Post on 27-Mar-2020
Scripps Health Formulary Administered by MedImpact
Effective October 2017
ForewordThis document represents the efforts of the MedImpactHealthcare Systems Pharmacy and Therapeutics (P & T) andFormulary Committees to provide physicians and pharmacistswith a method to evaluate the safety, efficacy and cost-effectiveness of commercially available drug products. Astructured approach to the drug selection process is essential inensuring continuing patient access to rational drug therapies.
This is accomplished through the auspices of the MedImpact P& T and Formulary Committees. These committees meetquarterly and more often as warranted to ensure clinicalrelevancy of the Formulary. To accommodate changes to thisdocument, updates are made accessible as necessary.
Access to the most current version of the Portfolio HighFormulary can be obtained by visitingwww.MedImpact.com.
The MedImpact P & T and Formulary Committees use thefollowing criteria in the evaluation of drug selection for theMarketplace Exchange Standard Formulary:• Drug safety profile• Drug efficacy• Comparison of relevant therapeutic benefits to currentformulary agents of similar use, and to minimize therapeuticduplication where possible
• Cost-effectiveness relative to comparable therapies
How to Use the FormularyThe Formulary is a list of medications available to MedImpactmembers under their pharmacy benefit. All drugs are listed bytheir generic names and most common proprietary (branded)name. The Formulary may be accessed by using the index,either by generic or proprietary name and by therapeutic drugcategory. In situations where an FDA-approved genericequivalent is available, brand names are listed for referencepurposes only, and do not denote coverage for the brand, unlessspecifically noted.
All drugs are listed in each category in alphabetical order bygeneric name. Where an FDA-approved generic is available forthe listed generic name, the generic name is .
For certain agents within the Formulary, a recommendedprescribing guideline may apply. These are denoted throughoutthe document using the following symbols:
Symbol Guideline Description
AGE Age Edit Coverage may depend on patientage
G Gender Edit Coverage may depend on patientgender
PA PriorAuthorization
Requires specific physician requestprocess
QL QuantityLimit
Coverage may be limited to specificquantities per prescription and/ortime period
ST Step Therapy Coverage may depend on previoususe of another drug
Please refer to the prescribing guideline appendix within thisdocument for details regarding specific agents.
Benefit Coverage and LimitationsThis printed Formulary does not provide information regardingthe specific coverage and limitations an individual member maybe subject to. Many members have specific benefit inclusions,exclusions, copays, or a lack of coverage, which are notreflected in the Formulary.
The Formulary applies only to outpatient drugs provided tomembers, and does not apply to medications used in inpatientsettings. If a member has any specific questions regarding theircoverage, they should contact their Plan Sponsor or MedImpactat (800) 788-2949.
Depending upon a member’s specificbenefit parameters, the following topicsmay apply:1.Generic SubstitutionWhen available, FDA-approved generic drugs are to beused in all situations, regardless of the brand nameindicated. The generic names are Bolded in the formularylisting wherever an FDA-approved generic drug product isavailable. Greater economy is realized through the use of
804 Portfolio High Formulary Page 1 of 133
generic equivalents. This policy is not meant to preclude orsupplant any state statutes that may exist. All drugs that areor become available generically are subject to review byMedImpact’s Pharmacy and Therapeutics Committee.MedImpact approves such multi-source drugs for additionto the MAC list based on the following criteria:• A multi-source drug product manufactured by at leastone (1) nationally marketed company.
• At least one (1) of the generic manufacturer’s productsmust have an “A” rating or the generic product has beendetermined to be unassociated with efficacy, safety orbioequivalency concerns by the MedImpact P & TCommittee.
• Drug product will be approved for generic substitutionby the MedImpact P & T Committee.
This list is reviewed and updated periodically based on theclinical literature and pharmacokinetic characteristics ofcurrently available versions of these drug products. If a member or physician requests a brand name product inlieu of an approved generic, the member, based upon theircoverage, will typically be required to pay the difference incost between the brand and the generic. If a physiciandetermines that there is a documented medical need for thebrand equivalent, a request for coverage may be made usingthe medication request process.
2.Tier Benefit DesignThe Formulary may be applied to a tier benefit design,where the member shares the cost of prescription drugtherapy based on the drug’s tier and copayment orcoinsurance. In most instances, generically available drugswill be covered in a separate lower tier (low copay),preferred branded drugs listed on the Formulary will becovered under a higher tier, and branded drugs not on theFormulary will be covered under a separate non-preferredbranded drug copay tier. Specialty drugs will be coveredunder the highest tier (highest copay). Essential healthbenefit/preventative medications, if available on your plansformulary (applies to new and non-grandfathered plans),will be covered without cost sharing (zero copay). Tier Definitions
Tier 0: EHB Zero Copay/PreventativeTier 1: Preferred generic medications (formulary
agents)Tier 2: Preferred brand medications (formulary
agents)Tier 3: Non-preferred medications (non-formulary
agents)
3.Medication Request ProcessDepending upon plan benefit design, a medication requestprocess may apply as follows:A.Coverage Exceptions
Drugs that are listed in the Formulary with associatedPrior Authorization (PA) require evaluation, perMedImpact P & T Committee Prior Authorizationguidelines prior to dispensing at a pharmacy. Eachrequest will be reviewed on an individual patient needbasis. If the request does not meet the guidelinesestablished by the P & T Committee, the request willnot be approved and alternative therapy may berecommended.
B.Obtaining CoverageCoverage, questions or information regarding themedication request or formulary process may beobtained by:1. Faxing a completed Medication Request Form to
MedImpact at (858) 790-7100.2. Contacting MedImpact at (800) 788-2949 and
providing all necessary information requested.MedImpact will provide an authorization number,specific for the medical need, for all approvedrequests. Non-approved requests may be appealed.The prescriber must provide information to support theappeal on the basis of medical necessity. PriorAuthorization is generally not available for drugs thatare specifically excluded by benefit design.
4.General Exclusions
A.Over the Counter (OTC) medications or theirequivalents, unless the individual's pharmacy benefitoffers coverage of OTC medications.
B. Drugs specifically listed as not covered.C. Any drug products used for cosmetic purposes.D. Experimental drug products or any drug product used
in an experimental manner.E. Replacement of lost or stolen medication.F. Non self-administered injectable drug products unless
otherwise specified in the Formulary listing.G. Foreign sourced drugs or drugs not approved by the
United States Food & Drug Administration, except incertain cases of drug shortage, when allowed under theindividual's pharmacy benefit.
The P & T and Formulary Committees recognize that notall medical needs can be met with this document andencourage inquiries about alternative therapies.
5.Pharmacist and Physician Communication
804 Portfolio High Formulary Page 2 of 133
The Formulary is a tool to promote cost-effectiveprescription drug use. The P & T and FormularyCommittees have made every attempt to create a documentthat meets all therapeutic needs; however, the art ofmedicine makes this a formidable task. MedImpactwelcomes the participation of physicians, pharmacists, andancillary medical providers, in this dynamic process.Physicians and pharmacists are highly encouraged to directany suggestions, comments or formulary additions toMedImpact at the following address: Chairperson, Pharmacy & Therapeutics CommitteeMedImpact Healthcare Systems, Inc.10181 Scripps Gateway CourtSan Diego, CA 92131
804 Portfolio High Formulary Page 3 of 133
Attn: Prior Authorization Department10181 Scripps Gateway CourtSan Diego, CA 92131Phone: (800) 788-2949Fax: (858) 790-7100
DO NOT WRITE IN BLOCKED AREAS FOR INTERNAL USE ONLYContacted: Approved:
Physician: Denied:
Pharmacy: Returned:
Patient: PA #:
Medication Request FormMedImpact Healthcare systems, Inc.
Instructions:This form is to be used by participating physicians and providers to obtain coverage for a non-formulary drug for which there is nosuitable alternative available. Please complete this form and fax to MedImpact Healthcare Systems, Inc. at (858) 790-7100 orplease call (800) 788-2949 with this information. If you have any questions regarding this process, please contact MedImpact’sCustomer Service at (800) 788-2949. Review Criteria:The following guidelines are used in reviewing medication requests:1.The use of Formulary Drug Products is contraindicated in the patient.2.The patient has failed an appropriate trial of Formulary or related agents.3.The choices available in the Formulary are not suited for the present patient care need and the drug selected is required forpatient safety.
4.The use of a Formulary Drug Product may provoke an underlying medical condition, which would be detrimental to patientcare
Medication Request Information (please complete each section of this form prior to transmittal): PATIENT NAME (REQUIRED):
PATIENT'S HEALTH PLAN (REQUIRED):
PATIENT ID # (REQUIRED):
PHYSICIAN NAME/SPECIALTY:
PHYSICIAN ID#/DEA#:
PATIENT DOB (REQUIRED):
PHYSICIAN AREA CODE AND TELEPHONE NUMBER:
DIAGNOSIS (REQUIRED):
PHYSICIAN AREA CODE AND FAX NUMBER (REQUIRED):
PHARMACY USED BY MEMBER:
PHARMACY AREA CODE AND TELEPHONE NUMBER:
DRUG REQUESTED:
QUANTITY (PER MONTH):
DOSE:
LENGTH OF TREATMENT (PLEASE BE SPECIFIC):
STRENGTH:
DOSAGE FORM (e.g., ORAL, INJECTION):
REASON FOR MEDICATION REQUEST (PLEASE BE SPECIFIC, GIVE DETAIL):
OTHER MEDICATIONS TRIED AND/OF FAILED (PLEASE BE SPECIFIC, GIVE DETAIL INCLUDING REASON FOR FAILURE):
OTHER PERTINENT HISTORY (RELATIVE OR PERTAINING TO THIS REQUEST):
ALLERGY2ND GEN ANTIHISTAMINE & DECONGESTANTCOMBINATIONST3DESLORATADINE/PSEUD
OEPHEDRINECLARINEX-D 12HOUR
ST, QL
T1FEXOFENADINE/PSEUDOEPHEDRINE
ALLEGRA-D 24HOUR (180-240MG)(TAB ER 24H)
T3 PSEUDOEPHEDRINEHCL/ACRIVAS
SEMPREX-D
ALLERGENIC EXTRACTS, THERAPEUTICST2GR POL-ORC/SW
VER/RYE/KENT/TIMORALAIR (100 IR)(TAB SUBL)
PA
T3GR POL-ORC/SWVER/RYE/KENT/TIM
ORALAIR (100-300IR) (TAB SUBL)
PA
T2GR POL-ORC/SWVER/RYE/KENT/TIM
ORALAIR (300 IR)(TAB SUBL)
PA
T2GRASS POLLEN-TIMOTHY, STANDARD
GRASTEK PA
T2WEED POLLEN-SHORTRAGWEED
RAGWITEK PA
ANTIHISTAMINES - 1ST GENERATIONT1CARBINOXAMINEMALEATE
CLISTIN AGE
T3CARBINOXAMINEMALEATE
KARBINAL ER ST,AGE,QL
T3CARBINOXAMINEMALEATE
RYVENT ST,AGE,QL
T1CLEMASTINEFUMARATE
TAVIST
T1CYPROHEPTADINE HCLPERIACTINT1HYDROXYZINE HCL ATARAXT1HYDROXYZINEPAMOATE
VISTARIL
T1PROMETHAZINE HCL PHENERGANT1PROMETHAZINE HCL PHENERGAN VC
ANTIHISTAMINES - 2ND GENERATIONT1CETIRIZINE HCL ZYRTEC (1 MG/ML)
(SOLUTION)T1DESLORATADINE CLARINEX (2.5 MG)
(TAB RAPDIS)ST, QL
T3DESLORATADINE CLARINEX (2.5MG/5ML) (SYRUP)
ST, QL
T1DESLORATADINE CLARINEX (5 MG)(TAB RAPDIS)
ST, QL
T1DESLORATADINE CLARINEX (5 MG)(TABLET)
QL
T1LEVOCETIRIZINEDIHYDROCHLORIDE
XYZAL (2.5MG/5ML)(SOLUTION)
ST, QL
T1LEVOCETIRIZINEDIHYDROCHLORIDE
XYZAL (5 MG)(TABLET)
NASAL ANTIHISTAMINET1AZELASTINE HCL ASTELIN QLT1AZELASTINE HCL ASTEPRO ST, QLT1OLOPATADINE HCL PATANASE ST, QL
NASAL ANTIHISTAMINE & ANTI-INFLAM. STEROIDCOMB.T3AZELAS/FLUTICASONE/S
OD CHLORIDTICALAST
T3AZELASTINE/FLUTICASONE
DYMISTA ST, QL
NASAL ANTI-INFLAMMATORY STEROIDST3BECLOMETHASONE
DIPROPIONATEBECONASE AQ ST, QL
T2BECLOMETHASONEDIPROPIONATE
QNASL ST, QL
T2BECLOMETHASONEDIPROPIONATE
QNASL CHILDREN ST, QL
T3CICLESONIDE OMNARIS ST, QLT3CICLESONIDE ZETONNA ST, QLT1FLUNISOLIDE NASALIDE QLT1FLUTICASONEPROPIONATE
FLONASE QL
T3 FLUTICASONE/SODCHL/SOD BICARB
TICANASE
T3 FLUTICASONE/SODCHL/SOD BICARB
TICASPRAY
T1MOMETASONEFUROATE
NASONEX QL
ANTIEMESIS/ANTIVERTIGOANTIEMETIC/ANTIVERTIGO AGENTST1APREPITANT APREPITANT (125
MG) (CAPSULE)QL
T1APREPITANT APREPITANT(125MG-80MG) (CAPDS PK)
QL
T1APREPITANT APREPITANT (40MG) (CAPSULE)
QL
T1APREPITANT APREPITANT (80MG) (CAPSULE)
QL
T2APREPITANT EMEND (125 MG)(CAPSULE)
QL
T2APREPITANT EMEND (125 MG)(SUSP RECON)
QL
T2APREPITANT EMEND (40 MG)(CAPSULE)
QL
T3DOLASETRONMESYLATE
ANZEMET (100 MG)(TABLET)
ST, QL
T3DOLASETRONMESYLATE
ANZEMET (50 MG)(TABLET)
ST, QL
T3DOXYLAMINESUCCINATE/VIT B6
DICLEGIS QL
T1DRONABINOL MARINOL ST, QLT3DRONABINOL SYNDROS ST, QLT3GRANISETRON SANCUSO ST, QLT1GRANISETRON HCL KYTRIL ST, QLT1MECLIZINE HCL ANTIVERTT3NABILONE CESAMET ST, QLT2NETUPITANT/PALONOSE
TRON HCLAKYNZEO QL
T1ONDANSETRON ZOFRAN ODTT3ONDANSETRON ZUPLENZ (4 MG)
(FILM)ST, QL
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T3ONDANSETRON ZUPLENZ (8 MG)(FILM)
ST, QL
T1ONDANSETRON HCL ZOFRAN (24 MG)(TABLET)
T1ONDANSETRON HCL ZOFRAN (4 MG)(TABLET)
T1ONDANSETRON HCL ZOFRAN (4 MG/5ML) (SOLUTION)
QL
T1ONDANSETRON HCL ZOFRAN (8 MG)(TABLET)
T1PROCHLORPERAZINE COMPAZINET1PROCHLORPERAZINEMALEATE
COMPAZINE
T1PROMETHAZINE HCL PHENERGANT3ROLAPITANT HCL VARUBI QLT1 SCOPOLAMINE TRANSDERM-SCOPT1TRIMETHOBENZAMIDEHCL
TIGAN
ASTHMA AND COPD5-LIPOXYGENASE INHIBITORST3 ZILEUTON ZYFLO ST, QLT1ZILEUTON ZYFLO CR ST, QL
ANTICHOLINERGIC, ORALLY INHALED SHORTACTINGT1 IPRATROPIUMBROMIDE
ATROVENT
T2 IPRATROPIUM BROMIDE ATROVENT HFA QL
ANTICHOLINERGICS, ORALLY INHALED LONGACTINGT3ACLIDINIUM BROMIDE TUDORZA
PRESSAIRST, QL
T3GLYCOPYRROLATE SEEBRI NEOHALER ST, QLT2 TIOTROPIUM BROMIDE SPIRIVA QLT2 TIOTROPIUM BROMIDE SPIRIVA RESPIMAT QLT3UMECLIDINIUM
BROMIDEINCRUSE ELLIPTA ST, QL
BETA-ADRENERGIC AGENTST1METAPROTERENOLSULFATE
ALUPENT
BETA-ADRENERGIC AGENTS, INHALED, SHORTACTINGT1ALBUTEROL SULFATE ACCUNEBT1ALBUTEROL SULFATE ALBUTEROL
SULFATET2ALBUTEROL SULFATE PROAIR HFAT2ALBUTEROL SULFATE PROAIR
RESPICLICKT1ALBUTEROL SULFATE PROVENTILT3ALBUTEROL SULFATE PROVENTIL HFAT2ALBUTEROL SULFATE VENTOLIN HFAT1ALBUTEROL SULFATE VOSPIRE ERT1LEVALBUTEROL HCL XOPENEXT1LEVALBUTEROL HCL XOPENEX
CONCENTRATET1LEVALBUTEROLTARTRATE
XOPENEX HFA
T1TERBUTALINESULFATE
BRETHINE
BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTINGT3 INDACATEROL MALEATEARCAPTA
NEOHALERST, QL
T2OLODATEROL HCL STRIVERDIRESPIMAT
QL
BETA-ADRENERGIC AGENTS, ORALLYINHALED,LONG ACTINGT3ARFORMOTEROL
TARTRATEBROVANA QL
T2 FORMOTEROLFUMARATE
PERFOROMIST QL
T2 SALMETEROLXINAFOATE
SEREVENT DISKUS QL
BETA-ADRENERGIC AND ANTICHOLINERGICCOMBINATIONST3GLYCOPYRROLATE/FOR
MOTEROL FUMBEVESPIAEROSPHERE
ST, QL
T3 INDACATEROL/GLYCOPYRROLATE
UTIBRONNEOHALER
ST, QL
T2 IPRATROPIUM/ALBUTEROL SULFATE
COMBIVENTRESPIMAT
T1 IPRATROPIUM/ALBUTEROL SULFATE
DUONEB
T2TIOTROPIUMBR/OLODATEROL HCL
STIOLTO RESPIMATQL
T3UMECLIDINIUMBRM/VILANTEROL TR
ANORO ELLIPTA ST, QL
BETA-ADRENERGIC AND GLUCOCORTICOIDCOMBINATIONST2BUDESONIDE/FORMOTE
ROL FUMARATESYMBICORT QL
T2 FLUTICASONE/SALMETEROL
ADVAIR DISKUS QL
T2 FLUTICASONE/SALMETEROL
ADVAIR HFA QL
T3 FLUTICASONE/SALMETEROL
FLUTICASONE-SALMETEROL
QL
T2 FLUTICASONE/VILANTEROL
BREO ELLIPTA QL
T2MOMETASONE/FORMOTEROL
DULERA QL
GLUCOCORTICOIDS, ORALLY INHALEDT2BECLOMETHASONE
DIPROPIONATEQVAR QL
T1BUDESONIDE PULMICORT(0.25MG/2ML)(AMPUL-NEB)
QL
T1BUDESONIDE PULMICORT (0.5MG/2ML) (AMPUL-NEB)
QL
T1BUDESONIDE PULMICORT (1MG/2 ML) (AMPUL-NEB)
QL
T3BUDESONIDE PULMICORTFLEXHALER
ST, QL
T3CICLESONIDE ALVESCO ST, QL
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T3 FLUNISOLIDE AEROSPAN ST, QLT2 FLUTICASONE FUROATE ARNUITY ELLIPTA QLT3 FLUTICASONE
PROPIONATEARMONAIRRESPICLICK
T2 FLUTICASONEPROPIONATE
FLOVENT DISKUS(100 MCG) (BLSTW/DEV)
QL
T2 FLUTICASONEPROPIONATE
FLOVENT DISKUS(250 MCG) (BLSTW/DEV)
QL
T2 FLUTICASONEPROPIONATE
FLOVENT DISKUS(50 MCG) (BLSTW/DEV)
QL
T2 FLUTICASONEPROPIONATE
FLOVENT HFA (110MCG) (AERW/ADAP)
QL
T2 FLUTICASONEPROPIONATE
FLOVENT HFA (220MCG) (AERW/ADAP)
QL
T2 FLUTICASONEPROPIONATE
FLOVENT HFA (44MCG) (AERW/ADAP)
QL
T3MOMETASONE FUROATE ASMANEX ST, QLT3MOMETASONE FUROATE ASMANEX HFA ST, QL
LEUKOTRIENE RECEPTOR ANTAGONISTST1MONTELUKASTSODIUM
SINGULAIR
T1ZAFIRLUKAST ACCOLATE
MAST CELL STABILIZERST1CROMOLYN SODIUM GASTROCROM
MAST CELL STABILIZERS, ORALLY INHALEDT1CROMOLYN SODIUM CROMOLYN
SODIUM
PHOSPHODIESTERASE-4 (PDE4) INHIBITORST2ROFLUMILAST DALIRESP ST, QL
RESPIRATORY AIDS,DEVICES,EQUIPMENTT3COMPRESSOR, FOR
NEBULIZERDEVILBISS PULMO-AIDE
T3COMPRESSOR, FORNEBULIZER
EBASECONTROLLER
T3COMPRESSOR, FORNEBULIZER
PULMO-AIDE
T3COMPRESSOR, FORNEBULIZER
SUNRISECOMPRESSOR-NEBULIZER
T3 INHALER, ASSISTDEVICES
ACE AEROSOLCLOUD ENHANCER
T3 INHALER, ASSISTDEVICES
AEROCHAMBERMINI
T3 INHALER, ASSISTDEVICES
AEROCHAMBERMV
T3 INHALER, ASSISTDEVICES
AEROCHAMBERPLUS FLOW-VU
T3 INHALER, ASSISTDEVICES
AEROCHAMBERWITHFLOWSIGNAL
T3 INHALER, ASSISTDEVICES
AEROCHAMBER Z-STAT PLUS
T3 INHALER, ASSISTDEVICES
AEROTRACH PLUS
T3 INHALER, ASSISTDEVICES
AEROVENT PLUS
T3 INHALER, ASSISTDEVICES
BREATHERITE
T3 INHALER, ASSISTDEVICES
BREATHRITE
T3 INHALER, ASSISTDEVICES
CLEVER CHOICEHOLDINGCHAMBER
T3 INHALER, ASSISTDEVICES
COMPACT SPACECHAMBER
T3 INHALER, ASSISTDEVICES
COMPACT SPACECHAMBER PLUS
T3 INHALER, ASSISTDEVICES
EASIVENT
T3 INHALER, ASSISTDEVICES
E-Z SPACER
T3 INHALER, ASSISTDEVICES
FLEXICHAMBER
T3 INHALER, ASSISTDEVICES
INSPIRACHAMBER
T3 INHALER, ASSISTDEVICES
LITEAIRE
T3 INHALER, ASSISTDEVICES
MICROCHAMBER
T3 INHALER, ASSISTDEVICES
MICROSPACER
T3 INHALER, ASSISTDEVICES
OPTICHAMBERDIAMOND
T3 INHALER, ASSISTDEVICES
POCKET CHAMBER
T3 INHALER, ASSISTDEVICES
PRIMEAIRE
T3 INHALER, ASSISTDEVICES
PROCHAMBER
T3 INHALER, ASSISTDEVICES
RITEFLO
T3 INHALER, ASSISTDEVICES
SPACE CHAMBERPLUS
T3 INHALER, ASSISTDEVICES
VORTEX
T3 INHALER, ASSISTDEVICES
VORTEX VHC FROGMASK
T3 INHALER, ASSISTDEVICES
VORTEX VHCLADYBUG MASK
T3 INHALER,ASSISTDEVICE,ACCESORY
EASIVENT
T3 INHALER,ASSISTDEVICE,ACCESORY
FLEXICHAMBERMASK
T3 INHALER,ASSISTDEVICE,ACCESORY
LITETOUCH
T3 INHALER,ASSISTDEVICE,ACCESORY
OPTICHAMBER
T3 INHALER,ASSISTDEVICE,ACCESORY
SILICONE MASK
T3MUCUS CLEARINGDEVICE
AEROBIKA
T3MUCUS CLEARINGDEVICE
QUAKE
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T3NASAL EXHALATIONRESISTANC.DEV
PROVENT
T3NEBULIZER AEROECLIPSE IIT3NEBULIZER AERONEB GO
NEBULIZERT3NEBULIZER ALTERA
NEBULIZERT3NEBULIZER BABY NEBULIZERT3NEBULIZER ERAPID
NEBULIZERT3NEBULIZER LC D NEBULIZER
SETT3NEBULIZER LC PLUST3NEBULIZER LC SPRINT
NEBULIZERT3NEBULIZER LC START3NEBULIZER MINI PLUS
NEBULIZERT3NEBULIZER PARI LC SPRINT
SINUST3NEBULIZER PRODIGY MINI-
MISTT3NEBULIZER SIDESTREAMT3NEBULIZER SIDESTREAM
NEBULIZERT3NEBULIZER SIDESTREAM PLUST3NEBULIZER SINUSTART3NEBULIZER TRUNEB
NEBULIZERT3NEBULIZER VIXONE
NEBULIZERT3NEBULIZER AND
COMPRESSORCLEVER CHOICENEBULIZER
T3NEBULIZER ANDCOMPRESSOR
CLEVER CHOICEWHISPER AIRE PED
T3NEBULIZER ANDCOMPRESSOR
COMP-AIRNEBULIZERCOMPRESSOR
T3NEBULIZER ANDCOMPRESSOR
DEVILBISSPULMONEB LTCOMP-NEB
T3NEBULIZER ANDCOMPRESSOR
DEVILBISSTRAVELER
T3NEBULIZER ANDCOMPRESSOR
HOME NEBULIZERPLUS SIDESTREAM
T3NEBULIZER ANDCOMPRESSOR
INNOSPIREDELUXE
T3NEBULIZER ANDCOMPRESSOR
INNOSPIREELEGANCE
T3NEBULIZER ANDCOMPRESSOR
INNOSPIREESSENCE
T3NEBULIZER ANDCOMPRESSOR
INNOSPIRE MINI
T3NEBULIZER ANDCOMPRESSOR
MY MDI PORTABLENEBULISER
T3NEBULIZER ANDCOMPRESSOR
PARI SINUSAEROSOL SYSTEM
T3NEBULIZER ANDCOMPRESSOR
PEDIATRICDINOSAURNEBULIZER
T3NEBULIZER ANDCOMPRESSOR
PEDIATRIC DOGNEBULIZER
T3NEBULIZER ANDCOMPRESSOR
PEDIATRIC FROGNEBULIZER
T3NEBULIZER ANDCOMPRESSOR
PORTABLENEBULIZERSYSTEM
T3NEBULIZER ANDCOMPRESSOR
PRONEB ULTRA II
T3NEBULIZER ANDCOMPRESSOR
SAMI THE SEAL
T3NEBULIZER ANDCOMPRESSOR
SINUSTAR
T3NEBULIZER ANDCOMPRESSOR
TREK S COMBOPACK
T3NEBULIZER ANDCOMPRESSOR
TREK S COMPACTCOMPRESSOR
T3NEBULIZER ANDCOMPRESSOR
VIOS AEROSOLDELIVERY SYSTEM
T3 PEAK FLOW METER MINI-WRIGHTPEAK FLOWMETER
T3 PEAK FLOW METER TRUZONE PEAKFLOW METER
T3 PEAK FLOW METER/INHASSIT DEV
AEROGEARASTHMA ACTIONKIT
T3 PEAK FLOW METER/INHASSIT DEV
ASTHMAPACKCHILDREN'S
T3 SPIROMETER/DRUGDELIVERY ADAPT
MISTASSIST KIT
T3 SPIROMETERS ANDACCESSORIES
MISTASSIST
T3 SPIROMETERS ANDACCESSORIES
PFLEX TRAINER
T3 SPIROMETERS ANDACCESSORIES
THRESHOLD IMT
T3 SPIROMETERS ANDACCESSORIES
THRESHOLD PEP
XANTHINEST1CAFFEINE CITRATE CAFCITT1THEOPHYLLINEANHYDROUS
ELIXOPHYLLIN
T1THEOPHYLLINEANHYDROUS
SLO-PHYLLIN
T2 THEOPHYLLINEANHYDROUS
THEO-24
T1THEOPHYLLINEANHYDROUS
THEO-DUR
T1THEOPHYLLINEANHYDROUS
UNIPHYL
AUTONOMIC NERVOUS SYSTEMDISORDERS
ALZHEIMER'S THERAPY, NMDA RECEPTORANTAGONISTST1MEMANTINE HCL NAMENDA (10 MG)
(TABLET)QL
T1MEMANTINE HCL NAMENDA (2MG/ML)(SOLUTION)
QL
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T1MEMANTINE HCL NAMENDA (5 MG)(TABLET)
QL
T1MEMANTINE HCL NAMENDA (5 MG-10 MG) (TAB DS PK)
QL
T2MEMANTINE HCL NAMENDA XR (14MG) (CAP SPR 24)
QL
T2MEMANTINE HCL NAMENDA XR (21MG) (CAP SPR 24)
QL
T2MEMANTINE HCL NAMENDA XR (28MG) (CAP SPR 24)
QL
T2MEMANTINE HCL NAMENDA XR (7MG) (CAP SPR 24)
QL
T2MEMANTINE HCL NAMENDA XR (7-14-21-28) (CAP24DSPK)
QL
ALZHEIMER'S THX,NMDA RECEPT ANTAG &CHOLINES INHIBT2MEMANTINE
HCL/DONEPEZIL HCLNAMZARIC (14MG-10MG) (CAP SPR 24)
ST, QL
T2MEMANTINEHCL/DONEPEZIL HCL
NAMZARIC (21 MG-10MG) (CAP SPR 24)
ST, QL
T2MEMANTINEHCL/DONEPEZIL HCL
NAMZARIC (28 MG-10MG) (CAP SPR 24)
ST, QL
T2MEMANTINEHCL/DONEPEZIL HCL
NAMZARIC (7 MG-10 MG) (CAP SPR24)
ST, QL
T2MEMANTINEHCL/DONEPEZIL HCL
NAMZARIC (7-10/14-10) (CAP24DSPK)
ST, QL
CHOLINESTERASE INHIBITORST1DONEPEZIL HCL ARICEPTT1DONEPEZIL HCL ARICEPT ODTT1GALANTAMINE HBR RAZADYNE (12 MG)
(TABLET)QL
T1GALANTAMINE HBR RAZADYNE (4 MG)(TABLET)
QL
T1GALANTAMINE HBR RAZADYNE (4MG/ML)(SOLUTION)
QL
T1GALANTAMINE HBR RAZADYNE (8 MG)(TABLET)
QL
T1GALANTAMINE HBR RAZADYNE ER QLT1PYRIDOSTIGMINEBROMIDE
MESTINON (180MG) (TABLET ER)
T1PYRIDOSTIGMINEBROMIDE
MESTINON (60 MG)(TABLET)
T2 PYRIDOSTIGMINEBROMIDE
MESTINON (60MG/5 ML) (SYRUP)
T1RIVASTIGMINE EXELON QLT1RIVASTIGMINETARTRATE
EXELON
BEHAVIORAL HEALTH -ANTIDEPRESSANTS
ALPHA-2 RECEPTOR ANTAGONISTANTIDEPRESSANTST1MIRTAZAPINE REMERON
MAOIS - NON-SELECTIVE & IRREVERSIBLET3 ISOCARBOXAZID MARPLAN
T1PHENELZINE SULFATE NARDILT1TRANYLCYPROMINESULFATE
PARNATE
NOREPINEPHRINE AND DOPAMINE REUPTAKEINHIB (NDRIS)T3BUPROPION HBR APLENZIN ST, QLT3BUPROPION HCL FORFIVO XL ST, QLT1BUPROPION HCL WELLBUTRINT1BUPROPION HCL WELLBUTRIN SRT1BUPROPION HCL WELLBUTRIN XL
SELECTIVE SEROTONIN REUPTAKE INHIBITOR(SSRIS)T1CITALOPRAMHYDROBROMIDE
CELEXA
T1ESCITALOPRAMOXALATE
LEXAPRO
T3 FLUOXETINE HCL FLUOXETINE HCL(60 MG) (TABLET)
T1FLUOXETINE HCL FLUOXETINE HCL(90 MG) (CAPSULEDR)
T1FLUOXETINE HCL PROZACT3 FLUOXETINE HCL SARAFEMT1FLUVOXAMINEMALEATE
LUVOX
T1FLUVOXAMINEMALEATE
LUVOX CR ST, QL
T1PAROXETINE HCL PAXIL (10 MG)(TABLET)
T2 PAROXETINE HCL PAXIL (10 MG/5 ML)(ORAL SUSP)
T1PAROXETINE HCL PAXIL (20 MG)(TABLET)
T1PAROXETINE HCL PAXIL (30 MG)(TABLET)
T1PAROXETINE HCL PAXIL (40 MG)(TABLET)
T1PAROXETINE HCL PAXIL CRT3 PAROXETINE MESYLATE BRISDELLE ST, QLT3 PAROXETINE MESYLATE PEXEVA ST, QLT1 SERTRALINE HCL ZOLOFT
SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS(SARIS)T1NEFAZODONE HCL SERZONET1TRAZODONE HCL DESYREL
SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB(SNRIS)T2DESVENLAFAXINE DESVENLAFAXINE
ERST, QL
T1DESVENLAFAXINE KHEDEZLA ST, QLT3DESVENLAFAXINE
FUMARATEDESVENLAFAXINEFUMARATE ER
ST, QL
T1DESVENLAFAXINESUCCINATE
PRISTIQ QL
T1DULOXETINE HCL CYMBALTA QLT1DULOXETINE HCL IRENKA ST, QLT2 LEVOMILNACIPRAN HCLFETZIMA ST, QLT1VENLAFAXINE HCL EFFEXORT1VENLAFAXINE HCL EFFEXOR XR
Commercial Formulary
804 Portfolio High Formulary Page 9 of 133
T1VENLAFAXINE HCL VENLAFAXINE HCLER
SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANTT2VILAZODONE HCL VIIBRYD ST, QL
SSRI & SEROTONIN RECEPTOR MODULATORANTIDEPRESSANTT2VORTIOXETINE
HYDROBROMIDETRINTELLIX ST, QL
TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINECOMBINATNST1AMITRIPTYLINE/CHLORDIAZEPOXIDE
LIMBITROL
T1AMITRIPTYLINE/CHLORDIAZEPOXIDE
LIMBITROL DS
TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINECOMBINATNST1PERPHENAZINE/AMITRIPTYLINE HCL
ETRAFON-A
T1PERPHENAZINE/AMITRIPTYLINE HCL
TRIAVIL 2-10
T1PERPHENAZINE/AMITRIPTYLINE HCL
TRIAVIL 2-25
T1PERPHENAZINE/AMITRIPTYLINE HCL
TRIAVIL 4-25
T1PERPHENAZINE/AMITRIPTYLINE HCL
TRIAVIL 4-50
TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL.RU-INHIBT1AMITRIPTYLINE HCL ELAVILT1AMOXAPINE ASENDINT1CLOMIPRAMINE HCL ANAFRANILT1DESIPRAMINE HCL NORPRAMINT1DOXEPIN HCL SINEQUANT1 IMIPRAMINE HCL TOFRANILT1 IMIPRAMINE PAMOATE TOFRANIL-PMT1MAPROTILINE HCL LUDIOMILT1NORTRIPTYLINE HCL PAMELORT1PROTRIPTYLINE HCL VIVACTILT1TRIMIPRAMINEMALEATE
SURMONTIL
BEHAVIORAL HEALTH - OTHERADRENERGICS, AROMATIC, NON-CATECHOLAMINET3AMPHETAMINE ADZENYS XR-ODT ST, QLT3AMPHETAMINE DYANAVEL XR ST, QLT3AMPHETAMINE SULFATEEVEKEO PAT1DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE (10MG) (CAPSULE ER)
QL
T1DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE (10MG) (TABLET)
QL
T1DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE (15MG) (CAPSULE ER)
QL
T1DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE (5MG) (CAPSULE ER)
QL
T1DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE (5MG) (TABLET)
QL
T1DEXTROAMPHETAMINE SULFATE
DEXTROAMPHETAMINE SULFATE (5MG/5 ML)(SOLUTION)
QL
T2DEXTROAMPHETAMINESULFATE
ZENZEDI (15 MG)(TABLET)
QL
T2DEXTROAMPHETAMINESULFATE
ZENZEDI (2.5 MG)(TABLET)
ST, QL
T2DEXTROAMPHETAMINESULFATE
ZENZEDI (20 MG)(TABLET)
QL
T2DEXTROAMPHETAMINESULFATE
ZENZEDI (30 MG)(TABLET)
QL
T2DEXTROAMPHETAMINESULFATE
ZENZEDI (7.5 MG)(TABLET)
ST, QL
T1DEXTROAMPHETAMINE/AMPHETAMINE
ADDERALL QL
T1DEXTROAMPHETAMINE/AMPHETAMINE
ADDERALL XR (10MG) (CAP ER 24H)
QL
T1DEXTROAMPHETAMINE/AMPHETAMINE
ADDERALL XR (15MG) (CAP ER 24H)
QL
T1DEXTROAMPHETAMINE/AMPHETAMINE
ADDERALL XR (20MG) (CAP ER 24H)
QL
T1DEXTROAMPHETAMINE/AMPHETAMINE
ADDERALL XR (25MG) (CAP ER 24H)
QL
T1DEXTROAMPHETAMINE/AMPHETAMINE
ADDERALL XR (30MG) (CAP ER 24H)
QL
T1DEXTROAMPHETAMINE/AMPHETAMINE
ADDERALL XR (5MG) (CAP ER 24H)
QL
T3DEXTROAMPHETAMINE/AMPHETAMINE
MYDAYIS
T2 LISDEXAMFETAMINEDIMESYLATE
VYVANSE ST, QL
T1METHAMPHETAMINEHCL
DESOXYN QL
ANTI-ALCOHOLIC PREPARATIONST1ACAMPROSATECALCIUM
CAMPRAL
T1DISULFIRAM ANTABUSE
ANTI-ANXIETY DRUGST2ALPRAZOLAM ALPRAZOLAM
INTENSOLT1ALPRAZOLAM NIRAVAMT1ALPRAZOLAM XANAXT1ALPRAZOLAM XANAX XRT1BUSPIRONE HCL BUSPART1CHLORDIAZEPOXIDEHCL
LIBRIUM
T1CLORAZEPATEDIPOTASSIUM
TRANXENE T-TAB
T1DIAZEPAM DIAZEPAMT1DIAZEPAM DIAZEPAM
INTENSOLT2DIAZEPAM VALIUM (10 MG)
(TABLET)T2DIAZEPAM VALIUM (2 MG)
(TABLET)T2DIAZEPAM VALIUM (5 MG)
(TABLET)
Commercial Formulary
804 Portfolio High Formulary Page 10 of 133
T1DIAZEPAM VALIUM (5 MG/5ML) (SOLUTION)
T1LORAZEPAM ATIVANT1LORAZEPAM LORAZEPAM
INTENSOLT1MEPROBAMATE MEPROBAMATET1OXAZEPAM SERAX
ANTI-MANIA DRUGST3CARBAMAZEPINE EQUETROT1LITHIUM CARBONATE ESKALITHT1LITHIUM CARBONATE ESKALITH CRT1LITHIUM CARBONATE LITHIUM
CARBONATET2 LITHIUM CARBONATE LITHOBIDT1LITHIUM CARBONATE LITHOTABST1LITHIUM CITRATE LITHIUM CITRATE
ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGTT3 SODIUM OXYBATE XYREM PA
ANTIPSYCH,DOPAMINEANTAG.,DIPHENYLBUTYLPIPERIDINEST1PIMOZIDE ORAP
ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HTMIXEDT2CARIPRAZINE HCL VRAYLAR (1.5 MG)
(CAPSULE)ST, QL
T2CARIPRAZINE HCL VRAYLAR (1.5 MG-3MG) (CAP DS PK)
ST, QL
T2CARIPRAZINE HCL VRAYLAR (3 MG)(CAPSULE)
ST, QL
T2CARIPRAZINE HCL VRAYLAR (4.5 MG)(CAPSULE)
ST, QL
T2CARIPRAZINE HCL VRAYLAR (6 MG)(CAPSULE)
ST, QL
ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HTMIXEDT1ARIPIPRAZOLE ABILIFY (1 MG/ML)
(SOLUTION)ST, QL
T1ARIPIPRAZOLE ABILIFY (10 MG)(TABLET)
QL
T1ARIPIPRAZOLE ABILIFY (15 MG)(TABLET)
QL
T1ARIPIPRAZOLE ABILIFY (2 MG)(TABLET)
QL
T1ARIPIPRAZOLE ABILIFY (20 MG)(TABLET)
QL
T1ARIPIPRAZOLE ABILIFY (30 MG)(TABLET)
QL
T1ARIPIPRAZOLE ABILIFY (5 MG)(TABLET)
QL
T1ARIPIPRAZOLE ABILIFY DISCMELT(10 MG) (TABRAPDIS)
ST, QL
T1ARIPIPRAZOLE ABILIFY DISCMELT(15 MG) (TABRAPDIS)
ST, QL
T2BREXPIPRAZOLE REXULTI ST, QL
ANTIPSYCHOTICS, DOPAMINE & SEROTONINANTAGONISTST3 LOXAPINE ADASUVET1LOXAPINE SUCCINATE LOXITANE
ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,&SEROTONIN ANTAGT2ASENAPINE MALEATE SAPHRIS ST, QLT1CLOZAPINE CLOZAPINE QLT1CLOZAPINE CLOZARIL QLT1CLOZAPINE FAZACLO ST, QLT3CLOZAPINE VERSACLOZ ST, QLT3 ILOPERIDONE FANAPT (1 MG)
(TABLET)ST, QL
T3 ILOPERIDONE FANAPT (10 MG)(TABLET)
ST, QL
T3 ILOPERIDONE FANAPT (12 MG)(TABLET)
ST, QL
T3 ILOPERIDONE FANAPT (1-2-4-6MG) (TAB DS PK)
ST, QL
T3 ILOPERIDONE FANAPT (2 MG)(TABLET)
ST, QL
T3 ILOPERIDONE FANAPT (4 MG)(TABLET)
ST, QL
T3 ILOPERIDONE FANAPT (6 MG)(TABLET)
ST, QL
T3 ILOPERIDONE FANAPT (8 MG)(TABLET)
ST, QL
T2 LURASIDONE HCL LATUDA (120 MG)(TABLET)
ST, QL
T2 LURASIDONE HCL LATUDA (20 MG)(TABLET)
ST, QL
T2 LURASIDONE HCL LATUDA (40 MG)(TABLET)
ST, QL
T2 LURASIDONE HCL LATUDA (60 MG)(TABLET)
ST, QL
T2 LURASIDONE HCL LATUDA (80 MG)(TABLET)
ST, QL
T1OLANZAPINE ZYPREXA QLT1OLANZAPINE ZYPREXA ZYDIS QLT1PALIPERIDONE INVEGA (1.5 MG)
(TAB ER 24)ST, QL
T1PALIPERIDONE INVEGA (3 MG)(TAB ER 24)
ST, QL
T1PALIPERIDONE INVEGA (6 MG)(TAB ER 24)
ST, QL
T1PALIPERIDONE INVEGA (9 MG)(TAB ER 24)
ST, QL
T1QUETIAPINEFUMARATE
SEROQUEL QL
T1QUETIAPINEFUMARATE
SEROQUEL XR (150MG) (TAB ER 24H)
QL
T1QUETIAPINEFUMARATE
SEROQUEL XR (200MG) (TAB ER 24H)
QL
T1QUETIAPINEFUMARATE
SEROQUEL XR (300MG) (TAB ER 24H)
QL
T1QUETIAPINEFUMARATE
SEROQUEL XR (400MG) (TAB ER 24H)
QL
T1QUETIAPINEFUMARATE
SEROQUEL XR (50MG) (TAB ER 24H)
QL
Commercial Formulary
804 Portfolio High Formulary Page 11 of 133
T3QUETIAPINE FUMARATE SEROQUEL XR (50-200-300)(TAB24HDSPK)
T1RISPERIDONE RISPERDAL (0.25MG) (TABLET)
QL
T1RISPERIDONE RISPERDAL (0.5MG) (TABLET)
QL
T1RISPERIDONE RISPERDAL (1 MG)(TABLET)
QL
T1RISPERIDONE RISPERDAL (1MG/ML)(SOLUTION)
QL
T1RISPERIDONE RISPERDAL (2 MG)(TABLET)
QL
T1RISPERIDONE RISPERDAL (3 MG)(TABLET)
QL
T1RISPERIDONE RISPERDAL (4 MG)(TABLET)
QL
T1RISPERIDONE RISPERDAL M-TAB QLT1RISPERIDONE RISPERIDONE ODT QLT1ZIPRASIDONE HCL GEODON QL
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,THIOXANTHENEST1THIOTHIXENE NAVANE
ANTIPSYCHOTICS,DOPAMINEANTAGONISTS,BUTYROPHENONEST1HALOPERIDOL HALDOLT1HALOPERIDOLLACTATE
HALDOL
ANTI-PSYCHOTICS,PHENOTHIAZINEST1CHLORPROMAZINEHCL
THORAZINE
T1FLUPHENAZINE HCL PROLIXINT1PERPHENAZINE TRILAFONT1THIORIDAZINE HCL MELLARILT1TRIFLUOPERAZINEHCL
STELAZINE
BARBITURATEST3BUTABARBITAL SODIUMBUTISOL SODIUMT1PHENOBARBITAL PHENOBARBITALT3 SECOBARBITAL SODIUM SECONAL SODIUM
HSDD AGENTS-MIXED SEROTONINAGONIST/ANTAGONISTST3 FLIBANSERIN ADDYI PA
HYPNOTICS, MELATONIN MT1/MT2 RECEPTORAGONISTST3RAMELTEON ROZEREM ST, QLT3 TASIMELTEON HETLIOZ PA
MONOAMINE OXIDASE(MAO) INHIBITORST3 SELEGILINE EMSAM QL
NARCOLEPSY AND SLEEP DISORDER THERAPYAGENTST1ARMODAFINIL NUVIGIL (150 MG)
(TABLET)QL
T1ARMODAFINIL NUVIGIL (200 MG)(TABLET)
QL
T1ARMODAFINIL NUVIGIL (250 MG)(TABLET)
QL
T1ARMODAFINIL NUVIGIL (50 MG)(TABLET)
QL
T1MODAFINIL PROVIGIL QL
NARCOTIC ANTAGONISTST3NALOXONE HCL EVZIO ST, QLT1NALOXONE HCL NARCAN (0.4
MG/ML) (SYRINGE)T1NALOXONE HCL NARCAN (1 MG/ML)
(SYRINGE)T2NALOXONE HCL NARCAN (4 MG)
(SPRAY)QL
T1NALTREXONE HCL REVIA
SEDATIVE-HYPNOTICS,NON-BARBITURATET2DOXEPIN HCL SILENOR ST, QLT1ESTAZOLAM PROSOMT1ESZOPICLONE LUNESTA QLT1FLURAZEPAM HCL DALMANET1MIDAZOLAM HCL VERSEDT1QUAZEPAM DORALT2 SUVOREXANT BELSOMRA ST, QLT1TEMAZEPAM RESTORILT1TRIAZOLAM HALCIONT1ZALEPLON SONATA QLT1ZOLPIDEM TARTRATE AMBIEN QLT1ZOLPIDEM TARTRATE AMBIEN CR QLT3 ZOLPIDEM TARTRATE EDLUAR ST, QLT1ZOLPIDEM TARTRATE INTERMEZZO ST, QLT3 ZOLPIDEM TARTRATE ZOLPIMIST ST, QL
SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS(SSIA)T3 PIMAVANSERIN
TARTRATENUPLAZID PA
SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONINANTAG COMBT1OLANZAPINE/FLUOXETINE HCL
SYMBYAX QL
TX FOR ADHD - SELECTIVE ALPHA-2A RECEPTORAGONISTT1CLONIDINE HCL KAPVAY QLT1GUANFACINE HCL INTUNIV QL
TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYT1DEXMETHYLPHENIDATE HCL
FOCALIN QL
T1DEXMETHYLPHENIDATE HCL
FOCALIN XR AGE,QL
T3METHYLPHENIDATE COTEMPLA XR-ODT
ST
T3METHYLPHENIDATE DAYTRANA ST, QLT3METHYLPHENIDATE
HCLAPTENSIO XR ST,
AGE,QL
T1METHYLPHENIDATEHCL
CONCERTA (18 MG)(TAB ER 24)
AGE,QL
Commercial Formulary
804 Portfolio High Formulary Page 12 of 133
T1METHYLPHENIDATEHCL
CONCERTA (27 MG)(TAB ER 24)
AGE,QL
T1METHYLPHENIDATEHCL
CONCERTA (36 MG)(TAB ER 24)
AGE,QL
T1METHYLPHENIDATEHCL
CONCERTA (54 MG)(TAB ER 24)
AGE,QL
T1METHYLPHENIDATEHCL
METADATE ER (10MG) (TABLET ER)
AGE,QL
T1METHYLPHENIDATEHCL
METADATE ER (20MG) (TABLET ER)
AGE,QL
T1METHYLPHENIDATEHCL
METHYLIN
T1METHYLPHENIDATEHCL
METHYLPHENIDATE HCL (10 MG)(CPBP 30-70)
AGE,QL
T1METHYLPHENIDATEHCL
METHYLPHENIDATE HCL (10 MG) (TABCHEW)
QL
T1METHYLPHENIDATEHCL
METHYLPHENIDATE HCL (2.5 MG)(TAB CHEW)
QL
T1METHYLPHENIDATEHCL
METHYLPHENIDATE HCL (20 MG)(CPBP 30-70)
AGE,QL
T1METHYLPHENIDATEHCL
METHYLPHENIDATE HCL (30 MG)(CPBP 30-70)
AGE,QL
T1METHYLPHENIDATEHCL
METHYLPHENIDATE HCL (40 MG)(CPBP 30-70)
AGE,QL
T1METHYLPHENIDATEHCL
METHYLPHENIDATE HCL (5 MG) (TABCHEW)
QL
T1METHYLPHENIDATEHCL
METHYLPHENIDATE HCL (50 MG)(CPBP 30-70)
AGE,QL
T1METHYLPHENIDATEHCL
METHYLPHENIDATE HCL (60 MG)(CPBP 30-70)
AGE,QL
T2METHYLPHENIDATEHCL
QUILLICHEW ER(20 MG) (TABCBP24H)
ST, QL
T2METHYLPHENIDATEHCL
QUILLICHEW ER(30 MG) (TABCBP24H)
ST, QL
T2METHYLPHENIDATEHCL
QUILLICHEW ER(40 MG) (TABCBP24H)
ST, QL
T2METHYLPHENIDATEHCL
QUILLIVANT XR (5MG/ML) (SU ERRC24)
ST, QL
T1METHYLPHENIDATEHCL
RITALIN QL
T2METHYLPHENIDATEHCL
RITALIN LA (10 MG)(CPBP 50-50)
AGE,QL
T1METHYLPHENIDATEHCL
RITALIN LA (20 MG)(CPBP 50-50)
AGE,QL
T1METHYLPHENIDATEHCL
RITALIN LA (30 MG)(CPBP 50-50)
AGE,QL
T1METHYLPHENIDATEHCL
RITALIN LA (40 MG)(CPBP 50-50)
AGE,QL
T1METHYLPHENIDATEHCL
RITALIN LA (60 MG)(CPBP 50-50)
AGE,QL
T1METHYLPHENIDATEHCL
RITALIN-SR AGE,QL
TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD),NRI-TYPET1ATOMOXETINE HCL STRATTERA (10
MG) (CAPSULE)QL
T1ATOMOXETINE HCL STRATTERA (100MG) (CAPSULE)
QL
T1ATOMOXETINE HCL STRATTERA (18MG) (CAPSULE)
QL
T1ATOMOXETINE HCL STRATTERA (25MG) (CAPSULE)
QL
T1ATOMOXETINE HCL STRATTERA (40MG) (CAPSULE)
QL
T1ATOMOXETINE HCL STRATTERA (60MG) (CAPSULE)
QL
T1ATOMOXETINE HCL STRATTERA (80MG) (CAPSULE)
QL
CARDIOVASCULAR DISEASE -ARRHYTHMIA
ANTIARRHYTHMICST1AMIODARONE HCL CORDARONET1DISOPYRAMIDEPHOSPHATE
NORPACE
T2DISOPYRAMIDEPHOSPHATE
NORPACE CR
T1DOFETILIDE TIKOSYNT2DRONEDARONE HCL MULTAQT1FLECAINIDE ACETATE TAMBOCORT1MEXILETINE HCL MEXITILT1PROPAFENONE HCL RYTHMOLT1PROPAFENONE HCL RYTHMOL SRT1QUINIDINEGLUCONATE
QUINAGLUTE
T1QUINIDINE SULFATE QUINIDINESULFATE
T1QUINIDINE SULFATE QUINORA
CARDIOVASCULAR DISEASE -CARDIAC STIMULANT
ADRENERGIC AGENTS,CATECHOLAMINEST1EPINEPHRINE EPIPEN
DIGITALIS GLYCOSIDEST1DIGOXIN DIGOXIN (125 MCG)
(TABLET)T1DIGOXIN DIGOXIN (250 MCG)
(TABLET)T2DIGOXIN DIGOXIN (50
MCG/ML)(SOLUTION)
T2DIGOXIN LANOXIN (125MCG) (TABLET)
T3DIGOXIN LANOXIN (187.5MCG) (TABLET)
T2DIGOXIN LANOXIN (250MCG) (TABLET)
Commercial Formulary
804 Portfolio High Formulary Page 13 of 133
T3DIGOXIN LANOXIN (62.5MCG) (TABLET)
CARDIOVASCULAR DISEASE -HYPERTENSION
ACE INHIBITOR/CALCIUM CHANNEL BLOCKERCOMBINATIONT1AMLODIPINEBESYLATE/BENAZEPRIL
LOTREL
T3 PERINDOPRILARG/AMLODIPINE BES
PRESTALIA ST, QL
T1TRANDOLAPRIL/VERAPAMIL HCL
TARKA
ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKEDIURETICT1BENAZEPRIL/HYDROCHLOROTHIAZIDE
LOTENSIN HCT
T1CAPTOPRIL/HYDROCHLOROTHIAZIDE
CAPOZIDE
T1ENALAPRIL/HYDROCHLOROTHIAZIDE
VASERETIC
T1FOSINOPRIL/HYDROCHLOROTHIAZIDE
MONOPRIL-HCT
T1LISINOPRIL/HYDROCHLOROTHIAZIDE
ZESTORETIC
T1MOEXIPRIL/HYDROCHLOROTHIAZIDE
UNIRETIC
T1QUINAPRIL/HYDROCHLOROTHIAZIDE
ACCURETIC
ALPHA/BETA-ADRENERGIC BLOCKING AGENTST1CARVEDILOL COREGT2CARVEDILOL
PHOSPHATECOREG CR
T1LABETALOL HCL TRANDATE
ALPHA-ADRENERGIC BLOCKING AGENTST1DOXAZOSIN MESYLATECARDURAT3DOXAZOSIN MESYLATE CARDURA XLT1PHENOXYBENZAMINEHCL
DIBENZYLINE
T1PRAZOSIN HCL MINIPRESST1TERAZOSIN HCL HYTRIN
ANGIOTEN.RECEPTR ANTAG./CAL.CHANLBLKR/THIAZIDE CBT1AMLODIPINE/VALSARTAN/HCTHIAZID
EXFORGE HCT
T1OLMESARTAN/AMLODIPIN/HCTHIAZID
TRIBENZOR
ANGIOTENSIN II RECEPTOR BLOCKER-BETABLOCKER COMB.T2NEBIVOLOL
HCL/VALSARTANBYVALSON
ANGIOTENSIN RECEPTOR ANTAG./THIAZIDEDIURETIC COMBT2AZILSARTAN
MED/CHLORTHALIDONEEDARBYCLOR ST
T1CANDESARTAN/HYDROCHLOROTHIAZID
ATACAND HCT
T1 IRBESARTAN/HYDROCHLOROTHIAZIDE
AVALIDE
T1LOSARTAN/HYDROCHLOROTHIAZIDE
HYZAAR
T1OLMESARTAN/HYDROCHLOROTHIAZIDE
BENICAR HCT
T1TELMISARTAN/HYDROCHLOROTHIAZID
MICARDIS HCT
T1VALSARTAN/HYDROCHLOROTHIAZIDE
DIOVAN HCT
ANGIOTENSIN RECEPTOR ANTGNST &CALC.CHANNEL BLOCKRT1AMLODIPINEBES/OLMESARTAN MED
AZOR
T1AMLODIPINEBESYLATE/VALSARTAN
EXFORGE
T1TELMISARTAN/AMLODIPINE
TWYNSTA
ANTIHYPERTENSIVES, ACE INHIBITORST1BENAZEPRIL HCL LOTENSINT1CAPTOPRIL CAPOTENT3ENALAPRIL MALEATE EPANED ST,
AGE,QL
T1ENALAPRIL MALEATE VASOTECT1FOSINOPRIL SODIUM MONOPRILT1LISINOPRIL PRINIVILT3 LISINOPRIL QBRELIS ST,
AGE,QL
T1LISINOPRIL ZESTRILT1MOEXIPRIL HCL UNIVASCT1PERINDOPRILERBUMINE
ACEON
T1QUINAPRIL HCL ACCUPRILT1RAMIPRIL ALTACET1TRANDOLAPRIL MAVIKT1TRANDOLAPRIL TRANDOLAPRIL
ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTORANTAGONISTT2AZILSARTAN
MEDOXOMILEDARBI ST
T1CANDESARTANCILEXETIL
ATACAND
T1EPROSARTANMESYLATE
TEVETEN
T1 IRBESARTAN AVAPROT1LOSARTAN POTASSIUM COZAART1OLMESARTANMEDOXOMIL
BENICAR
T1TELMISARTAN MICARDIST1VALSARTAN DIOVAN
ANTIHYPERTENSIVES, GANGLIONIC BLOCKERST3MECAMYLAMINE HCL VECAMYL PA
ANTIHYPERTENSIVES, MISCELLANEOUST3METYROSINE DEMSER
Commercial Formulary
804 Portfolio High Formulary Page 14 of 133
ANTIHYPERTENSIVES, SYMPATHOLYTICT1CLONIDINE CATAPRES-TTS 1T1CLONIDINE CATAPRES-TTS 2T1CLONIDINE CATAPRES-TTS 3T1CLONIDINE HCL CATAPREST1CLONIDINEHCL/CHLORTHALIDONE
COMBIPRES
T1GUANFACINE HCL TENEXT1METHYLDOPA ALDOMETT1METHYLDOPA/HYDROCHLOROTHIAZIDE
ALDORIL 15
T1METHYLDOPA/HYDROCHLOROTHIAZIDE
ALDORIL 25
ANTIHYPERTENSIVES, VASODILATORST1HYDRALAZINE HCL APRESOLINET1MINOXIDIL LONITEN
BETA-ADRENERGIC BLOCKING AGENTST1ACEBUTOLOL HCL SECTRALT1ATENOLOL TENORMINT1BETAXOLOL HCL KERLONET1BISOPROLOLFUMARATE
BISOPROLOLFUMARATE
T1BISOPROLOLFUMARATE
ZEBETA
T1METOPROLOLSUCCINATE
TOPROL XL
T1METOPROLOLTARTRATE
LOPRESSOR
T1METOPROLOLTARTRATE
METOPROLOLTARTRATE
T1NADOLOL CORGARDT2NEBIVOLOL HCL BYSTOLICT3 PENBUTOLOL SULFATE LEVATOLT1PINDOLOL VISKENT3 PROPRANOLOL HCL HEMANGEOL ST,
AGE,QL
T1PROPRANOLOL HCL INDERALT1PROPRANOLOL HCL INDERAL LAT3 PROPRANOLOL HCL INDERAL XLT3 PROPRANOLOL HCL INNOPRAN XLT1 SOTALOL HCL SOTALOL HCLT3 SOTALOL HCL SOTYLIZE (5
MG/ML)(SOLUTION)
ST, QL
T1TIMOLOL MALEATE BLOCADREN
BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE& RELATEDT1ATENOLOL/CHLORTHALIDONE
TENORETIC 100
T1ATENOLOL/CHLORTHALIDONE
TENORETIC 50
T1BISOPROLOL/HYDROCHLOROTHIAZIDE
ZIAC
T1METOPROLOLSU/HYDROCHLOROTHIAZ
DUTOPROL (100-12.5MG) (TAB ER24H)
QL
T1METOPROLOLSU/HYDROCHLOROTHIAZ
DUTOPROL (25-12.5MG) (TAB ER 24H)
QL
T1METOPROLOLSU/HYDROCHLOROTHIAZ
DUTOPROL (50-12.5MG) (TAB ER 24H)
QL
T1METOPROLOL/HYDROCHLOROTHIAZIDE
LOPRESSOR HCT
T1NADOLOL/BENDROFLUMETHIAZIDE
CORZIDE
T1PROPRANOLOL/HYDROCHLOROTHIAZID
INDERIDE-40/25
T1PROPRANOLOL/HYDROCHLOROTHIAZID
INDERIDE-80/25
CALCIUM CHANNEL BLOCKING AGENTST1AMLODIPINEBESYLATE
NORVASC
T1DILTIAZEM HCL CARDIZEMT1DILTIAZEM HCL CARDIZEM CDT3DILTIAZEM HCL CARDIZEM LA (120
MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (180
MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (240
MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (300
MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (360
MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (420
MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM SRT1DILTIAZEM HCL DILACOR XRT1DILTIAZEM HCL TIAZACT1FELODIPINE PLENDILT1 ISRADIPINE DYNACIRCT1NICARDIPINE HCL CARDENET1NIFEDIPINE ADALAT CCT1NIFEDIPINE PROCARDIAT1NIFEDIPINE PROCARDIA XLT1NIMODIPINE NIMOTOPT3NIMODIPINE NYMALIZE PAT1NISOLDIPINE SULART1VERAPAMIL HCL CALANT1VERAPAMIL HCL CALAN SRT1VERAPAMIL HCL VERELANT1VERAPAMIL HCL VERELAN PM
LOOP DIURETICST1BUMETANIDE BUMEXT1ETHACRYNIC ACID EDECRINT1FUROSEMIDE LASIXT1TORSEMIDE DEMADEX
OSMOTIC DIURETICST3MANNITOL RESECTISOL
POTASSIUM SPARING DIURETICST1AMILORIDE HCL MIDAMORT1EPLERENONE INSPRAT1 SPIRONOLACTONE ALDACTONET3 SPIRONOLACTONE CAROSPIR
Commercial Formulary
804 Portfolio High Formulary Page 15 of 133
T3 TRIAMTERENE DYRENIUM
POTASSIUM SPARING DIURETICS IN COMBINATIONT1AMILORIDE/HYDROCHLOROTHIAZIDE
MODURETIC 5-50
T1 SPIRONOLACT/HYDROCHLOROTHIAZID
ALDACTAZIDE (25MG-25MG)(TABLET)
T3 SPIRONOLACT/HYDROCHLOROTHIAZID
ALDACTAZIDE (50MG-50MG)(TABLET)
T1TRIAMTERENE/HYDROCHLOROTHIAZID
DYAZIDE
T1TRIAMTERENE/HYDROCHLOROTHIAZID
MAXZIDE
T1TRIAMTERENE/HYDROCHLOROTHIAZID
MAXZIDE-25 MG
PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASESTIMULATORT2RIOCIGUAT ADEMPAS PA
PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASET5 INHIBT3 SILDENAFIL CITRATE REVATIO (10
MG/ML) (SUSPRECON)
PA
T1 SILDENAFIL CITRATE REVATIO (20 MG)(TABLET)
PA
T2 TADALAFIL ADCIRCA PA
PULMONARY ANTI-HTN, ENDOTHELIN RECEPTORANTAGONISTT2AMBRISENTAN LETAIRIS PAT2BOSENTAN TRACLEER PAT2MACITENTAN OPSUMIT PA
PULMONARY ANTIHYPERTENSIVES,PROSTACYCLIN-TYPET3 ILOPROST
TROMETHAMINEVENTAVIS PA
T2 SELEXIPAG UPTRAVI PAT3 TREPROSTINIL TYVASO PAT3TREPROSTINIL
DIOLAMINEORENITRAM ER PA
T3TREPROSTINIL SODIUM REMODULIN PAT3TREPROSTINIL/NEB
ACCESSORIESTYVASO REFILLKIT
PA
T3 TREPROSTINIL/NEBULIZER/ACCESOR
TYVASOINSTITUTIONALSTART KIT
PA
T3 TREPROSTINIL/NEBULIZER/ACCESOR
TYVASO STARTERKIT
PA
RENIN INHIBITOR, DIRECTT3ALISKIREN
HEMIFUMARATETEKTURNA PA
RENIN INHIBITOR, DIRECT & CALCIUM CHANNELBLOCKERT3ALISKIREN/AMLODIPINE
BESYLATETEKAMLO PA
RENIN INHIBITOR, DIRECT/THIAZIDE DIURETICCOMBT3ALISKIREN/HYDROCHLO
ROTHIAZIDETEKTURNA HCT PA
THIAZIDE AND RELATED DIURETICST1CHLOROTHIAZIDE DIURIL (250 MG)
(TABLET)T3CHLOROTHIAZIDE DIURIL (250
MG/5ML) (ORALSUSP)
T1CHLOROTHIAZIDE DIURIL (500 MG)(TABLET)
T1CHLORTHALIDONE HYGROTONT1HYDROCHLOROTHIAZIDE
HYDROCHLOROTHIAZIDE
T1HYDROCHLOROTHIAZIDE
HYDRODIURIL
T1HYDROCHLOROTHIAZIDE
MICROZIDE
T1 INDAPAMIDE LOZOLT1METHYCLOTHIAZIDE METHYCLOTHIAZI
DET1METOLAZONE ZAROXOLYNT1PHENOXYBENZAMINEHCL
DIBENZYLINE
VASODILATORS, COMBINATIONT2 ISOSORBIBE
DINIT/HYDRALAZINEBIDIL
CARDIOVASCULAR DISEASE - LIPIDIRREGULARITY
ANTIHYPERLIP.HMG COA REDUCTINHIB&CHOLEST.AB.INHIBT1EZETIMIBE/SIMVASTATIN
VYTORIN (10 MG-10MG) (TABLET)
QL
T1EZETIMIBE/SIMVASTATIN
VYTORIN (10 MG-20MG) (TABLET)
QL
T1EZETIMIBE/SIMVASTATIN
VYTORIN (10 MG-40MG) (TABLET)
QL
T1EZETIMIBE/SIMVASTATIN
VYTORIN (10 MG-80MG) (TABLET)
ST, QL
ANTIHYPERLIPIDEMIC - APO B-100 SYNTHESISINHIBITORT2MIPOMERSEN SODIUM KYNAMRO PA
ANTIHYPERLIPIDEMIC - HMG COA REDUCTASEINHIBITORST1ATORVASTATINCALCIUM
LIPITOR QL
T1FLUVASTATIN SODIUM LESCOL ST, QLT1FLUVASTATIN SODIUM LESCOL XL ST, QLT3 LOVASTATIN ALTOPREV ST, QLT1LOVASTATIN MEVACOR QLT2 PITAVASTATIN CALCIUM LIVALO QLT1PRAVASTATIN SODIUM PRAVACHOL QLT1ROSUVASTATINCALCIUM
CRESTOR QL
T3 SIMVASTATIN FLOLIPID ST, QL
Commercial Formulary
804 Portfolio High Formulary Page 16 of 133
T1 SIMVASTATIN ZOCOR (10 MG)(TABLET)
QL
T1 SIMVASTATIN ZOCOR (20 MG)(TABLET)
QL
T1 SIMVASTATIN ZOCOR (40 MG)(TABLET)
QL
T1 SIMVASTATIN ZOCOR (5 MG)(TABLET)
QL
T1 SIMVASTATIN ZOCOR (80 MG)(TABLET)
ST, QL
ANTIHYPERLIPIDEMIC - MTP INHIBITORT2 LOMITAPIDE MESYLATE JUXTAPID PA
ANTIHYPERLIPIDEMIC - PCSK9 INHIBITORST2ALIROCUMAB PRALUENT PEN PAT2EVOLOCUMAB REPATHA
PUSHTRONEXPA
T2EVOLOCUMAB REPATHASURECLICK
PA
T2EVOLOCUMAB REPATHA SYRINGE PA
BILE SALT SEQUESTRANTST1CHOLESTYRAMINE(WITH SUGAR)
QUESTRAN
T1CHOLESTYRAMINE/ASPARTAME
QUESTRAN LIGHT
T2COLESEVELAM HCL WELCHOLT1COLESTIPOL HCL COLESTID (1 G)
(TABLET)T1COLESTIPOL HCL COLESTID (5 G)
(GRANULES)T1COLESTIPOL HCL COLESTID (5 G)
(PACKET)T3COLESTIPOL HCL COLESTID (7.5 G)
(PACKET)
LIPOTROPICST1EZETIMIBE ZETIA QLT1FENOFIBRATE FENOGLIDET1FENOFIBRATE LIPOFENT1FENOFIBRATE LOFIBRAT1FENOFIBRATENANOCRYSTALLIZED
TRICOR
T2 FENOFIBRATENANOCRYSTALLIZED
TRIGLIDE ST
T1FENOFIBRATE,MICRONIZED
ANTARA (130 MG)(CAPSULE)
T3 FENOFIBRATE,MICRONIZED
ANTARA (30 MG)(CAPSULE)
ST
T1FENOFIBRATE,MICRONIZED
ANTARA (43 MG)(CAPSULE)
T3 FENOFIBRATE,MICRONIZED
ANTARA (90 MG)(CAPSULE)
ST
T1FENOFIBRATE,MICRONIZED
LOFIBRA
T1FENOFIBRIC ACID FIBRICORT1FENOFIBRIC ACID(CHOLINE)
TRILIPIX
T1GEMFIBROZIL LOPIDT2 ICOSAPENT ETHYL VASCEPA (0.5
GRAM) (CAPSULE)QL
T2 ICOSAPENT ETHYL VASCEPA (1 G)(CAPSULE)
QL
T3METHIONINE/INOSI/CHOL/FOLIC AC
LIPOCHOL PLUS
T1NIACIN NIACORT1NIACIN NIASPAN STT1OMEGA-3 ACID ETHYLESTERS
LOVAZA QL
CARDIOVASCULAR DISEASE -MISCELLANEOUS AGENTS
ADRENERGIC VASOPRESSOR AGENTST3DROXIDOPA NORTHERA PAT1MIDODRINE HCL PROAMATINE
ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITORCOMB(ARNI)T2 SACUBITRIL/VALSARTA
NENTRESTO QL
ANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMICT2RANOLAZINE RANEXA (1000 MG)
(TAB ER 12H)QL
T2RANOLAZINE RANEXA (500 MG)(TAB ER 12H)
QL
ANTIANGINAL, HEART RATE REDUCING, I(F)INHIBITORT2 IVABRADINE HCL CORLANOR PA, QL
ANTIHYPERLIP - HMG-COA&CALCIUM CHANNELBLOCKER CBT1AMLODIPINE/ATORVASTATIN
CADUET QL
CARDIOVASCULAR DISEASE -VASODILATION
VASODILATORS,CORONARYT1AMYL NITRITE AMYL NITRITET3 ISOSORBIDE DINITRATE DILATRATE-SRT1 ISOSORBIDEDINITRATE
ISOCHRON
T1 ISOSORBIDEDINITRATE
ISORDIL (10 MG)(TABLET)
T1 ISOSORBIDEDINITRATE
ISORDIL (20 MG)(TABLET)
T1 ISOSORBIDEDINITRATE
ISORDIL (30 MG)(TABLET)
T2 ISOSORBIDE DINITRATE ISORDIL (40 MG)(TABLET)
T1 ISOSORBIDEDINITRATE
ISORDILTITRADOSE
T1 ISOSORBIDEMONONITRATE
IMDUR
T1 ISOSORBIDEMONONITRATE
MONOKET
T3NITROGLYCERIN GONITRO STT2NITROGLYCERIN NITRO-BID
Commercial Formulary
804 Portfolio High Formulary Page 17 of 133
T1NITROGLYCERIN NITRO-DUR(0.1MG/HR) (PATCHTD24)
T1NITROGLYCERIN NITRO-DUR(0.2MG/HR) (PATCHTD24)
T2NITROGLYCERIN NITRO-DUR (0.3MG/HR) (PATCHTD24)
T1NITROGLYCERIN NITRO-DUR(0.4MG/HR) (PATCHTD24)
T1NITROGLYCERIN NITRO-DUR(0.6MG/HR) (PATCHTD24)
T2NITROGLYCERIN NITRO-DUR(0.8MG/HR) (PATCHTD24)
T1NITROGLYCERIN NITROLINGUALT1NITROGLYCERIN NITROMISTT1NITROGLYCERIN NITROSTATT1NITROGLYCERIN NITRO-TIME
VASODILATORS,PERIPHERALT1ERGOLOID MESYLATESHYDERGINET1 ISOXSUPRINE HCL ISOXSUPRINE HCLT1 ISOXSUPRINE HCL VASODILANT1PAPAVERINE HCL PAPAVERINE HCLT1PAPAVERINE/PHENTOLAMINE/WATER
PAPAVERINE/PHENTOLAMINE/WATER
CONTRACEPTION/OXYTOCICSCONTRACEPTIVES, INTRAVAGINAL, SYSTEMICT0 ETONOGESTREL/ETHINY
L ESTRADIOLNUVARING QL
CONTRACEPTIVES,INJECTABLET0MEDROXYPROGESTERONE ACETATE
DEPO-PROVERA QL
T0MEDROXYPROGESTERONE ACETATE
DEPO-SUBQPROVERA 104
QL
CONTRACEPTIVES,INTRAVAGINALT0NONOXYNOL 9 CONCEPTROLT0NONOXYNOL 9 DELFENT0NONOXYNOL 9 GYNOL IIT0NONOXYNOL 9 TODAY
CONTRACEPTIVESPONGE
T0NONOXYNOL 9 VCF
CONTRACEPTIVES,ORALT0DESOG-E.ESTRADIOL/E.ESTRADIOL
MIRCETTE
T0DESOGESTREL-ETHINYL ESTRADIOL
CYCLESSA
T0DESOGESTREL-ETHINYL ESTRADIOL
DESOGEN
T0DROSPIR/ETHESTRA/LEVOMEFOL CA
BEYAZ ST
T3DROSPIR/ETHESTRA/LEVOMEFOL CA
SAFYRAL ST
T3 ESTRADIOLVALERATE/DIENOGEST
NATAZIA ST
T0ETHINYLESTRADIOL/DROSPIRENONE
YASMIN 28 ST
T0ETHINYLESTRADIOL/DROSPIRENONE
YAZ ST
T0ETHYNODIOL D-ETHINYL ESTRADIOL
DEMULEN
T0ETHYNODIOL D-ETHINYL ESTRADIOL
DEMULEN 1-50-21
T0ETHYNODIOL D-ETHINYL ESTRADIOL
ETHYNODIOL D-ETHINYLESTRADIOL
T0LEVONORGESTREL PLAN B ONE-STEPT0LEVONORGESTREL TAKE ACTIONT0LEVONORGESTREL-ETHIN ESTRADIOL
AMETHYST
T0LEVONORGESTREL-ETHIN ESTRADIOL
AVIANE
T0LEVONORGESTREL-ETHIN ESTRADIOL
LEVONORGESTREL-ETHIN ESTRADIOL
T0LEVONORGESTREL-ETHIN ESTRADIOL
NORDETTE-28
T0LEVONORGESTREL-ETHIN ESTRADIOL
SEASONALE QL
T0LEVONORGESTREL-ETHIN ESTRADIOL
TRIVORA
T0L-NORGEST/E.ESTRADIOL-E.ESTRAD
LOSEASONIQUE QL
T0L-NORGEST/E.ESTRADIOL-E.ESTRAD
QUARTETTE
T0L-NORGEST/E.ESTRADIOL-E.ESTRAD
SEASONIQUE QL
T0NORETH-ETHINYLESTRADIOL/IRON
NORETH-ETHINYLESTRADIOL/IRON
T0NORETHINDRONE ORTHO MICRONORT0NORETHINDRONE AC-ETH ESTRADIOL
LOESTRIN
T2NORETHINDRONE-E.ESTRADIOL-IRON
LO LOESTRIN FE ST
T0NORETHINDRONE-E.ESTRADIOL-IRON
NORETHINDRONE-E.ESTRADIOL-IRON
T3NORETHINDRONE-E.ESTRADIOL-IRON
TAYTULLA
T0NORETHINDRONE-ETHINYL ESTRAD
MODICON
T0NORETHINDRONE-ETHINYL ESTRAD
ORTHO-NOVUM
T0NORETHINDRONE-ETHINYL ESTRAD
OVCON-35
T0NORETHINDRONE-ETHINYL ESTRAD
TRI-NORINYL
T0NORETHINDRONE-MESTRANOL
NORINYL 1+50
T0NORGESTIMATE-ETHINYL ESTRADIOL
ORTHO TRI-CYCLEN
Commercial Formulary
804 Portfolio High Formulary Page 18 of 133
T0NORGESTIMATE-ETHINYL ESTRADIOL
ORTHO TRI-CYCLEN LO
T0NORGESTIMATE-ETHINYL ESTRADIOL
ORTHO-CYCLEN
T0NORGESTREL-ETHINYL ESTRADIOL
LO-OVRAL-28
T0NORGESTREL-ETHINYL ESTRADIOL
LO-OVRAL-8
T0NORGESTREL-ETHINYL ESTRADIOL
NORGESTREL-ETHINYLESTRADIOL
T0ULIPRISTAL ACETATE ELLA
CONTRACEPTIVES,TRANSDERMALT0NORELGESTROMIN/ETHIN.ESTRADIOL
ORTHO EVRA QL
DIAPHRAGMS/CERVICAL CAPT0CERVICAL CAP FEMCAPT3DIAPHRAGMS,
CONTOUREDCAYA CONTOURED
T0DIAPHRAGMS, WIDESEAL
WIDE SEALDIAPHRAGM
OXYTOCICST3DINOPROSTONE CERVIDILT3DINOPROSTONE PREPIDILT3DINOPROSTONE PROSTIN E2
VAGINALSUPPOSITORY
T2METHYLERGONOVINEMALEATE
METHERGINE
COUGH AND COLD1ST GEN ANTIHISTAMINE & DECONGESTANTCOMBINATIONST1CHLORPHENIRAMINE/PHENYLEPHRINE
CHLORPHENIRAMINE/PHENYLEPHRINE
T1PHENYLEPHRINEHCL/PROMETH HCL
PHENERGAN VC
T1PHENYLEPHRINEHCL/PROMETH HCL
PHEN-TUSS AD
1ST GEN ANTIHIST-DECONGEST-ANTICHOLINERGIC COMBT1PSEUDOEPHED/CHLOR-MAL/BELL ALK
PSEUDOEPHED/CHLOR-MAL/BELLALK
ANTITUSSIVES,NON-NARCOTICT1BENZONATATE TESSALONT1BENZONATATE TESSALON PERLET1BENZONATATE ZONATUSS
NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTT1HYDROCODONE/CPM/PSEUDOEPHED
ZUTRIPRO
T1PROMETHAZINE/PHENYLEPH/CODEINE
PENTAZINE VCWITH CODEINE
AGE
T1PROMETHAZINE/PHENYLEPH/CODEINE
PHENERGAN VCWITH CODEINE
AGE
NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMBT3HYDROCODONE/PSEUD
OEPHED/GUAIFHYCOFENIX ST, QL
NARCOTIC ANTITUSSIVE-1ST GENERATIONANTIHISTAMINET3CODEINE
POLI/CHLORPHENIRPOLIS
TUZISTRA XR ST,AGE,QL
T3HYDROCODONE/CHLORPHEN P-STIREX
TUSSICAPS
T1HYDROCODONE/CHLORPHEN P-STIREX
TUSSIONEX
T3HYDROCODONE/CHLORPHENIRAMINE
VITUZ
T1PROMETHAZINEHCL/CODEINE
PHENERGAN WITHCODEINE
AGE
NARCOTIC ANTITUSSIVE-ANTICHOLINERGICCOMB.T1HYDROCODONEBIT/HOMATROP ME-BR
HYDROCODONEBIT/HOMATROPME-BR
NARCOTIC ANTITUSSIVE-DECONGESTANTCOMBINATIONST3 PSEUDOEPHED/HYDROC
ODONEREZIRA
NARCOTIC ANTITUSSIVE-EXPECTORANTCOMBINATIONT3GUAIFENESIN/HYDROCO
DONEFLOWTUSS ST, QL
T3GUAIFENESIN/HYDROCODONE
OBREDON ST, QL
NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTT1BROMPHENIRAMINE/PSEUDOEPHED/DM
BROMFED DM
T1BROMPHENIRAMINE/PSEUDOEPHED/DM
BROMPHENIRAMINE/PSEUDOEPHED/DM
T1CHLORPHENIRAMINE/PHENYLEPH/DM
CHLORPHENIRAMINE/PHENYLEPH/DM
NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINECOMB.T1PROMETHAZINE/DEXTROMETHORPHAN
PHEN TUSS DM
NOSE PREPARATIONS, VASOCONSTRICTORS (RX)T3 EPINEPHRINE HCL ADRENALIN
CHLORIDET3 TETRAHYDROZOLINE
HCLTYZINE
DERMATOLOGY - ACNEACNE AGENTS,SYSTEMICT3 ISOTRETINOIN ABSORICA STT1 ISOTRETINOIN ACCUTANET1 ISOTRETINOIN ISOTRETINOIN
Commercial Formulary
804 Portfolio High Formulary Page 19 of 133
ACNE AGENTS,TOPICALT1ADAPALENE/BENZOYLPEROXIDE
EPIDUO ST,AGE
T2ADAPALENE/BENZOYLPEROXIDE
EPIDUO FORTE ST,AGE
T3AZELAIC ACID AZELEXT3CLINDAMYCIN
PHOS/BENZOYL PEROXACANYA ST
T1CLINDAMYCINPHOS/BENZOYL PEROX
BENZACLIN
T1CLINDAMYCINPHOS/BENZOYL PEROX
DUAC
T2CLINDAMYCINPHOS/BENZOYL PEROX
ONEXTON ST
T3CLINDAMYCIN/BENZOYL/EMOL CMB94
NEUAC
T3CLINDAMYCIN/TRETINOIN
VELTIN ST
T1CLINDAMYCIN/TRETINOIN
ZIANA
T3DAPSONE ACZONET1 SULFACETAMIDESODIUM
KLARON
ANTICORROSIVE AGENTST3BUTYLATED
HYDROXYTOLUENEBUTYLATEDHYDROXYTOLUENE(BHT)
KERATOLYTIC-GLUCOCORTICOID COMBINATIONST2BENZOYL
PEROXIDE/HYDROCORTISON
VANOXIDE-HC
ROSACEA AGENTS, TOPICALT2AZELAIC ACID FINACEAT3BRIMONIDINE
TARTRATEMIRVASO
T3 IVERMECTIN SOOLANTRA STT1METRONIDAZOLE METROCREAMT1METRONIDAZOLE METROGELT1METRONIDAZOLE METROLOTIONT3METRONIDAZOLE NORITATE STT1METRONIDAZOLE ROSADANT3METRONIDAZOLE/SKIN
CLEANSER 23ROSADAN
T3OXYMETAZOLINE HCL RHOFADE
TOPICAL PREPARATIONS,ANTIBACTERIALST3CADEXOMER IODINE IODOFLEXT3CADEXOMER IODINE IODOSORBT3CLIOQUINOL/HYDROCO
RTIS/EMOL 88DERMASORB AF
T3CLIOQUINOL/HYDROCORTISONE
ALA-QUIN
T3HYDROCORTISONE/IODOQUIN/ALOE 2
ALCORTIN A
T1HYDROCORTISONE/IODOQUINOL
DERMAZENE
T1HYDROCORTISONE/IODOQUINOL/ALOE
VYTONE
T1 IODINE/POTASSIUMIODIDE
LUGOL'S
T3 IODOQUINOL/ALOE P-SACCHARIDE 1
ALOQUIN
T3 IODOQUINOL/ALOE P-SACCHARIDE 1
QUINJA
T3 SILVER SILVRSTATT3 SILVER CARBONATE NORMLGEL AGT1 SILVER NITRATE SILVER NITRATE
VITAMIN A DERIVATIVEST1ADAPALENE DIFFERIN AGET1TRETINOIN ATRALIN AGET1TRETINOIN RETIN-A AGET3TRETINOIN TRETIN-XT1TRETINOINMICROSPHERES
RETIN-A MICRO AGE
T1TRETINOINMICROSPHERES
RETIN-A MICROPUMP (0.04 %) (GELW/PUMP)
AGE
T3 TRETINOINMICROSPHERES
RETIN-A MICROPUMP (0.08 %) (GELW/PUMP)
ST,AGE
T1TRETINOINMICROSPHERES
RETIN-A MICROPUMP (0.1 %) (GELW/PUMP)
AGE
T3 TRETINOIN/EMOL 9/SKINCLEANSR1
TRETIN-X AGE
VITAMIN A DERIVATIVES, TOPICAL ACNE AGENTST2 TAZAROTENE FABIOR AGE
DERMATOLOGY - ANTIINFECTIVETOPICAL ANTIBIOTICST3CLINDAMYCIN
PHOS/SKIN CLNSR 19CLINDACIN ETZ
T3CLINDAMYCINPHOS/SKIN CLNSR 19
CLINDACIN PAC
T1CLINDAMYCINPHOSPHATE
CLEOCIN T
T1CLINDAMYCINPHOSPHATE
CLINDACIN ETZ
T1CLINDAMYCINPHOSPHATE
CLINDACIN P
T3CLINDAMYCINPHOSPHATE
CLINDAGEL ST
T1CLINDAMYCINPHOSPHATE
EVOCLIN
T1ERYTHROMYCINBASE/ETHANOL
ERY
T1ERYTHROMYCINBASE/ETHANOL
ERYGEL
T1ERYTHROMYCINBASE/ETHANOL
ERYMAX
T2ERYTHROMYCIN/BENZOYL PEROXIDE
AKTIPAK
T1ERYTHROMYCIN/BENZOYL PEROXIDE
BENZAMYCIN
T1GENTAMICIN SULFATE GENTAMICINSULFATE
T1MUPIROCIN CENTANYT3MUPIROCIN CENTANY ATT1MUPIROCIN CALCIUM BACTROBAN
Commercial Formulary
804 Portfolio High Formulary Page 20 of 133
TOPICALANTIFUNGAL/ANTIINFLAMMATORY,STERIODAGENTT3CLOTRIMAZOLE/BETAM
ETH DIP/ZINCDERMACINRXTHERAZOLE PAK
T1CLOTRIMAZOLE/BETAMETHASONE DIP
LOTRISONE
TOPICAL ANTIFUNGALST3BUTENAFINE HCL MENTAXT1CICLOPIROX CICLODANT1CICLOPIROX LOPROXT1CICLOPIROX PENLACT1CICLOPIROX OLAMINE CICLODANT1CICLOPIROX OLAMINE LOPROXT3CICLOPIROX/SKIN
CLEANSER NO.28CICLODAN
T3CICLOPIROX/SKINCLEANSER NO.40
LOPROX
T1CICLOPIROX/UREA/CAMPH/MEN/EUC
CICLODAN
T1CLOTRIMAZOLE LOTRIMINT3 ECONAZOLE NITRATE ECOZAT1ECONAZOLE NITRATE SPECTAZOLET3 EFINACONAZOLE JUBLIA PAT1GENTIANVIOLET/BRGREEN/PROFLAV
GENTIANVIOLET/BRGREEN/PROFLAV
T1KETOCONAZOLE EXTINA (2 %)(FOAM)
T3KETOCONAZOLE EXTINA (2 %)(FOAM)
T1KETOCONAZOLE NIZORALT3KETOCONAZOLE XOLEGELT3 LULICONAZOLE LUZU ST, QLT3MICONAZOLE
NITRATE/ZINC OX/PETVUSION
T1NAFTIFINE HCL NAFTIN (1 %)(CREAM (G))
T2NAFTIFINE HCL NAFTIN (1 %) (GEL(GRAM))
T1NAFTIFINE HCL NAFTIN (2 %)(CREAM (G))
T2NAFTIFINE HCL NAFTIN (2 %) (GEL(GRAM))
T1NYSTATIN MYCOSTATINT1NYSTATIN NYAMYCT1NYSTATIN NYSTATINT1NYSTATIN NYSTEXT1NYSTATIN NYSTOPT1NYSTATIN/TRIAMCIN MYCOGEN IIT1OXICONAZOLENITRATE
OXISTAT (1 %)(CREAM (G))
T3OXICONAZOLE NITRATE OXISTAT (1 %)(LOTION)
T3 SERTACONAZOLENITRATE
ERTACZO
T1 SODIUMTHIOSULFATE/SALACID
VERSICLEAR
T2 SULCONAZOLE NITRATE EXELDERMT3TAVABOROLE KERYDIN PA
TOPICAL ANTIPARASITICST3BENZYL ALCOHOL ULESFIAT2CROTAMITON EURAXT3 IVERMECTIN SKLICET1LINDANE KWELLT1MALATHION OVIDET1PERMETHRIN PERMETHRINT1 SPINOSAD NATROBA
TOPICAL ANTIVIRALST2ACYCLOVIR ZOVIRAX (5 %)
(CREAM (G))T1ACYCLOVIR ZOVIRAX (5 %)
(OINT. (G))T3 PENCICLOVIR DENAVIR
TOPICAL ANTIVIRALS/ANTIINFLAMMATORY,STEROID AGENTT3ACYCLOVIR/HYDROCOR
TISONEXERESE ST, QL
TOPICAL GENITAL WART-HPV TREATMENTAGENTST3 SINECATECHINS VEREGEN ST
TOPICAL PLEUROMUTILIN DERIVATIVEST3RETAPAMULIN ALTABAX
TOPICAL SULFONAMIDEST3MAFENIDE ACETATE SULFAMYLONT1 SILVER SULFADIAZINE SILVADENET1 SILVER SULFADIAZINE THERMAZENET1 SULFACETAMIDESOD/SULFUR/UREA
CLARIS
T1 SULFACETAMIDESOD/SULFUR/UREA
SULFACETAMIDESOD/SULFUR/UREA
T1 SULFACETAMIDESODIUM/SULFUR
AVAR (10-5%(W/W))(CLEANSER)
T3 SULFACETAMIDESODIUM/SULFUR
AVAR (9.5 %-5 %)(FOAM)
T3 SULFACETAMIDESODIUM/SULFUR
AVAR (9.5 %-5 %)(MED. PAD)
T1 SULFACETAMIDESODIUM/SULFUR
AVAR LS (10 %-2 %)(CLEANSER)
T3 SULFACETAMIDESODIUM/SULFUR
AVAR LS (10 %-2 %)(FOAM)
T3 SULFACETAMIDESODIUM/SULFUR
AVAR LS (10 %-2 %)(MED. PAD)
T1 SULFACETAMIDESODIUM/SULFUR
AVAR-E
T1 SULFACETAMIDESODIUM/SULFUR
AVAR-E GREEN
T1 SULFACETAMIDESODIUM/SULFUR
AVAR-E LS
T1 SULFACETAMIDESODIUM/SULFUR
BP 10-1
T1 SULFACETAMIDESODIUM/SULFUR
CLARIFOAM EF
T1 SULFACETAMIDESODIUM/SULFUR
PLEXION (10-5%(W/W)) (LOTION)
T1 SULFACETAMIDESODIUM/SULFUR
PLEXION (9.8%-4.8%) (CLEANSER)
Commercial Formulary
804 Portfolio High Formulary Page 21 of 133
T1 SULFACETAMIDESODIUM/SULFUR
PLEXION (9.8%-4.8%) (CREAM (G))
T1 SULFACETAMIDESODIUM/SULFUR
PLEXION (9.8%-4.8%) (LOTION)
T3 SULFACETAMIDESODIUM/SULFUR
PLEXION (9.8%-4.8%) (MED. PAD)
T1 SULFACETAMIDESODIUM/SULFUR
PLEXION TS
T3 SULFACETAMIDESODIUM/SULFUR
ROSANIL
T3 SULFACETAMIDESODIUM/SULFUR
ROSULA (10 %-4.5%) (CLEANSER)
T1 SULFACETAMIDESODIUM/SULFUR
ROSULA (10 %-5 %)(MED. PAD)
T1 SULFACETAMIDESODIUM/SULFUR
SODIUMSULFACETAMIDE-SULFUR
T1 SULFACETAMIDESODIUM/SULFUR
SULFACET-R
T1 SULFACETAMIDESODIUM/SULFUR
SUMADAN
T1 SULFACETAMIDESODIUM/SULFUR
SUMAXIN
T1 SULFACETAMIDESODIUM/SULFUR
SUMAXIN TS
T1 SULFACETAMIDE/SULFUR/CLEANSR23
PLEXION
T3 SULFACETAMIDE/SULFUR/CLEANSR23
SUMADAN
T3 SULFACETAMIDE/SULFUR/CLEANSR23
SUMAXIN CP
T1 SULFACTSOD/SULUR/AVOB/OTN/OCT
SUMADAN XLT
DERMATOLOGY -ANTIINFLAMMATORY
TOP. ANTI-INFLAM.,PHOSPHODIESTERASE-4 (PDE4)INHIBT2CRISABOROLE EUCRISA
TOPICALANTIBIOTICS/ANTIINFLAMMATORY,STEROIDALT2NEOMYC/BACIT/POLYM
YX/HYDROCORTCORTISPORIN
T3NEOMYCINSULFATE/FLUOCINOLONE
NEO-SYNALAR ST
T3NEOMYCIN/FLUOCINOLONE/EMOLL 65
NEO-SYNALAR ST
T2NEOMYCIN/POLYMYXINB/HYDROCORT
CORTISPORIN
TOPICAL ANTI-INFLAMMATORY STEROIDALT1ALCLOMETASONEDIPROPIONATE
ACLOVATE
T1AMCINONIDE CYCLOCORTT1BETAMETHASONEDIPROPIONATE
DIPROLENE
T3BETAMETHASONEDIPROPIONATE
SERNIVO ST
T1BETAMETHASONEVALERATE
LUXIQ
T1BETAMETHASONEVALERATE
VALISONE
T1BETAMETHASONE/PROPYLENE GLYC
DIPROLENE
T1BETAMETHASONE/PROPYLENE GLYC
DIPROLENE AF
T1CLOBETASOLPROPIONATE
CLOBEX
T1CLOBETASOLPROPIONATE
CLODAN
T1CLOBETASOLPROPIONATE
OLUX
T1CLOBETASOLPROPIONATE
TEMOVATE
T1CLOBETASOLPROPIONATE/EMOLL
OLUX-E
T1CLOBETASOLPROPIONATE/EMOLL
TEMOVATE E
T1CLOBETASOLPROPIONATE/EMOLL
TEMOVATEEMOLLIENT
T3CLOBETASOL/SKINCLEANSER NO.28
CLODAN
T1CLOCORTOLONEPIVALATE
CLODERM
T3DESONIDE DESONATET1DESONIDE DESONIDET1DESONIDE DESOWENT3DESONIDE VERDESOT1DESOXIMETASONE TOPICORT (0.05 %)
(CREAM (G))T1DESOXIMETASONE TOPICORT (0.05 %)
(GEL (GRAM))T1DESOXIMETASONE TOPICORT (0.05 %)
(OINT. (G))T1DESOXIMETASONE TOPICORT (0.25 %)
(CREAM (G))T1DESOXIMETASONE TOPICORT (0.25 %)
(OINT. (G))T3DESOXIMETASONE TOPICORT (0.25 %)
(SPRAY)ST
T1DIFLORASONEDIACETATE
APEXICON
T1DIFLORASONEDIACETATE
PSORCON
T2DIFLORASONEDIACETATE/EMOLL
APEXICON E
T3 FLUOCINOLONEACETONIDE
CAPEX SHAMPOO
T1FLUOCINOLONEACETONIDE
DERMA-SMOOTHE-FS
T1FLUOCINOLONEACETONIDE
SYNALAR
T3 FLUOCINOLONE/EMOLCOMB NO.65
SYNALAR
T1FLUOCINOLONE/SHOWER CAP
DERMA-SMOOTHE-FS
T3 FLUOCINOLONE/SKINCLNSR10/TAPE
XILAPAK
T3 FLUOCINOLONE/SKINCLNSR28
SYNALAR TS
Commercial Formulary
804 Portfolio High Formulary Page 22 of 133
T3 FLUOCINOLONE/UREA/SILICONE,ADH
NOXIPAK
T1FLUOCINONIDE LIDEXT1FLUOCINONIDE VANOST1FLUOCINONIDE/EMOLLIENT BASE
LIDEX-E
T1FLURANDRENOLIDE CORDRAN (0.05 %)(CREAM (G))
T1FLURANDRENOLIDE CORDRAN (0.05 %)(LOTION)
T1FLURANDRENOLIDE CORDRAN (0.05 %)(OINT. (G))
T3 FLURANDRENOLIDE CORDRAN(4MCG/SQ CM)(MED. TAPE)
ST, QL
T1FLURANDRENOLIDE NOLIXT1FLUTICASONEPROPIONATE
CUTIVATE
T3HALCINONIDE HALOGT1HALOBETASOLPROPIONATE
ULTRAVATE (0.05%) (CREAM (G))
T3HALOBETASOLPROPIONATE
ULTRAVATE (0.05%) (LOTION)
T1HALOBETASOLPROPIONATE
ULTRAVATE (0.05%) (OINT. (G))
T3HALOBETASOL/LACTICACID
ULTRAVATE X
T1HYDROCORT/MINOIL/PETROLAT,WHT
HYDROCORT/MINOIL/PETROLAT,WHT
T2HYDROCORT/SALACID/SULF/SHAMP1
SCALACORT DK
T1HYDROCORTISONE ALACORTT1HYDROCORTISONE ANUSOL HCT1HYDROCORTISONE CORTAIDT1HYDROCORTISONE HYDROCORTISONET1HYDROCORTISONE HYTONET1HYDROCORTISONE NUCORTT1HYDROCORTISONE PROCTOZONE-HCT1HYDROCORTISONE SCALACORTT2HYDROCORTISONE TEXACORTT3HYDROCORTISONE
ACET/ALOE VERANUCORT
T1HYDROCORTISONEACETATE
HYDROCORTISONEACETATE
T3HYDROCORTISONEACETATE
MICORT-HC
T1HYDROCORTISONEBUTYRATE
LOCOID (0.1 %)(CREAM (G))
T3HYDROCORTISONEBUTYRATE
LOCOID (0.1 %)(LOTION)
T1HYDROCORTISONEBUTYRATE
LOCOID (0.1 %)(OINT. (G))
T1HYDROCORTISONEBUTYRATE
LOCOID (0.1 %)(SOLUTION)
T1HYDROCORTISONEBUTYRATE/EMOLL
LOCOIDLIPOCREAM
T2HYDROCORTISONEPROBUTATE
PANDEL
T1HYDROCORTISONEVALERATE
HYDROCORTISONEVALERATE
T1HYDROCORTISONEVALERATE
WESTCORT
T3HYDROCORTISONE/SKINCLEANSER25
AQUA GLYCOLICHC
T3HYDROCORTISONE/SKINCLEANSER35
DERMASORB HC
T1MOMETASONEFUROATE
ELOCON
T1PREDNICARBATE DERMATOPT3 TRIAMCINOLONE
ACETON/SILICONESDERMACINRXSILAZONE
T3TRIAMCINOLONEACETON/SILICONES
DERMAZONE
T3TRIAMCINOLONEACETON/SILICONES
SILAZONE-II
T1TRIAMCINOLONEACETONIDE
KENALOG
T1TRIAMCINOLONEACETONIDE
TRIAMCINOLONEACETONIDE
T1TRIAMCINOLONE/DIMETH/SILICONE
DERMACINRXSILAPAK
ST, QL
T1TRIAMCINOLONE/DIMETH/SILICONE
DERMAWERX SDS ST, QL
T1TRIAMCINOLONE/DIMETH/SILICONE
NUTRIARX ST, QL
T1TRIAMCINOLONE/DIMETH/SILICONE
SURE RESULT TACPAK
ST, QL
T1TRIAMCINOLONE/DIMETH/SILICONE
TRI-SILA ST, QL
T3 TRIAMCINOLONE/DIMETH/SILICONE
WHYTEDERMTDPAK
T3TRIAMCINOLONE/DIMETH/SILICONE
WHYTEDERMTRILASIL PAK
T3TRIAMCINOLONE/EMOLLIENT COMB86
DERMASORB TA
TOPICAL ANTI-INFLAMMATORY, NSAIDST3DICLOFEN
SOD/KINESIOLOGY TAPEDICLO GEL-XRYLIX SHEET
T3DICLOFENSOD/KINESIOLOGY TAPE
XRYLIX
T3DICLOFENACEPOLAMINE
FLECTOR
T3DICLOFENAC SODIUM DICLOZORT1DICLOFENAC SODIUM PENNSAID (1.5 %)
(DROPS)T3DICLOFENAC SODIUM PENNSAID
(20MG/G(2%)) (SOLMD PMP)
ST
T1DICLOFENAC SODIUM VOLTARENT3DICLOFENAC SODIUM VOPAC MDST3DICLOFENAC
SODIUM/CAPSAICINNUDICLO
T3DICLOFENAC/BENZALKONIUM CHLOR
DS PREP PAK
T3DICLOFENAC/CAPSICUMOLEORESIN
DERMACINRXLEXITRAL
T3DICLOFENAC/CAPSICUMOLEORESIN
DICLOTRAL
T3DICLOFENAC/CAPSICUMOLEORESIN
SURE RESULT DSSPREMIUM PACK
Commercial Formulary
804 Portfolio High Formulary Page 23 of 133
T3DICLOFENAC/CAPSICUMOLEORESIN
XELITRAL
T3DICLOFENAC/ME-SALIC/MENTH/CAMP
INFLAMMA-K
DERMATOLOGY - ANTIPRURITICDRUGS
ANTIPRURITICS,TOPICALT1DOXEPIN HCL PRUDOXIN STT1DOXEPIN HCL ZONALON STT3 E101/NAMG FL/NA
PH/NACL/HA-NAHALEVICYN PLUS
T3NA MG FL/NAPHO/NACL/HA/NA HYP
ALEVICYN
T3NA MG FL/NAPHO/NACL/HA/NA HYP
SP ANTIPRURITIC
DERMATOLOGY - MISCELLANEOUSANTIPERSPIRANTST2ALUMINUM CHLORIDE DRYSOL
ANTISEBORRHEIC AGENTST3 EMOLLIENT
COMBINATION NO.43PROMISEB
T1EMOLLIENTCOMBINATION NO.85
EMOLLIENTCOMBINATIONNO.85
T3 EMOLLIENT NO43/SKINCLEANSER27
PROMISEBCOMPLETE
T1 SELENIUM SULFIDE SELENIUMSULFIDE
T3 SELENIUM SULFIDE SELRXT1 SELENIUM SULFIDE SELSUNT3 SELENIUM SULFIDE TERSI FOAMT1 SULFACETAMIDESODIUM
OVACE
T3 SULFACETAMIDESODIUM
OVACE PLUS (10 %)(CLEANSR ER)
T3 SULFACETAMIDESODIUM
OVACE PLUS (10 %)(CREAM (G))
T2 SULFACETAMIDESODIUM
OVACE PLUS (10 %)(SHAMPOO)
T3 SULFACETAMIDESODIUM
OVACE PLUS (9.8 %)(FOAM)
T3 SULFACETAMIDESODIUM
OVACE PLUS (9.8 %)(LOTION)
ST
T1 SULFACETAMIDESODIUM
SULFACETAMIDESODIUM
ANTISEPTICS,MISCELLANEOUST3GUAIACOL GUAIACOL
EMOLLIENTST1AMMONIUM LACTATE LAC-HYDRINT1EMOL53/NAMGFS/HA/NAHYPOCHLORIT
EMOL53/NAMGFS/HA/NAHYPOCHLORIT
T1EMOL53/SOD MAGFL.SIL/CYCLOMET
EMOL53/SOD MAGFL.SIL/CYCLOMET
T1EMOLLIENTCOMBINATION NO.10
BIAFINE
T3 EMOLLIENTCOMBINATION NO.10
LUXAMEND
T3EMOLLIENTCOMBINATION NO.101
CERAMAX
T3EMOLLIENTCOMBINATION NO.103
CERACADE
T3EMOLLIENTCOMBINATION NO.104
DEXERYL
T3 EMOLLIENTCOMBINATION NO.107
NUTRASEB
T1EMOLLIENTCOMBINATION NO.32
EMOLLIENTCOMBINATIONNO.32
T3 EMOLLIENTCOMBINATION NO.32
EPICERAM
T1EMOLLIENTCOMBINATION NO.35
EMOLLIENTCOMBINATIONNO.35
T3 EMOLLIENTCOMBINATION NO.38
NEOSALUS
T3 EMOLLIENTCOMBINATION NO.44
HPR
T3 EMOLLIENTCOMBINATION NO.44
HYLATOPIC
T3 EMOLLIENTCOMBINATION NO.47
NEOSALUS
T3 EMOLLIENTCOMBINATION NO.47
NEOSALUS CP
T3 EMOLLIENTCOMBINATION NO.53
HPR PLUS
T3 EMOLLIENTCOMBINATION NO.53
HYLATOPICPLUS
T3 EMOLLIENTCOMBINATION NO.53
NIVATOPIC PLUS
T3 EMOLLIENTCOMBINATION NO.60
ALEVICYNANTIPRURITIC SG
T3 EMOLLIENTCOMBINATION NO.60
ATRAPROHYDROGEL
T3 EMOLLIENTCOMBINATION NO.60
CELACYN
T3EMOLLIENTCOMBINATION NO.60
RESTIZAN
T3EMOLLIENTCOMBINATION NO.60
SEBUDERM
T3EMOLLIENTCOMBINATION NO.60
SP SCARMANAGEMENT
T3EMOLLIENTCOMBINATION NO.80
PRESERA
T3EMOLLIENT COMBOSNO.47, NO.60
ATRAPRO CP
T3HYALURONT/E/EMOL12/ALLAN/SHEA
XCLAIR
T3 PALM OIL SYNERDERMT3 PALM OIL/EUCALYPTUS
OILPHLAG SPRAY
T3 PALMOIL/HYALURONATESODIUM
ENTTY
T1VITEAC/GRAPE/HYALURONIC ACID
ATOPICLAIR
Commercial Formulary
804 Portfolio High Formulary Page 24 of 133
IODINE ANTISEPTICST1POVIDONE-IODINE POVIDONE-IODINE
IRRIGANTST1ACETIC ACID ACETIC ACIDT1MANNITOL/SORBITOLSOLUTION
MANNITOL/SORBITOL SOLUTION
T1NEOMYCINSULF/POLYMYXIN BSULF
NEOSPORIN G.U.IRRIGANT
T3 PHYSIOLOGICAL IRRIGSOLN NO.1
PHYSIOLYTE
T3 PHYSIOLOGICAL IRRIGSOLN NO.1
PHYSIOSOL
T1RINGER'S SOLUTION RINGER'SSOLUTION
T3RINGER'SSOLUTION,LACTATED
LACTATEDRINGERS
T3 SOD,POTCHLOR/MAG/SOD,POTPHOS
TIS-U-SOLPENTALYTE
T3 SODIUMCHLOR/HYPOCHLOROUSACID
VASHE WOUND
T3 SODIUMCHLOR/HYPOCHLOROUSACID
VASHE WOUNDTHERAPY
T1 SODIUM CHLORIDEIRRIG SOLUTION
SODIUM CHLORIDEIRRIG SOLUTION
T1 SORBITOL SOLUTION SORBITOLSOLUTION
T1WATER FORIRRIGATION,STERILE
WATER FORIRRIGATION,STERILE
IRRITANTS/COUNTER-IRRITANTST3CAPSAICIN/SKIN
CLEANSERQUTENZA PA
KERATOLYTICST1BENZOYL PEROXIDE BENZEFOAMT1BENZOYL PEROXIDE BENZEFOAM
ULTRAT1BENZOYL PEROXIDE BENZOYL
PEROXIDET1BENZOYL PEROXIDE PACNEXT3BENZOYL PEROXIDE PACNEX HPT3BENZOYL PEROXIDE PACNEX LPT1BENZOYL PEROXIDEMICROSPHERES
BENZOYLPEROXIDEMICROSPHERES
T3BENZOYLPEROXIDE/SULFUR
NUOX
T3BENZOYL PEROXIDE/VITE MIX
INOVA
T3 PODOFILOX CONDYLOX STT1PODOFILOX PODOFILOXT1PODOPHYLLUM RESIN PODOPHYLLUM
RESINT1POTASSIUMHYDROXIDE
POTASSIUMHYDROXIDE
T3 SALICYLIC AC/BENZOYLPER/VIT E
INOVA 4-1
T3 SALICYLIC AC/BENZOYLPER/VIT E
INOVA 8-2
T3 SALICYLIC ACID BENSAL HPT3 SALICYLIC ACID KERALYT SCALPT1 SALICYLIC ACID SALICYLIC ACIDT3 SALICYLIC ACID ULTRASAL-ERT1 SALICYLICACID/AMMONLACT/ALOE
SALKERA
T1 SALICYLICACID/CERAMIDE COMB1
SALICYLICACID/CERAMIDECOMB 1
T3 SALICYLIC ACID/UREA SALVAX DUO PLUST1 SILVER NITRATE SILVER NITRATET1 SILVER NITRATEAPPLICATOR
SILVER NITRATEAPPLICATOR
T3UREA GORDO-UREAT3UREA HYDRO 35T1UREA HYDRO 40T3UREA KERAFOAMT1UREA KERALACT1UREA REA LO 39T1UREA REA LO 40T3UREA RYNODERMT3UREA URAMAXIN (20 %)
(FOAM)T1UREA URAMAXIN (45 %)
(CREAM (G))T1UREA URAMAXIN (45 %)
(GEL (ML))T1UREA URAMAXIN (45 %)
(LOTION)T1UREA URAMAXIN GTT1UREA UREAT1UREA URE-KT3UREA UREVAZT3UREA UTOPICT3UREA/EMOLLIENT
COMBINATION 65URAMAXIN GT
T1UREA/LACTICACID/ZINC UNDECYL
UREA/LACTICACID/ZINCUNDECYL
OXIDIZING AGENTST3HYP AC/SOD CHL/SOD
SUL/SOD PHOALEVICYN
T3HYPOC ACID/SODHYPO/NACL/WATER
ATRAPRO DERMALSPRAY
T3HYPOC ACID/SODHYPO/NACL/WATER
MICROCYN
PROTECTIVEST3BIO/CARB/EQUIS/ETHAN
/CHIT/MSMGENADUR
T3CARBIT/EQUISXT/ETHAN/CHIT/MSM
GENADUR
T3DI-MESILOX/DIMETHIC/HEXAMETHY
BEAU RX ST, QL
T3HOCL/NA HY/NAMGF/NAPH/NACL/WA
MICROCYNHYDROGEL
T3HYALURONATE SODIUM BIONECT
Commercial Formulary
804 Portfolio High Formulary Page 25 of 133
T3HYALURONATESODIUM/HE-CELL/PEG
HYGEL
T3HYALURONATE/ALLANTOIN/ALOE EXT
RADIAPLEXRX
T1PETROLATUM,WHITE PETROLATUM,WHITE
T3 POLYDIMETHYLSILOXANES/SILICON
RECEDO
T3 POLY-UREAURETHANE NUVAILT3 PROTECTIVES
COMBINATION NO.2TETRIX
T1PROTECTIVES2/CERAMIDE 1,3,6-11
PROTECTIVES2/CERAMIDE 1,3,6-11
TOPICAL ANTI-INFLAMMATORY STEROID-LOCALANESTHETICT2HYDROCORTISONE/PRA
MOXINEANALPRAM HC
T3HYDROCORTISONE/PRAMOXINE
EPIFOAM
T3HYDROCORTISONE/PRAMOXINE
NOVACORT
T2HYDROCORTISONE/PRAMOXINE
PRAMOSONE (1 %-1%) (CREAM (G))
T2HYDROCORTISONE/PRAMOXINE
PRAMOSONE (1 %-1%) (LOTION)
T2HYDROCORTISONE/PRAMOXINE
PRAMOSONE (1 %-1%) (OINT. (G))
T1HYDROCORTISONE/PRAMOXINE
PRAMOSONE (2.5%-1 %) (CREAM (G))
T2HYDROCORTISONE/PRAMOXINE
PRAMOSONE (2.5%-1 %) (LOTION)
T2HYDROCORTISONE/PRAMOXINE
PRAMOSONE (2.5%-1 %) (OINT. (G))
T3HYDROCORTISONE/PRAMOXINE/EMOLL
PRAMOSONE E
T1LIDOCAINE/HYDROCORTISONE AC
LIDAMANTLE HC
TOPICAL ANTINEOPLASTIC & PREMALIGNANTLESION AGNTST3ALITRETINOIN PANRETINT2BEXAROTENE TARGRETIN PAT1DICLOFENAC SODIUM SOLARAZE PA, QLT1FLUOROURACIL CARACT1FLUOROURACIL EFUDEXT3 FLUOROURACIL FLUOROPLEXT3 FLUOROURACIL TOLAKT2 INGENOL MEBUTATE PICATO (0.015 %)
(GEL (EA))QL
T2 INGENOL MEBUTATE PICATO (0.05 %)(GEL (EA))
QL
T2MECHLORETHAMINEHCL
VALCHLOR PA
TOPICAL LOCAL ANESTHETICST3BENZOCAINE ANACAINET1COCAINE HCL COCAINE HCLT1ETHYL CHLORIDE ETHYL CHLORIDET1LIDOCAINE LIDODERMT3LIDOCAINE LIDOPACT3LIDOCAINE LIDOVEXT3LIDOCAINE TRANZAREL
T1LIDOCAINE XYLOCAINE ST, QLT3 LIDOCAINE HCL ANASTIAT3 LIDOCAINE HCL ASTEROT1LIDOCAINE HCL CIDALEAZET3 LIDOCAINE HCL LDO PLUST1LIDOCAINE HCL LIDO-KT1LIDOCAINE HCL LIDOPIN (3 %)
(CREAM (G))T3 LIDOCAINE HCL LIDOPIN (3.25 %)
(CREAM (G))T3 LIDOCAINE HCL LIDORXT3LIDOCAINE HCL LIDOTRALT3 LIDOCAINE HCL NUMBONEXT1LIDOCAINE HCL PRE-ATTACHED
LTA KITT3 LIDOCAINE
HCL/COLLAGENREGENECARE
T3 LIDOCAINE/BENZOCAIN/ME-SAL/CAP
ADAZIN
T3 LIDOCAINE/DIMETHICONE
DERMACINRX ZRMPAK
T3LIDOCAINE/DIMETHICONE
DERMAZYL
T3LIDOCAINE/EMOLLIENTCMB NO.102
DERMACINRX PHNPAK
T3LIDOCAINE/GAUZE/ALGINATE
WOUNDDEBRIDEMENT-LIDOCAINE
T3 LIDOCAINE/KINESIOLOGY TAPE
XRYLIDERM
T3LIDOCAINE/MENTHOL MENTHO-CAINET3 LIDOCAINE/METHYL
SAL/MENTHOLSOLUPAK
T3LIDOCAINE/PRILO/M.SALICY/MENTH
PAINGO KFT
T1LIDOCAINE/PRILOCAINE
AGONEAZE
T1LIDOCAINE/PRILOCAINE
DERMACINRXEMPRICAINE
T1LIDOCAINE/PRILOCAINE
DERMACINRXPRIZOPAK
T3LIDOCAINE/PRILOCAINEDOLOTRANZT1LIDOCAINE/PRILOCAINE
EMLA
T1LIDOCAINE/PRILOCAINE
LEVA SET
T1LIDOCAINE/PRILOCAINE
LIDOPRIL
T1LIDOCAINE/PRILOCAINE
LIDOPRIL XR
T1LIDOCAINE/PRILOCAINE
LIDO-PRILO CAINEPACK
T1LIDOCAINE/PRILOCAINE
LIPROZONEPAK
T1LIDOCAINE/PRILOCAINE
LIVIXIL PAK
T1LIDOCAINE/PRILOCAINE
LP LITE PAK
T1LIDOCAINE/PRILOCAINE
MEDOLOR PAK
T1LIDOCAINE/PRILOCAINE
PRILOLID
Commercial Formulary
804 Portfolio High Formulary Page 26 of 133
T1LIDOCAINE/PRILOCAINE
RELADOR PAK
T1LIDOCAINE/PRILOCAINE
RELADOR PAKPLUS
T3 LIDOCAINE/RACEPINEP/TETRACAINE
L.E.T. (LIDO-EPINEPH-TETRA)
T3 LIDOCAINE/SKINCLEANSER NO.37
LIDORXKIT
T1LIDOCAINE/TETRACAINE
PLIAGLIS
T3 LIDOCAINE/TETRACAINE
SYNERA
T3LIDOCAINE/TRANSPARENT DRESSING
LIDOTRANS 5 PAK
T3NORFLURANE/PENTAFLUOROPROPANE
PAIN EASE
T3NORFLURANE/PENTAFLUOROPROPANE
SPRAY ANDSTRETCH
T3TETRACAINE HCL PONTOCAINET3 TETRACAINE/BENZOCAI
NE/BUTAMBENCETACAINE
T3 TETRACAINE/BENZOCAINE/BUTAMBEN
CETACAINEANESTHETIC
T3VITE/LIDOCAINE/ALOE/COLLAGEN
LIDOTREX
T3VITE/LIDOCAINE/ALOE/COLLAGEN
REGENECARE
TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMEST3COLLAGENASE
CLOSTRIDIUM HIST.SANTYL
T3HYALURONIDASE,HUMAN RECOMB.
HYQVIA HYCOMPONENT
DERMATOLOGY -PSORIASIS/ECZEMA
ANTIPSORIATIC AGENTS,SYSTEMICT1ACITRETIN SORIATANET3BRODALUMAB SILIQ PAT3GUSELKUMAB TREMFYA PAT3 IXEKIZUMAB TALTZ
AUTOINJECTORPA
T3 IXEKIZUMAB TALTZAUTOINJECTOR (2PACK)
PA
T3 IXEKIZUMAB TALTZAUTOINJECTOR (3PACK)
PA
T3 IXEKIZUMAB TALTZ SYRINGE PAT3 IXEKIZUMAB TALTZ SYRINGE (2
PACK)PA
T3 IXEKIZUMAB TALTZ SYRINGE (3PACK)
PA
T1METHOXSALEN METHOXSALENT2 SECUKINUMAB COSENTYX (2
SYRINGES)PA
T2 SECUKINUMAB COSENTYX PEN PAT2 SECUKINUMAB COSENTYX PEN (2
PENS)PA
T2 SECUKINUMAB COSENTYXSYRINGE
PA
ANTIPSORIATICS AGENTST2ANTHRALIN DRITHOCREME HP STT3ANTHRALIN
MICRONIZEDZITHRANOL ST
T1CALCIPOTRIENE DOVONEX STT3CALCIPOTRIENE SORILUX STT1CALCITRIOL VECTICAL STT2 TAZAROTENE TAZORAC (0.05 %)
(CREAM (G))T2 TAZAROTENE TAZORAC (0.05 %)
(GEL (GRAM))T1TAZAROTENE TAZORAC (0.1 %)
(CREAM (G))T2 TAZAROTENE TAZORAC (0.1 %)
(GEL (GRAM))
ECZEMA AGENTS,SYSTEMIC,INTERLEUKIN-4REC.ANTAG MABT3DUPILUMAB DUPIXENT PA
TOPICAL AGENTS,MISCELLANEOUST3 PYROGALLOL PYROGALLIC ACIDT3UREA GORDO-UREA
TOPICAL IMMUNOSUPPRESSIVE AGENTST2 PIMECROLIMUS ELIDEL STT1TACROLIMUS TACROLIMUS
TOPICAL VIT D ANALOG/ANTIINFLAMMATORY,STEROIDALT3CALCIPOTRIENE/BETAM
ETHASONEENSTILAR ST
T1CALCIPOTRIENE/BETAMETHASONE
TACLONEX (0.005-.064) (OINT. (G))
ST
T3CALCIPOTRIENE/BETAMETHASONE
TACLONEX (0.005-.064) (SUSPENSION)
ST
DIABETESANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDECOMB.T3ALOGLIPTIN
BENZ/METFORMIN HCLALOGLIPTIN-METFORMIN
ST, QL
T2 LINAGLIPTIN/METFORMIN HCL
JENTADUETO QL
T2LINAGLIPTIN/METFORMIN HCL
JENTADUETO XR(2.5-1000MG) (TABBP 24H)
QL
T2 LINAGLIPTIN/METFORMIN HCL
JENTADUETO XR(5MG-1000MG) (TABBP 24H)
QL
T3 SAXAGLIPTINHCL/METFORMIN HCL
KOMBIGLYZE XR(2.5-1000MG) (TBMP24HR)
ST, QL
T3 SAXAGLIPTINHCL/METFORMIN HCL
KOMBIGLYZE XR (5MG-500MG) (TBMP24HR)
ST, QL
T3 SAXAGLIPTINHCL/METFORMIN HCL
KOMBIGLYZE XR(5MG-1000MG)(TBMP 24HR)
ST, QL
Commercial Formulary
804 Portfolio High Formulary Page 27 of 133
T2 SITAGLIPTINPHOS/METFORMIN HCL
JANUMET QL
T2 SITAGLIPTINPHOS/METFORMIN HCL
JANUMET XR (100-1000MG) (TBMP24HR)
QL
T2 SITAGLIPTINPHOS/METFORMIN HCL
JANUMET XR (50-1000 MG) (TBMP24HR)
QL
T2 SITAGLIPTINPHOS/METFORMIN HCL
JANUMET XR(50MG-500MG)(TBMP 24HR)
QL
ANTIHYPERGLY,DPP-4 ENZYME INHIB&THIAZOLIDINEDIONET3ALOGLIPTIN
BENZ/PIOGLITAZONEALOGLIPTIN-PIOGLITAZONE
ST, QL
ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1RECEP.AGONIST)T3ALBIGLUTIDE TANZEUM ST, QLT2DULAGLUTIDE TRULICITY ST, QLT3 EXENATIDE BYETTA
(10MCG/0.04) (PENINJCTR)
ST, QL
T3 EXENATIDE BYETTA(5MCG/0.02) (PENINJCTR)
ST, QL
T3 EXENATIDEMICROSPHERES
BYDUREON ST, QL
T3 EXENATIDEMICROSPHERES
BYDUREON PEN ST, QL
T2 LIRAGLUTIDE VICTOZA 2-PAK ST, QLT2 LIRAGLUTIDE VICTOZA 3-PAK ST, QLT3 LIXISENATIDE ADLYXIN ST, QL
ANTIHYPERGLYCEMC-SOD/GLUCCOTRANSPORT2(SGLT2)INHIBT2CANAGLIFLOZIN INVOKANA ST, QLT3DAPAGLIFLOZIN
PROPANEDIOLFARXIGA ST, QL
T2 EMPAGLIFLOZIN JARDIANCE ST, QL
ANTIHYPERGLYCEMIC - DOPAMINE RECEPTORAGONISTST3BROMOCRIPTINE
MESYLATECYCLOSET ST
ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASEINHIB (N-S)T1ACARBOSE PRECOSET1MIGLITOL GLYSET
ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPET2 PRAMLINTIDE ACETATE SYMLINPEN 120T2 PRAMLINTIDE ACETATE SYMLINPEN 60
ANTIHYPERGLYCEMIC, DPP-4 INHIBITORST3ALOGLIPTIN BENZOATE ALOGLIPTIN ST, QLT2 LINAGLIPTIN TRADJENTA QLT3 SAXAGLIPTIN HCL ONGLYZA ST, QLT2 SITAGLIPTIN
PHOSPHATEJANUVIA QL
ANTIHYPERGLYCEMIC, INSULIN-RELEASESTIMULANT TYPET1CHLORPROPAMIDE DIABINESET1GLIMEPIRIDE AMARYLT1GLIPIZIDE GLUCOTROLT1GLIPIZIDE GLUCOTROL XLT1GLYBURIDE GLYBURIDET1GLYBURIDE,MICRONIZED
GLYNASE
T1NATEGLINIDE STARLIXT1REPAGLINIDE PRANDINT1TOLAZAMIDE TOLINASET1TOLBUTAMIDE ORINASE
ANTIHYPERGLYCEMIC, INSULIN-RESPONSEENHANCER (N-S)T1PIOGLITAZONE HCL ACTOST3ROSIGLITAZONE
MALEATEAVANDIA ST
ANTIHYPERGLYCEMIC, SGLT-2 & DPP-4 INHIBITORCOMB.T2 EMPAGLIFLOZIN/LINAGL
IPTINGLYXAMBI ST, QL
ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)T1METFORMIN HCL FORTAMET STT1METFORMIN HCL GLUCOPHAGET1METFORMIN HCL GLUCOPHAGE XRT1METFORMIN HCL GLUMETZA STT2METFORMIN HCL RIOMETT3METFORMIN/BLOOD
SUGAR DIAGNOSTDM2 ST
ANTIHYPERGLYCEMIC,INSULIN & GLP-1RECEPTOR AGONISTT2 INSULIN
DEGLUDEC/LIRAGLUTIDE
XULTOPHY 100-3.6 ST, QL
T2 INSULINGLARGINE/LIXISENATIDE
SOLIQUA 100-33 ST, QL
ANTIHYPERGLYCEMIC,INSULIN-REL STIM.&BIGUANIDE CMBT1GLIPIZIDE/METFORMIN HCL
METAGLIP
T1GLYBURIDE/METFORMIN HCL
GLUCOVANCE
T1REPAGLINIDE/METFORMIN HCL
PRANDIMET
ANTIHYPERGLYCEMIC,INSULIN-RESPONSE &RELEASE COMB.T1PIOGLITAZONEHCL/GLIMEPIRIDE
DUETACT ST
ANTIHYPERGLYCEMIC-GLUCOCORTICOIDRECEPTOR BLOCKERT2MIFEPRISTONE KORLYM PA
Commercial Formulary
804 Portfolio High Formulary Page 28 of 133
ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR &BIGUANIDE COMBT2CANAGLIFLOZIN/METFO
RMIN HCLINVOKAMET ST, QL
T2CANAGLIFLOZIN/METFORMIN HCL
INVOKAMET XR ST, QL
T3DAPAGLIFLOZIN/METFORMIN HCL
XIGDUO XR ST, QL
T2 EMPAGLIFLOZIN/METFORMIN HCL
SYNJARDY ST, QL
T2 EMPAGLIFLOZIN/METFORMIN HCL
SYNJARDY XR (10-1000 MG) (TAB BP24H)
ST, QL
T2 EMPAGLIFLOZIN/METFORMIN HCL
SYNJARDY XR(12.5-1000) (TAB BP24H)
ST, QL
T2 EMPAGLIFLOZIN/METFORMIN HCL
SYNJARDY XR (25-1000 MG) (TAB BP24H)
ST, QL
T2 EMPAGLIFLOZIN/METFORMIN HCL
SYNJARDY XR(5MG-1000MG) (TABBP 24H)
ST, QL
ANTIHYPERGLYCM,INSUL-RESP.ENHANCER &BIGUANIDE CMBT1PIOGLITAZONEHCL/METFORMIN HCL
ACTOPLUS MET ST
T2 PIOGLITAZONEHCL/METFORMIN HCL
ACTOPLUS MET XRST
T3ROSIGLITAZONE/METFORMIN HCL
AVANDAMET ST
BLOOD SUGAR DIAGNOSTICST3BLOOD SUGAR
DIAGNOSTICACCU-CHEK AVIVAPLUS
ST, QL
T3BLOOD SUGARDIAGNOSTIC
ACCU-CHEK GUIDETEST STRIP
ST, QL
T3BLOOD SUGARDIAGNOSTIC
ACCU-CHEKSMARTVIEW
ST, QL
T3BLOOD SUGARDIAGNOSTIC
ACCUTRENDGLUCOSE
ST, QL
T3BLOOD SUGARDIAGNOSTIC
ADVANCEDGLUCOSE TESTSTRIPS
ST, QL
T3BLOOD SUGARDIAGNOSTIC
ADVOCATE REDI-CODE
ST, QL
T3BLOOD SUGARDIAGNOSTIC
ADVOCATE REDI-CODE+
ST, QL
T3BLOOD SUGARDIAGNOSTIC
ADVOCATE TESTSTRIP
ST, QL
T3BLOOD SUGARDIAGNOSTIC
AGAMATRIX AMP ST, QL
T3BLOOD SUGARDIAGNOSTIC
ASSURE 4 ST, QL
T3BLOOD SUGARDIAGNOSTIC
ASSURE PLATINUMST, QL
T3BLOOD SUGARDIAGNOSTIC
ASSURE PRISMMULTI
ST, QL
T3BLOOD SUGARDIAGNOSTIC
BLOOD GLUCOSETEST
ST, QL
T3BLOOD SUGARDIAGNOSTIC
BLOOD GLUCOSETEST STRIP
ST, QL
T3BLOOD SUGARDIAGNOSTIC
CARESENS N ST, QL
T3BLOOD SUGARDIAGNOSTIC
CHOICEDMCLARUS TESTSTRIPS
ST, QL
T3BLOOD SUGARDIAGNOSTIC
CLEVER CHOICEMICRO TEST STRIP
ST, QL
T3BLOOD SUGARDIAGNOSTIC
CLEVER CHOICEPRO
ST, QL
T3BLOOD SUGARDIAGNOSTIC
CLEVER CHOICETALK
ST, QL
T3BLOOD SUGARDIAGNOSTIC
CLEVER CHOICETEST STRIPS
ST, QL
T3BLOOD SUGARDIAGNOSTIC
CLEVER CHOICEVOICE+ TST STRIP
ST, QL
T3BLOOD SUGARDIAGNOSTIC
CONTOUR ST, QL
T3BLOOD SUGARDIAGNOSTIC
CONTOUR NEXT ST, QL
T3BLOOD SUGARDIAGNOSTIC
COOL GLUCOSETEST STRIP
ST, QL
T3BLOOD SUGARDIAGNOSTIC
DIATRUE PLUS ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASY GLUCO G2 ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASY PLUS II ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASY STEP ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASY TALK ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASY TOUCH TESTSTRIP
ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASY TRAK ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASYGLUCO PLUS ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASYGLUCO TESTSTRIPS
ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASYMAX ST, QL
T3BLOOD SUGARDIAGNOSTIC
EASYMAX 15 ST, QL