 3 (PA)Kit
* Coverage based on indication.
CIMZIA STARTER KIT 3 (PA)Kit
* Coverage based on indication.
ILUMYA 3 (PA)
* Coverage based on indication.
INFLECTRA 3 (PA)Solution Reconstituted
* Coverage based on indication.
KEVZARA 3 (PA)Solution Prefilled Syringe
* Coverage based on indication.
KINERET 3 (PA)Solution Prefilled Syringe
* Coverage based on indication.
OLUMIANT 3 (PA)
* Coverage based on indication.
ORENCIA 3 (PA)Solution Prefilled Syringe
* Coverage based on indication.
ORENCIA CLICKJECT 3 (PA)Solution Auto-injector
* Coverage based on indication.
REMICADE 3 (PA)Solution Reconstituted
* Coverage based on indication.
RENFLEXIS 3 (PA)Solution Reconstituted
* Coverage based on indication.
SILIQ 3 (PA)Solution Prefilled Syringe
* Coverage based on indication.
SIMPONI 3 (PA)Solution Auto-injector
* Coverage based on indication.
TALTZ 3 (PA)Solution Auto-injector
* Coverage based on indication.
TREMFYA 3 (PA)Solution Prefilled Syringe
* Coverage based on indication.
GOUT THERAPYallopurinol 1Tablet
probenecid 1Tablet
COLCRYS 2Tablet
Printed Date:12/6/2018
Page 28 | 2019 National FormularyData Last Updated:12/6/2018
GOUT THERAPYULORIC 2Tablet
MUSCLE RELAXANTSbaclofen 1Tablet
carisoprodol 1Tablet
carisoprodol/aspirin 1Tablet
carisoprodol/aspirin/codeine 1Tablet
chlorzoxazone 1Tablet
cyclobenzaprine hcl 1Tablet
dantrolene sodium 1Capsule
meprobamate 1Tablet
metaxalone 1Tablet
methocarbamol 1Tablet
orphenadrine citrate er 1Tablet Extended Release 12 Hour
tizanidine hcl 1Tablet
AMRIX 3Capsule Extended Release 24 Hour
LORZONE 3Tablet
OSTEOPOROSISalendronate sodium 1Tablet
alendronate sodium 1Solution
ibandronate sodium 1Tablet
FORTEO 2 (PA)Solution
* Based on Clinical Indications Only
ACTONEL 3Tablet
ATELVIA 3Tablet Delayed Release
BINOSTO 3Tablet Effervescent
FOSAMAX PLUS D 3Tablet
PROLIA 3 (PA)Solution
* Based on Clinical Indications Only
ONCOLOGY
anastrozole 1Tablet
bicalutamide 1Tablet
cytarabine 1Solution
exemestane 1Tablet
flutamide 1Capsule
hydroxyurea 1Capsule
imatinib mesylate 1Tablet
letrozole 1Tablet
leucovorin calcium 1Tablet
megestrol acetate 1Suspension
megestrol acetate 1Tablet
mercaptopurine 1Tablet
methotrexate 1Tablet
tamoxifen citrate 1Tablet
temozolomide 1Capsule
AFINITOR 2Tablet
AFINITOR DISPERZ 2Tablet Soluble
ALECENSA 2Capsule
BOSULIF 2Tablet
CAPRELSA 2Tablet
DROXIA 2Capsule
ELIGARD 2Kit
EMCYT 2Capsule
FARESTON 2Tablet
GILOTRIF 2Tablet
HYCAMTIN 2Capsule
ICLUSIG 2Tablet
IMBRUVICA 2Capsule
INLYTA 2Tablet
JAKAFI 2Tablet
Printed Date:12/6/2018
Page 29 | 2019 National FormularyData Last Updated:12/6/2018
LEUKERAN 2Tablet
LYSODREN 2Tablet
MATULANE 2Capsule
MEKINIST 2Tablet
MESNEX 2Tablet
NEXAVAR 2Tablet
POMALYST 2Capsule
REVLIMID 2Capsule
SPRYCEL 2Tablet
STIVARGA 2Tablet
SUTENT 2Capsule
TABLOID 2Tablet
TAFINLAR 2Capsule
TARCEVA 2Tablet
TASIGNA 2Capsule
THALOMID 2Capsule
TREXALL 2Tablet
TYKERB 2Tablet
VOTRIENT 2Tablet
XALKORI 2Capsule
ZELBORAF 2Tablet
ZOLINZA 2Capsule
ZYTIGA 2Tablet
BRAFTOVI 3
COMETRIQ 3Kit
GLEEVEC 3Tablet
MEGACE ES 3Suspension
MEKTOVI 3Tablet
SOLTAMOX 3Solution
TEMODAR 3Capsule
VIDAZA 3Suspension Reconstituted
XTANDI 3 (ST)Capsule
* Must try and fail Zytiga
OPHTHALMICANTIBIOTICSbacitracin 1Ointment
bacitracin/polymyxin b 1Ointment
ciprofloxacin hcl 1Solution
erythromycin 1Ointment
gatifloxacin 1Solution
gentamicin sulfate 1Ointment
gentamicin sulfate 1Solution
levofloxacin 1Solution
moxifloxacin hcl 1Solution
neomycin/bacitracin/polymyxin 1Ointment
neomycin/polymyxin/bacitracin/hydrocortisone 1Ointment
neomycin/polymyxin/dexamethasone 1Suspension
neomycin/polymyxin/dexamethasone 1Ointment
neomycin/polymyxin/gramicidin 1Solution
neomycin/polymyxin/hc 1Solution
neomycin/polymyxin/hydrocortisone 1Suspension
ofloxacin 1Solution
sodium sulfacetamide 1Solution
sulfacetamide sodium/prednisolone sodium phosphate 1Solution
tobramycin sulfate 1Solution
tobramycin/dexamethasone 1Suspension
trimethoprim sulfate/polymyxin b sulfate 1Solution
AZASITE 2Solution
Printed Date:12/6/2018
Page 30 | 2019 National FormularyData Last Updated:12/6/2018
ANTIBIOTICSCIPRODEX 2Suspension
MOXEZA 2Solution
NATACYN 2Suspension
TOBRADEX 2Ointment
TOBRADEX ST 2Suspension
ZYLET 2Suspension
BESIVANCE 3Suspension
BLEPH-10 3Solution
BLEPHAMIDE 3Suspension
BLEPHAMIDE S.O.P. 3Ointment
CILOXAN 3Ointment
CIPRO HC 3Suspension
COLY-MYCIN S 3Suspension
PRED-G S.O.P. 3Ointment
TOBREX 3Ointment
BETA BLOCKERSbetaxolol hcl 1Solution
carteolol hcl 1Solution
levobunolol hcl 1Solution
metipranolol 1Solution
timolol maleate 1Solution
BETIMOL 3Solution
BETOPTIC-S 3Suspension
ISTALOL 3Solution
TIMOPTIC OCUDOSE 3Solution
GLAUCOMAdorzolamide hcl 1Solution
dorzolamide hcl/timolol maleate 1Solution
latanoprost 1Solution
pilocarpine hcl 1Solution
AZOPT 2Suspension
COMBIGAN 2Solution
LUMIGAN 2Solution
MITOSOL 2Kit
RHOPRESSA 2Solution
TRAVATAN Z 2Solution
VYZULTA 2Solution
COSOPT PF 3Solution
RESCULA 3Solution
SIMBRINZA 3Suspension
XALATAN 3Solution
ZIOPTAN 3Solution
MISCELLANEOUSaltacaine 1Solution
apraclonidine 1Solution
azelastine hcl 1Solution
brimonidine tartrate 1Solution
cromolyn sodium 1Solution
epinastine hcl 1Solution
flucaine 1Solution
fluorescein-benoxinate 1Solution
proparacaine hcl 1Solution
tetravisc 1Solution
trifluridine 1Solution
ALPHAGAN P 2Solution
BEPREVE 2Solution
CYSTARAN 2Solution
PAZEO 2Solution
Printed Date:12/6/2018
Page 31 | 2019 National FormularyData Last Updated:12/6/2018
MISCELLANEOUSRESTASIS 2Emulsion
RESTASIS MULTIDOSE 2Emulsion
XIIDRA 2Solution
ZIRGAN 2Gel
ALOCRIL 3Solution
EMADINE 3Solution
IOPIDINE 3Solution
LASTACAFT 3Solution
PATADAY 3Solution
PATANOL 3Solution
VIROPTIC 3Solution
MYDRIATICSatropine sulfate 1Solution
cyclopentolate hcl 1Solution
homatropine hbr 1Solution
tropicamide 1Solution
CYCLOGYL 3Solution
PAREMYD 3Solution
NSAIDSbromfenac 1Solution
diclofenac sodium 1Solution
flurbiprofen sodium 1Solution
ketorolac tromethamine 1Solution
ILEVRO 2Suspension
NEVANAC 2Suspension
PROLENSA 2Solution
ACUVAIL 3Solution
STEROIDSdexamethasone sodium phosphate 1Solution
fluorometholone 1Suspension
prednisolone acetate 1Suspension
ALREX 2Suspension
DUREZOL 2Emulsion
LOTEMAX 2Gel
LOTEMAX 2Ointment
LOTEMAX 2Suspension
PRED MILD 2Suspension
FLAREX 3Suspension
FML FORTE 3Suspension
MAXIDEX 3Suspension
VASOCONSTRICTORCYCLOMYDRIL 3Solution
OTICMISCELLANEOUSacetasol hc 1Solution
acetic acid 1Solution
ciprofloxacin 1Solution
hydrocortisone/acetic acid 1Solution
CETRAXAL 3Solution
RESPIRATORYANTIHISTAMINEScarbinoxamine maleate 1Tablet
carbinoxamine maleate 1Solution
clemastine fumarate 1Tablet
cyproheptadine hcl 1Tablet
desloratadine 1Tablet
diphenhydramine hcl 1Elixir
hydroxyzine hcl 1Tablet
hydroxyzine hcl 1Syrup
hydroxyzine pamoate 1Capsule
levocetirizine dihydrochloride 1Tablet
Printed Date:12/6/2018
Page 32 | 2019 National FormularyData Last Updated:12/6/2018
ANTIHISTAMINESpromethazine hcl 1Tablet
cyproheptadine hcl 3Syrup
SEMPREX-D 3Capsule
ANTITUSSIVEbenzonatate 1Capsule
bromfed dm 1Syrup
guaifenesin/codeine 1Solution
hydrocodone bitartrate/homatropine methylbromide 1Tablet
hydrocodone polistirex/chlorpheniramine polistirex 1Suspension Extended Release
promethazine vc/codeine 1Syrup
promethazine-dm 1Syrup
TUSSICAPS 2Capsule Extended Release 12 Hour
ASTHMA/COPDipratropium bromide/albuterol sulfate 1Solution
montelukast sodium 1Tablet
montelukast sodium 1Packet
zafirlukast 1Tablet
ADVAIR DISKUS 2Aerosol Powder Breath Activated
ADVAIR HFA 2Aerosol
ANORO ELLIPTA 2Aerosol Powder Breath Activated
ATROVENT HFA 2Aerosol Solution
BREO ELLIPTA 2Aerosol Powder Breath Activated
COMBIVENT RESPIMAT 2Aerosol Solution
DALIRESP 2Tablet
INCRUSE ELLIPTA 2Aerosol Powder Breath Activated
KALYDECO 2Tablet
PULMOZYME 2Solution
SPIRIVA RESPIMAT 2Aerosol Solution
STIOLTO RESPIMAT 2Aerosol Solution
SYMBICORT 2Aerosol
XOLAIR 2Solution Reconstituted
AIRDUO RESPICLICK 113/14 3Aerosol Powder Breath Activated
DULERA 3Aerosol
TUDORZA PRESSAIR 3Aerosol Powder Breath Activated
UTIBRON NEOHALER 3Capsule
ZYFLO 3Tablet
BETA AGONISTSalbuterol sulfate 1Syrup
albuterol sulfate 1Nebulization Solution
albuterol sulfate 1Tablet
levalbuterol hcl 1Nebulization Solution
metaproterenol sulfate 1Tablet
metaproterenol sulfate 1Syrup
terbutaline sulfate 1Tablet
ARCAPTA NEOHALER 2Capsule
PERFOROMIST 2Nebulization Solution
PROAIR HFA 2Aerosol Solution
PROAIR RESPICLICK 2Aerosol Powder Breath Activated
STRIVERDI RESPIMAT 2Aerosol Solution
VENTOLIN HFA 2Aerosol Solution
FORADIL AEROLIZER 3Capsule
PROVENTIL HFA 3Aerosol Solution
XOPENEX HFA 3Aerosol
INHALED STEROIDSbudesonide 1Suspension
ARNUITY ELLIPTA 2Aerosol Powder Breath Activated
FLOVENT DISKUS 2Aerosol Powder Breath Activated
FLOVENT HFA 2Aerosol
PULMICORT FLEXHALER 2Aerosol Powder Breath Activated
Printed Date:12/6/2018
Page 33 | 2019 National FormularyData Last Updated:12/6/2018
INHALED STEROIDSQVAR 2Aerosol Solution
TRELEGY ELLIPTA 2Aerosol Powder Breath Activated
ALVESCO 3Aerosol Solution
ASMANEX TWISTHALER 120 METERED DOSES 3Aerosol Powder Breath Activated
NASAL STEROIDSflunisolide 1Solution
fluticasone propionate 1Suspension
DYMISTA 2Suspension
QNASL 2Aerosol Solution
BECONASE AQ 3Suspension
NASONEX 3Suspension
OMNARIS 3Suspension
ZETONNA 3Aerosol Solution
OTHERazelastine hcl 1Solution
ipratropium bromide 1Solution
theophylline 1Solution
theophylline er 1Tablet Extended Release 12 Hour
AEROCHAMBER PLUS FLOW-VU/SMALL MASK 2Miscellaneous
AEROCHAMBER/FLOWSIGNAL 2Miscellaneous
PATANASE 3Solution
PAHsildenafil citrate 1Tablet
ADEMPAS 2Tablet
LETAIRIS 2Tablet
TRACLEER 2Tablet
ADCIRCA 3Tablet
TOPICALACNEadapalene 1Gel
benzoyl peroxide 1Foam
claravis 1Capsule
clindamycin phosphate 1Lotion
clindamycin phosphate 1Swab
clindamycin phosphate 1Foam
clindamycin phosphate 1Gel
clindamycin phosphate 1Solution
clindamycin phosphate/tretinoin 1Gel
clindamycin/benzoyl peroxide 1Gel
erygel 1Gel
erythromycin 1Gel
erythromycin 1Solution
erythromycin/benzoyl peroxide 1Gel
myorisan 1Capsule
pr benzoyl peroxide wash 1Liquid
sodium sulfacetamide/sulfur 1Lotion
sodium sulfacetamide/sulfur cleanser in urea 1Emulsion
tretinoin 1Cream
tretinoin 1Gel
tretinoin microsphere 1Gel
ABSORICA 2Capsule
ACANYA 2Gel
ONEXTON 2Gel
TAZORAC 2Gel
TAZORAC 2Cream
ACCUCAINE 3Kit
ACZONE 3Gel
ATRALIN 3Gel
AVAGE 3Cream
AVAR 3Pad
Printed Date:12/6/2018
Page 34 | 2019 National FormularyData Last Updated:12/6/2018
ACNEAZELEX 3Cream
BENZACLIN WITH PUMP 3Gel
BENZEFOAM 3Foam
CLINDAGEL 3Gel
DIFFERIN 3Lotion
EPIDUO 3Gel
FABIOR 3Foam
INOVA 3Kit
NUOX 3Gel
VELTIN 3Gel
ANESTHETICSlidocaine 1Ointment
lidocaine hcl/hydrocortisone acetate 1Cream
lidocaine/prilocaine 1Cream
NOVACORT 3Gel
PLIAGLIS 3Cream
ANTIBACTERIALSmupirocin 1Ointment
SULFAMYLON 2Cream
ALCORTIN A 3Gel
ALTABAX 3Ointment
CENTANY 3Ointment
ANTIFUNGALSciclopirox 1Suspension
ciclopirox 1Shampoo
ciclopirox 1Gel
clotrimazole 1Solution
clotrimazole 1Cream
clotrimazole/betamethasone dipropionate 1Lotion
clotrimazole/betamethasone dipropionate 1Cream
econazole nitrate 1Cream
ketoconazole 1Shampoo
ketoconazole 1Cream
nystatin 1Ointment
nystatin/triamcinolone 1Cream
JUBLIA 2Solution
LUZU 2Cream
ECOZA 3Foam
ERTACZO 3Cream
EXELDERM 3Solution
EXODERM 3Lotion
KERYDIN 3Solution
MENTAX 3Cream
NAFTIN 3Gel
NAFTIN 3Cream
OXISTAT 3Lotion
OXISTAT 3Cream
ANTIPSORIATICacitretin 1Capsule
calcipotriene 1Cream
calcipotriene 1Solution
calcipotriene 1Ointment
calcitrene 1Ointment
dritho-creme hp 1Cream
selenium sulfide 1Shampoo
selenium sulfide 1Lotion
sodium sulfacetamide 1Shampoo
sodium sulfacetamide wash 1Liquid
ENSTILAR 2Foam
Printed Date:12/6/2018
Page 35 | 2019 National FormularyData Last Updated:12/6/2018
ANTIPSORIATICTACLONEX 2Suspension
EPIFOAM 3Foam
OVACE PLUS 3Shampoo
PRAMOSONE 3Lotion
PRAMOSONE 3Cream
PRAMOSONE E 3Cream
SORILUX 3Foam
TERSI FOAM 3Foam
ZITHRANOL-RR 3Cream
ANTIVIRALSacyclovir 1Ointment
DENAVIR 3Cream
XERESE 3Cream
CORTICOSTEROIDS HIGH POTENCYamcinonide 1Lotion
amcinonide 1Ointment
amcinonide 1Cream
augmented betamethasone dipropionate 1Cream
betamethasone dipropionate 1Lotion
betamethasone dipropionate 1Ointment
betamethasone valerate 1Ointment
desoximetasone 1Gel
desoximetasone 1Ointment
desoximetasone 1Cream
diflorasone diacetate 1Cream
fluocinonide 1Ointment
fluocinonide 1Cream
fluocinonide emulsified base 1Cream
triamcinolone acetonide 1Cream
APEXICON E 3Cream
HALOG 3Cream
HALOG 3Ointment
TOPICORT 3Liquid
TOPICORT 3Ointment
CORTICOSTEROIDS VERY HIGH POTENCYclobetasol propionate 1Shampoo
clobetasol propionate 1Solution
clobetasol propionate 1Ointment
clobetasol propionate emollient 1Cream
halobetasol propionate 1Ointment
CLOBEX 3Liquid
MISCELLANEOUSfluorouracil 1Cream
imiquimod 1Cream
malathion 1Lotion
permethrin 1Cream
podofilox 1Solution
silver sulfadiazine 1Cream
thermazene 1Cream
CARAC 2Cream
ELIDEL 2Cream
EUCRISA 2Ointment
LINDANE 2Shampoo
PICATO 2Gel
REGRANEX 2Gel
SANTYL 2Ointment
TOLAK 2Cream
ALDARA 3Cream
BIONECT 3Cream
Printed Date:12/6/2018
Page 36 | 2019 National FormularyData Last Updated:12/6/2018
MISCELLANEOUSBIONECT 3Gel
EURAX 3Cream
PROTOPIC 3Ointment
ZYCLARA 3Cream
ZYCLARA PUMP 3Cream
ROSACEAmetronidazole 1Cream
metronidazole 1Lotion
metronidazole 1Gel
rosadan 1Cream
rosadan 1Gel
FINACEA 2Foam
MIRVASO 2Gel
RHOFADE 2Cream
NORITATE 3Cream
SOOLANTRA 3Cream
TOPICAL CORTICOSTEROIDS LOW POTENCYalclometasone dipropionate 1Ointment
alclometasone dipropionate 1Cream
desonide 1Ointment
desonide 1Lotion
fluocinolone acetonide 1Solution
fluocinolone acetonide 1Cream
hydrocortisone 1Cream
CAPEX 3Shampoo
DESONATE 3Gel
SYNALAR CREAM KIT 3Kit
TEXACORT 3Solution
VERDESO 3Foam
TOPICAL CORTICOSTEROIDS MEDIUM POTENCY
betamethasone valerate 1Lotion
betamethasone valerate 1Cream
fluticasone propionate 1Cream
fluticasone propionate 1Lotion
hydrocortisone butyrate 1Solution
hydrocortisone butyrate 1Cream
mometasone furoate 1Solution
mometasone furoate 1Ointment
prednicarbate 1Ointment
triderm 1Cream
CLODERM PUMP 3Cream
CORDRAN 3Cream
KENALOG 3Aerosol Solution
LOCOID 3Lotion
TRIANEX 3Ointment
UROLOGICALANTISPASMODICSbethanechol chloride 1Tablet
flavoxate hcl 1Tablet
oxybutynin chloride 1Syrup
oxybutynin chloride 1
oxybutynin chloride 1Tablet
oxybutynin chloride er 1Tablet Extended Release 24 Hour
tolterodine tartrate 1Tablet
tolterodine tartrate er 1Capsule Extended Release 24 Hour
trospium chloride 1Tablet
MYRBETRIQ 2Tablet Extended Release 24 Hour
TOVIAZ 2Tablet Extended Release 24 Hour
VESICARE 2Tablet
ENABLEX 3Tablet Extended Release 24 Hour
Printed Date:12/6/2018
Page 37 | 2019 National FormularyData Last Updated:12/6/2018
ANTISPASMODICSGELNIQUE 3Gel
OXYTROL 3Patch Twice Weekly
BPHfinasteride 1Tablet
tamsulosin hcl 1Capsule
RAPAFLO 2Capsule
AVODART 3Capsule
JALYN 3Capsule
ERECTILE DYSFUNCTIONsildenafil citrate 1Tablet
tadalafil 1Tablet
CIALIS 3Tablet
VIAGRA 3Tablet
LEVITRA 3 (ST)Tablet
* Must try and fail generic Viagra and generic Cialis
MUSE 3 (ST)Pellet
* Must try and fail generic Viagra and generic Cialis
STAXYN 3 (ST)Tablet Disintegrating
* Must try and fail generic Viagra and generic Cialis
STENDRA 3 (ST)Tablet
* Must try and fail generic Viagra and generic Cialis
VACCINES
BOOSTRIX 2Suspension
ENGERIX-B 2Suspension
HAVRIX 2Suspension
INFANRIX 2Suspension
PNEUMOVAX 23/1 DOSE 2Injectable
PREVNAR 13 2Suspension
RECOMBIVAX HB 2Suspension
ROTATEQ 2Solution
SHINGRIX 2Suspension Reconstituted
TWINRIX 2Suspension
CERVARIX 3Suspension
GARDASIL 3Suspension
VITAMINS/ELECTROLYTES
calcium acetate 1Capsule
dialyvite 1Tablet
fluoride 1Tablet Chewable
folic acid 1Tablet
klor-con 1Packet
omega-3 acid ethyl esters 1
potassium chloride 1Solution
potassium chloride cr 1Tablet Extended Release
DUET DHA 400 2Miscellaneous
ELITE-OB 2Tablet
NASCOBAL 2Solution
OB COMPLETE 2Tablet
OBSTETRIX DHA 2Miscellaneous
PHOSLYRA 2Solution
PNV PRENATAL PLUS MULTIVITAMIN 2Tablet
PRENATABS RX 2Tablet
K-TAB 3Tablet Extended Release
Printed Date:12/6/2018
Page 38 | 2019 National FormularyData Last Updated:12/6/2018
Printed Date:12/6/2018
Page 39 | 2019 National FormularyData Last Updated:12/6/2018