Formulary 2017 Master Negative Changes from 2016 to 2017€¦ · BeHealthy 5 Tier to Ideal 6 Tier...

Affected Drug Description of ChangeFormulary Alternative, if

ApplicableCategory Class

1ST TIER UNI MIS

29GX12MM On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

1ST TIER UNI MIS


1ST TIER UNI MIS


1ST TIER UNI MIS


1ST TIER UNI MIS


8-MOP CAP 10MG Not on 2017 formulary

methoxsalen 10 mg

capsules Dermatological Agents Dermatological Agents

ABACAV/LAMIV TAB

/ZIDOVUD

On formulary, quantity

limit may apply 60 tablets per 30 days Antivirals

Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse

Transcriptase Inhibitors

ABACAVIR TAB

300MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


ABELCET INJ

5MG/ML Not on 2017 formulary

amphotericin inj,

Ambisome inj Antifungals Antifungals

ABELCET INJ

5MG/ML

On formulary, requires

prior authorization check with your doctor Antifungals Antifungals

ABILIFY DISC TAB 10MG On formulary, tier change tier 4 to tier 5 Antipsychotics 2nd Generation/Atypical

ABILIFY DISC TAB 10MG


limit may apply 60 tablets per 30 days Antipsychotics 2nd Generation/Atypical

BeHealthy 5 Tier to Ideal 6 Tier Formulary 2017 Master Negative Changes from 2016 to 2017

Pg. 1 of 331



ABILIFY DISC TAB 10MG


prior authorization if claim

history shows a missed

refill check with your doctor Antipsychotics 2nd Generation/Atypical

ABILIFY MAIN INJ

300MG On formulary, tier change tier 4 to tier 5 Antipsychotics 2nd Generation/Atypical

ABILIFY MAIN INJ

300MG


limit may apply

1 syringe or vial per 30

days Antipsychotics 2nd Generation/Atypical

ABILIFY MAIN INJ

300MG





ABRAXANE INJ

100MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

ACARBOSE TAB

100MG


limit may apply 90 tablets per 30 days Blood Glucose Regulators Antidiabetic Agents

ACARBOSE TAB

25MG



ACARBOSE TAB

50MG



ACETAZOLAMID TAB

125MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents

Diuretics, Carbonic

Anhydrase Inhibitors

ACITRETIN CAP 10MG On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents

ACITRETIN CAP

17.5MG On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents

ACITRETIN CAP 25MG On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents

Pg. 2 of 331



ACTEMRA INJ 162/0.9 Not on 2017 formulary

Humira*, Enbrel*, Stelara*

*These drugs will need a

prior authorization. To

download the specific

form, please visit

www.MyPrime.com. You

may also call the number

on the back of your

insurance card for more

information. Immunological Agents Immune Suppressants

ACTEMRA INJ

200/10ML Not on 2017 formulary





form, please visit



on the back of your



ACYCLOVIR NA INJ

1000MG


prior authorization check with your doctor Antivirals Antiherpetic Agents

ACYCLOVIR NA INJ

500MG



ACYCLOVIR NA INJ

50MG/ML On formulary, tier change tier 1 to tier 2 Antivirals Antiherpetic Agents

ACYCLOVIR NA INJ

50MG/ML



Pg. 3 of 331



ADAPALENE GEL 0.3% Not on 2017 formulary

tretinoin cream (0.025%,

0.05%, 0.1%), tretinoin

gel (0.025%, 0.01%),

Tazorac (cream, gel) Dermatological Agents Dermatological Agents

ADAPALENE GEL PMP

0.3% Not on 2017 formulary

tretinoin cream (0.025%,

0.05%, 0.1%), tretinoin

gel (0.025%, 0.01%),

Tazorac (cream, gel) Dermatological Agents Dermatological Agents

ADCIRCA TAB 20MG


limit may apply 60 tablets per 30 days Respiratory Tract Agents

Pulmonary

Antihypertensives

ADEMPAS TAB

0.5MG



Pulmonary

Antihypertensives

ADVAIR DISKU AER

100/50


limit may apply 1 inhaler per 30 days Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ADVAIR DISKU AER

250/50



Bronchodilators,

Sympathomimetic

ADVAIR DISKU AER

500/50



Bronchodilators,

Sympathomimetic

ADVAIR HFA AER

115/21


limit may apply 1 canister per 30 days Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ADVAIR HFA AER

230/21



Bronchodilators,

Sympathomimetic

ADVAIR HFA AER 45/21



Bronchodilators,

Sympathomimetic

AFINITOR TAB 10MG


limit may apply 30 tablets per 30 days Antineoplastics Antineoplastics

AFINITOR TAB 10MG




refill check with your doctor Antineoplastics Antineoplastics

Pg. 4 of 331



AFINITOR TAB 2.5MG



AFINITOR TAB 2.5MG





AFINITOR TAB 5MG



AFINITOR TAB 5MG





AFINITOR TAB 7.5MG



AFINITOR TAB 7.5MG





AFINITOR DIS TAB 2MG
















Pg. 5 of 331











ALA CORT CRE 1% On formulary, tier change tier 1 to tier 2

Hormonal Agents,

Stimulant/ Replacement/

Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

ALBUTEROL NEB

0.083% On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ALBUTEROL NEB

1.25MG/3 On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ALBUTEROL TAB 2MG On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ALBUTEROL TAB 4MG On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ALBUTEROL TAB 4MG

ER On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ALCOH-GLOVE PAD

CONTOURE On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOHOL PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOHOL PAD PREP On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOHOL PAD

SWABSTIC On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOHOL PREP PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOHOL PREP PAD

70% On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

Pg. 6 of 331



ALCOHOL PREP PAD

MED 70% On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOHOL PREP PAD

PADS 70% On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOHOL SWAB PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOHOL SWAB PAD

EX-THICK On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOHOL WIPE PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALCOH-WIPE PAD

12"X12" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

ALENDRONATE TAB

10MG


limit may apply 120 tablets per 30 days

Metabolic Bone Disease

Agents


Agents

ALENDRONATE TAB

35MG




Agents


Agents

ALENDRONATE TAB

40MG Not on 2017 formulary

alendronate tablets (5mg,

10mg, 35mg, 70mg)


Agents


Agents

ALENDRONATE TAB

5MG




Agents


Agents

ALENDRONATE TAB

70MG




Agents


Agents

ALPHAGAN P SOL

0.1% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents

Ophthalmic Antiglaucoma

Agents

Pg. 7 of 331



ALPRAZOLAM CON 1

MG/ML Not on 2017 formulary

clorazepate*,

clonazepam*, diazepam

(tablets, oral solution, oral

concentrate)*, lorazepam

tablets* *These drugs will

need a prior authorization.

To download the specific

form, please visit



on the back of your


information. Anxiolytics Benzodiazepines

ALPRAZOLAM TAB

0.25 ODT Not on 2017 formulary

clorazepate*,







form, please visit



on the back of your



Pg. 8 of 331



ALPRAZOLAM TAB

0.25MG Not on 2017 formulary

clorazepate*,







form, please visit



on the back of your



ALPRAZOLAM TAB


clorazepate*,







form, please visit



on the back of your



Pg. 9 of 331



ALPRAZOLAM TAB

0.5MG ER Not on 2017 formulary

clorazepate*,







form, please visit



on the back of your



ALPRAZOLAM TAB

0.5MG OD Not on 2017 formulary

clorazepate*,







form, please visit



on the back of your



Pg. 10 of 331



ALPRAZOLAM TAB

0.5MG XR Not on 2017 formulary

clorazepate*,







form, please visit



on the back of your



ALPRAZOLAM TAB


clorazepate*,







form, please visit



on the back of your



Pg. 11 of 331



ALPRAZOLAM TAB

1MG ER Not on 2017 formulary

clorazepate*,







form, please visit



on the back of your



ALPRAZOLAM TAB

1MG ODT Not on 2017 formulary

clorazepate*,







form, please visit



on the back of your



Pg. 12 of 331



ALPRAZOLAM TAB

1MG XR Not on 2017 formulary

clorazepate*,







form, please visit



on the back of your



ALPRAZOLAM TAB


clorazepate*,







form, please visit



on the back of your



Pg. 13 of 331



ALPRAZOLAM TAB


clorazepate*,







form, please visit



on the back of your



ALPRAZOLAM TAB


clorazepate*,







form, please visit



on the back of your



Pg. 14 of 331



ALPRAZOLAM TAB


clorazepate*,







form, please visit



on the back of your



ALPRAZOLAM TAB


clorazepate*,







form, please visit



on the back of your



Pg. 15 of 331



ALPRAZOLAM TAB


clorazepate*,







form, please visit



on the back of your



AMANTADINE TAB

100MG On formulary, tier change tier 2 to tier 4 Antiparkinson Agents

Antiparkinson Agents,

Other

AMBISOME INJ 50MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals

AMBISOME INJ 50MG



Pg. 16 of 331



AMCINONIDE CRE


betamethasone

dipropionate 0.05%

(cream), augmented

betamethasone 0.05%

(cream), betamethasone

valerate 0.1% (cream),

clobetasol 0.05%

(solution), clobetasol

emollient 0.05% (cream),

fluocinonide 0.05%

(cream, gel, ointment,

solution), mometasone

0.1% (cream, ointment,

solution), triamcinolone

0.025%/0.1% (cream),

triamcinolone 0.5%

(cream, ointment) Dermatological Agents Dermatological Agents

Pg. 17 of 331



AMCINONIDE LOT


betamethasone

dipropionate 0.05%

(cream), augmented

betamethasone 0.05%



clobetasol 0.05%



fluocinonide 0.05%





0.025%/0.1% (cream),

triamcinolone 0.5%


Pg. 18 of 331



AMCINONIDE OIN 0.1% Not on 2017 formulary

betamethasone

dipropionate 0.05%

(cream), augmented

betamethasone 0.05%



clobetasol 0.05%



fluocinonide 0.05%





0.025%/0.1% (cream),

triamcinolone 0.5%


AMILOR/HCTZ TAB 5-50 On formulary, tier change tier 1 to tier 2 Cardiovascular Agents

Cardiovascular Agents,

Other

AMILORIDE TAB 5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents

Diuretics, Potassium-

sparing

AMINOPHYLLIN INJ


Theochron CR tablets,

theophylline anhydrous

ER/CR tablets Respiratory Tract Agents

Bronchodilators,

Phosphodiesterase

Inhibitors (Xanthines)

AMINOSYN INJ

8.5/LYTE Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,

Plenamine 15%, Clinisol

SF 15%

Therapeutic Nutrients/

Minerals/ Electrolytes Nutrients

Pg. 19 of 331



AMINOSYN 7% INJ

/LYTES Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



AMINOSYN II INJ 10% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



AMINOSYN II INJ 7% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



AMINOSYN II INJ 8.5% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



AMINOSYN II INJ

8.5/LYTE Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



AMINOSYN M INJ 3.5% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



Pg. 20 of 331



AMINOSYN-HBC INJ 7% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



AMINOSYN-HF INJ 8% On formulary, tier change tier 1 to tier 2



AMINOSYN-PF INJ 10% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



AMINOSYN-PF INJ 7% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



AMINOSYN-RF INJ 5.2% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



AMIODARONE INJ

150MG/3M Not on 2017 formulary

amiodarone tablets (200

mg, 400 mg) Cardiovascular Agents Antiarrhythmics

AMIODARONE INJ




AMIODARONE TAB




AMITIZA CAP 24MCG


prior authorization check with your doctor Gastrointestinal Agents

Irritable Bowel Syndrome

Agents

Pg. 21 of 331



AMITIZA CAP 8MCG




Agents

AMITRIPTYLIN TAB

100MG On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics

AMITRIPTYLIN TAB


AMITRIPTYLIN TAB


AMITRIPTYLIN TAB


AMITRIPTYLIN TAB


AMITRIPTYLIN TAB


AMLOD/ATORVA TAB 10-


Dyslipidemics, HMG CoA

Reductase Inhibitors













AMLOD/ATORVA TAB

2.5-10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents



AMLOD/ATORVA TAB




AMLOD/ATORVA TAB




AMLOD/ATORVA TAB 5-




Pg. 22 of 331



AMLOD/ATORVA TAB 5-




AMLOD/ATORVA TAB 5-




AMLOD/ATORVA TAB 5-




AMLOD/BENAZP CAP 10-


Antihypertensive

Combinations

AMLOD/BENAZP CAP 10-


Antihypertensive

Combinations

AMLOD/BENAZP CAP


Antihypertensive

Combinations

AMLOD/BENAZP CAP 5-


Antihypertensive

Combinations

AMLOD/BENAZP CAP 5-


Antihypertensive

Combinations

AMLOD/BENAZP CAP 5-


Antihypertensive

Combinations

AMLOD/VALSAR TAB

/HCTZ On formulary, tier change tier 2 to tier 6 Cardiovascular Agents

Antihypertensive

Combinations

AMLOD/VALSAR TAB

/HCTZ


limit may apply 30 tablets per 30 days Cardiovascular Agents

Antihypertensive

Combinations

AMLOD/VALSAR TAB 10-


Antihypertensive

Combinations


160MG



Antihypertensive

Combinations



Antihypertensive

Combinations


320MG



Antihypertensive

Combinations

Pg. 23 of 331



AMLOD/VALSAR TAB 5-


Antihypertensive

Combinations

AMLOD/VALSAR TAB 5-

160MG



Antihypertensive

Combinations

AMLOD/VALSAR TAB 5-


Antihypertensive

Combinations

AMLOD/VALSAR TAB 5-

320MG



Antihypertensive

Combinations

AMOX/K CLAV CHW

200MG On formulary, tier change tier 1 to tier 4 Antibacterials Beta-lactam, Penicillins

AMOX/K CLAV CHW

400MG On formulary, tier change tier 1 to tier 4 Antibacterials Beta-lactam, Penicillins

AMOX/K CLAV SUS

200/5ML On formulary, tier change tier 1 to tier 2 Antibacterials Beta-lactam, Penicillins

AMOXAPINE TAB


AMOXAPINE TAB


AMOXAPINE TAB


AMOXAPINE TAB


AMOXICILLIN CHW


amoxicillin capsules (250

mg, 500 mg), amoxicillin

tablets (500 mg, 875 mg),

amoxicillin suspensions

(125/5 mL, 200/5 mL,

250/5 mL, 400/5 mL) Antibacterials Beta-lactam, Penicillins

Pg. 24 of 331



AMOXICILLIN CHW


amoxicillin capsules (250

mg, 500 mg), amoxicillin

tablets (500 mg, 875 mg),

amoxicillin suspensions

(125/5 mL, 200/5 mL,

250/5 mL, 400/5 mL) Antibacterials Beta-lactam, Penicillins

AMPHET/DEXTR TAB

10MG



Central Nervous System

Agents

Attention Deficit

Hyperactivity Disorder

Agents, Amphetamines

AMPHET/DEXTR TAB

12.5MG On formulary, tier change tier 1 to tier 2


Agents

Attention Deficit



AMPHET/DEXTR TAB

12.5MG




Agents

Attention Deficit



AMPHET/DEXTR TAB

15MG




Agents

Attention Deficit



AMPHET/DEXTR TAB

20MG




Agents

Attention Deficit



AMPHET/DEXTR TAB

30MG




Agents

Attention Deficit



AMPHET/DEXTR TAB

5MG




Agents

Attention Deficit



AMPHET/DEXTR TAB

7.5MG




Agents

Attention Deficit



Pg. 25 of 331



AMPHOTERICIN INJ

50MG On formulary, tier change tier 2 to tier 4 Antifungals Antifungals

AMPHOTERICIN INJ

50MG



AMPICILLIN INJ 125MG Not on 2017 formulary

ampicillin inj (250 mg, 500

mg, 1 gm, 2 gm, 10 gm) Antibacterials Beta-lactam, Penicillins

AMPICILLIN SUS


AMPICILLIN SUS


AMP-SULBACTA INJ 10-

5GM Not on 2017 formulary

ampicillin/sulbactam inj 2-

1 gm Antibacterials Beta-lactam, Penicillins

AMP-SULBACTA INJ

15GM Not on 2017 formulary

ampicillin/sulbactam inj 2-

1 gm Antibacterials Beta-lactam, Penicillins

AMPYRA TAB 10MG


prior authorization check with your doctor


Agents Multiple Sclerosis Agents

ANDRODERM DIS

2MG/24HR



Hormonal Agents,


Modifying (Sex

Hormones/ Modifiers) Androgens

ANDRODERM DIS

2MG/24HR


limit may apply 30 patches per 30 days

Hormonal Agents,


Modifying (Sex


ANDRODERM DIS

4MG/24HR



Hormonal Agents,


Modifying (Sex


Pg. 26 of 331



ANDRODERM DIS

4MG/24HR


limit may apply 30 patches per 30 days

Hormonal Agents,


Modifying (Sex


ANDROID CAP 10MG Not on 2017 formulary

methyltestosterone 10 mg

capsules* *This drug

requires prior

authorization. To


form, please visit

www.MyPrime.com or

contact the number on the

back of your insurance

card for more information.

Hormonal Agents,


Modifying (Sex


APAP/CODEINE SOL

120-12/5


limit may apply 2700 mls per 30 days Analgesics

Opioid Analgesics, Short-

acting

APAP/CODEINE TAB 300-

15MG


limit may apply 360 tablets per 30 days Analgesics


acting


30MG




acting


60MG




acting

APIDRA INJ

SOLOSTAR Not on 2017 formulary

Humalog (vials or

Kwikpen) Blood Glucose Regulators Insulins

APIDRA INJ U-100 Not on 2017 formulary

Humalog (vials or


APLENZIN TAB


bupropion tablets (IR, SR,

XL) Antidepressants Antidepressants, Other

APLENZIN TAB




Pg. 27 of 331



APLENZIN TAB




APRACLONIDIN SOL

0.5% OP Not on 2017 formulary

Alphagan P 0.1%,

brimonidine (0.15%,

0.2%) Ophthalmic Agents


Agents

APRISO CAP

0.375GM On formulary, tier change tier 3 to tier 4

Inflammatory Bowel

Disease Agents Aminosalicylates

APTIOM TAB 200MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents

APTIVUS CAP 250MG


limit may apply 120 capsules per 30 days Antivirals

Anti-HIV Agents, Protease

Inhibitors

APTIVUS SOL


limit may apply 380 mls per 30 days Antivirals


Inhibitors

ARCALYST INJ

220MG


prior authorization check with your doctor Immunological Agents Immunomodulators

ARIPIPRAZOLE SOL

1MG/ML


limit may apply 750 mls per 30 days Antipsychotics 2nd Generation/Atypical

ARIPIPRAZOLE SOL

1MG/ML





ARIPIPRAZOLE TAB

10MG



ARIPIPRAZOLE TAB

10MG





ARIPIPRAZOLE TAB

10MG ODT On formulary, tier change tier 2 to tier 5 Antipsychotics 2nd Generation/Atypical

ARIPIPRAZOLE TAB

10MG ODT



Pg. 28 of 331



ARIPIPRAZOLE TAB

10MG ODT





ARIPIPRAZOLE TAB

15MG



ARIPIPRAZOLE TAB

15MG





ARIPIPRAZOLE TAB

15MG ODT



ARIPIPRAZOLE TAB

15MG ODT





ARIPIPRAZOLE TAB

20MG



ARIPIPRAZOLE TAB

20MG





ARIPIPRAZOLE TAB

2MG



ARIPIPRAZOLE TAB

2MG





ARIPIPRAZOLE TAB

30MG



Pg. 29 of 331



ARIPIPRAZOLE TAB

30MG





ARIPIPRAZOLE TAB

5MG



ARIPIPRAZOLE TAB

5MG





ARRANON INJ

5MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

ASCOMP/COD CAP


diclofenac, etodolac,

ketoprofen IR, ibuprofen,

naproxen Analgesics


acting

ASTAGRAF XL CAP


tacrolimus capsule* *This

drug requires prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Immunological Agents Immune Suppressants

Pg. 30 of 331



ASTAGRAF XL CAP



drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




ASTAGRAF XL CAP



drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




ATENOL/CHLOR TAB

100-25MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Other

ATENOL/CHLOR TAB 50-



Other

ATORVASTATIN TAB




ATORVASTATIN TAB

10MG





ATORVASTATIN TAB




Pg. 31 of 331



ATORVASTATIN TAB

20MG





ATORVASTATIN TAB




ATORVASTATIN TAB

40MG





ATORVASTATIN TAB




ATORVASTATIN TAB

80MG





ATRIPLA TAB



Anti-HIV Agents, Non-

nucleoside Reverse


ATROPINE SUL INJ

0.05MG/1 Not on 2017 formulary check with your doctor Gastrointestinal Agents

Antispasmodics,

Gastrointestinal

ATROPINE SUL INJ

0.05MG/1



Antispasmodics,

Gastrointestinal

ATROPINE SUL INJ

0.1MG/ML Not on 2017 formulary check with your doctor Gastrointestinal Agents

Antispasmodics,

Gastrointestinal

ATROPINE SUL INJ

0.1MG/ML



Antispasmodics,

Gastrointestinal

ATROPINE SUL INJ

0.4/0.5



Antispasmodics,

Gastrointestinal

ATROPINE SUL INJ

0.4MG/ML



Antispasmodics,

Gastrointestinal

ATROPINE SUL INJ

1MG/ML



Antispasmodics,

Gastrointestinal

ATROVENT HFA AER

17MCG On formulary, tier change tier 3 to tier 4 Respiratory Tract Agents

Bronchodilators,

Anticholinergic

ATROVENT HFA AER

17MCG


limit may apply 2 canisters per 30 days Respiratory Tract Agents

Bronchodilators,

Anticholinergic

Pg. 32 of 331



AUTOSHIELD MIS

29X3/16" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

AUTOSHIELD MIS

29X5/16" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

AUTOSHIELD MIS

30GX3/16 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

AVANDAMET TAB 2-

1000MG Not on 2017 formulary pioglitazone/metformin Blood Glucose Regulators Antidiabetic Agents

AVANDIA TAB 2MG Not on 2017 formulary pioglitazone Blood Glucose Regulators Antidiabetic Agents



AVODART CAP

0.5MG Not on 2017 formulary dutasteride 0.5 capsules Genitourinary Agents

Benign Prostatic

Hypertrophy Agents

AVONEX KIT 30MCG





AVONEX KIT 30MCG


limit may apply 1 kit per 28 days



AVONEX PREFL KIT

30MCG





AVONEX PREFL KIT

30MCG


limit may apply 1 kit per 28 days



AZACTAM/DEX INJ 1GM On formulary, tier change tier 3 to tier 4 Antibacterials Beta-lactam, Other

AZELASTINE SPR 0.1%


limit may apply 2 bottles per 30 days Respiratory Tract Agents Nasal Agents

AZELASTINE SPR

0.15%



Pg. 33 of 331



AZITHROMYCIN POW

1GM PAK On formulary, tier change tier 2 to tier 4 Antibacterials Macrolides

AZITHROMYCIN SUS

100/5ML On formulary, tier change tier 1 to tier 2 Antibacterials Macrolides

AZOPT SUS 1% OP On formulary, tier change tier 3 to tier 4 Ophthalmic Agents


Agents

AZOR TAB 10-20MG Not on 2017 formulary

amlodipine/valsartan,

amlodipine in combination

with candesartan,


with irbesartan,


with losartan, amlodipine

in combination with

telmisartan Cardiovascular Agents

Antihypertensive

Combinations




with candesartan,


with irbesartan,



in combination with


Antihypertensive

Combinations

Pg. 34 of 331






with candesartan,


with irbesartan,



in combination with


Antihypertensive

Combinations




with candesartan,


with irbesartan,



in combination with


Antihypertensive

Combinations

BACIIM INJ

50000UNT Not on 2017 formulary

aztreonam inj,

colistimethate inj,

Dalvance inj,

metronidazole/NaCl inj,

vancomycin inj Antibacterials Antibacterials, Other

BACITRACIN INJ


aztreonam inj,

colistimethate inj,

Dalvance inj,

metronidazole/NaCl inj,

vancomycin inj Antibacterials Antibacterials, Other

BACITRACIN OIN OP On formulary, tier change tier 2 to tier 4 Ophthalmic Agents Ophthalmic Anti Infectives

BACLOFEN TAB

10MG On formulary, tier change tier 1 to tier 2

Skeletal Muscle

Relaxants

Skeletal Muscle

Relaxants

Pg. 35 of 331



BALZIVA TAB On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Sex

Hormones/ Modifiers) Contraceptives

BAND-AID PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

BANZEL SUS

40MG/ML On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents

BANZEL TAB 400MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents

BD PEN NEEDL MIS

29GX1/2" On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

BD PEN NEEDL MIS


BD PEN NEEDL MIS


BD PEN NEEDL MIS


BD SWAB BFLY PAD

SNGL USE On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

BD SWAB REG PAD

SNGL USE On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

BENAZEP/HCTZ TAB 10-

12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents

Antihypertensive

Combinations



Antihypertensive

Combinations



Antihypertensive

Combinations

BENAZEP/HCTZ TAB 5-


Antihypertensive

Combinations

BENAZEPRIL TAB


Angiotensin-converting

Enzyme (ACE) Inhibitors

Pg. 36 of 331



BENAZEPRIL TAB




BENAZEPRIL TAB




BENAZEPRIL TAB 5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents



BENICAR TAB 20MG Not on 2017 formulary

candesartan (4 mg, 8 mg,

16 mg, 32 mg), irbesartan

(75 mg, 150 mg, 300 mg),

losartan (25 mg, 50 mg,

100 mg) , telmisartan (20

mg, 40 mg, 80 mg),

valsartan (40 mg, 80 mg,

160 mg, 320 mg) Cardiovascular Agents

Angiotensin II Receptor

Antagonists




(75 mg, 150 mg, 300 mg),



mg, 40 mg, 80 mg),




Antagonists




(75 mg, 150 mg, 300 mg),



mg, 40 mg, 80 mg),




Antagonists

Pg. 37 of 331



BENICAR HCT TAB 20-

12.5 Not on 2017 formulary

candesartan/hydrochlorot

hiazide,

irbesartan/hydrochlorothia

zide,

losartan/hydrochlorothiazi

de,

telmisartan/hydrochlorothi

azide,

valsartan/hydrochlorothiaz

ide Cardiovascular Agents

Antihypertensive

Combinations

BENICAR HCT TAB 40-



hiazide,


zide,


de,


azide,



Antihypertensive

Combinations

BENICAR HCT TAB 40-



hiazide,


zide,


de,


azide,



Antihypertensive

Combinations

Pg. 38 of 331



BENLYSTA INJ 120MG


prior authorization check with your doctor Immunological Agents Immune Suppressants

BENLYSTA INJ 400MG



BENZTROPINE INJ

1MG/ML Not on 2017 formulary check with your doctor Antiparkinson Agents Anticholinergics

BENZTROPINE TAB

0.5MG On formulary, tier change tier 2 to tier 3 Antiparkinson Agents Anticholinergics

BENZTROPINE TAB

1MG On formulary, tier change tier 2 to tier 3 Antiparkinson Agents Anticholinergics

BENZTROPINE TAB

2MG On formulary, tier change tier 1 to tier 3 Antiparkinson Agents Anticholinergics

BETAMETH DIP CRE

0.05% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents

BETAMETH VAL CRE


BETAMETH VAL OIN


BETASERON INJ

0.3MG





BETASERON INJ

0.3MG


limit may apply

15 vials/syringes per 30

days



BETAXOLOL SOL 0.5%

OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents


Agents

BETAXOLOL TAB


Beta-adrenergic Blocking

Agents

BETAXOLOL TAB



Agents

Pg. 39 of 331



BEXAROTENE CAP

75MG





BIMATOPROST SOL


latanoprost, Lumigan,

Travatan Z Ophthalmic Agents

Ophthalmic

Prostaglandin and

Prostamide Analogs

BIVIGAM INJ 10% Not on 2017 formulary

Gammaplex*, Gamunex-

C* *These drugs require a



form, please visit



on the back of your


information. Immunological Agents

Immunizing Agents,

Passive

BLEO 15K INJ


prior authorization check with your doctor Antineoplastics Antineoplastics

BLEOMYCIN INJ

15UNIT



BLEOMYCIN INJ

30UNIT



Pg. 40 of 331



BLEPHAMIDE OIN

S.O.P. Not on 2017 formulary

sulfacetamide/prednisolon

e solution,

tobramycin/dexamethaso

ne suspension, Tobradex

ointment,

neomycin/polymyxin/dexa

methasone suspension

and ointment, Poly-dex

ointment, Neo-polycin–HC

ointment,

neomycin/polymyxin/bacitr

acin-HC ointment Ophthalmic Agents

Ophthalmic Anti-

inflammatories

BLEPHAMIDE SUS OP Not on 2017 formulary


e solution,



ointment,





ointment,



Ophthalmic Anti-

inflammatories

BLINCYTO INJ 35MCG



BOOSTRIX INJ On formulary, tier change tier 3 to tier 4 Immunological Agents Vaccines

BORDER GAUZE PAD


BOSULIF TAB 100MG



Pg. 41 of 331



BOSULIF TAB 500MG



BREO ELLIPTA INH 100-

25


limit may apply 1 package per 30 days Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

BRIELLYN TAB On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Sex


BRISDELLE CAP

7.5MG Not on 2017 formulary venlafaxine, citalopram Antidepressants

Serotonin/Norepinephrine

Reuptake Inhibitors

BUDESONIDE CAP

3MG DR On formulary, tier change tier 2 to tier 5

Hormonal Agents,


Modifying (Adrenal)

Glucocorticoids/Mineraloc

orticoids

BUDESONIDE CAP

3MG/24HR On formulary, tier change tier 2 to tier 5

Hormonal Agents,


Modifying (Adrenal)


orticoids

BUDESONIDE SUS

0.25MG/2


prior authorization check with your doctor Respiratory Tract Agents

Anti-inflammatories,

Inhaled Corticosteroids

BUDESONIDE SUS

0.5MG/2





BUDESONIDE SUS

1MG/2ML





BUDESONIDE SUS

32MCG Not on 2017 formulary

fluticasone nasal spray,

mometasone nasal spray

(generic Nasonex),

triamcinolone nasal spray Respiratory Tract Agents Nasal Agents

BUMETANIDE INJ

0.25/ML On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Loop

BUMETANIDE TAB

0.5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Loop

Pg. 42 of 331



BUMETANIDE TAB

1MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Loop

BUPREN/NALOX SUB 2-

0.5MG



Anti-Addiction/Substance

Abuse Treatment Agents Opioid Antagonists

BUPREN/NALOX SUB 8-

2MG





BUPRENORPHIN INJ

0.3MG/ML Not on 2017 formulary

buprenorphine SL tablets*

*This drug requires prior

authorization. To


form, please visit

www.MyPrime.com or






BUPRENORPHIN SUB

2MG





BUPRENORPHIN SUB

8MG





BUPROPION TAB

100MG


limit may apply 120 tablets per 30 days Antidepressants Antidepressants, Other

BUPROPION TAB

100MG ER



BUPROPION TAB

100MG SR



BUPROPION TAB

150MG ER




Abuse Treatment Agents

Smoking Cessation

Agents

BUPROPION TAB

150MG SR





Smoking Cessation

Agents

Pg. 43 of 331



BUPROPION TAB

200MG ER



BUPROPION TAB

200MG SR



BUPROPION TAB

75MG



BUPROPN HCL TAB

150MG XL



BUPROPN HCL TAB

300MG XL



BUSPIRONE TAB

10MG On formulary, tier change tier 1 to tier 2 Anxiolytics Anxiolytics

BUSPIRONE TAB 5MG On formulary, tier change tier 1 to tier 2 Anxiolytics Anxiolytics

BUSULFEX INJ


BUT/APAP/CAF CAP

CODEINE Not on 2017 formulary



naproxen Analgesics


acting

BUT/ASA/CAF/ CAP COD




naproxen Analgesics


acting

BUTISOL SOD TAB

30MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Barbiturates

CALCIPOTRIEN OIN

BETAMETH Not on 2017 formulary

betamethasone

dipropionate (cream,

lotion, ointment) and

calcipotriene (cream,

ointment, solution) used

together Dermatological Agents Dermatological Agents

CANCIDAS INJ 50MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals

Pg. 44 of 331



CANCIDAS INJ 70MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals

CANDESA/HCTZ TAB 16-


Antihypertensive

Combinations


12.5



Antihypertensive

Combinations



Antihypertensive

Combinations


12.5



Antihypertensive

Combinations



Antihypertensive

Combinations


25MG



Antihypertensive

Combinations

CANDESARTAN TAB



Antagonists

CANDESARTAN TAB

16MG




Antagonists

CANDESARTAN TAB



Antagonists

CANDESARTAN TAB

32MG




Antagonists

CANDESARTAN TAB



Antagonists

CANDESARTAN TAB

4MG




Antagonists

CANDESARTAN TAB



Antagonists

CANDESARTAN TAB

8MG




Antagonists

CAPRELSA TAB

100MG



Pg. 45 of 331



CAPRELSA TAB

100MG





CAPRELSA TAB

300MG



CAPRELSA TAB

300MG





CAPTOPR/HCTZ TAB 25-


captopril used in

combination with

hydrochlorothiazide Cardiovascular Agents

Antihypertensive

Combinations



captopril used in

combination with


Antihypertensive

Combinations



captopril used in

combination with


Antihypertensive

Combinations



captopril used in

combination with


Antihypertensive

Combinations

CAPTOPRIL TAB




CAPTOPRIL TAB

12.5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents



CAPTOPRIL TAB




CAPTOPRIL TAB




Pg. 46 of 331



CARAFATE SUS

1GM/10ML Not on 2017 formulary sucralfate tablets Gastrointestinal Agents Protectants

CARBIDOPA TAB

25MG On formulary, tier change tier 2 to tier 5 Antiparkinson Agents

Dopamine Precursors/ L-

Amino Acid

Decarboxylase Inhibitors

CAREFINE MIS


CAREFINE MIS


CAREFINE MIS


CAREFINE MIS


CARIMUNE NF INJ 6GM Not on 2017 formulary





form, please visit



on the back of your



Immunizing Agents,

Passive

CAYSTON INH 75MG Not on 2017 formulary check with your doctor Antibacterials Beta-lactam, Other

Pg. 47 of 331



CDP/AMITRIP TAB 10-


citalopram, fluoxetine,

escitalopram, sertraline,

duloxetine capsules

(20mg, 30mg, 60mg),

venlafaxine IR tablet, ER

tablet (37.5mg, 75mg,

150mg ), and ER capsule,

mirtazapine, bupropion Antidepressants Tricyclics

CDP/AMITRIP TAB 5-




duloxetine capsules

(20mg, 30mg, 60mg),




mirtazapine, bupropion Antidepressants Tricyclics

CEFACLOR ER TAB


cefaclor capsule (250mg,

500mg) Antibacterials

Beta-lactam,

Cephalosporins

CEFAZOLIN INJ 10GM On formulary, tier change tier 1 to tier 2 Antibacterials

Beta-lactam,

Cephalosporins

CEFAZOLIN INJ

1GM/50ML Not on 2017 formulary

cefazolin inj (500 mg, 1

gm, 10 gm, 20 gm) Antibacterials

Beta-lactam,

Cephalosporins

CEFAZOLIN INJ

500MG On formulary, tier change tier 1 to tier 2 Antibacterials

Beta-lactam,

Cephalosporins

CEFDINIR SUS

125/5ML On formulary, tier change tier 1 to tier 2 Antibacterials

Beta-lactam,

Cephalosporins

CEFDINIR SUS


Beta-lactam,

Cephalosporins

Pg. 48 of 331



CEFUROXIME INJ

1.5GM On formulary, tier change tier 1 to tier 2 Antibacterials

Beta-lactam,

Cephalosporins

CEFUROXIME INJ

7.5GM On formulary, tier change tier 1 to tier 2 Antibacterials

Beta-lactam,

Cephalosporins

CEFUROXIME INJ

750MG On formulary, tier change tier 1 to tier 2 Antibacterials

Beta-lactam,

Cephalosporins

CELECOXIB CAP

100MG


limit may apply 60 capsules per 30 days Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

CELECOXIB CAP

200MG



Nonsteroidal Anti-

inflammatory Drugs

CELECOXIB CAP

400MG



Nonsteroidal Anti-

inflammatory Drugs

CELECOXIB CAP

50MG



Nonsteroidal Anti-

inflammatory Drugs

CELLCEPT IV INJ

500MG On formulary, tier change tier 3 to tier 4 Immunological Agents Immune Suppressants

CEPHALEXIN SUS


Beta-lactam,

Cephalosporins

CEPHALEXIN TAB


cephalexin capsule

(250mg, 500mg) Antibacterials

Beta-lactam,

Cephalosporins

CEPHALEXIN TAB


cephalexin capsule

(250mg, 500mg) Antibacterials

Beta-lactam,

Cephalosporins

CEREBYX INJ


fosphenytoin inj 100 mg/2

mL Anticonvulsants Sodium Channel Agents

CEREBYX INJ


fosphenytoin inj 500

mg/10 mL Anticonvulsants Sodium Channel Agents

CESAMET CAP 1MG



Gastrointestinal Agents,

Other

CETIRIZINE SYP

1MG/ML Not on 2017 formulary levocetirizine tablets Respiratory Tract Agents Antihistamines

Pg. 49 of 331



CHLORAMPHEN INJ

1GM On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

CHLORDIAZEP CAP


clorazepate*,







form, please visit



on the back of your



CHLORDIAZEP CAP


clorazepate*,







form, please visit



on the back of your



Pg. 50 of 331



CHLORDIAZEP CAP


clorazepate*,







form, please visit



on the back of your



CHLOROQUINE TAB

250MG On formulary, tier change tier 1 to tier 2 Antiparasitics Antiprotozoals

CHLOROQUINE TAB


CHLOROTHIAZ TAB

250MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Thiazide

CHLORPROMAZ INJ

25MG/ML On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical

CHLORPROMAZ INJ

25MG/ML




refill check with your doctor Antipsychotics 1st Generation/Typical

CHLORPROMAZ INJ

50MG/2ML On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical

Pg. 51 of 331



CHLORPROMAZ INJ

50MG/2ML





CHLORPROMAZ TAB

100MG





CHLORPROMAZ TAB

10MG





CHLORPROMAZ TAB

200MG





CHLORPROMAZ TAB

25MG





CHLORPROMAZ TAB

50MG





CHLORPROPAM TAB


glimepiride, glipizide,

glipizide ER Blood Glucose Regulators Antidiabetic Agents

CHLORPROPAM TAB




CHLORTHALID TAB


Pg. 52 of 331



CHLORTHALID TAB


CHOR GONADOT INJ

10000UNT



Hormonal Agents,

Stimulant/Replacement/

Modifying (Pituitary)

Hormonal Agents,



CIMZIA KIT Not on 2017 formulary


*These alternatives

require a prior

authorization. To


form, please visit

www.MyPrime.com or




CIMZIA KIT

STARTER Not on 2017 formulary


*These alternatives

require a prior

authorization. To


form, please visit

www.MyPrime.com or




Pg. 53 of 331



CIMZIA PREFL KIT



*These alternatives

require a prior

authorization. To


form, please visit

www.MyPrime.com or




CINRYZE SOL 500

UNIT


limit may apply 20 vials per 30 days Cardiovascular Agents


Other

CIPRODEX SUS 0.3-

0.1% On formulary, tier change tier 3 to tier 4 Otic Agents Otic Agents

CIPROFLOXACN INJ

200MG On formulary, tier change tier 1 to tier 2 Antibacterials Quinolones

CIPROFLOXACN INJ


CIPROFLOXACN SUS

250MG/5 On formulary, tier change tier 1 to tier 2 Antibacterials Quinolones

CIPROFLOXACN SUS

500MG/5 On formulary, tier change tier 1 to tier 2 Antibacterials Quinolones

CIPROFLOXACN TAB


CITALOPRAM SOL

10MG/5ML


limit may apply 600 mls per 30 days Antidepressants


Reuptake Inhibitors

CITALOPRAM TAB

10MG


limit may apply 30 tablets per 30 days Antidepressants


Reuptake Inhibitors

CITALOPRAM TAB

20MG




Reuptake Inhibitors

Pg. 54 of 331



CITALOPRAM TAB

40MG




Reuptake Inhibitors

CLADRIBINE INJ


CLICKFINE MIS


CLICKFINE MIS


CLICKFINE MIS


CLINDACIN KIT ETZ

1% Not on 2017 formulary

erythromycin-benzoyl

peroxide gel 5-3%,

clindamycin-benzoyl

peroxide gel 1-5% Dermatological Agents Dermatological Agents

CLINDACIN KIT PAC


erythromycin-benzoyl

peroxide gel 5-3%,

clindamycin-benzoyl

peroxide gel 1-5% Dermatological Agents Dermatological Agents

CLINDAMYCIN INJ

150MG/ML On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other

CLINDAMYCIN INJ

300/2ML On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other

CLINDAMYCIN INJ

300MG On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other

CLINDAMYCIN INJ

600/4ML On formulary, tier change tier 1 to tier 2 Antibacterials Antibacterials, Other

CLINDAMYCIN INJ


CLINDAMYCIN INJ


Pg. 55 of 331



CLINDAMYCIN SOL

75MG/5ML Not on 2017 formulary clindamycin capsules Antibacterials Antibacterials, Other

CLINIMIX INJ

2.75/D5W Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX INJ 4.25/D10 Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%




Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%




Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



Pg. 56 of 331



CLINIMIX INJ

5%/D15W Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX E INJ

2.75/D10 Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX E INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX E INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



Pg. 57 of 331



CLINIMIX E INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX E INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX E INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX E INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLINIMIX E INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



CLOLAR INJ 1MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

CLOMIPRAMINE CAP


CLOMIPRAMINE CAP


Pg. 58 of 331



CLOMIPRAMINE CAP


CLONAZEP ODT TAB

0.125MG On formulary, tier change tier 1 to tier 2 Anticonvulsants Benzodiazepines

CLONAZEP ODT TAB

0.125MG


limit may apply 90 tablets per 30 days Anticonvulsants Benzodiazepines

CLONAZEP ODT TAB

0.125MG




refill check with your doctor Anticonvulsants Benzodiazepines

CLONAZEP ODT TAB


CLONAZEP ODT TAB

0.25MG



CLONAZEP ODT TAB

0.25MG





CLONAZEP ODT TAB


CLONAZEP ODT TAB

0.5MG



CLONAZEP ODT TAB

0.5MG





CLONAZEP ODT TAB

1MG On formulary, tier change tier 1 to tier 2 Anticonvulsants Benzodiazepines

CLONAZEP ODT TAB

1MG



Pg. 59 of 331



CLONAZEP ODT TAB

1MG





CLONAZEP ODT TAB

2MG On formulary, tier change tier 1 to tier 2 Anticonvulsants Benzodiazepines

CLONAZEP ODT TAB

2MG



CLONAZEP ODT TAB

2MG





CLONAZEPAM TAB

0.5MG



CLONAZEPAM TAB

0.5MG





CLONAZEPAM TAB

1MG



CLONAZEPAM TAB

1MG





CLONAZEPAM TAB

2MG



CLONAZEPAM TAB

2MG





Pg. 60 of 331



CLOPIDOGREL TAB

300MG Not on 2017 formulary clopidogrel 75 mg

Blood Products/Modifiers/

Volume Expanders Platelet Modifying Agents

CLORAZ DIPOT TAB

15MG On formulary, tier change tier 1 to tier 2 Anxiolytics Benzodiazepines

CLORAZ DIPOT TAB

15MG




refill check with your doctor Anxiolytics Benzodiazepines

CLORAZ DIPOT TAB

3.75MG On formulary, tier change tier 1 to tier 2 Anxiolytics Benzodiazepines

CLORAZ DIPOT TAB

3.75MG





CLORAZ DIPOT TAB

7.5MG On formulary, tier change tier 1 to tier 2 Anxiolytics Benzodiazepines

CLORAZ DIPOT TAB

7.5MG





CLOTRIMAZOLE CRE

1% On formulary, tier change tier 1 to tier 2 Antifungals Antifungals

CLOTRIMAZOLE SOL


clotrimazole 1% cream,

ciclopirox 0.77% (cream,

suspension, gel),

ciclopirox solution (or

Ciclodan solution),

econazole 1% cream, 2%

(cream, shampoo) Dermatological Agents Dermatological Agents

CLOZAPINE TAB

100/ODT


limit may apply 270 tablets per 30 days Antipsychotics Treatment-Resistant

Pg. 61 of 331



CLOZAPINE TAB

100/ODT




refill check with your doctor Antipsychotics Treatment-Resistant

CLOZAPINE TAB

100MG



CLOZAPINE TAB

100MG





CLOZAPINE TAB

12.5/ODT Not on 2017 formulary

clozapine tablets (25 mg,

50 mg, 100 mg, 200 mg)*,

clozapine ODT tablets (25

mg, 100 mg)* *These

drugs require prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Antipsychotics Treatment-Resistant

Pg. 62 of 331



CLOZAPINE TAB

150/ODT Not on 2017 formulary


50 mg, 100 mg, 200 mg)*,


mg, 100 mg)* *These

drugs require prior

authorization. To


form, please visit

www.MyPrime.com or




CLOZAPINE TAB

200/ODT Not on 2017 formulary


50 mg, 100 mg, 200 mg)*,


mg, 100 mg)* *These

drugs require prior

authorization. To


form, please visit

www.MyPrime.com or




CLOZAPINE TAB

200MG



Pg. 63 of 331



CLOZAPINE TAB

200MG





CLOZAPINE TAB

25MG



CLOZAPINE TAB

25MG





CLOZAPINE TAB

25MG ODT



CLOZAPINE TAB

25MG ODT





CLOZAPINE TAB

50MG



CLOZAPINE TAB

50MG





COLESTIPOL GRA

5GM On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Dyslipidemics, Other

COMETRIQ KIT

100MG


limit may apply 56 capsules per 28 days Antineoplastics Antineoplastics

COMETRIQ KIT

100MG





Pg. 64 of 331



COMETRIQ KIT

140MG



COMETRIQ KIT

140MG





COMETRIQ KIT 60MG



COMETRIQ KIT 60MG





COMFORT EZ MIS


COMFORT EZ MIS


COMFORT EZ MIS


COMFORT EZ MIS


COMFORT EZ MIS


COMFORT EZ MIS


COMFORT EZ MIS


COMFORT EZ MIS


COMFORT EZ MIS


Pg. 65 of 331



COMFORT EZ MIS


COMFORT EZ MIS


COMFORT EZ MIS


COMPLERA TAB




nucleoside Reverse


COMVAX INJ Not on 2017 formulary check with your doctor Immunological Agents Vaccines

CONDYLOX GEL 0.5% Not on 2017 formulary podofilox 0.5% solution Dermatological Agents Dermatological Agents

CONSTULOSE SOL

10GM/15 On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents Laxatives

COPAXONE INJ

20MG/ML





COPAXONE INJ

20MG/ML


limit may apply 30 syringes per 30 days



COPAXONE INJ

40MG/ML





COPAXONE INJ

40MG/ML





COSMEGEN INJ

0.5MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

CRESTOR TAB 10MG





CRESTOR TAB 20MG





CRESTOR TAB 40MG





Pg. 66 of 331



CRESTOR TAB 5MG





CRIXIVAN CAP

200MG




Inhibitors

CRIXIVAN CAP

400MG




Inhibitors

CROMOLYN SOD NEB

20MG/2ML On formulary, tier change tier 1 to tier 3 Respiratory Tract Agents Mast Cell Stabilizers

CUBICIN SOL 500MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other

CUBICIN RF SOL


CURITY GAUZE PAD


CURITY PREP PAD

ALCOHOL On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

CURITY SPONG PAD


CURITY SWABS PAD


CYCLOBENZAPR TAB


Skeletal Muscle

Relaxants

Skeletal Muscle

Relaxants

CYCLOBENZAPR TAB


Skeletal Muscle

Relaxants

Skeletal Muscle

Relaxants

CYCLOPHOSPH CAP

25MG On formulary, tier change tier 2 to tier 4 Antineoplastics Alkylating Agents

CYCLOPHOSPH CAP


CYCLOSET TAB

0.8MG



CYPROHEPTAD TAB

4MG Not on 2017 formulary check with your doctor Respiratory Tract Agents Antihistamines

Pg. 67 of 331



CYTARABINE INJ

100MG



CYTARABINE INJ

100MG/ML



CYTARABINE INJ 1GM



CYTARABINE INJ

20MG/ML



CYTARABINE INJ

500MG



D10W/NACL INJ 0.2% Not on 2017 formulary D5W/NACL inj 0.2%


Minerals/ Electrolytes

Electrolyte/Mineral

Replacement

D2.5W/NACL INJ 0.45% On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

D5W/NACL INJ 0.2% On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement




Electrolyte/Mineral

Replacement




Electrolyte/Mineral

Replacement

DACARBAZINE INJ


DALIRESP TAB

500MCG On formulary, tier change tier 3 to tier 4 Respiratory Tract Agents

Respiratory Tract Agents,

Other

DANAZOL CAP

100MG



Hormonal Agents,


Modifying (Sex


Pg. 68 of 331



DANAZOL CAP

200MG



Hormonal Agents,


Modifying (Sex


DANAZOL CAP 50MG



Hormonal Agents,


Modifying (Sex


DARAPRIM TAB 25MG On formulary, tier change tier 4 to tier 5 Antiparasitics Antiprotozoals

DAUNOXOME INJ


daunorubicin injection 5

mg/ml Antineoplastics Antineoplastics

DECITABINE INJ 50MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antimetabolites

DELTASONE TAB

20MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

DEMSER CAP


Diuretics, Potassium-

sparing

DEPEN TITRA TAB

250MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antiangiogenic Agents

DEPOCYT INJ

50MG/5ML



DESIPRAMINE TAB


DESLORATADIN TAB 2.5

ODT Not on 2017 formulary levocetirizine tablets Respiratory Tract Agents Antihistamines

DESLORATADIN TAB

5MG Not on 2017 formulary levocetirizine tablets Respiratory Tract Agents Antihistamines

Pg. 69 of 331



DESLORATADIN TAB

5MG ODT Not on 2017 formulary levocetirizine tablets Antivirals

Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


DESOXIMETAS CRE


DESVENLAFAX TAB

100MG ER Not on 2017 formulary Pristiq (brand name) Antidepressants


Reuptake Inhibitors

DESVENLAFAX TAB

50MG ER Not on 2017 formulary Pristiq (brand name) Antidepressants


Reuptake Inhibitors

DEXAMETH PHO INJ


dexamethasone sodium

phosphate 4 mg/mL inj

Hormonal Agents,


Modifying (Adrenal)


orticoids

DEXAMETH PHO SOL

0.1% OP On formulary, tier change tier 2 to tier 4 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

DEXAMETHASON TAB


Hormonal Agents,


Modifying (Adrenal)


orticoids

DEXAMETHASON TAB


Hormonal Agents,


Modifying (Adrenal)


orticoids

DEXEDRINE TAB

10MG




Agents

Attention Deficit



DEXEDRINE TAB 5MG




Agents

Attention Deficit



Pg. 70 of 331



DEXILANT CAP 30MG

DR Not on 2017 formulary

esomeprazole (20 mg, 40

mg), lansoprazole (15 mg,

30 mg), Nexium granules

(2.5mg, 5 mg, 10 mg, 20

mg, 40 mg), omeprazole

(10mg, 20 mg, 40 mg),

pantoprazole (20 mg, 40

mg), rabeprazole 20mg Gastrointestinal Agents Proton Pump Inhibitors

DEXILANT CAP 60MG

DR Not on 2017 formulary




(2.5mg, 5 mg, 10 mg, 20


(10mg, 20 mg, 40 mg),



DEXTROAMPHET CAP

10MG ER


limit may apply 120 capsules per 30 days


Agents

Attention Deficit



DEXTROAMPHET CAP

15MG ER




Agents

Attention Deficit



DEXTROAMPHET CAP

5MG ER




Agents

Attention Deficit



DEXTROAMPHET TAB

10MG




Agents

Attention Deficit



Pg. 71 of 331



DEXTROAMPHET TAB

5MG




Agents

Attention Deficit



DEXTROSE INJ 10% On formulary, tier change tier 1 to tier 2





DIAZEPAM CON

5MG/ML





DIAZEPAM GEL 10MG On formulary, tier change tier 2 to tier 4 Anticonvulsants Benzodiazepines

DIAZEPAM GEL 10MG


limit may apply 5 twin pack(s) per 30 days Anticonvulsants Benzodiazepines

DIAZEPAM GEL


DIAZEPAM GEL

2.5MG



DIAZEPAM GEL 20MG On formulary, tier change tier 2 to tier 4 Anticonvulsants Benzodiazepines

DIAZEPAM GEL 20MG



DIAZEPAM SOL

1MG/ML On formulary, tier change tier 2 to tier 4 Anxiolytics Benzodiazepines

DIAZEPAM SOL

1MG/ML





DIAZEPAM TAB 10MG





Pg. 72 of 331



DIAZEPAM TAB 2MG


limit may apply 120 tablets per 30 days Anxiolytics Benzodiazepines

DIAZEPAM TAB 2MG





DIAZEPAM TAB 5MG



DIAZEPAM TAB 5MG





DICLOFEN POT TAB

50MG


limit may apply 120 tablets per 30 days Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

DICLOFENAC GEL 1%


step therapy check with your doctor Dermatological Agents Dermatological Agents

DICLOFENAC GEL 3% On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents

DICLOFENAC TAB

100MG ER



Nonsteroidal Anti-

inflammatory Drugs

DICLOFENAC TAB

25MG DR



Nonsteroidal Anti-

inflammatory Drugs

DICLOFENAC TAB

50MG DR



Nonsteroidal Anti-

inflammatory Drugs

DICLOFENAC TAB

75MG DR On formulary, tier change tier 1 to tier 2 Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

DICLOFENAC TAB

75MG DR



Nonsteroidal Anti-

inflammatory Drugs

DICYCLOMINE CAP

10MG Not on 2017 formulary check with your doctor Gastrointestinal Agents

Antispasmodics,

Gastrointestinal

DICYCLOMINE SOL

10MG/5ML Not on 2017 formulary check with your doctor Gastrointestinal Agents

Antispasmodics,

Gastrointestinal

Pg. 73 of 331



DIDANOSINE CAP

125MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


DIDANOSINE CAP

200MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


DIDANOSINE CAP

250MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


DIDANOSINE CAP

400MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


Pg. 74 of 331



DIFLORASONE CRE


betamethasone

dipropionate 0.05%

(cream), augmented

betamethasone 0.05%



clobetasol 0.05%



fluocinonide 0.05%





0.025%/0.1% (cream),

triamcinolone 0.5%


DIFLORASONE OIN


Pg. 75 of 331



DIFLUNISAL TAB


diclofenac tablets,

etodolac, flurbiprofen,

ibuprofen, ketoprofen IR,

meloxicam, nabumetone,

naproxen, oxaprozin,

piroxicam, sulindac,

tolmetin 400 mg,

celecoxib, diclofenac gel

1% (generic Voltaren)*

*This drug needs a prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

DIGITEK TAB



Other

DIGITEK TAB

0.125MG




Other

DIGITEK TAB 0.25MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents


Other

DIGITEK TAB 0.25MG




Other

DIGOX TAB



Other

DIGOX TAB

0.125MG




Other

Pg. 76 of 331



DIGOX TAB 0.25MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents


Other

DIGOX TAB 0.25MG




Other

DIGOXIN INJ

0.25MG/1 Not on 2017 formulary check with your doctor Cardiovascular Agents


Other

DIGOXIN SOL

50MCG/ML On formulary, tier change tier 1 to tier 4 Cardiovascular Agents


Other

DIGOXIN SOL

50MCG/ML


limit may apply 150 mls per 30 days Cardiovascular Agents


Other

DIGOXIN TAB



Other

DIGOXIN TAB

0.125MG




Other

DIGOXIN TAB 0.25MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents


Other

DIGOXIN TAB 0.25MG




Other

DIHYDROERGOT INJ


naratriptan (1 mg, 2.5

mg), rizatriptan (5 mg, 10

mg, 5 mg ODT, 10 mg

ODT), sumatriptan nasal

spray (5 mg, 20 mg),

sumatriptan inj (4 mg/0.5

mL, 6 mg/0.5 mL),

sumatriptan tablets (25

mg, 50 mg, 100 mg),

Migranal, Migergot Antimigraine Agents Ergot Alkaloids

DILAUDID INJ 1MG/ML


prior authorization check with your doctor Analgesics


acting

Pg. 77 of 331



DILAUDID INJ 2MG/ML




acting

DILAUDID INJ 4MG/ML




acting

DILAUDID-HP INJ

10MG/ML




acting

DILTIAZEM INJ 100MG Not on 2017 formulary diltiazem IR tablets Cardiovascular Agents

Calcium Channel Blocking

Agents

DILTIAZEM INJ

125/25ML Not on 2017 formulary diltiazem IR tablets Cardiovascular Agents


Agents

DILTIAZEM INJ

25MG/5ML Not on 2017 formulary diltiazem IR tablets Cardiovascular Agents


Agents

DILTIAZEM INJ

50/10ML Not on 2017 formulary diltiazem IR tablets Cardiovascular Agents


Agents

DILTIAZEM TAB



Agents

DILTIAZEM TAB 30MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Agents



Agents



Agents

DIP/TET PED INJ 25-

5LFU On formulary, tier change tier 2 to tier 4 Immunological Agents Vaccines

DIPENTUM CAP


Inflammatory Bowel


DIPHEN/ATROP LIQ

2.5/5 Not on 2017 formulary loperamide 2mg capsule Gastrointestinal Agents


Other

DIPHEN/ATROP TAB

2.5MG Not on 2017 formulary loperamide 2mg capsule Gastrointestinal Agents


Other

Pg. 78 of 331



DIPYRIDAMOLE TAB




DIPYRIDAMOLE TAB




DIPYRIDAMOLE TAB




DISOPYRAMIDE CAP


quinidine gluconate CR

tablet 324mg, quinidine

sulfate tablet 200mg Cardiovascular Agents Antiarrhythmics

DISOPYRAMIDE CAP





DOXAZOSIN TAB 1MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents

Alpha-adrenergic Blocking

Agents

DOXAZOSIN TAB 1MG




Agents



Agents

DOXAZOSIN TAB 2MG




Agents



Agents

DOXAZOSIN TAB 4MG




Agents



Agents

DOXAZOSIN TAB 8MG




Agents

DOXEPIN HCL CAP


Pg. 79 of 331



DOXEPIN HCL CAP


DOXEPIN HCL CAP


DOXEPIN HCL CAP


DOXEPIN HCL CAP


DOXEPIN HCL CAP


DOXEPIN HCL CON

10MG/ML On formulary, tier change tier 1 to tier 4 Antidepressants Tricyclics

DOXIL INJ 2MG/ML Not on 2017 formulary

doxorubicin inj 2 mg/mL*,

Lipodox inj 2 mg/mL*


authorization. To


form, please visit

www.MyPrime.com or



card for more information. Antineoplastics Antineoplastics

DOXORUBICIN INJ

10MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

DOXORUBICIN INJ

2MG/ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics, Other

DOXORUBICIN INJ

50MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

DOXY 100 INJ 100MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines

Pg. 80 of 331



DOXYCYC MONO TAB

50MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines

DOXYCYCL HYC CAP


DOXYCYCL HYC CAP


DOXYCYCL HYC INJ


DOXYCYCL HYC TAB


DOXYCYCLINE SUS

25MG/5ML Not on 2017 formulary

doxycycline tablets,

doxycycline capsules Antibacterials Tetracyclines

DRONABINOL CAP

10MG


prior authorization check with your doctor Antiemetics

Emetogenic Therapy

Adjuncts

DRONABINOL CAP

2.5MG



Emetogenic Therapy

Adjuncts

DRONABINOL CAP

5MG



Emetogenic Therapy

Adjuncts

DULOXETINE CAP

20MG


limit may apply 60 capsules per 30 days Antidepressants


Reuptake Inhibitors

DULOXETINE CAP

30MG




Reuptake Inhibitors

DULOXETINE CAP


duloxetine capsules

(20mg, 30mg, 60mg) Antidepressants


Reuptake Inhibitors

DULOXETINE CAP

60MG




Reuptake Inhibitors

DURAMORPH INJ

0.5MG/ML On formulary, tier change tier 1 to tier 2 Analgesics


acting

DURAMORPH INJ

0.5MG/ML




acting

Pg. 81 of 331



DURAMORPH INJ

1MG/ML On formulary, tier change tier 1 to tier 2 Analgesics


acting

DURAMORPH INJ

1MG/ML




acting

DUTAST/TAMSU CAP

0.5-0.4


limit may apply 30 capsules per 30 days Genitourinary Agents

Benign Prostatic

Hypertrophy Agents

DUTASTERIDE CAP

0.5MG



Benign Prostatic

Hypertrophy Agents

EASY COMFORT MIS


EASY COMFORT MIS


EASY COMFORT MIS


EASY COMFORT MIS


EASY TOUCH MIS


EASY TOUCH MIS


EASY TOUCH MIS


EASY TOUCH MIS


EASY TOUCH MIS


EASY TOUCH MIS


EASY TOUCH MIS


Pg. 82 of 331



EASY TOUCH MIS


EASY TOUCH MIS


EDURANT TAB 25MG




nucleoside Reverse


ELIDEL CRE 1%


prior authorization check with your doctor Dermatological Agents Dermatological Agents

ELIQUIS TAB 2.5MG




Volume Expanders Anticoagulants

ELIQUIS TAB 5MG





ELLENCE INJ

2MG/ML Not on 2017 formulary epirubicin inj 2 mg/mL Antineoplastics Antineoplastics

ELMIRON CAP

100MG Not on 2017 formulary check with your doctor Genitourinary Agents

Genitourinary Agents,

Other

EMTRIVA CAP

200MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


EMTRIVA SOL

10MG/ML On formulary, tier change tier 3 to tier 4 Antivirals

Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


EMTRIVA SOL

10MG/ML



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


ENALAPR/HCTZ TAB 10-



Other

Pg. 83 of 331



ENALAPR/HCTZ TAB 5-


Antihypertensive

Combinations

ENALAPRIL TAB 10MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents



ENALAPRIL TAB










ENBREL INJ

25/0.5ML



ENBREL INJ 25MG



ENBREL INJ

50MG/ML



ENDOCET TAB 10-

325MG




acting

ENDOCET TAB 2.5-

325




acting

ENDOCET TAB 5-

325MG




acting

ENDOCET TAB 7.5-

325




acting

ENOXAPARIN INJ

100MG/ML





ENOXAPARIN INJ

120/0.8





ENOXAPARIN INJ

150MG/ML





Pg. 84 of 331



ENOXAPARIN INJ

30/0.3ML





ENOXAPARIN INJ

300/3ML


limit may apply 10 vials per 90 days



ENOXAPARIN INJ

40/0.4ML





ENOXAPARIN INJ

60/0.6ML





ENOXAPARIN INJ

80/0.8ML





ENTECAVIR TAB

0.5MG On formulary, tier change tier 2 to tier 5 Antivirals Antihepatitis Agents

ENTECAVIR TAB 1MG On formulary, tier change tier 2 to tier 5 Antivirals Antihepatitis Agents

ENULOSE SOL


EPROSART MES TAB




(75 mg, 150 mg, 300 mg),



mg, 40 mg, 80 mg),




Antagonists

EPZICOM TAB 600-

300



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


EQL GAUZE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

Pg. 85 of 331



EQUETRO CAP


carbamazepine ER

capsules (generic

Carbatrol),

carbamazepine ER

tablets (generic Tegretol-

XR) Bipolar Agents Mood Stabilizers

EQUETRO CAP


carbamazepine ER

capsules (generic

Carbatrol),

carbamazepine ER



EQUETRO CAP


carbamazepine ER

capsules (generic

Carbatrol),

carbamazepine ER



ERAXIS INJ 100MG Not on 2017 formulary

Cancidas inj, Mycamine

inj Antifungals Antifungals

ERGOLOID MES TAB

1MG ORAL On formulary, tier change tier 2 to tier 3 Antidementia Agents

Antidementia Agents,

Other

ERGOMAR SUB 2MG Not on 2017 formulary



mg, 5 mg ODT, 10 mg




mL, 6 mg/0.5 mL),


mg, 50 mg, 100 mg) Antimigraine Agents Ergot Alkaloids

Pg. 86 of 331



ERIVEDGE CAP

150MG



ERIVEDGE CAP

150MG





ERWINAZE INJ

10000UNT On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

ERYTHROCIN INJ

500MG On formulary, tier change tier 2 to tier 4 Antibacterials Macrolides

ERYTHROCIN TAB

250MG On formulary, tier change tier 2 to tier 4 Antibacterials Macrolides

ERYTHROM ETH TAB


erythromycin base tablet

(250mg, 500mg), Ery-tab

DR (250mg, 333mg,

500mg) Antibacterials Macrolides

ERYTHROMYCIN GEL


clindamycin 1 % (solution,

gel, lotion, pads) ,

erythromycin 2%

(solution, pad),

sulfacetamide 10% lotion Dermatological Agents Dermatological Agents

ERYTHROMYCIN OIN

5MG/GM On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives

ERYTHROMYCIN OIN

OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives

ESBRIET CAP 267MG


limit may apply 270 capsules per 30 days Respiratory Tract Agents


Other

ESCITALOPRAM SOL

5MG/5ML




Reuptake Inhibitors

ESCITALOPRAM TAB

10MG




Reuptake Inhibitors

Pg. 87 of 331



ESCITALOPRAM TAB

20MG




Reuptake Inhibitors

ESCITALOPRAM TAB

5MG




Reuptake Inhibitors

ESOMEPRAZOLE INJ

20MG On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents Proton Pump Inhibitors

ESTAZOLAM TAB 1MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines

ESTAZOLAM TAB 2MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines

ESTRAD VAL INJ

200MG/5 Not on 2017 formulary check with your doctor

Hormonal Agents,


Modifying (Sex

Hormones/ Modifiers) Estrogens

ESTRAD VAL INJ

40MG/ML Not on 2017 formulary check with your doctor

Hormonal Agents,


Modifying (Sex


ESTRADIOL TAB


Hormonal Agents,


Modifying (Sex


ESTRADIOL TAB 1MG On formulary, tier change tier 1 to tier 4

Hormonal Agents,


Modifying (Sex


ESTRADIOL TAB 2MG On formulary, tier change tier 1 to tier 4

Hormonal Agents,


Modifying (Sex


Pg. 88 of 331



ESZOPICLONE TAB

1MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents

GABA Receptor

Modulators

ESZOPICLONE TAB

3MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents

GABA Receptor

Modulators

ETHOSUXIMIDE SOL

250/5ML On formulary, tier change tier 1 to tier 2 Anticonvulsants

Calcium Channel

Modifying Agents

ETODOLAC CAP

200MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC CAP

300MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC TAB

400MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC ER TAB

400MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC ER TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC ER TAB

600MG



Nonsteroidal Anti-

inflammatory Drugs

EURAX CRE 10% Not on 2017 formulary permethrin 5% cream Dermatological Agents Dermatological Agents

EVOTAZ TAB 300-

150



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


EVZIO INJ Not on 2017 formulary check with your doctor



EXELON DIS 13.3/24 Not on 2017 formulary

rivastigmine 13.3 mg/24

patches Antidementia Agents Cholinesterase Inhibitors

EXELON DIS

4.6MG/24 Not on 2017 formulary



Pg. 89 of 331



EXELON DIS

9.5MG/24 Not on 2017 formulary



EXJADE TAB 125MG On formulary, tier change tier 4 to tier 5



Electrolyte/Mineral

Modifiers

FAMOTIDINE INJ

20MG/50M Not on 2017 formulary famotidine inj 10mg/mL Gastrointestinal Agents

Histamine2 (H2) Receptor

Antagonists

FAMOTIDINE TAB

20MG On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents


Antagonists

FANAPT PAK


limit may apply

7 packs (56 tablets) per

28 days Antipsychotics 2nd Generation/Atypical

FANAPT PAK





FANAPT TAB 10MG



FANAPT TAB 10MG





FANAPT TAB 12MG



FANAPT TAB 12MG





FANAPT TAB 1MG



Pg. 90 of 331



FANAPT TAB 1MG





FANAPT TAB 2MG



FANAPT TAB 2MG





FANAPT TAB 4MG



FANAPT TAB 4MG





FANAPT TAB 6MG



FANAPT TAB 6MG





FANAPT TAB 8MG



FANAPT TAB 8MG





FARESTON TAB


Pg. 91 of 331



FARYDAK CAP 10MG



FARYDAK CAP 15MG



FARYDAK CAP 20MG



FENOFIBRATE CAP

134MG


limit may apply 30 capsules per 30 days Cardiovascular Agents

Dyslipidemics, Fibric Acid

Derivatives

FENOFIBRATE CAP


fenofibric capsule (45 mg,

135 mg [generic Trilipix]),

fenofibrate tablet (48 mg,

145 mg [generic Tricor]),


160 mg [generic Lofibra]),

fenofibrate capsule (67

mg, 134 mg, 200 mg

[generic Lofibra]),

gemfibrozil Cardiovascular Agents


Derivatives

FENOFIBRATE CAP

200MG




Derivatives

FENOFIBRATE CAP


fenofibric capsule (45 mg,

135 mg [generic Trilipix]),


145 mg [generic Tricor]),


160 mg [generic Lofibra]),

fenofibrate capsule (67

mg, 134 mg, 200 mg

[generic Lofibra]),

gemfibrozil Cardiovascular Agents


Derivatives

Pg. 92 of 331



FENOFIBRATE CAP

67MG




Derivatives

FENOFIBRATE TAB

145MG




Derivatives

FENOFIBRATE TAB

160MG




Derivatives

FENOFIBRATE TAB

48MG




Derivatives

FENOFIBRATE TAB

54MG




Derivatives

FENOPROFEN TAB


diclofenac tablets,






tolmetin 400 mg,




authorization. To


form, please visit

www.MyPrime.com or




Nonsteroidal Anti-

inflammatory Drugs

Pg. 93 of 331



FENTORA TAB


Abstral*, fentanyl

lozenges (generic)*,

Lazanda*

*These drugs require prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Analgesics


acting

FENTORA TAB


Abstral*, fentanyl


Lazanda*


authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 94 of 331



FENTORA TAB


Abstral*, fentanyl


Lazanda*


authorization. To


form, please visit

www.MyPrime.com or





acting

FENTORA TAB


Abstral*, fentanyl


Lazanda*


authorization. To


form, please visit

www.MyPrime.com or





acting

FERRIPROX SOL

100MG/ML Not on 2017 formulary Jadenu, Exjade, Chemet



Electrolyte/Mineral

Modifiers

FERRIPROX TAB

500MG Not on 2017 formulary Jadenu, Exjade, Chemet



Electrolyte/Mineral

Modifiers

FETZIMA CAP 120MG On formulary, tier change tier 3 to tier 4 Antidepressants


Reuptake Inhibitors

Pg. 95 of 331



FETZIMA CAP 120MG




Reuptake Inhibitors



Reuptake Inhibitors

FETZIMA CAP 20MG




Reuptake Inhibitors



Reuptake Inhibitors

FETZIMA CAP 40MG




Reuptake Inhibitors



Reuptake Inhibitors

FETZIMA CAP 80MG




Reuptake Inhibitors

FETZIMA CAP

TITRATIO On formulary, tier change tier 3 to tier 4 Miscellaneous Miscellaneous

FETZIMA CAP

TITRATIO


limit may apply 28 capsules per 28 days Miscellaneous Miscellaneous

FIFTY50 MIS


FIFTY50 MIS


FIFTY50 MIS


FIFTY50 PEN MIS


FIFTY50 PEN MIS


FIFTY50 PEN MIS


Pg. 96 of 331



FIFTY50 PREP PAD

PADS On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

FINASTERIDE TAB 5MG


limit may apply 30 tablets per 30 days Genitourinary Agents

Benign Prostatic

Hypertrophy Agents

FIRAZYR INJ

30MG/3ML


prior authorization check with your doctor Miscellaneous Miscellaneous

FIRAZYR INJ

30MG/3ML


limit may apply 6 syringes per 30 days Miscellaneous Miscellaneous

FLOVENT DISK AER

100MCG





FLOVENT DISK AER

250MCG


limit may apply 4 inhalers per 30 days Respiratory Tract Agents



FLOVENT DISK AER

50MCG





FLOVENT HFA AER

110MCG





FLOVENT HFA AER

220MCG





FLOVENT HFA AER

44MCG





FLUNISOLIDE SPR


fluticasone nasal spray,

mometasone nasal spray

(generic Nasonex),

triamcinolone nasal spray Respiratory Tract Agents Nasal Agents

FLUOCIN ACET CRE


Pg. 97 of 331



FLUOCIN ACET CRE


betamethasone

dipropionate 0.05%

(cream), augmented

betamethasone 0.05%



clobetasol 0.05%



fluocinonide 0.05%





0.025%/0.1% (cream),

triamcinolone 0.5%


Pg. 98 of 331



FLUOCIN ACET OIL

0.01%BDY Not on 2017 formulary

betamethasone

dipropionate 0.05%

(cream), augmented

betamethasone 0.05%



clobetasol 0.05%



fluocinonide 0.05%





0.025%/0.1% (cream),

triamcinolone 0.5%


Pg. 99 of 331



FLUOCIN ACET OIL

BODY Not on 2017 formulary

betamethasone

dipropionate 0.05%

(cream), augmented

betamethasone 0.05%



clobetasol 0.05%



fluocinonide 0.05%





0.025%/0.1% (cream),

triamcinolone 0.5%


Pg. 100 of 331



FLUOCIN ACET OIN


betamethasone

dipropionate 0.05%

(cream), augmented

betamethasone 0.05%



clobetasol 0.05%



fluocinonide 0.05%





0.025%/0.1% (cream),

triamcinolone 0.5%


Pg. 101 of 331



FLUOCIN ACET SOL


betamethasone

dipropionate 0.05%

(cream), augmented

betamethasone 0.05%



clobetasol 0.05%



fluocinonide 0.05%





0.025%/0.1% (cream),

triamcinolone 0.5%


FLUOXETINE CAP

10MG




Reuptake Inhibitors

FLUOXETINE CAP

20MG




Reuptake Inhibitors

FLUOXETINE CAP

40MG




Reuptake Inhibitors

FLUOXETINE CAP

90MG DR




Reuptake Inhibitors

FLUOXETINE SOL

20MG/5ML




Reuptake Inhibitors

FLUOXETINE TAB

10MG On formulary, tier change tier 1 to tier 2 Antidepressants


Reuptake Inhibitors

FLUOXETINE TAB

10MG




Reuptake Inhibitors

Pg. 102 of 331



FLUOXETINE TAB

20MG




Reuptake Inhibitors

FLUOXETINE TAB


fluoxetine tablets (10 mg,

20 mg), fluoxetine

capsules (10 mg, 20 mg,

40 mg) Antidepressants


Reuptake Inhibitors

FLUPHENAZ DE INJ

25MG/ML





FLUPHENAZINE CON

5MG/ML On formulary, tier change tier 2 to tier 4 Antipsychotics 1st Generation/Typical

FLUPHENAZINE CON

5MG/ML





FLUPHENAZINE ELX

2.5/5ML On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical

FLUPHENAZINE ELX

2.5/5ML





FLUPHENAZINE INJ

2.5MG/ML On formulary, tier change tier 1 to tier 4 Antipsychotics 1st Generation/Typical

FLUPHENAZINE INJ

2.5MG/ML





Pg. 103 of 331



FLUPHENAZINE TAB

10MG





FLUPHENAZINE TAB

1MG On formulary, tier change tier 1 to tier 2 Antipsychotics 1st Generation/Typical

FLUPHENAZINE TAB

1MG





FLUPHENAZINE TAB

2.5MG





FLUPHENAZINE TAB

5MG





FLURAZEPAM CAP

15MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines

FLURAZEPAM CAP


FLURBIPROFEN TAB

100MG



Nonsteroidal Anti-

inflammatory Drugs

FLURBIPROFEN TAB

50MG On formulary, tier change tier 1 to tier 2 Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

FLURBIPROFEN TAB

50MG



Nonsteroidal Anti-

inflammatory Drugs

FLUTICASONE SPR

50MCG


limit may apply 1 bottle per 30 days Respiratory Tract Agents Nasal Agents

Pg. 104 of 331



FLUVASTATIN CAP


atorvastatin, lovastatin,

Livalo, rosuvastatin,

pravastatin, simvastatin Cardiovascular Agents



FLUVASTATIN CAP







FLUVASTATIN TAB







FLUVOXAMINE CAP


fluvoxamine IR tablets (25

mg, 50 mg, 100 mg) Antidepressants


Reuptake Inhibitors

FLUVOXAMINE CAP


fluvoxamine IR tablets (25

mg, 50 mg, 100 mg) Antidepressants


Reuptake Inhibitors

FLUVOXAMINE TAB

100MG




Reuptake Inhibitors

FLUVOXAMINE TAB

25MG




Reuptake Inhibitors

FLUVOXAMINE TAB

50MG




Reuptake Inhibitors

FOLOTYN INJ


FOLOTYN INJ

40MG/2ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

FONDAPARINUX INJ

10/0.8ML





FONDAPARINUX INJ

2.5/0.5





FONDAPARINUX INJ

5/0.4ML





FONDAPARINUX INJ

7.5/0.6





Pg. 105 of 331



FORFIVO XL TAB




FORTEO SOL

600/2.4




Agents


Agents

FOSAMAX + D TAB 70-

2800 Not on 2017 formulary


10 mg, 35 mg, 70 mg)


Agents


Agents

FOSAMAX + D TAB 70-



10 mg, 35 mg, 70 mg)


Agents


Agents

FOSCAVIR INJ

24MG/ML


prior authorization check with your doctor Antivirals

Anti-cytomegalovirus

(CMV) Agents

FOSINOP/HCTZ TAB

10/12.5 On formulary, tier change tier 1 to tier 6 Cardiovascular Agents

Antihypertensive

Combinations

FOSINOP/HCTZ TAB

20/12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents

Antihypertensive

Combinations

FOSINOPRIL TAB




FOSINOPRIL TAB




FOSINOPRIL TAB




FRAGMIN INJ

10000/ML Not on 2017 formulary enoxaparin inj



FRAGMIN INJ

12500UNT Not on 2017 formulary enoxaparin inj



FRAGMIN INJ




FRAGMIN INJ




FRAGMIN INJ

2500/0.2 Not on 2017 formulary enoxaparin inj



Pg. 106 of 331



FRAGMIN INJ




FRAGMIN INJ




FRAGMIN INJ




FREAMINE HBC INJ


Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



FULYZAQ TAB

125MG Not on 2017 formulary loperamide 2mg capsule Gastrointestinal Agents


Other

FUROSEMIDE SOL


furosemide oral solution

(10mg/mL) Cardiovascular Agents Diuretics, Loop

FUZEON INJ 90MG


limit may apply 60 vials per 30 days Antivirals Anti-HIV Agents, Other

GABAPENTIN CAP

100MG


limit may apply

1080 capsules per 30

days Anticonvulsants

Gamma-aminobutyric

Acid (GABA) Augmenting

Agents

GABAPENTIN CAP

300MG


limit may apply 360 capsules per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GABAPENTIN CAP

400MG


limit may apply 270 capsules per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GABAPENTIN SOL

250/5ML


limit may apply 2160 mls per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

Pg. 107 of 331



GABAPENTIN SOL

300/6ML


limit may apply 2160 mls per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GABAPENTIN TAB

600MG


limit may apply 180 tablets per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GABAPENTIN TAB

800MG


limit may apply 120 tablets per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GAMASTAN S/D INJ Not on 2017 formulary





form, please visit



on the back of your



Immunizing Agents,

Passive

GAMMAGARD INJ

10GM/100 Not on 2017 formulary





form, please visit



on the back of your



Immunizing Agents,

Passive

Pg. 108 of 331



GAMMAGARD INJ






form, please visit



on the back of your



Immunizing Agents,

Passive

GAMMAGARD INJ

2.5GM/25 Not on 2017 formulary





form, please visit



on the back of your



Immunizing Agents,

Passive

GAMMAGARD INJ






form, please visit



on the back of your



Immunizing Agents,

Passive

Pg. 109 of 331



GAMMAGARD INJ






form, please visit



on the back of your



Immunizing Agents,

Passive

GAMMAGARD INJ






form, please visit



on the back of your



Immunizing Agents,

Passive

GAMMAPLEX INJ

10GM


prior authorization check with your doctor Immunological Agents

Immunizing Agents,

Passive

GAMMAPLEX INJ

2.5GM



Immunizing Agents,

Passive

GAMMAPLEX INJ

20GM



Immunizing Agents,

Passive

GAMMAPLEX INJ 5GM



Immunizing Agents,

Passive

GAMUNEX-C INJ

10GM/100 On formulary, tier change tier 4 to tier 5 Immunological Agents

Immunizing Agents,

Passive

Pg. 110 of 331



GAMUNEX-C INJ

10GM/100



Immunizing Agents,

Passive

GAMUNEX-C INJ

1GM/10ML On formulary, tier change tier 4 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GAMUNEX-C INJ

1GM/10ML



Immunizing Agents,

Passive

GAMUNEX-C INJ

2.5GM/25 On formulary, tier change tier 4 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GAMUNEX-C INJ

2.5GM/25



Immunizing Agents,

Passive

GAMUNEX-C INJ

20GM/200 On formulary, tier change tier 4 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GAMUNEX-C INJ

20GM/200



Immunizing Agents,

Passive

GAMUNEX-C INJ

40/400ML On formulary, tier change tier 4 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GAMUNEX-C INJ

40/400ML



Immunizing Agents,

Passive

GAMUNEX-C INJ

5GM/50ML On formulary, tier change tier 4 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GAMUNEX-C INJ

5GM/50ML



Immunizing Agents,

Passive

GAUZE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

GAUZE SPONGE PAD

2X2 8PLY On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

GEMFIBROZIL TAB

600MG




Derivatives

GENERLAC SOL


Pg. 111 of 331



GENTAM/NACL INJ


gentamicin in saline

injection (0.8 mg/ml, 1

mg/ml, 1.2 mg/ml, 1.6

mg/ml) Antibacterials Aminoglycosides

GENTAM/NACL INJ


gentamicin in saline

injection (0.8 mg/ml, 1

mg/ml, 1.2 mg/ml, 1.6

mg/ml) Antibacterials Aminoglycosides

GENTAM/NACL INJ

100MG On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides

GENTAM/NACL INJ


GENTAM/NACL INJ


GENTAM/NACL INJ

60MG PB On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides

GENTAM/NACL INJ


GENTAMICIN CRE


GENTAMICIN INJ

10MG/ML On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides

GENTAMICIN OIN 0.1% On formulary, tier change tier 1 to tier 4 Dermatological Agents Dermatological Agents

GENTAMICIN SOL 0.3%

OP On formulary, tier change tier 1 to tier 2 Antibacterials Aminoglycosides

GEODON INJ 20MG


limit may apply 60 vials per 30 days Antipsychotics 2nd Generation/Atypical

Pg. 112 of 331



GEODON INJ 20MG





GILDAGIA TAB 0.4-35 On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Sex


GILOTRIF TAB 20MG



GILOTRIF TAB 30MG



GILOTRIF TAB 40MG



GLEEVEC TAB


imatinib 100 mg* *This

drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




Pg. 113 of 331



GLEEVEC TAB



drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




GLEEVEC TAB



drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




GLIMEPIRIDE TAB 1MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents

GLIMEPIRIDE TAB 1MG




GLIMEPIRIDE TAB 2MG




Pg. 114 of 331



GLIMEPIRIDE TAB 4MG



GLIP/METFORM TAB 2.5-

250M On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents


250M




500M On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents


500M



GLIP/METFORM TAB 5-

500MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents

GLIP/METFORM TAB 5-

500MG



GLIPIZIDE TAB 10MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents

GLIPIZIDE TAB 10MG



GLIPIZIDE TAB 5MG On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents

GLIPIZIDE TAB 5MG



GLIPIZIDE ER TAB


GLIPIZIDE ER TAB

10MG



GLIPIZIDE ER TAB

2.5MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents

GLIPIZIDE ER TAB

2.5MG



Pg. 115 of 331



GLIPIZIDE ER TAB 5MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents

GLIPIZIDE ER TAB 5MG



GLIPIZIDE XL TAB 10MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents

GLIPIZIDE XL TAB 10MG



GLIPIZIDE XL TAB


GLIPIZIDE XL TAB

2.5MG



GLIPIZIDE XL TAB 5MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents

GLIPIZIDE XL TAB 5MG



GLOBAL PREP PAD

PADS On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

GLYB/METFORM TAB

1.25-250 Not on 2017 formulary

glipizide/metformin,

glimepiride used in

combination with

metformin tablets Blood Glucose Regulators Antidiabetic Agents

GLYB/METFORM TAB



glimepiride used in

combination with


GLYB/METFORM TAB 5-



glimepiride used in

combination with


Pg. 116 of 331



GLYBURID MCR TAB




GLYBURID MCR TAB




GLYBURID MCR TAB




GLYBURIDE TAB




GLYBURIDE TAB




GLYBURIDE TAB 5MG Not on 2017 formulary



GNP ALCOHOL PAD

SWABS On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

GRANISETRON INJ

0.1MG/ML Not on 2017 formulary ondansetron inj, Aloxi inj Antiemetics

Emetogenic Therapy

Adjuncts

GRANISETRON INJ

1MG/ML Not on 2017 formulary ondansetron inj, Aloxi inj Antiemetics

Emetogenic Therapy

Adjuncts

GRANISETRON INJ

4MG/4ML Not on 2017 formulary ondansetron inj, Aloxi inj Antiemetics

Emetogenic Therapy

Adjuncts

GRISEOFULVIN SUS

125/5ML On formulary, tier change tier 1 to tier 2 Antifungals Antifungals

GUANFACINE TAB

1MG ER Not on 2017 formulary Strattera, clonidine ER


Agents

Attention Deficit


Agents, Non-

amphetamines

GUANFACINE TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 117 of 331



GUANFACINE TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

GUANFACINE TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

GUANIDINE TAB

125MG On formulary, tier change tier 2 to tier 4 Antimyasthenic Agents Parasympathomimetics

HALOPER DEC INJ

100MG/ML





HALOPER DEC INJ

50MG/ML





HALOPER LAC INJ

5MG/ML





HALOPERIDOL CON

2MG/ML





HALOPERIDOL TAB

0.5MG On formulary, tier change tier 1 to tier 2 Antipsychotics 1st Generation/Typical

Pg. 118 of 331



HALOPERIDOL TAB

0.5MG





HALOPERIDOL TAB

10MG





HALOPERIDOL TAB


HALOPERIDOL TAB

1MG





HALOPERIDOL TAB

20MG





HALOPERIDOL TAB


HALOPERIDOL TAB

2MG





HALOPERIDOL TAB


HALOPERIDOL TAB

5MG





Pg. 119 of 331



HEP SOD/D5W INJ

100/ML Not on 2017 formulary

heparin sodium/D5W

20000 units (40 unit/mL)



HEP SOD/D5W INJ

20000UNT On formulary, tier change tier 1 to tier 2



HEP SOD/D5W INJ


heparin sodium/D5W




HEP SOD/D5W INJ

50UNT/ML Not on 2017 formulary

heparin sodium/D5W




HEPARIN SOD INJ

1000/ML On formulary, tier change tier 1 to tier 2



HEPARIN SOD INJ




HEPARIN SOD INJ




HEPATAMINE SOL 8% On formulary, tier change tier 1 to tier 2



HETLIOZ CAP 20MG


limit may apply 30 capsules per 30 days Sleep Disorder Agents Sleep Disorders, Other

HEXALEN CAP 50MG On formulary, tier change tier 4 to tier 5 Antineoplastics Alkylating Agents

HEXALEN CAP 50MG




refill check with your doctor Antineoplastics Alkylating Agents

Pg. 120 of 331



HUMATROPE INJ


Omnitrope inj* *This drug

requires prior

authorization. To


form, please visit



on the back of your


information.

Hormonal Agents,



Hormonal Agents,



HUMATROPE INJ



requires prior

authorization. To


form, please visit



on the back of your


information.

Hormonal Agents,



Hormonal Agents,



HUMIRA KIT

20MG/0.4



HUMIRA KIT

40MG/0.8



HUMIRA PEDIA INJ

CROHNS



HUMIRA PEN INJ

40MG/0.8



HUMIRA PEN INJ

CROHNS



Pg. 121 of 331



HUMIRA PEN INJ

PSORIASI



HUMULIN R INJ U-500


prior authorization check with your doctor Blood Glucose Regulators Insulins

HYDRALAZINE INJ

20MG/ML Not on 2017 formulary hydralazine tablet Cardiovascular Agents

Vasodilators, Direct-acting

Arterial

HYDRALAZINE TAB



Arterial

HYDRALAZINE TAB



Arterial

HYDROCO/APAP SOL

7.5-325 On formulary, tier change tier 1 to tier 2 Analgesics


acting

HYDROCO/APAP SOL

7.5-325




acting

HYDROCO/APAP TAB 10-

325MG




acting

HYDROCO/APAP TAB


hydrocodone/acetaminop

hen (5/300mg,

7.5/300mg, 10/300mg,

5/325mg, 7.5/325mg,

10/325mg) Analgesics


acting

HYDROCO/APAP TAB 5-

325MG




acting

HYDROCO/APAP TAB

7.5-325




acting

HYDROCOD/IBU TAB 7.5-

200




acting

HYDROCORT CRE 1% On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

Pg. 122 of 331



HYDROCORT CRE

2.5% On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

HYDROCORT OIN 1% On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

HYDROCORT/AB OIN

1% On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

HYDROCORTISO CRE

2.5% On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

HYDROMORPHON INJ

10MG/ML




acting

HYDROMORPHON INJ

1MG/ML




acting

HYDROMORPHON INJ

2MG/ML




acting

HYDROMORPHON INJ

4MG/ML




acting

HYDROMORPHON INJ

500/50ML




acting

HYDROMORPHON INJ

50MG/5ML




acting

HYDROMORPHON LIQ

1MG/ML




acting

Pg. 123 of 331



HYDROMORPHON TAB


fentanyl patch (12mcg,

25mcg, 50mcg, 75mcg,

100mcg), Nucynta ER,

tramadol ER, morphine

sulfate ER tablets,

methadone tablets,

Opana ER (crush

resistant), Oxycontin,

Zohydro ER* *This drug

requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 124 of 331



HYDROMORPHON TAB






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

HYDROMORPHON TAB

2MG




acting

HYDROMORPHON TAB

4MG




acting

HYDROMORPHON TAB

8MG




acting

Pg. 125 of 331



HYDROMORPHON TAB






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

HYDROXYZ HCL INJ

25MG/ML Not on 2017 formulary check with your doctor Anxiolytics Anxiolytics, Other

HYDROXYZ HCL INJ

50MG/ML Not on 2017 formulary check with your doctor Anxiolytics Anxiolytics, Other

HYDROXYZ HCL SOL

10MG/5ML On formulary, tier change tier 1 to tier 4 Anxiolytics Anxiolytics, Other

HYDROXYZ HCL SYP

10MG/5ML On formulary, tier change tier 1 to tier 4 Anxiolytics Anxiolytics, Other

HYDROXYZ HCL TAB

10MG On formulary, tier change tier 2 to tier 4 Anxiolytics Anxiolytics, Other

HYDROXYZ HCL TAB


Pg. 126 of 331



HYDROXYZ HCL TAB


HYDROXYZ PAM CAP

100MG Not on 2017 formulary check with your doctor Anxiolytics Anxiolytics, Other

HYDROXYZ PAM CAP


HYDROXYZ PAM CAP


IBANDRONATE TAB

150MG


limit may apply 1 tablet per 28 days


Agents


Agents

IBRANCE CAP

100MG



IBRANCE CAP

125MG



IBRANCE CAP 75MG



IBUPROFEN SUS

100/5ML On formulary, tier change tier 1 to tier 2 Analgesics

Nonsteroidal Anti-

inflammatory Drugs

IBUPROFEN SUS

100/5ML


limit may apply 4800 mls per 30 days Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

IBUPROFEN TAB

400MG



Nonsteroidal Anti-

inflammatory Drugs

IBUPROFEN TAB

600MG



Nonsteroidal Anti-

inflammatory Drugs

IBUPROFEN TAB

800MG



Nonsteroidal Anti-

inflammatory Drugs

ICLUSIG TAB 15MG



ICLUSIG TAB 45MG



Pg. 127 of 331



IDAMYCIN PFS INJ

10/10ML Not on 2017 formulary idarubicin inj 1 mg/mL Antineoplastics Antineoplastics

IDAMYCIN PFS INJ

20/20ML Not on 2017 formulary idarubicin inj 1 mg/mL Antineoplastics Antineoplastics

IDAMYCIN PFS INJ

5MG/5ML Not on 2017 formulary idarubicin inj 1 mg/mL Antineoplastics Antineoplastics

IDARUBICIN INJ

10/10ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics

IDARUBICIN INJ


IDARUBICIN INJ


IFOSFAMIDE INJ 3GM On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics

ILARIS INJ 180MG On formulary, tier change tier 4 to tier 5 Immunological Agents Immunomodulators

ILARIS INJ 180MG



ILOTYCIN OIN OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives

IMATINIB MES TAB

100MG



IMATINIB MES TAB

100MG





IMATINIB MES TAB

400MG



IMATINIB MES TAB

400MG





IMBRUVICA CAP

140MG



Pg. 128 of 331



IMIPRAM HCL TAB


IMIPRAM HCL TAB


IMIPRAM HCL TAB


IMIPRAM PAM CAP




duloxetine capsules

(20mg, 30mg, 60mg),

venlafaxine IR tablets, ER

tablets (37.5mg, 75mg,

150mg ), and ER

capsules, mirtazapine,

bupropion Antidepressants Tricyclics

IMIPRAM PAM CAP




duloxetine capsules

(20mg, 30mg, 60mg),



150mg ), and ER



Pg. 129 of 331



IMIPRAM PAM CAP




duloxetine capsules

(20mg, 30mg, 60mg),



150mg ), and ER



IMIPRAM PAM CAP




duloxetine capsules

(20mg, 30mg, 60mg),



150mg ), and ER



IMIQUIMOD CRE 5%




refill check with your doctor Dermatological Agents Dermatological Agents

IMOVAX RABIE INJ

2.5/ML


prior authorization check with your doctor Immunological Agents Vaccines

IN CONTROL MIS


IN CONTROL MIS


IN CONTROL MIS


Pg. 130 of 331



INCONTROL MIS


INCONTROL PAD


INDAPAMIDE TAB

1.25MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Thiazide

INDAPAMIDE TAB

2.5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents Diuretics, Thiazide

INDOMETHACIN CAP


diclofenac, etodolac IR,

ibuprofen, meloxicam,

nabumetone, naproxen,

sulindac Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

INDOMETHACIN CAP






Nonsteroidal Anti-

inflammatory Drugs

INDOMETHACIN CAP






Nonsteroidal Anti-

inflammatory Drugs

INFUMORPH INJ

10MG/ML




acting

INFUMORPH INJ

25MG/ML




acting

INLYTA TAB 1MG



INLYTA TAB 1MG





Pg. 131 of 331



INLYTA TAB 5MG



INLYTA TAB 5MG





INSULIN PEN MIS


INSULIN PEN MIS


INSULIN PEN MIS


INSULIN SYR MIS

0.3/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

INSULIN SYR MIS


INSULIN SYR MIS

1ML/31G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


Pg. 132 of 331



INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS 1ML On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS

2/27.5G On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

INSULIN SYRG MIS


INSULIN SYRG MIS


INSULIN SYRG MIS


Pg. 133 of 331



INSULIN SYRG MIS


INSULIN SYRG MIS


INSUPEN MIS


INSUPEN MIS


INSUPEN SENS MIS


INSUPEN SENS MIS


INSUPEN ULTR MIS


INSUPEN ULTR MIS


INSUPEN ULTR MIS


INSUPEN ULTR MIS


INTELENCE TAB

100MG




nucleoside Reverse


INTELENCE TAB

200MG




nucleoside Reverse


INTELENCE TAB 25MG




nucleoside Reverse


INTRALIPID INJ 20% On formulary, tier change tier 1 to tier 2



Pg. 134 of 331



INTRON A INJ 18MU On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

INTRON A INJ 50MU On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

INVEGA TAB 1.5MG Not on 2017 formulary

paliperidone 1.5 mg*


authorization. To


form, please visit

www.MyPrime.com or



card for more information. Antipsychotics 2nd Generation/Atypical

INVEGA TAB 3MG Not on 2017 formulary

paliperidone 3 mg* *This

drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




Pg. 135 of 331





drug requires prior

authorization. To


form, please visit

www.MyPrime.com or






drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




INVEGA SUST INJ

117/0.75


limit may apply 1 kit per 30 days Antipsychotics 2nd Generation/Atypical

INVEGA SUST INJ

117/0.75





INVEGA SUST INJ

156MG/ML



Pg. 136 of 331



INVEGA SUST INJ

156MG/ML





INVEGA SUST INJ

234/1.5



INVEGA SUST INJ

234/1.5





INVEGA SUST INJ

39/0.25



INVEGA SUST INJ

39/0.25





INVEGA SUST INJ

78/0.5ML On formulary, tier change tier 4 to tier 5 Antipsychotics 2nd Generation/Atypical

INVEGA SUST INJ

78/0.5ML



INVEGA SUST INJ

78/0.5ML





INVEGA TRINZ INJ

273MG





INVEGA TRINZ INJ

273MG



Pg. 137 of 331



INVEGA TRINZ INJ

410MG





INVEGA TRINZ INJ

410MG



INVEGA TRINZ INJ

546MG





INVEGA TRINZ INJ

546MG



INVEGA TRINZ INJ

819MG





INVEGA TRINZ INJ

819MG



INVIRASE CAP 200MG On formulary, tier change tier 4 to tier 5 Antivirals


Inhibitors

INVIRASE CAP 200MG




Inhibitors

INVIRASE TAB 500MG




Inhibitors

INVOKAMET TAB 150-

1000



INVOKAMET TAB 150-

500



INVOKAMET TAB 50-

1000



Pg. 138 of 331



INVOKAMET TAB 50-

500MG



INVOKANA TAB

100MG



INVOKANA TAB

300MG



IPRATROPIUM SOL

0.02%INH On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents

Bronchodilators,

Anticholinergic

IPRATROPIUM SOL

INHAL On formulary, tier change tier 1 to tier 2 Respiratory Tract Agents

Bronchodilators,

Anticholinergic

IPRATROPIUM SPR

0.03%



IPRATROPIUM SPR

0.06%



IPRATROPIUM/ SOL

ALBUTER Not on 2017 formulary check with your doctor Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

IPRATROPIUM/ SOL

SULFATE Not on 2017 formulary check with your doctor Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

IRBESAR/HCTZ TAB 150-


Antihypertensive

Combinations


12.5



Antihypertensive

Combinations



Antihypertensive

Combinations


12.5



Antihypertensive

Combinations

IRBESARTAN TAB



Antagonists

IRBESARTAN TAB

150MG




Antagonists

Pg. 139 of 331



IRBESARTAN TAB



Antagonists

IRBESARTAN TAB

300MG




Antagonists

IRBESARTAN TAB



Antagonists

IRBESARTAN TAB

75MG




Antagonists

IRENKA CAP 40MG Not on 2017 formulary

duloxetine capsules

(20mg, 30mg, 60mg) Antidepressants


Reuptake Inhibitors

ISENTRESS CHW

100MG


limit may apply 180 tablets per 30 days Antivirals Anti-HIV Agents, Other

ISENTRESS CHW

25MG



ISENTRESS POW

100MG


limit may apply 60 packets per 30 days Antivirals Anti-HIV Agents, Other

ISENTRESS TAB

400MG



ISOLYTE-P INJ /D5W Not on 2017 formulary D5W/lactated ringers inj



Electrolyte/Mineral

Replacement

ISOLYTE-S INJ Not on 2017 formulary lactated ringers inj



Electrolyte/Mineral

Replacement

ISONIAZID INJ

100MG/ML On formulary, tier change tier 1 to tier 4 Antimycobacterials Antituberculars

ISONIAZID SYP

50MG/5ML Not on 2017 formulary isoniazid tablets Antimycobacterials Antituberculars

ISOSORB DIN TAB


isosorbide dinitrate IR

tablet (5 mg, 10 mg, 20

mg, 30 mg), isosorbide

mononitrate ER tablet (30

mg, 60 mg, 120 mg) Cardiovascular Agents


Arterial/Venous

Pg. 140 of 331



ISOSORB MONO TAB

30MG ER On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Arterial/Venous

ISOSORB MONO TAB

60MG ER On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Arterial/Venous

ISRADIPINE CAP



Agents

ISRADIPINE CAP 5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Agents

IXEMPRA KIT INJ 15MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

IXEMPRA KIT INJ 45MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

J&J GAUZE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

JAKAFI TAB 10MG



JAKAFI TAB 10MG





JAKAFI TAB 15MG



JAKAFI TAB 15MG





JAKAFI TAB 20MG



JAKAFI TAB 20MG





Pg. 141 of 331



JAKAFI TAB 25MG



JAKAFI TAB 25MG





JAKAFI TAB 5MG



JAKAFI TAB 5MG





JALYN CAP Not on 2017 formulary

dutasteride/tamsulosin 0.5

mg/0.4 mg capsules Genitourinary Agents

Benign Prostatic

Hypertrophy Agents

JANUMET TAB 50-

1000



JANUMET TAB 50-

500MG



JANUMET XR TAB 100-

1000



JANUMET XR TAB 50-

1000



JANUMET XR TAB 50-

500MG



JANUVIA TAB 100MG



JANUVIA TAB 25MG



JANUVIA TAB 50MG



Pg. 142 of 331



JENTADUETO TAB 2.5-

1000 On formulary, tier change tier 3 to tier 4 Blood Glucose Regulators Antidiabetic Agents

JENTADUETO TAB 2.5-

1000



JUXTAPID CAP 10MG


prior authorization check with your doctor Cardiovascular Agents Dyslipidemics, Other

JUXTAPID CAP 20MG



JUXTAPID CAP 5MG



KADIAN CAP 40MG

ER Not on 2017 formulary





sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or




Opioid Analgesics, Long-

acting

KALETRA SOL




Inhibitors

Pg. 143 of 331



KALETRA TAB 100-

25MG




Inhibitors

KALETRA TAB 200-

50MG




Inhibitors

KALYDECO PAK

50MG


limit may apply 60 packets per 30 days Respiratory Tract Agents


Other

KALYDECO PAK

75MG


limit may apply 60 packets per 30 days Respiratory Tract Agents


Other

KALYDECO TAB

150MG




Other

KAZANO 12.5- TAB


Jentadueto, Kombiglyze,

Janumet, Janumet XR Blood Glucose Regulators Antidiabetic Agents

KAZANO 12.5- TAB


Jentadueto, Kombiglyze,

Janumet, Janumet XR Blood Glucose Regulators Antidiabetic Agents

KCL/D5W INJ 0.15% On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

KCL/D5W INJ 0.3% On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

KCL/D5W/LR INJ 0.15% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ

.075/.45 On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ .15-

.45% On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ

.15/.33% On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ

.15/.45% On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ




Electrolyte/Mineral

Replacement

Pg. 144 of 331



KCL/D5W/NACL INJ




Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ

0.15/0.2 Not on 2017 formulary

KCL/D5W/NACL inj

0.15/0.2%



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ

0.3/0.45 On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

KCL/NACL INJ 0.15-

0.9 Not on 2017 formulary KCL/NACL inj 0.15-0.45



Electrolyte/Mineral

Replacement

KEPIVANCE INJ


KETEK TAB 300MG Not on 2017 formulary check with your doctor Antibacterials Macrolides

KETEK TAB 400MG Not on 2017 formulary check with your doctor Antibacterials Macrolides

KETOPROFEN CAP

200MG ER Not on 2017 formulary ketoprofen IR Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

KETOPROFEN CAP


Nonsteroidal Anti-

inflammatory Drugs

KETOPROFEN CAP

50MG



Nonsteroidal Anti-

inflammatory Drugs

KETOPROFEN CAP

75MG



Nonsteroidal Anti-

inflammatory Drugs

KETOROLAC INJ


codeine/acetaminophen,

ibuprofen, naproxen,

meloxicam, diclofenac,

nabumetone, etodolac IR,

sulindac,


hen,

oxycodone/acetaminophe

n Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

Pg. 145 of 331



KETOROLAC INJ






sulindac,


hen,



Nonsteroidal Anti-

inflammatory Drugs

KETOROLAC TAB






sulindac,


hen,



Nonsteroidal Anti-

inflammatory Drugs

KHEDEZLA TAB


Pristiq (brand name),

duloxetine (20 mg, 30 mg,

60 mg), Fetzima,



150mg ), and ER capsule Antidepressants


Reuptake Inhibitors

KHEDEZLA TAB 50MG

ER Not on 2017 formulary

Pristiq (brand name),

duloxetine (20 mg, 30 mg,

60 mg), Fetzima,





Reuptake Inhibitors

Pg. 146 of 331



KINERET INJ



KLOR-CON 10 TAB

10MEQ ER On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

KLOR-CON 8 TAB




Electrolyte/Mineral

Replacement

KLOR-CON M10 TAB




Electrolyte/Mineral

Replacement

KORLYM TAB 300MG



Hormonal Agents,

Suppressant (Pituitary)

Hormonal Agents,


KUVAN TAB 100MG



Enzyme Replacement/

Modifiers

Enzyme Replacement/

Modifiers

KYNAMRO INJ

200MG/ML



LABETALOL INJ

5MG/ML Not on 2017 formulary labetalol tablets Cardiovascular Agents


Agents

LACTATED RIN INJ On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

LACTATED RIN SOL

IRRIGAT Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous

LACTULOSE SOL


LACTULOSE SOL


LAMICTAL KIT START


lamotrigine tablets,

lamotrigine chewable

tablets (5 mg, 25 mg) Anticonvulsants

Glutamate Reducing

Agents

LAMICTAL KIT START





Glutamate Reducing

Agents

Pg. 147 of 331



LAMICTAL KIT START





Glutamate Reducing

Agents

LAMICTAL ODT TAB





Glutamate Reducing

Agents

LAMICTAL ODT TAB





Glutamate Reducing

Agents

LAMICTAL ODT TAB





Glutamate Reducing

Agents

LAMICTAL ODT TAB





Glutamate Reducing

Agents

LAMICTAL XR KIT Not on 2017 formulary




Glutamate Reducing

Agents

LAMIVUD/ZIDO TAB 150-

300



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


LAMIVUDINE SOL

10MG/ML



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


LAMIVUDINE TAB

150MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


Pg. 148 of 331



LAMIVUDINE TAB

300MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


LAMOTRIGINE TAB





Glutamate Reducing

Agents

LAMOTRIGINE TAB





Glutamate Reducing

Agents

LAMOTRIGINE TAB





Glutamate Reducing

Agents

LAMOTRIGINE TAB





Glutamate Reducing

Agents

LAMOTRIGINE TAB





Glutamate Reducing

Agents

LAMOTRIGINE TAB





Glutamate Reducing

Agents

LAMOTRIGINE TAB





Glutamate Reducing

Agents

LAMOTRIGINE TAB





Glutamate Reducing

Agents

LAMOTRIGINE TAB





Glutamate Reducing

Agents

Pg. 149 of 331



LAMOTRIGINE TAB





Glutamate Reducing

Agents

LATUDA TAB 120MG On formulary, tier change tier 3 to tier 5 Antipsychotics 2nd Generation/Atypical

LATUDA TAB 120MG



LATUDA TAB 120MG






LATUDA TAB 20MG



LATUDA TAB 20MG






LATUDA TAB 40MG



LATUDA TAB 40MG






LATUDA TAB 60MG



Pg. 150 of 331



LATUDA TAB 60MG






LATUDA TAB 80MG



LATUDA TAB 80MG





LAZANDA SPR

100MCG


limit may apply 30 bottles per 30 days Analgesics


acting

LAZANDA SPR

300MCG




acting

LAZANDA SPR

400MCG




acting

LENVIMA CAP 10 MG On formulary, tier change tier 3 to tier 5 Antineoplastics Antineoplastics

LENVIMA CAP 10 MG



LENVIMA CAP 10 MG





LENVIMA CAP 14 MG



LENVIMA CAP 14 MG





Pg. 151 of 331



LENVIMA CAP 18 MG



LENVIMA CAP 18 MG





LENVIMA CAP 20 MG



LENVIMA CAP 20 MG





LENVIMA CAP 24 MG



LENVIMA CAP 24 MG





LENVIMA CAP 8 MG



LENVIMA CAP 8 MG





LESCOL XL TAB 80MG Not on 2017 formulary






LETAIRIS TAB 10MG



Pulmonary

Antihypertensives

LETAIRIS TAB 10MG



Pulmonary

Antihypertensives

Pg. 152 of 331



LETAIRIS TAB 5MG



Pulmonary

Antihypertensives

LETAIRIS TAB 5MG



Pulmonary

Antihypertensives

LEUCOVOR CA INJ


LEUCOVOR CA TAB


LEUCOVOR CA TAB


LEUCOVORIN INJ

CALCIUM On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics

LEVETIRACETA TAB

500MG ER Not on 2017 formulary levetiracetam IR tablets Anticonvulsants Anticonvulsants, Other

LEVETIRACETA TAB

750MG ER Not on 2017 formulary levetiracetam IR tablets Anticonvulsants Anticonvulsants, Other

LEVOCARNITIN INJ

200MG/ML Not on 2017 formulary levocarnitine tablet 330mg

Enzyme Replacement/

Modifiers

Enzyme Replacement/

Modifiers

LEVOCARNITIN SOL

1GM/10ML On formulary, tier change tier 1 to tier 2

Enzyme Replacement/

Modifiers

Enzyme Replacement/

Modifiers

LEVOLEUCOVOR INJ

175/17.5 Not on 2017 formulary leucovorin calcium inj Antineoplastics Antineoplastics

LEVOLEUCOVOR INJ

50MG Not on 2017 formulary leucovorin calcium inj Antineoplastics Antineoplastics

LEVOTHYROXIN TAB

100MCG On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

Pg. 153 of 331



LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOTHYROXIN TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

Pg. 154 of 331



LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

Pg. 155 of 331



LEVOXYL TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

LEXIVA SUS

50MG/ML




Inhibitors

LEXIVA TAB 700MG




Inhibitors

LIDOCAINE INJ 0.5% Not on 2017 formulary check with your doctor Anesthetics Local Anesthetics

LIDOCAINE INJ 2% Not on 2017 formulary check with your doctor Anesthetics Local Anesthetics

LINCOCIN INJ


clindamycin inj 150

mg/mL Antibacterials Antibacterials, Other

LINCOMYCIN INJ


clindamycin inj 150

mg/mL Antibacterials Antibacterials, Other

LINDANE LOT 1% Not on 2017 formulary

Lindane 1% shampoo,

malathion 0.5% lotion Dermatological Agents Dermatological Agents

LINZESS CAP

145MCG




Agents

LINZESS CAP

290MCG




Agents

LIPODOX INJ


LIPODOX 50 INJ


LISINOP/HCTZ TAB 10-


Antihypertensive

Combinations



Antihypertensive

Combinations



Antihypertensive

Combinations

LISINOPRIL TAB 10MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents



Pg. 156 of 331



LISINOPRIL TAB 2.5MG On formulary, tier change tier 1 to tier 6 Cardiovascular Agents















LITETOUCH MIS

29GX12.7 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

LITETOUCH MIS


LITHIUM SOL

8MEQ/5ML On formulary, tier change tier 1 to tier 4 Bipolar Agents Mood Stabilizers

LITHOSTAT TAB

250MG Not on 2017 formulary check with your doctor Genitourinary Agents


Other

LIVALO TAB 1MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents



LIVALO TAB 1MG








LIVALO TAB 2MG








LIVALO TAB 4MG





Pg. 157 of 331



LOFENE TAB 2.5MG Not on 2017 formulary loperamide 2mg capsule Gastrointestinal Agents


Other

LOMUSTINE CAP


LOMUSTINE CAP


LOMUSTINE CAP


LORAZEPAM CON


lorazepam tablets*,

diazepam conc* *This

drug will need a prior

authorization. To


form, please visit



on the back of your



LORAZEPAM TAB

0.5MG



LORAZEPAM TAB

0.5MG





LORAZEPAM TAB 1MG





Pg. 158 of 331



LORAZEPAM TAB 2MG





LORCET TAB 5-

325MG




acting

LORCET HD TAB 10-

325MG




acting

LORCET PLUS TAB 7.5-

325




acting

LORTAB TAB 10-

325MG




acting

LORTAB TAB 5-

325MG




acting

LORTAB TAB 7.5-325




acting

LOSARTAN POT TAB



Antagonists

LOSARTAN POT TAB

100MG




Antagonists

LOSARTAN POT TAB



Antagonists

LOSARTAN POT TAB

25MG




Antagonists

LOSARTAN POT TAB



Antagonists

LOSARTAN POT TAB

50MG




Antagonists

LOSARTAN/HCT TAB

100-12.5 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents

Antihypertensive

Combinations

Pg. 159 of 331



LOSARTAN/HCT TAB

100-12.5



Antihypertensive

Combinations

LOSARTAN/HCT TAB

100-25 On formulary, tier change tier 2 to tier 6 Cardiovascular Agents

Antihypertensive

Combinations

LOSARTAN/HCT TAB

100-25



Antihypertensive

Combinations

LOSARTAN/HCT TAB 50-


Antihypertensive

Combinations

LOSARTAN/HCT TAB 50-

12.5



Antihypertensive

Combinations

LOTEMAX GEL 0.5% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

LOVASTATIN TAB




LOVASTATIN TAB

10MG





LOVASTATIN TAB




LOVASTATIN TAB

20MG





LOVASTATIN TAB




LOVASTATIN TAB

40MG





LOXAPINE CAP 10MG





Pg. 160 of 331



LOXAPINE CAP 25MG





LOXAPINE CAP 50MG





LOXAPINE CAP 5MG





LUMIZYME INJ 50MG Not on 2017 formulary check with your doctor

Enzyme Replacement/

Modifiers

Enzyme Replacement/

Modifiers

LUPR DEP-PED INJ


Hormonal Agents,


Hormonal Agents,


LUPR DEP-PED INJ


Hormonal Agents,


Hormonal Agents,


LUPRON DEPOT INJ


Hormonal Agents,


Hormonal Agents,


LUPRON DEPOT INJ


LUPRON DEPOT INJ


LUPRON DEPOT INJ


LUPRON DEPOT INJ


LYNPARZA CAP

50MG



Pg. 161 of 331



MAGNESIUM SU INJ

50% On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

MAPROTILINE TAB

25MG On formulary, tier change tier 1 to tier 4 Antidepressants Antidepressants, Other

MAPROTILINE TAB

25MG



MAPROTILINE TAB


MAPROTILINE TAB

50MG



MAPROTILINE TAB


MAPROTILINE TAB

75MG



MARINOL CAP 10MG



Emetogenic Therapy

Adjuncts

MARINOL CAP 2.5MG



Emetogenic Therapy

Adjuncts

MARINOL CAP 5MG



Emetogenic Therapy

Adjuncts

MATULANE CAP


MATULANE CAP

50MG





MECLIZINE TAB

12.5MG On formulary, tier change tier 1 to tier 2 Antiemetics Antiemetics, Other

MECLIZINE TAB 25MG On formulary, tier change tier 1 to tier 2 Antiemetics Antiemetics, Other

Pg. 162 of 331



MECLOFEN SOD CAP


diclofenac tablets,






tolmetin 400 mg,




authorization. To


form, please visit

www.MyPrime.com or




Nonsteroidal Anti-

inflammatory Drugs

Pg. 163 of 331



MECLOFEN SOD CAP


diclofenac tablets,






tolmetin 400 mg,




authorization. To


form, please visit

www.MyPrime.com or




Nonsteroidal Anti-

inflammatory Drugs

MEDROL TAB 16MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

MEDROL TAB 2MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

MEDROL TAB 32MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

MEDROL TAB 4MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

Pg. 164 of 331



MEDROL TAB 8MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

MEGACE ES SUS

625/5ML Not on 2017 formulary check with your doctor Antineoplastics Antineoplastics

MEGESTROL AC SUS

400MG/10 On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics

MEGESTROL AC SUS


MEGESTROL AC TAB


MEGESTROL AC TAB


MEKINIST TAB 0.5MG



MEKINIST TAB 0.5MG





MEKINIST TAB 2MG



MEKINIST TAB 2MG





MELOXICAM SUS

7.5/5ML Not on 2017 formulary

meloxicam tablets,

ibuprofen suspension Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

MELOXICAM TAB

15MG



Nonsteroidal Anti-

inflammatory Drugs

MELOXICAM TAB

7.5MG



Nonsteroidal Anti-

inflammatory Drugs

Pg. 165 of 331



MELPHALAN INJ 50MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics

MENEST TAB 0.3MG On formulary, tier change tier 2 to tier 4

Hormonal Agents,


Modifying (Sex


MENEST TAB


Hormonal Agents,


Modifying (Sex


MENEST TAB


Hormonal Agents,


Modifying (Sex


MENEST TAB 2.5MG On formulary, tier change tier 2 to tier 4

Hormonal Agents,


Modifying (Sex


MEPROBAMATE TAB


buspirone, escitalopram,

fluoxetine, sertraline,

venlafaxine, duloxetine Anxiolytics Anxiolytics, Other

MEPROBAMATE TAB


buspirone, escitalopram,

fluoxetine, sertraline,

venlafaxine, duloxetine Anxiolytics Anxiolytics, Other

Pg. 166 of 331



MESALAMINE KIT 4GM Not on 2017 formulary

Canasa suppository,

mesalamine enema. The

drug being requested is a

kit that contains cleansing

wipes. The kit is not

covered by your plan. The

enema only is covered by

your plan without a prior

authorization.

Inflammatory Bowel


METADATE TAB

20MG ER




Agents

Attention Deficit


Agents, Non-

amphetamines

METFORMIN TAB


METFORMIN TAB

1000MG



METFORMIN TAB


METFORMIN TAB

500MG



METFORMIN TAB

500MG ER On formulary, tier change tier 1 to tier 6 Blood Glucose Regulators Antidiabetic Agents

METFORMIN TAB

500MG ER



METFORMIN TAB

750MG ER On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents

METFORMIN TAB

750MG ER



METFORMIN TAB


Pg. 167 of 331



METFORMIN TAB

850MG



METFORMIN ER TAB


metformin tablet IR and

ER (500 mg, 750 mg

[generic Glucophage

XR])* *Please note, the

requested drug,

metformin ER (generic

Fortamet), is an extended-

release tablet with an

osmotic-release

formulation and is not

covered by your plan.

However, metformin ER

500 mg and 750 mg

(generic Glucophage XR),

which are also extended-

release tablets, are

covered by your plan

without prior

authorization. Please

follow up with your

prescriber with any

questions. Blood Glucose Regulators Antidiabetic Agents

Pg. 168 of 331



METHADONE INJ






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 169 of 331



METHADONE SOL






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 170 of 331



METHADONE SOL






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 171 of 331



METHADONE SOL






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 172 of 331



METHADONE SOL






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

METHADONE TAB

10MG




acting

METHADONE TAB

5MG




acting

METHOCARBAM TAB


Skeletal Muscle

Relaxants

Skeletal Muscle

Relaxants

METHOCARBAM TAB


Skeletal Muscle

Relaxants

Skeletal Muscle

Relaxants

METHOTREXATE INJ

1GM On formulary, tier change tier 1 to tier 2 Antineoplastics Antimetabolites

METHOXSALEN CAP

10MG On formulary, tier change tier 2 to tier 5 Dermatological Agents Dermatological Agents

Pg. 173 of 331



METHYCLOTHIA TAB


chlorothiazide,

chlorthalidone,

hydrochlorothiazide,

indapamide, metolazone Cardiovascular Agents Diuretics, Thiazide

METHYLD/HCTZ TAB

250/15 Not on 2017 formulary

clonidine IR tablet,

hydrochlorothiazide, an

ACEI (lisinopril, ramipril,

benazepril), an ARB

(losartan, irbesartan),

beta-blocker (atenolol,

metoprolol), calcium

channel blocker

(amlodipine or nifedipine

ER) Cardiovascular Agents

Antihypertensive

Combinations

METHYLD/HCTZ TAB





benazepril), an ARB




channel blocker



Antihypertensive

Combinations

METHYLDOPA TAB

250MG Not on 2017 formulary clonidine IR tablet Cardiovascular Agents

Alpha-adrenergic

Agonists

METHYLDOPA TAB

500MG Not on 2017 formulary clonidine IR tablet Cardiovascular Agents

Alpha-adrenergic

Agonists

METHYLDOPATE INJ

250/5ML Not on 2017 formulary clonidine IR tablet Cardiovascular Agents

Alpha-adrenergic

Agonists

Pg. 174 of 331



METHYLIN CHW


amphetamine/dextroamph

etamine ER capsules

(generic Adderall XR),


etamine IR tablets

(generic Adderall),

dexmethylphenidate IR

tablets (generic Focalin),

methylphenidate IR

tablets (generic Ritalin),

dextroamphetamine IR

(generic Dexedrine),

dextroamphetamine ER

(generic Dexedrine ER

capsule)


Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLIN CHW



etamine ER capsules



etamine IR tablets

(generic Adderall),



methylphenidate IR






capsule)


Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 175 of 331



METHYLIN CHW 5MG Not on 2017 formulary


etamine ER capsules



etamine IR tablets

(generic Adderall),



methylphenidate IR






capsule)


Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID CAP



etamine IR tablets and ER

capsules,


(generic Focalin),





capsule),

methylphenidate IR


methylphenidate ER

20mg tablets (generic

Ritalin SR)


Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 176 of 331



METHYLPHENID SOL




capsules,


(generic Focalin),





capsule),

methylphenidate IR


methylphenidate ER


Ritalin SR)


Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID SOL




capsules,


(generic Focalin),





capsule),

methylphenidate IR


methylphenidate ER


Ritalin SR)


Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 177 of 331



METHYLPHENID TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID TAB

10MG




Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID TAB

20MG




Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID TAB

20MG ER




Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID TAB

20MG SR




Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 178 of 331



METHYLPHENID TAB




capsules,


(generic Focalin),





capsule),

methylphenidate IR


methylphenidate ER


Ritalin SR)


Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID TAB




capsules,


(generic Focalin),





capsule),

methylphenidate IR


methylphenidate ER


Ritalin SR)


Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 179 of 331



METHYLPHENID TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID TAB

5MG




Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPR ACE INJ


methylprednisolone

sodium succinate inj (40

mg, 125 mg, 1000 mg)

Hormonal Agents,


Modifying (Adrenal)


orticoids

METHYLPR ACE INJ


methylprednisolone

sodium succinate inj (40

mg, 125 mg, 1000 mg)

Hormonal Agents,


Modifying (Adrenal)


orticoids

METHYLPRED TAB

16MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

METHYLPRED TAB


Hormonal Agents,


Modifying (Adrenal)


orticoids

METHYLPRED TAB

32MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

METHYLPRED TAB

4MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

METHYLPRED TAB


Hormonal Agents,


Modifying (Adrenal)


orticoids

Pg. 180 of 331



METHYLPRED TAB

8MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

METHYLTESTOS CAP

10MG



Hormonal Agents,


Modifying (Sex


METIPRANOLOL SOL

0.3% OPH Not on 2017 formulary

betaxolol, carteolol,

levobunolol, timolol

maleate (solution, gel) Ophthalmic Agents


Agents

METOCLOPRAM INJ

10MG/2ML On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents


Other

METOCLOPRAM INJ

5MG/ML On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents


Other

METOCLOPRAM SOL

10/10ML On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents


Other

METOCLOPRAM SOL

5MG/5ML On formulary, tier change tier 1 to tier 2 Gastrointestinal Agents


Other

METOPRL/HCTZ TAB

100-50MG Not on 2017 formulary

metoprolol/hydrochlorothi

azide (50-25 mg, 100-25

mg) Cardiovascular Agents

Antihypertensive

Combinations

METOPROLOL INJ


metoprolol (IR and ER)

tablets Cardiovascular Agents


Agents

METOPROLOL INJ


metoprolol (IR and ER)

tablets Cardiovascular Agents


Agents

METRONIDAZOL CAP


METRONIDAZOL TAB


METRONIDAZOL TAB


Pg. 181 of 331



MICONAZOLE 3 SUP


terconazole cream (0.4%,

0.8%), terconazole 80mg

suppository Genitourinary Agents Vaginal Products

MILLIPRED TAB 5MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

MIRTAZAPINE TAB

15MG



MIRTAZAPINE TAB

15MG ODT



MIRTAZAPINE TAB

30MG



MIRTAZAPINE TAB

30MG ODT



MIRTAZAPINE TAB

45MG



MIRTAZAPINE TAB

45MG ODT



MIRTAZAPINE TAB

7.5MG



MIRVASO GEL 0.33% Not on 2017 formulary

Finacea, Oracea,

metronidazole 0.75%

(cream, gel, lotion),

metronidazole 1% gel Dermatological Agents Dermatological Agents

MITOMYCIN INJ 5MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics

MITOXANTRON INJ


MODAFINIL TAB

100MG


limit may apply 30 tablets per 30 days Sleep Disorder Agents Sleep Disorders, Other

MODAFINIL TAB

200MG


limit may apply 30 tablets per 30 days Sleep Disorder Agents Sleep Disorders, Other

Pg. 182 of 331



MOEXIPR/HCTZ TAB 15-


Antihypertensive

Combinations

MOEXIPR/HCTZ TAB 15-


Antihypertensive

Combinations

MOEXIPR/HCTZ TAB 7.5-


Antihypertensive

Combinations

MOEXIPRIL TAB 15MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents



MOEXIPRIL TAB




MORGIDOX CAP

1X100MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines

MORGIDOX CAP

2X100MG On formulary, tier change tier 1 to tier 2 Antibacterials Tetracyclines

Pg. 183 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 184 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 185 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 186 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 187 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 188 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 189 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 190 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 191 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 192 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 193 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 194 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 195 of 331



MORPHINE SUL CAP






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

MORPHINE SUL INJ

0.5MG/ML On formulary, tier change tier 1 to tier 2 Analgesics


acting

MORPHINE SUL INJ

0.5MG/ML




acting

MORPHINE SUL INJ

10MG/ML




acting

MORPHINE SUL INJ

150/30ML




acting

MORPHINE SUL INJ

15MG/ML




acting

MORPHINE SUL INJ

1MG/ML




acting

Pg. 196 of 331



MORPHINE SUL INJ

1MG/ML On formulary, tier change tier 1 to tier 2 Analgesics


acting

MORPHINE SUL INJ

25MG/ML




acting

MORPHINE SUL INJ

2MG/ML




acting

MORPHINE SUL INJ

4MG/ML




acting

MORPHINE SUL INJ

50MG/ML




acting

MORPHINE SUL INJ

5MG/ML




acting

MORPHINE SUL INJ

8MG/ML




acting

MORPHINE SUL SOL

100/5ML




acting

MORPHINE SUL SOL

10MG/5ML




acting

MORPHINE SUL SOL

20MG/5ML On formulary, tier change tier 1 to tier 2 Analgesics


acting

MORPHINE SUL SOL

20MG/5ML




acting

MORPHINE SUL TAB

100MG ER




acting

MORPHINE SUL TAB

15MG On formulary, tier change tier 2 to tier 4 Analgesics


acting

MORPHINE SUL TAB

15MG




acting

MORPHINE SUL TAB

15MG ER




acting

Pg. 197 of 331



MORPHINE SUL TAB

30MG On formulary, tier change tier 2 to tier 4 Analgesics


acting

MORPHINE SUL TAB

30MG




acting

MORPHINE SUL TAB

30MG ER




acting

MORPHINE SUL TAB

60MG ER




acting

MOXEZA SOL 0.5% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents Ophthalmic Anti Infectives

MYCAMINE INJ 50MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals

MYCOPHENOLAT SUS

200MG/ML On formulary, tier change tier 2 to tier 5 Immunological Agents Immune Suppressants

MYRBETRIQ TAB


Toviaz, oxybutynin IR,

oxybutynin ER, tolterodine

IR tablets, tolterodine ER

capsules, trospium IR

tablets, trospium ER

capsules Genitourinary Agents Antispasmodics, Urinary

MYRBETRIQ TAB








NABUMETONE TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

NABUMETONE TAB

750MG



Nonsteroidal Anti-

inflammatory Drugs

NADOLOL TAB 20MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Agents

Pg. 198 of 331



NADOLOL TAB 40MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Agents

NADOLOL/BEND TAB 40-


nadolol tablets used in

combination with


propranolol tablets used

in combination with



azide (50-25 mg, 100-25


Antihypertensive

Combinations

NADOLOL/BEND TAB 80-


nadolol tablets used in

combination with



in combination with



azide (50-25 mg, 100-25


Antihypertensive

Combinations

NAFCILLIN INJ 10GM On formulary, tier change tier 2 to tier 5 Antibacterials Beta-lactam, Penicillins

NAFTIFINE CRE HCL




suspension, gel),


Ciclodan solution),



Pg. 199 of 331



NAFTIN CRE 2% Not on 2017 formulary



suspension, gel),


Ciclodan solution),



NALBUPHINE INJ

10MG/ML Not on 2017 formulary check with your doctor Analgesics


acting

NALBUPHINE INJ

20MG/ML Not on 2017 formulary check with your doctor Analgesics


acting

NALOXONE INJ

1MG/ML On formulary, tier change tier 1 to tier 3



NAMENDA XR CAP


memantine IR tablets*


authorization. To


form, please visit

www.MyPrime.com or



card for more information. Antidementia Agents

N-METHYL-D-

ASPARTATE (NMDA)

RECEPTOR

ANTAGONIST

NAMENDA XR CAP

14MG


prior authorization check with your doctor Antidementia Agents

N-METHYL-D-

ASPARTATE (NMDA)

RECEPTOR

ANTAGONIST

Pg. 200 of 331



NAMENDA XR CAP




authorization. To


form, please visit

www.MyPrime.com or




N-METHYL-D-

ASPARTATE (NMDA)

RECEPTOR

ANTAGONIST

NAMENDA XR CAP

21MG



N-METHYL-D-

ASPARTATE (NMDA)

RECEPTOR

ANTAGONIST

NAMENDA XR CAP




authorization. To


form, please visit

www.MyPrime.com or




N-METHYL-D-

ASPARTATE (NMDA)

RECEPTOR

ANTAGONIST

NAMENDA XR CAP

28MG



N-METHYL-D-

ASPARTATE (NMDA)

RECEPTOR

ANTAGONIST

Pg. 201 of 331



NAMENDA XR CAP




authorization. To


form, please visit

www.MyPrime.com or




N-METHYL-D-

ASPARTATE (NMDA)

RECEPTOR

ANTAGONIST

NAMENDA XR CAP

7MG



N-METHYL-D-

ASPARTATE (NMDA)

RECEPTOR

ANTAGONIST

NAMENDA XR CAP

TITRATIO



N-METHYL-D-

ASPARTATE (NMDA)

RECEPTOR

ANTAGONIST

NAPHAZOLINE SOL

0.1% OP On formulary, tier change tier 1 to tier 3 Ophthalmic Agents Ophthalmic Agents, Other

NAPROXEN SUS

125/5ML On formulary, tier change tier 1 to tier 2 Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN SUS

125/5ML


limit may apply 1800 mls per 30 days Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN TAB

250MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN TAB

375MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

Pg. 202 of 331



NAPROXEN DR TAB


Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN DR TAB

375MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN DR TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN SOD TAB

275MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN SOD TAB

550MG



Nonsteroidal Anti-

inflammatory Drugs

NATEGLINIDE TAB


NATEGLINIDE TAB

120MG



NATEGLINIDE TAB


NATEGLINIDE TAB

60MG



NATPARA INJ 25MCG


limit may apply 2 cartridges per 28 days


Agents


Agents

NEBUPENT INH


NEFAZODONE TAB


NEFAZODONE TAB


NEFAZODONE TAB


NEFAZODONE TAB


NEO/BAC/POLY OIN OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives

Pg. 203 of 331



NEO/POLY GU SOL

40/ML IR On formulary, tier change tier 1 to tier 2 Genitourinary Agents


Other

NEO/POLY/BAC OIN /HC

1%OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

NEO/POLY/DEX OIN

0.1% OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

NEO/POLY/HC SUS OP Not on 2017 formulary


e solution,


ne suspension,


methasone suspension Ophthalmic Agents

Ophthalmic Anti-

inflammatories

NEO-POLYCIN OIN HC

1%OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

NEO-POLYCIN OIN OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives

NEPHRAMINE INJ 5.4% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



NESINA TAB 12.5MG Not on 2017 formulary

Tradjenta, Onglyza,

Januvia Blood Glucose Regulators Antidiabetic Agents

NESINA TAB 25MG Not on 2017 formulary

Tradjenta, Onglyza,


NESINA TAB 6.25MG Not on 2017 formulary

Tradjenta, Onglyza,


NEUPOGEN INJ

300/0.5 Not on 2017 formulary Neulasta, Granix


Volume Expanders Blood Formation Modifiers

NEUPOGEN INJ

480/0.8 Not on 2017 formulary Neulasta, Granix



Pg. 204 of 331



NEUPOGEN INJ

480MCG Not on 2017 formulary Neulasta, Granix



NEVANAC SUS 0.1% Not on 2017 formulary

Prolensa, bromfenac

0.09%, diclofenac drops,

flurbiprofen drops,

ketorolac drops, Ilevro Ophthalmic Agents

Ophthalmic Anti-

inflammatories

NEVIRAPINE SUS

50MG/5ML On formulary, tier change tier 2 to tier 4 Antivirals


nucleoside Reverse


NEVIRAPINE SUS

50MG/5ML




nucleoside Reverse


NEVIRAPINE TAB

100MG




nucleoside Reverse


NEVIRAPINE TAB

200MG




nucleoside Reverse


NEVIRAPINE TAB

400MG ER




nucleoside Reverse


NEXAVAR TAB

200MG



NEXAVAR TAB

200MG





NIACIN TAB 500MG

ER


limit may apply 30 tablets per 30 days Cardiovascular Agents Dyslipidemics, Other

NIACIN ER TAB

1000MG



Pg. 205 of 331



NIACIN ER TAB 500MG



NIACIN ER TAB 750MG



NIACOR TAB 500MG Not on 2017 formulary niacin ER tablets Cardiovascular Agents Dyslipidemics, Other

NICARDIPINE CAP



Agents

NICOTROL INH On formulary, tier change tier 3 to tier 4



Smoking Cessation

Agents

NIFEDIPINE CAP 10MG Not on 2017 formulary nifedipine ER tablet Cardiovascular Agents


Agents

NIFEDIPINE CAP 20MG Not on 2017 formulary nifedipine ER tablet Cardiovascular Agents


Agents

NILANDRON TAB


NILUTAMIDE TAB


NIMODIPINE CAP

30MG Not on 2017 formulary check with your doctor Cardiovascular Agents


Agents

Pg. 206 of 331



NISOLDIPINE TAB


amlodipine, diltiazem IR

tablet, diltiazem ER

capsule (generic Cartia-

XT 120mg, 180mg,

240mg, 300mg), diltiazem

ER capsule (generic

Taztia-XT 120mg, 180mg,

240mg, 300mg, 360mg),

diltiazem ER capsule

(generic Dilt-XR 120mg,

180mg, 240mg),

felodipine ER, isradipine,

nicardipine capsule,

nifedipine ER tablet,

verapamil IR and ER Cardiovascular Agents


Agents

Pg. 207 of 331



NISOLDIPINE TAB





XT 120mg, 180mg,


ER capsule (generic


240mg, 300mg, 360mg),



180mg, 240mg),






Agents

Pg. 208 of 331



NISOLDIPINE TAB





XT 120mg, 180mg,


ER capsule (generic


240mg, 300mg, 360mg),



180mg, 240mg),






Agents

NITROFUR MAC CAP


NITROFURANTN CAP


NITROGLYCER INJ


Nitrostat tablets,

nitroglycerin lingual spray Cardiovascular Agents


Arterial/Venous

NORETHIN ACE TAB


Hormonal Agents,


Modifying (Sex

Hormones/ Modifiers) Progestins

NORMOSOL -M INJ

/D5W On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

NORMOSOL -R INJ

/D5W Not on 2017 formulary D5W/lactated ringers inj



Electrolyte/Mineral

Replacement

Pg. 209 of 331



NORMOSOL-R INJ PH

7.4 Not on 2017 formulary lactated ringers inj



Electrolyte/Mineral

Replacement

NORTRIPTYLIN SOL

10MG/5ML On formulary, tier change tier 2 to tier 4 Antidepressants Tricyclics

NORVIR CAP 100MG




Inhibitors

NORVIR SOL



Inhibitors

NORVIR SOL

80MG/ML




Inhibitors

NORVIR TAB 100MG




Inhibitors

NOVOFINE MIS


NOVOFINE MIS


NOVOFINE AUT MIS


NOVOFINE PLS MIS


NOVOLIN INJ 70/30 Not on 2017 formulary Humulin 70/30 Blood Glucose Regulators Insulins

NOVOLIN N INJ

RELION Not on 2017 formulary Humulin N Blood Glucose Regulators Insulins

NOVOLIN N INJ U-100 Not on 2017 formulary Humulin N Blood Glucose Regulators Insulins

NOVOLIN R INJ

RELION Not on 2017 formulary Humulin R U-100 Blood Glucose Regulators Insulins

NOVOLIN R INJ U-100 Not on 2017 formulary Humulin R U-100 Blood Glucose Regulators Insulins

Pg. 210 of 331



NOVOLIN70/30 INJ

RELION Not on 2017 formulary Humulin 70/30 Blood Glucose Regulators Insulins

NOVOLOG INJ

100/ML Not on 2017 formulary

Humalog (vials or


NOVOLOG INJ

FLEXPEN Not on 2017 formulary

Humalog (vials or


NOVOLOG MIX INJ


Humalog mix (vials or


NOVOLOG MIX INJ

FLEXPEN Not on 2017 formulary

Humalog mix (vials or


NOVOTWIST MIS


NOVOTWIST MIS


NOXAFIL SUS

40MG/ML On formulary, tier change tier 4 to tier 5 Antifungals Antifungals

NOXAFIL SUS

40MG/ML



NOXAFIL TAB 100MG On formulary, tier change tier 4 to tier 5 Antifungals Antifungals

NOXAFIL TAB 100MG



NUCYNTA TAB


codeine sulfate,



hen, hydromorphone,

oxycodone,


n, morphine sulfate IR

tablets, tramadol,

tramadol/acetaminophen Analgesics


acting

Pg. 211 of 331



NUCYNTA TAB 50MG Not on 2017 formulary

codeine sulfate,



hen, hydromorphone,

oxycodone,



tablets, tramadol,



acting

NUCYNTA TAB 75MG Not on 2017 formulary

codeine sulfate,



hen, hydromorphone,

oxycodone,



tablets, tramadol,



acting

NUCYNTA ER TAB

100MG




acting

NUCYNTA ER TAB

150MG




acting

NUCYNTA ER TAB

200MG




acting

NUCYNTA ER TAB

250MG




acting

NUCYNTA ER TAB

50MG




acting

NUTRILIPID EMU 20% On formulary, tier change tier 1 to tier 2



Pg. 212 of 331



NUTROPIN AQ INJ



requires prior

authorization. To


form, please visit



on the back of your


information.

Hormonal Agents,



Hormonal Agents,



NUTROPIN AQ INJ

NUSPIN 5 Not on 2017 formulary


requires prior

authorization. To


form, please visit



on the back of your


information.

Hormonal Agents,



Hormonal Agents,



NYSTAT/TRIAM CRE On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents

NYSTAT/TRIAM OIN On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents

NYSTATIN CRE

100000 On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents

NYSTATIN OIN

100000 On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents

OCTREOTIDE INJ

1000MCG



Hormonal Agents,


Hormonal Agents,


OCTREOTIDE INJ

100MCG



Hormonal Agents,


Hormonal Agents,


Pg. 213 of 331



OCTREOTIDE INJ

200MCG



Hormonal Agents,


Hormonal Agents,


OCTREOTIDE INJ

500MCG



Hormonal Agents,


Hormonal Agents,


OCTREOTIDE INJ

50MCG/ML



Hormonal Agents,


Hormonal Agents,


OFEV CAP 100MG




Other

OFLOXACIN TAB


OLANZA/FLUOX CAP 12-


olanzapine* used in

combination with

fluoxetine *This drug

requires prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Antidepressants


Reuptake Inhibitors

Pg. 214 of 331



OLANZA/FLUOX CAP 12-


olanzapine* used in

combination with


requires prior

authorization. To


form, please visit

www.MyPrime.com or





Reuptake Inhibitors

OLANZA/FLUOX CAP 3-


olanzapine* used in

combination with


requires prior

authorization. To


form, please visit

www.MyPrime.com or





Reuptake Inhibitors

Pg. 215 of 331



OLANZA/FLUOX CAP 6-


olanzapine* used in

combination with


requires prior

authorization. To


form, please visit

www.MyPrime.com or





Reuptake Inhibitors

OLANZA/FLUOX CAP 6-


olanzapine* used in

combination with


requires prior

authorization. To


form, please visit

www.MyPrime.com or





Reuptake Inhibitors

OLANZAPINE INJ 10MG



OLANZAPINE INJ 10MG





Pg. 216 of 331



OLANZAPINE TAB

10MG



OLANZAPINE TAB

10MG





OLANZAPINE TAB

10MG ODT



OLANZAPINE TAB

10MG ODT





OLANZAPINE TAB

15MG



OLANZAPINE TAB

15MG





OLANZAPINE TAB

15MG ODT



OLANZAPINE TAB

15MG ODT





OLANZAPINE TAB

2.5MG



OLANZAPINE TAB

2.5MG





Pg. 217 of 331



OLANZAPINE TAB

20MG



OLANZAPINE TAB

20MG





OLANZAPINE TAB

20MG ODT



OLANZAPINE TAB

20MG ODT





OLANZAPINE TAB 5MG



OLANZAPINE TAB 5MG





OLANZAPINE TAB 5MG

ODT



OLANZAPINE TAB 5MG

ODT





OLANZAPINE TAB

7.5MG



OLANZAPINE TAB

7.5MG





Pg. 218 of 331



OMEPRA/BICAR CAP 20-





(2.5mg, 5 mg, 10 mg, 20


(10mg, 20 mg, 40 mg),



OMEPRA/BICAR CAP 40-





(2.5mg, 5 mg, 10 mg, 20


(10mg, 20 mg, 40 mg),



OMEPRAZOLE CAP

10MG


limit may apply 30 capsules per 30 days Gastrointestinal Agents Proton Pump Inhibitors

OMEPRAZOLE CAP

20MG



OMEPRAZOLE CAP

40MG



ONFI SUS

2.5MG/ML


limit may apply 480 mls per 30 days Anticonvulsants Benzodiazepines

ONFI SUS

2.5MG/ML





Pg. 219 of 331



ONFI TAB 10MG



ONFI TAB 10MG





ONFI TAB 20MG



ONFI TAB 20MG





OPANA ER TAB 10MG




acting

OPANA ER TAB 15MG




acting

OPANA ER TAB 20MG




acting

OPANA ER TAB 30MG




acting

OPANA ER TAB 40MG




acting

OPANA ER TAB 5MG




acting

OPANA ER TAB

7.5MG




acting

OPSUMIT TAB 10MG



Pulmonary

Antihypertensives

OPSUMIT TAB 10MG



Pulmonary

Antihypertensives

ORAP TAB 1MG Not on 2017 formulary pimozide 1 mg Antipsychotics 1st Generation/Typical

Pg. 220 of 331



ORAP TAB 2MG Not on 2017 formulary pimozide 2 mg Antipsychotics 1st Generation/Typical

ORAPRED ODT TAB

10MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

ORAPRED ODT TAB

15MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

ORAPRED ODT TAB

30MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

ORENCIA INJ

125MG/ML



ORENCIA INJ 250MG Not on 2017 formulary





form, please visit



on the back of your


information. Immunological Agents Immunomodulators

Pg. 221 of 331



ORENITRAM TAB


Adcirca*, Letairis*,

sildenafil*, Tracleer*,

Opsumit* *These drugs

require prior authorization.


form, please visit



on the back of your


information. Respiratory Tract Agents

Pulmonary

Antihypertensives

ORENITRAM TAB







form, please visit



on the back of your



Pulmonary

Antihypertensives

Pg. 222 of 331



ORENITRAM TAB 1MG Not on 2017 formulary






form, please visit



on the back of your



Pulmonary

Antihypertensives

ORENITRAM TAB







form, please visit



on the back of your



Pulmonary

Antihypertensives

Pg. 223 of 331



ORPHENADRINE INJ


tizanidine, diclofenac

tablets, etodolac,

flurbiprofen, ibuprofen,

ketoprofen IR, meloxicam,


oxaprozin, piroxicam,

sulindac, tolmetin 400mg,




authorization. To


form, please visit

www.MyPrime.com or




Skeletal Muscle

Relaxants

Skeletal Muscle

Relaxants

Pg. 224 of 331



ORPHENADRINE TAB


tizanidine, diclofenac

tablets, etodolac,

flurbiprofen, ibuprofen,

ketoprofen IR, meloxicam,


oxaprozin, piroxicam,

sulindac, tolmetin 400mg,




authorization. To


form, please visit

www.MyPrime.com or




Skeletal Muscle

Relaxants

Skeletal Muscle

Relaxants

OSENI TAB 12.5-15 Not on 2017 formulary

Tradjenta taken in

combination with

pioglitazone, Onglyza

taken in combination with

pioglitazone, Januvia


pioglitazone Blood Glucose Regulators Antidiabetic Agents

Pg. 225 of 331




Tradjenta taken in

combination with







Tradjenta taken in

combination with






OSENI TAB 25-


Tradjenta taken in

combination with






OSENI TAB 25-


Tradjenta taken in

combination with






Pg. 226 of 331



OSENI TAB 25-


Tradjenta taken in

combination with






OTREXUP INJ 10MG Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics

OTREXUP INJ

12.5/0.4 Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics


OTREXUP INJ



OTREXUP INJ



OTREXUP INJ 7.5/0.4 Not on 2017 formulary methotrexate (tablet, inj) Antineoplastics Antineoplastics

OXALIPLATIN INJ


OXALIPLATIN INJ 50MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics

OXANDROLONE TAB


Hormonal Agents,


Modifying (Sex

Hormones/ Modifiers) Anabolic Steroids

OXANDROLONE TAB

10MG



Hormonal Agents,


Modifying (Sex


Pg. 227 of 331



OXANDROLONE TAB


Hormonal Agents,


Modifying (Sex


OXANDROLONE TAB

2.5MG



Hormonal Agents,


Modifying (Sex


OXAPROZIN TAB

600MG



Nonsteroidal Anti-

inflammatory Drugs

OXAZEPAM CAP


clorazepate*,







form, please visit



on the back of your



Pg. 228 of 331



OXAZEPAM CAP


clorazepate*,







form, please visit



on the back of your



OXAZEPAM CAP


clorazepate*,







form, please visit



on the back of your



Pg. 229 of 331



OXTELLAR XR TAB


topiramate IR (tablets,

capsules), lamotrigine IR

tablets, levetiracetam IR

tablets Anticonvulsants Sodium Channel Agents

OXTELLAR XR TAB






OXTELLAR XR TAB






OXYBUTYNIN SYP

5MG/5ML


limit may apply 600 mls per 30 days Genitourinary Agents Antispasmodics, Urinary

OXYBUTYNIN TAB

10MG ER


limit may apply 60 tablets per 30 days Genitourinary Agents Antispasmodics, Urinary

OXYBUTYNIN TAB

15MG ER



OXYBUTYNIN TAB

5MG On formulary, tier change tier 1 to tier 2 Genitourinary Agents Antispasmodics, Urinary

OXYBUTYNIN TAB

5MG



OXYBUTYNIN TAB

5MG ER



OXYCOD/APAP TAB 10-

325MG




acting

OXYCOD/APAP TAB 2.5-

325




acting

OXYCOD/APAP TAB 5-

325MG




acting

Pg. 230 of 331



OXYCOD/APAP TAB 7.5-

325




acting

OXYCOD/ASA TAB




acting

OXYCOD/IBU TAB 5-


codeine sulfate,



hen, hydromorphone,

oxycodone,



tablets, tramadol,



acting

OXYCODONE CAP

5MG Not on 2017 formulary oxycodone 5 mg tablet Analgesics


acting

OXYCODONE TAB

10MG




acting

OXYCODONE TAB

15MG




acting

OXYCODONE TAB

20MG




acting

OXYCODONE TAB

30MG




acting

OXYCODONE TAB

5MG




acting

OXYCONTIN TAB

10MG CR




acting

OXYCONTIN TAB

15MG CR




acting

OXYCONTIN TAB

20MG CR




acting

Pg. 231 of 331



OXYCONTIN TAB

30MG CR




acting

OXYCONTIN TAB

40MG CR




acting

OXYCONTIN TAB

60MG CR




acting

OXYCONTIN TAB

80MG CR




acting

OXYMORPHONE TAB






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 232 of 331



OXYMORPHONE TAB






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 233 of 331



OXYMORPHONE TAB






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 234 of 331



OXYMORPHONE TAB






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 235 of 331



OXYMORPHONE TAB






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 236 of 331



OXYMORPHONE TAB






sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 237 of 331



OXYMORPHONE TAB

7.5MG ER Not on 2017 formulary





sulfate ER tablets,

methadone tablets,

Opana ER (crush



requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

OXYMORPHONE TAB

HCL 10MG Not on 2017 formulary

codeine sulfate,



hen, hydromorphone,

oxycodone,



tablets, tramadol,



acting

Pg. 238 of 331



OXYMORPHONE TAB

HCL 5MG Not on 2017 formulary

codeine sulfate,



hen, hydromorphone,

oxycodone,



tablets, tramadol,



acting

PACERONE TAB




PACLITAXEL INJ


paclitaxel inj

(30mg/5mL,100mg/16.7m

L, 300mg/50mL) Antineoplastics Antineoplastics

PALIPERIDONE TAB ER

1.5MG



PALIPERIDONE TAB ER

1.5MG





PALIPERIDONE TAB ER

3MG



PALIPERIDONE TAB ER

3MG





PALIPERIDONE TAB ER

6MG



Pg. 239 of 331



PALIPERIDONE TAB ER

6MG





PALIPERIDONE TAB ER

9MG



PALIPERIDONE TAB ER

9MG





PAMIDRONATE INJ

30/10ML Not on 2017 formulary zoledronic acid injection


Agents


Agents

PAMIDRONATE INJ

6MG/ML Not on 2017 formulary zoledronic acid injection


Agents


Agents

PAMIDRONATE INJ

90/10ML Not on 2017 formulary zoledronic acid injection


Agents


Agents

PANRETIN GEL 0.1% On formulary, tier change tier 4 to tier 5 Dermatological Agents Dermatological Agents

PAROXETIN ER TAB


citalopram, escitalopram,

fluoxetine, fluvoxamine

IR, sertraline Antidepressants


Reuptake Inhibitors

PAROXETIN ER TAB






Reuptake Inhibitors

PAROXETINE TAB

10MG




Reuptake Inhibitors

PAROXETINE TAB

20MG




Reuptake Inhibitors

PAROXETINE TAB






Reuptake Inhibitors

Pg. 240 of 331



PAROXETINE TAB

30MG




Reuptake Inhibitors

PAROXETINE TAB

40MG




Reuptake Inhibitors

PAXIL SUS

10MG/5ML




Reuptake Inhibitors

PEDIAPRED SOL

6.7/5ML



Hormonal Agents,


Modifying (Adrenal)


orticoids

PEGASYS INJ


prior authorization check with your doctor Antivirals Antihepatitis Agents

PEGASYS INJ

180MCG/M



PEGASYS INJ

PROCLICK



PEGINTRON KIT

120MCG



PEGINTRON KIT

150MCG



PEGINTRON KIT

50MCG



PEGINTRON KIT

80MCG



PEG-INTRON KIT 120

RP



PEG-INTRON KIT

120MCG



PEG-INTRON KIT 150

RP



PEG-INTRON KIT

150MCG



Pg. 241 of 331



PEG-INTRON KIT

50MCG



PEG-INTRON KIT

50MCG RP



PEG-INTRON KIT

80MCG



PEG-INTRON KIT

80MCG RP



PEN G SOD INJ

5000000 On formulary, tier change tier 1 to tier 4 Antibacterials Beta-lactam, Penicillins

PEN NEEDLE MIS


PEN NEEDLE MIS


PEN NEEDLES MIS


PEN NEEDLES MIS


PEN NEEDLES MIS

29GX12.7 On formulary, tier change tier 2 to tier 3 Blood Glucose Regulators Antidiabetic Agents

PEN NEEDLES MIS


PEN NEEDLES MIS


PEN NEEDLES MIS


PEN NEEDLES MIS


PEN NEEDLES MIS


Pg. 242 of 331



PEN NEEDLES MIS


PEN NEEDLES MIS


PEN NEEDLES MIS


PEN NEEDLES MIS


PEN NEEDLES MIS


PEN NEEDLES MIS


PEN NEEDLES MIS


PENICILLN GK INJ 5MU On formulary, tier change tier 1 to tier 2 Antibacterials Beta-lactam, Penicillins

PENTAM 300 INJ

300MG


prior authorization check with your doctor Antiparasitics Antiprotozoals

PENTAZ/NALOX TAB 50-






sulindac,


hen (5/300, 7.5/300,

10/300, 5/325, 7.5/325,

10/325),


n (2.5/325, 5/325,

7.5/325, 10/325) Analgesics


acting

PENTIPS MIS


Pg. 243 of 331



PENTIPS MIS


PENTIPS MIS


PENTIPS MIS


PENTIPS MIS


PERINDOPRIL TAB




PERINDOPRIL TAB




PERINDOPRIL TAB




PERPHEN/AMIT TAB 2-




duloxetine capsules

(20mg, 30mg, 60mg),




mirtazapine, bupropion Antipsychotics 1st Generation/Typical

Pg. 244 of 331



PERPHEN/AMIT TAB 2-




duloxetine capsules

(20mg, 30mg, 60mg),





PERPHEN/AMIT TAB 4-




duloxetine capsules

(20mg, 30mg, 60mg),





PERPHEN/AMIT TAB 4-




duloxetine capsules

(20mg, 30mg, 60mg),





Pg. 245 of 331



PERPHEN/AMIT TAB 4-




duloxetine capsules

(20mg, 30mg, 60mg),





PERPHENAZINE TAB

16MG





PERPHENAZINE TAB

2MG





PERPHENAZINE TAB

4MG





PERPHENAZINE TAB

8MG





PEXEVA TAB 10MG Not on 2017 formulary





Reuptake Inhibitors






Reuptake Inhibitors

Pg. 246 of 331








Reuptake Inhibitors






Reuptake Inhibitors

PHENADOZ SUP

12.5MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines

PHENADOZ SUP

12.5MG


prior authorization check with your doctor Respiratory Tract Agents Antihistamines

PHENERGAN SUP


PHENERGAN SUP

12.5MG



PHENERGAN SUP


PHENOBARB ELX

20MG/5ML On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates

PHENOBARB SOL

20MG/5ML On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates

PHENOBARB TAB

100MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates

PHENOBARB TAB


PHENOBARB TAB

16.2MG On formulary, tier change tier 1 to tier 4 Anticonvulsants Barbiturates

PHENOBARB TAB


PHENOBARB TAB


Pg. 247 of 331



PHENOBARB TAB


PHENOBARB TAB


PHENOBARB TAB


PHENYTOIN INJ


phenytoin (chewable

tablets, ER capsules,

125/5 mL suspension) Anticonvulsants Sodium Channel Agents

PHILITH TAB 0.4-35 On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Sex


PHOSPHOLINE SOL

0.125%OP On formulary, tier change tier 3 to tier 4 Ophthalmic Agents


Agents

PHYSIOLYTE SOL Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous

PHYSIOSOL SOL

IRRIGAT Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous

PICATO GEL 0.015%


limit may apply 3 tubes per 30 days Dermatological Agents Dermatological Agents

PICATO GEL 0.05%


limit may apply 2 tubes per 30 days Dermatological Agents Dermatological Agents

PINDOLOL TAB 10MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Agents

PINDOLOL TAB 5MG On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Agents

PIOGLIT/GLIM TAB 30-


Antihypertensive

Combinations


2MG



Antihypertensive

Combinations

Pg. 248 of 331






4MG



PIOGLITA/MET TAB 15-



500MG






850MG



PIOGLITAZONE TAB


PIOGLITAZONE TAB

15MG



PIOGLITAZONE TAB


PIOGLITAZONE TAB

30MG



PIOGLITAZONE TAB


PIOGLITAZONE TAB

45MG



PIROXICAM CAP

10MG



Nonsteroidal Anti-

inflammatory Drugs

PIROXICAM CAP


Nonsteroidal Anti-

inflammatory Drugs

PIROXICAM CAP

20MG



Nonsteroidal Anti-

inflammatory Drugs

Pg. 249 of 331



PLASMA-LYTE INJ -148 Not on 2017 formulary lactated ringers inj



Electrolyte/Mineral

Replacement

PLASMA-LYTE INJ

56/D5W Not on 2017 formulary D5W/lactated ringers inj



Electrolyte/Mineral

Replacement

PODOFILOX SOL 0.5% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents

POLY-DEX OIN 0.1%

OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

POMALYST CAP 1MG



POMALYST CAP 1MG





POMALYST CAP 2MG



POMALYST CAP 2MG





POMALYST CAP 3MG



POMALYST CAP 3MG





POMALYST CAP 4MG



Pg. 250 of 331



POMALYST CAP 4MG





POT CHLORIDE INJ

10MEQ Not on 2017 formulary

potassium chloride inj 2

mEq/mL



Electrolyte/Mineral

Replacement

POT CHLORIDE INJ

20MEQ Not on 2017 formulary

potassium chloride inj 2

mEq/mL



Electrolyte/Mineral

Replacement

POT CHLORIDE TAB

10MEQ CR On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

POT CHLORIDE TAB




Electrolyte/Mineral

Replacement

POT CHLORIDE TAB




Electrolyte/Mineral

Replacement

POT CHLORIDE TAB

8MEQ SR On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

POT CL MICRO TAB

10MEQ CR On formulary, tier change tier 1 to tier 2



Electrolyte/Mineral

Replacement

POT CL MICRO TAB




Electrolyte/Mineral

Replacement

POTIGA TAB 200MG On formulary, tier change tier 3 to tier 4 Anticonvulsants Anticonvulsants, Other




PRADAXA CAP 75MG





PRANDIMET TAB 1-


repaglinide tablets used in

combination with


Pg. 251 of 331



PRANDIMET TAB 2-



combination with


PRAVASTATIN TAB




PRAVASTATIN TAB

10MG





PRAVASTATIN TAB




PRAVASTATIN TAB

20MG





PRAVASTATIN TAB




PRAVASTATIN TAB

40MG





PRAVASTATIN TAB




PRAVASTATIN TAB

80MG





PRAZOSIN HCL CAP



Agents

PRAZOSIN HCL CAP



Agents

PRAZOSIN HCL CAP



Agents

PRED SOD PHO SOL 1%

OP Not on 2017 formulary

dexamethasone drops,

Lotemax, Durezol,

fluorometholone drops,

prednisolone suspension

1% drops Ophthalmic Agents

Ophthalmic Anti-

inflammatories

Pg. 252 of 331



PRED SOD PHO SOL

5MG/5ML



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNICARBAT CRE


PREDNICARBAT OIN


PREDNISOLONE SOL

15MG/5ML



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISOLONE SOL


prednisolone solution

(15mg/5mL, 5mg/mL),

prednisolone syrup

15mg/5mL

Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISOLONE SYP

15MG/5ML



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISOLONE TAB



(15mg/5mL, 5mg/mL),

prednisolone syrup

15mg/5mL

Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISOLONE TAB

10MG ODT



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISOLONE TAB



(15mg/5mL, 5mg/mL),

prednisolone syrup

15mg/5mL

Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISOLONE TAB

15MG ODT



Hormonal Agents,


Modifying (Adrenal)


orticoids

Pg. 253 of 331



PREDNISOLONE TAB



(15mg/5mL, 5mg/mL),

prednisolone syrup

15mg/5mL

Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISOLONE TAB

30MG ODT



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISONE SOL

5MG/5ML On formulary, tier change tier 2 to tier 4

Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISONE SOL

5MG/5ML



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISONE TAB

10MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISONE TAB

1MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISONE TAB

2.5MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISONE TAB

20MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISONE TAB


Hormonal Agents,


Modifying (Adrenal)


orticoids

PREDNISONE TAB

50MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

Pg. 254 of 331



PREDNISONE TAB

5MG



Hormonal Agents,


Modifying (Adrenal)


orticoids

PREGNYL INJ

10000UNT



Hormonal Agents,



Hormonal Agents,



PREMARIN INJ 25MG Not on 2017 formulary check with your doctor

Hormonal Agents,


Modifying (Sex


PREMARIN TAB


Hormonal Agents,


Modifying (Sex


PREMARIN TAB


Hormonal Agents,


Modifying (Sex


PREMARIN TAB


Hormonal Agents,


Modifying (Sex


PREMARIN TAB


Hormonal Agents,


Modifying (Sex


PREMARIN TAB


Hormonal Agents,


Modifying (Sex


Pg. 255 of 331



PREMASOL SOL 6% On formulary, tier change tier 1 to tier 2



PREMPHASE TAB On formulary, tier change tier 3 to tier 4

Hormonal Agents,


Modifying (Sex


PREMPRO TAB .625-

2.5 On formulary, tier change tier 3 to tier 4

Hormonal Agents,


Modifying (Sex


PREMPRO TAB 0.3-


Hormonal Agents,


Modifying (Sex


PREMPRO TAB 0.45-


Hormonal Agents,


Modifying (Sex


PREMPRO TAB 0.625-

5 On formulary, tier change tier 3 to tier 4

Hormonal Agents,


Modifying (Sex


PRENATAL TAB 27-

1MG Not on 2017 formulary check with your doctor


Minerals/ Electrolytes Vitamins

PREP PADS PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

PREPLUS TAB 27-

1MG Not on 2017 formulary check with your doctor



Pg. 256 of 331



PREPOPIK PAK Not on 2017 formulary

Suprep, PEG-3350,

Gavilyte-N, Gavilyte-G,

Gavilyte-C, Trilyte,

Moviprep Gastrointestinal Agents Laxatives

PREZISTA SUS



Inhibitors

PREZISTA SUS

100MG/ML




Inhibitors

PREZISTA TAB

150MG On formulary, tier change tier 3 to tier 4 Antivirals


Inhibitors

PREZISTA TAB

150MG




Inhibitors

PREZISTA TAB

600MG




Inhibitors

PREZISTA TAB 75MG




Inhibitors

PREZISTA TAB

800MG




Inhibitors

PRISTIQ TAB 100MG




Reuptake Inhibitors

PRISTIQ TAB 25MG




Reuptake Inhibitors

PRISTIQ TAB 50MG




Reuptake Inhibitors

Pg. 257 of 331



PRIVIGEN INJ

20GRAMS Not on 2017 formulary





form, please visit



on the back of your



Immunizing Agents,

Passive

PRO COMFORT PAD


PROAIR HFA AER



Bronchodilators,

Sympathomimetic

PROCAINAMIDE INJ





PROCALAMINE INJ 3% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



PROCRIT INJ




PROCRIT INJ




PROCYSBI CAP 25MG Not on 2017 formulary Cystagon Genitourinary Agents


Other

PROCYSBI CAP 75MG Not on 2017 formulary Cystagon Genitourinary Agents


Other

Pg. 258 of 331



PROGLYCEM SUS

50MG/ML On formulary, tier change tier 3 to tier 4 Blood Glucose Regulators Glycemic Agents

PROLASTIN-C INJ

1000MG




Other

PROLIA SOL

60MG/ML




Agents


Agents

PROMACTA TAB

12.5MG





PROMACTA TAB

25MG





PROMACTA TAB

50MG





PROMACTA TAB

75MG





PROMETHAZINE INJ

25MG/ML Not on 2017 formulary check with your doctor Respiratory Tract Agents Antihistamines

PROMETHAZINE INJ

50MG/ML Not on 2017 formulary check with your doctor Respiratory Tract Agents Antihistamines

PROMETHAZINE SOL

6.25/5ML On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines

PROMETHAZINE SUP


PROMETHAZINE SUP

12.5MG



PROMETHAZINE SUP


PROMETHAZINE SYP

6.25/5ML On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines

PROMETHAZINE TAB


Pg. 259 of 331



PROMETHAZINE TAB

25MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines

PROMETHAZINE TAB

50MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents Antihistamines

PROMETHEGAN SUP


PROMETHEGAN SUP

12.5MG



PROMETHEGAN SUP


PROPRAN/HCTZ TAB



in combination with


Antihypertensive

Combinations

PROPRAN/HCTZ TAB



in combination with


Antihypertensive

Combinations

PROPRANOLOL INJ

1MG/ML On formulary, tier change tier 1 to tier 2 Cardiovascular Agents


Agents

PROPRANOLOL SOL


propranolol IR tablets and

ER capsules (60mg,

80mg, 120mg, 160mg) Cardiovascular Agents


Agents

PROPRANOLOL SOL


propranolol IR tablets and

ER capsules (60mg,

80mg, 120mg, 160mg) Cardiovascular Agents


Agents

PROPRANOLOL TAB



Agents

PROPRANOLOL TAB



Agents

PROPRANOLOL TAB



Agents

Pg. 260 of 331



PROPRANOLOL TAB



Agents

PROSOL INJ 20% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



PULMICORT INH


Arnuity Ellipta, Flovent

(Diskus, HFA), Asmanex

(HFA, Twisthaler), Qvar Respiratory Tract Agents



PULMICORT INH


Arnuity Ellipta, Flovent

(Diskus, HFA), Asmanex

(HFA, Twisthaler), Qvar Respiratory Tract Agents



PULMICORT SUS

0.25MG/2





PULMICORT SUS

0.5MG/2





PULMICORT SUS


budesonide 1 mg/2 mL

suspension* *This drug

requires prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Respiratory Tract Agents



PULMICORT SUS

1MG/2ML





Pg. 261 of 331



PURIXAN SUS

20MG/ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antimetabolites

QC ALCOHOL PAD


QNAPRIL/HCTZ TAB 10-


Antihypertensive

Combinations



Antihypertensive

Combinations



Antihypertensive

Combinations

QUDEXY XR CAP

100/24HR Not on 2017 formulary




tablets Anticonvulsants

Glutamate Reducing

Agents

QUDEXY XR CAP






Glutamate Reducing

Agents

QUDEXY XR CAP






Glutamate Reducing

Agents

QUDEXY XR CAP






Glutamate Reducing

Agents

QUDEXY XR CAP






Glutamate Reducing

Agents

Pg. 262 of 331



QUETIAPINE TAB

100MG



QUETIAPINE TAB

100MG





QUETIAPINE TAB

200MG



QUETIAPINE TAB

200MG





QUETIAPINE TAB

25MG



QUETIAPINE TAB

25MG





QUETIAPINE TAB

300MG



QUETIAPINE TAB

300MG





QUETIAPINE TAB

400MG



QUETIAPINE TAB

400MG





Pg. 263 of 331



QUETIAPINE TAB

50MG



QUETIAPINE TAB

50MG





QUINAPRIL TAB 10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents












QUINIDINE SU TAB

200MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents Antiarrhythmics

QUINIDINE SU TAB

300MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents Antiarrhythmics

QUININE SULF CAP

324MG Not on 2017 formulary check with your doctor Antiparasitics Antiprotozoals

QVAR AER 40MCG





QVAR AER 80MCG





RA ALCOHOL PAD


RA PEN NEEDL MIS


RA STERILE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

Pg. 264 of 331



RABAVERT INJ



RAMIPRIL CAP




RAMIPRIL CAP 10MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents



RAMIPRIL CAP 2.5MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents



RAMIPRIL CAP 5MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents



RANITIDINE INJ


ranitidine (tablets,

capsules) Gastrointestinal Agents


Antagonists

RANITIDINE INJ


ranitidine (tablets,

capsules) Gastrointestinal Agents


Antagonists

RAPAFLO CAP 4MG



Benign Prostatic

Hypertrophy Agents

RAPAFLO CAP 8MG



Benign Prostatic

Hypertrophy Agents

RAPAMUNE SOL

1MG/ML On formulary, tier change tier 3 to tier 5 Immunological Agents Immune Suppressants

RAVICTI LIQ

1.1GM/ML Not on 2017 formulary Buphenyl 500mg tablet

Enzyme Replacement/

Modifiers

Enzyme Replacement/

Modifiers

REALITY SWAB PAD On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

REGRANEX GEL

0.01%


prior authorization check with your doctor Dermatological Agents Dermatological Agents

REGRANEX GEL

0.01%


limit may apply 15 grams per 30 days Dermatological Agents Dermatological Agents

RELENZA MIS

DISKHALE Not on 2017 formulary Tamiflu Antivirals Anti-influenza Agents

Pg. 265 of 331



RELION PEN MIS


RELION PEN MIS


RELION PEN MIS


RELION PEN MIS


RELISTOR INJ

12/0.6ML




Other

RELPAX TAB 20MG Not on 2017 formulary



mg, 5 mg ODT, 10 mg




mL, 6 mg/0.5 mL),


mg, 50 mg, 100 mg) Antimigraine Agents

Serotonin (5-HT) 1b/1d

Receptor Agonists

RELPAX TAB 40MG Not on 2017 formulary



mg, 5 mg ODT, 10 mg




mL, 6 mg/0.5 mL),


mg, 50 mg, 100 mg) Antimigraine Agents


Receptor Agonists

RENVELA PAK 0.8GM On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders

Pg. 266 of 331



RENVELA PAK 2.4GM On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders

RENVELA TAB

800MG On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders

REPAGLINIDE TAB


REPAGLINIDE TAB

0.5MG



REPAGLINIDE TAB 1-



combination with


REPAGLINIDE TAB 1MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents

REPAGLINIDE TAB 1MG



REPAGLINIDE TAB 2-



combination with


REPAGLINIDE TAB 2MG On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents

REPAGLINIDE TAB 2MG



RESCRIPTOR TAB 100

MG On formulary, tier change tier 3 to tier 4 Antivirals


nucleoside Reverse


RESCRIPTOR TAB 100

MG




nucleoside Reverse


RESCRIPTOR TAB



nucleoside Reverse


Pg. 267 of 331



RESCRIPTOR TAB

200MG




nucleoside Reverse


RESERPINE TAB





benazepril), an ARB




channel blocker




Other

RESTASIS EMU 0.05% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents Ophthalmic Agents, Other

RESTASIS EMU 0.05%


prior authorization check with your doctor Ophthalmic Agents Ophthalmic Agents, Other

RESTASIS EMU 0.05%


limit may apply 60 vials per 30 days Ophthalmic Agents Ophthalmic Agents, Other

REVLIMID CAP 10MG


limit may apply 30 capsules per 30 days Antineoplastics Antiangiogenic Agents

REVLIMID CAP 10MG




refill check with your doctor Antineoplastics Antiangiogenic Agents

REVLIMID CAP 15MG



REVLIMID CAP 15MG





Pg. 268 of 331



REVLIMID CAP 2.5MG



REVLIMID CAP 2.5MG





REVLIMID CAP 20MG



REVLIMID CAP 20MG





REVLIMID CAP 25MG



REVLIMID CAP 25MG





REVLIMID CAP 5MG



REVLIMID CAP 5MG





REYATAZ CAP

150MG




Inhibitors

REYATAZ CAP

200MG




Inhibitors

REYATAZ CAP

300MG




Inhibitors

Pg. 269 of 331



REYATAZ POW

50MG


limit may apply 240 packets per 30 days Antivirals


Inhibitors

RHEUMATREX TAB

2.5MG Not on 2017 formulary methotrexate tablet Antineoplastics Antineoplastics

RIBAPAK PAK

1000/DAY Not on 2017 formulary

ribavirin tablet and

capsule, Ribasphere

tablet, Ribapak (800/day

and 1200/day) Antivirals Antihepatitis Agents

RIBASPHERE TAB

400MG On formulary, tier change tier 2 to tier 4 Antivirals Antihepatitis Agents

RIFAMPIN CAP

150MG On formulary, tier change tier 1 to tier 2 Antimycobacterials Antituberculars

RIFAMPIN INJ 600 MG On formulary, tier change tier 1 to tier 2 Antimycobacterials Antituberculars

RIFATER TAB Not on 2017 formulary

isoniazid tablets in

combination with rifampin

capsules Antimycobacterials Antituberculars

RIMANTADINE TAB

100MG On formulary, tier change tier 1 to tier 2 Antivirals Anti-influenza Agents

RINGERS INJ Not on 2017 formulary lactated ringers inj



Electrolyte/Mineral

Replacement

RINGERS IRR SOL Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous

RIOMET SOL Not on 2017 formulary


ER (500 mg, 750 mg

[generic Glucophage XR]) Blood Glucose Regulators Antidiabetic Agents

RIOMET SOL



ER (500 mg, 750 mg

[generic Glucophage XR]) Blood Glucose Regulators Antidiabetic Agents

RISEDRON SOD TAB

35MG DR




Agents


Agents

Pg. 270 of 331



RISEDRONATE TAB

150MG


limit may apply 1 tablet per 28 days


Agents


Agents

RISPERDAL INJ

12.5MG



RISPERDAL INJ

12.5MG





RISPERDAL INJ 25MG



RISPERDAL INJ 25MG





RISPERDAL INJ

37.5MG



RISPERDAL INJ

37.5MG





RISPERDAL INJ 50MG



RISPERDAL INJ 50MG





RISPERIDONE SOL

1MG/ML


limit may apply 480 mls per 30 days Antipsychotics 2nd Generation/Atypical

Pg. 271 of 331



RISPERIDONE SOL

1MG/ML





RISPERIDONE TAB 0.25

ODT



RISPERIDONE TAB 0.25

ODT





RISPERIDONE TAB

0.25MG



RISPERIDONE TAB

0.25MG





RISPERIDONE TAB

0.5MG



RISPERIDONE TAB

0.5MG





RISPERIDONE TAB

0.5MG OD



RISPERIDONE TAB

0.5MG OD





RISPERIDONE TAB

1MG



Pg. 272 of 331



RISPERIDONE TAB

1MG





RISPERIDONE TAB

1MG ODT



RISPERIDONE TAB

1MG ODT





RISPERIDONE TAB

2MG



RISPERIDONE TAB

2MG





RISPERIDONE TAB

2MG ODT



RISPERIDONE TAB

2MG ODT





RISPERIDONE TAB

3MG



RISPERIDONE TAB

3MG





RISPERIDONE TAB

3MG ODT



Pg. 273 of 331



RISPERIDONE TAB

3MG ODT





RISPERIDONE TAB

4MG



RISPERIDONE TAB

4MG





RISPERIDONE TAB

4MG ODT



RISPERIDONE TAB

4MG ODT





RITUXAN INJ 100MG On formulary, tier change tier 3 to tier 5 Antineoplastics Antineoplastics

RITUXAN INJ 100MG





RITUXAN INJ 500MG On formulary, tier change tier 3 to tier 5 Antineoplastics Antineoplastics

RITUXAN INJ 500MG





ROMYCIN OIN OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives

ROSUVASTATIN TAB




ROSUVASTATIN TAB




Pg. 274 of 331



ROSUVASTATIN TAB




ROSUVASTATIN TAB




ROTATEQ SOL On formulary, tier change tier 3 to tier 4 Immunological Agents Vaccines

ROXICET TAB 5-

325MG




acting

ROZEREM TAB 8MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents

GABA Receptor

Modulators

SAIZEN INJ 5MG Not on 2017 formulary


requires prior

authorization. To


form, please visit



on the back of your


information.

Hormonal Agents,



Hormonal Agents,



SAIZEN INJ 8.8MG Not on 2017 formulary


requires prior

authorization. To


form, please visit



on the back of your


information.

Hormonal Agents,



Hormonal Agents,



Pg. 275 of 331



SANCUSO DIS 3.1MG Not on 2017 formulary

granisetron tablets*,

ondansetron (ODT,

tablets, solution)* *These

drugs require a prior

authorization. To


form, please visit



on the back of your


information. Antiemetics

Emetogenic Therapy

Adjuncts

SANDIMMUNE CAP


cyclosporine 100 mg


requires prior

authorization. To


form, please visit

www.MyPrime.com or




Pg. 276 of 331



SANDIMMUNE CAP


cyclosporine 25 mg


requires prior

authorization. To


form, please visit

www.MyPrime.com or




SANDOSTATIN KIT LAR


Somatuline inj*,

Octreotide inj*, Signifor

inj*, Signifor LAR inj*


authorization. To


form, please visit

www.MyPrime.com or




Hormonal Agents,


Hormonal Agents,


Pg. 277 of 331



SANDOSTATIN KIT LAR


Somatuline inj*,




authorization. To


form, please visit

www.MyPrime.com or




Hormonal Agents,


Hormonal Agents,


SANDOSTATIN KIT LAR


Somatuline inj*,




authorization. To


form, please visit

www.MyPrime.com or




Hormonal Agents,


Hormonal Agents,


SAPHRIS SUB 10MG



SAPHRIS SUB 10MG





Pg. 278 of 331



SAPHRIS SUB 2.5MG



SAPHRIS SUB 2.5MG





SAPHRIS SUB 5MG



SAPHRIS SUB 5MG





SAPS CARE PAD


SAVELLA MIS TITR

PAK Not on 2017 formulary

gabapentin, Lyrica,



duloxetine capsules

(20mg, 30mg, 60mg),



150mg ),and ER capsule


Agents Fibromyalgia Agents

SAVELLA TAB 100MG Not on 2017 formulary

gabapentin, Lyrica,



duloxetine capsules

(20mg, 30mg, 60mg),






Pg. 279 of 331



SAVELLA TAB


gabapentin, Lyrica,



duloxetine capsules

(20mg, 30mg, 60mg),







gabapentin, Lyrica,



duloxetine capsules

(20mg, 30mg, 60mg),







gabapentin, Lyrica,



duloxetine capsules

(20mg, 30mg, 60mg),






SB ALCOHOL PAD

PREP On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

SECONAL CAP


SECONAL SOD CAP


Pg. 280 of 331



SELENIUM SUL LOT


SELZENTRY TAB

150MG



SELZENTRY TAB

300MG



SENSIPAR TAB 30MG



Hormonal Agents,

Suppressant (Parathyroid)

Hormonal Agents,


SENSIPAR TAB 60MG



Hormonal Agents,


Hormonal Agents,


SENSIPAR TAB 90MG



Hormonal Agents,


Hormonal Agents,


SEREVENT DIS AER

50MCG



Bronchodilators,

Sympathomimetic

SEROQUEL XR TAB


SEROQUEL XR TAB

150MG



SEROQUEL XR TAB

150MG





SEROQUEL XR TAB


SEROQUEL XR TAB

200MG



Pg. 281 of 331



SEROQUEL XR TAB

200MG





SEROQUEL XR TAB


SEROQUEL XR TAB

300MG



SEROQUEL XR TAB

300MG





SEROQUEL XR TAB


SEROQUEL XR TAB

400MG



SEROQUEL XR TAB

400MG





SEROQUEL XR TAB


SEROQUEL XR TAB

50MG



SEROQUEL XR TAB

50MG





SERTRALINE CON

20MG/ML




Reuptake Inhibitors

Pg. 282 of 331



SERTRALINE TAB

100MG




Reuptake Inhibitors

SERTRALINE TAB

25MG




Reuptake Inhibitors

SERTRALINE TAB

50MG




Reuptake Inhibitors

SIGNIFOR INJ

0.3MG/ML On formulary, tier change tier 4 to tier 5

Hormonal Agents,


Hormonal Agents,


SIGNIFOR INJ

0.3MG/ML



Hormonal Agents,


Hormonal Agents,


SIGNIFOR INJ


Hormonal Agents,


Hormonal Agents,


SIGNIFOR INJ

0.6MG/ML



Hormonal Agents,


Hormonal Agents,


SIGNIFOR INJ


Hormonal Agents,


Hormonal Agents,


SIGNIFOR INJ

0.9MG/ML



Hormonal Agents,


Hormonal Agents,


SILDENAFIL INJ Not on 2017 formulary

sildenafil tablets* *This

drug requires a prior

authorization. To


form, please visit



on the back of your



Pulmonary

Antihypertensives

SILDENAFIL TAB 20MG



Pulmonary

Antihypertensives

SILVER SULFA CRE 1% On formulary, tier change tier 1 to tier 2 Antibacterials Sulfonamides

Pg. 283 of 331



SIMPONI INJ






form, please visit



on the back of your



SIMPONI INJ






form, please visit



on the back of your



Pg. 284 of 331



SIMPONI INJ

50/0.5ML Not on 2017 formulary





form, please visit



on the back of your



SIMPONI INJ

50/0.5ML Not on 2017 formulary





form, please visit



on the back of your



Pg. 285 of 331



SIMPONI ARIA SOL






form, please visit



on the back of your



SIMULECT INJ 10MG



SIMULECT INJ 20MG



SIMVASTATIN TAB




SIMVASTATIN TAB

10MG





SIMVASTATIN TAB




SIMVASTATIN TAB

20MG





SIMVASTATIN TAB




SIMVASTATIN TAB

40MG





SIMVASTATIN TAB 5MG On formulary, tier change tier 2 to tier 6 Cardiovascular Agents



SIMVASTATIN TAB 5MG





Pg. 286 of 331



SIMVASTATIN TAB




SIMVASTATIN TAB

80MG





SIROLIMUS TAB 2MG On formulary, tier change tier 2 to tier 5 Immunological Agents Immune Suppressants

SM ALCOHOL PAD

PREP On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

SM GAUZE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

SM STERILE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

SMZ-TMP INJ 400-

80/5 On formulary, tier change tier 2 to tier 4 Antibacterials Sulfonamides

SMZ-TMP SUS 200-


SOD CHLORIDE INJ

2.5/ML Not on 2017 formulary check with your doctor



Electrolyte/Mineral

Replacement

SOD CHLORIDE INJ 3% Not on 2017 formulary check with your doctor



Electrolyte/Mineral

Replacement

SOD CHLORIDE INJ 5% Not on 2017 formulary check with your doctor



Electrolyte/Mineral

Replacement

SOD FLUORIDE TAB

1MG F Not on 2017 formulary check with your doctor



SOD LACTATE INJ

5MEQ/ML Not on 2017 formulary check with your doctor



Electrolyte/Mineral

Replacement

SOD SULFACET SOL

10% OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives

SOMATULINE INJ

120/.5ML




refill check with your doctor

Hormonal Agents,


Hormonal Agents,


Pg. 287 of 331



SOMATULINE INJ

60/0.2ML





Hormonal Agents,


Hormonal Agents,


SOMATULINE INJ

90/0.3ML





Hormonal Agents,


Hormonal Agents,


SOMAVERT INJ 10MG



Hormonal Agents,


Hormonal Agents,


SOMAVERT INJ 15MG



Hormonal Agents,


Hormonal Agents,


SOMAVERT INJ 20MG



Hormonal Agents,


Hormonal Agents,


SPIRIVA CAP

HANDIHLR



Bronchodilators,

Anticholinergic

SPIRIVA SPR 2.5MCG



Bronchodilators,

Anticholinergic

SPRYCEL TAB

100MG



SPRYCEL TAB

100MG





SPRYCEL TAB

140MG



SPRYCEL TAB

140MG





Pg. 288 of 331



SPRYCEL TAB 20MG



SPRYCEL TAB 20MG





SPRYCEL TAB 50MG



SPRYCEL TAB 50MG





SPRYCEL TAB 70MG



SPRYCEL TAB 70MG





SPRYCEL TAB 80MG



SPRYCEL TAB 80MG





SSD CRE 1% On formulary, tier change tier 1 to tier 2 Antibacterials Sulfonamides

STAVUDINE CAP

15MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


Pg. 289 of 331



STAVUDINE CAP

20MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


STAVUDINE CAP

30MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


STAVUDINE CAP

40MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


STAVUDINE SOL

1MG/ML


limit may apply 2400 mls per 30 days Respiratory Tract Agents Antihistamines

STELARA INJ

45MG/0.5



STERILE PAD 2"X2" On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

STERILE GAUZ PAD


STIVARGA TAB 40MG



STRATTERA CAP



Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP

100MG




Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 290 of 331



STRATTERA CAP



Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP

10MG




Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP



Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP

18MG




Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP



Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP

25MG




Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP



Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 291 of 331



STRATTERA CAP

40MG




Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP



Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP

60MG




Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP



Agents

Attention Deficit


Agents, Non-

amphetamines

STRATTERA CAP

80MG




Agents

Attention Deficit


Agents, Non-

amphetamines

STREPTOMYCIN INJ

1GM On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides

STRIBILD TAB



SUBOXONE MIS 12-




SUBOXONE MIS 12-

3MG





SUBOXONE MIS 2-




Pg. 292 of 331



SUBOXONE MIS 2-

0.5MG





SUBOXONE MIS 4-




SUBOXONE MIS 4-

1MG





SUBOXONE MIS 8-




SUBOXONE MIS 8-

2MG





SULF/PRED NA SOL OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

SULFACET SOD SOL

10% OP On formulary, tier change tier 1 to tier 2 Ophthalmic Agents Ophthalmic Anti Infectives

SULFADIAZINE TAB

500MG On formulary, tier change tier 2 to tier 4 Antibacterials Sulfonamides

SULFATRIM PD SUS 200-


SULINDAC TAB

150MG



Nonsteroidal Anti-

inflammatory Drugs

SULINDAC TAB

200MG



Nonsteroidal Anti-

inflammatory Drugs

SUMATRIPTAN TAB

100MG


limit may apply 18 tablets per 30 days Antimigraine Agents


Receptor Agonists

SUMATRIPTAN TAB

25MG




Receptor Agonists

SUMATRIPTAN TAB

50MG




Receptor Agonists

SUPRAX SUS


Suprax 400 mg capsules,

Suprax chewable tablets

(100 mg, 200 mg) Antibacterials

Beta-lactam,

Cephalosporins

Pg. 293 of 331



SURE COMFORT MIS


SURE COMFORT MIS


SURE COMFORT MIS


SURE COMFORT MIS


SURE COMFORT MIS


SURE COMFORT MIS


SURE-FINE MIS


SURE-FINE MIS


SURE-FINE MIS


SURMONTIL CAP




duloxetine capsules

(20mg, 30mg, 60mg),



150mg ), and ER



Pg. 294 of 331



SURMONTIL CAP




duloxetine capsules

(20mg, 30mg, 60mg),



150mg ), and ER



SURMONTIL CAP




duloxetine capsules

(20mg, 30mg, 60mg),



150mg ), and ER



SUSTIVA CAP 200MG On formulary, tier change tier 3 to tier 5 Antivirals


nucleoside Reverse


SUSTIVA CAP 200MG




nucleoside Reverse


SUSTIVA CAP 50MG On formulary, tier change tier 3 to tier 4 Antivirals


nucleoside Reverse


SUSTIVA CAP 50MG




nucleoside Reverse


Pg. 295 of 331



SUSTIVA TAB 600MG On formulary, tier change tier 3 to tier 5 Antivirals


nucleoside Reverse


SUSTIVA TAB 600MG




nucleoside Reverse


SUTENT CAP

12.5MG



SUTENT CAP

12.5MG





SUTENT CAP 25MG



SUTENT CAP 25MG





SUTENT CAP

37.5MG



SUTENT CAP

37.5MG





SUTENT CAP 50MG



SUTENT CAP 50MG





Pg. 296 of 331



SYLATRON KIT

200MCG





SYLATRON KIT

300MCG





SYLATRON KIT

600MCG





SYMBICORT AER 160-

4.5



Bronchodilators,

Sympathomimetic

SYMBICORT AER 80-

4.5



Bronchodilators,

Sympathomimetic

SYNAGIS INJ 50MG On formulary, tier change tier 3 to tier 5 Immunological Agents

Immunizing Agents,

Passive

SYNERCID INJ 500MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other

SYPRINE CAP 250MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antiangiogenic Agents

TAFINLAR CAP 50MG



TAFINLAR CAP 50MG





TAFINLAR CAP 75MG



Pg. 297 of 331



TAFINLAR CAP 75MG





TAMOXIFEN TAB


TAMOXIFEN TAB


TAMSULOSIN CAP

0.4MG



Benign Prostatic

Hypertrophy Agents

TARCEVA TAB

100MG



TARCEVA TAB

100MG





TARCEVA TAB

150MG



TARCEVA TAB

150MG





TARCEVA TAB 25MG



TARCEVA TAB 25MG





Pg. 298 of 331



TARGRETIN CAP


bexarotene 75mg capsule

* *This drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




TASIGNA CAP 150MG



TASIGNA CAP 150MG





TASIGNA CAP 200MG



TASIGNA CAP 200MG





TAXOTERE INJ

20MG/ML Not on 2017 formulary docetaxel inj 20 mg/mL Antineoplastics Antineoplastics

TAXOTERE INJ


docetaxel inj 80 mg/4 mL

(20 mg/mL) Antineoplastics Antineoplastics

TECFIDERA CAP

120MG





TECFIDERA CAP

120MG





Pg. 299 of 331



TECFIDERA CAP

240MG





TECFIDERA CAP

240MG





TECFIDERA MIS

STARTER





TECFIDERA MIS

STARTER





TEFLARO INJ 400MG On formulary, tier change tier 4 to tier 5 Antibacterials

Beta-lactam,

Cephalosporins

TEFLARO INJ 600MG On formulary, tier change tier 4 to tier 5 Antibacterials

Beta-lactam,

Cephalosporins

TEGRETOL-XR TAB


carbamazepine ER 100

mg tablets Anticonvulsants Sodium Channel Agents

TEKTURNA TAB

150MG




Other

TEKTURNA TAB

300MG




Other

TELMIS/AMLOD TAB 40-


amlodipine in

combination with


Antihypertensive

Combinations



amlodipine in

combination with


Antihypertensive

Combinations



amlodipine in

combination with


Antihypertensive

Combinations



amlodipine in

combination with


Antihypertensive

Combinations

Pg. 300 of 331



TELMISA/HCTZ TAB 40-


Antihypertensive

Combinations


12.5



Antihypertensive

Combinations



Antihypertensive

Combinations


12.5



Antihypertensive

Combinations



Antihypertensive

Combinations


25MG



Antihypertensive

Combinations

TELMISARTAN TAB



Antagonists

TELMISARTAN TAB

20MG




Antagonists

TELMISARTAN TAB



Antagonists

TELMISARTAN TAB

40MG




Antagonists

TELMISARTAN TAB



Antagonists

TELMISARTAN TAB

80MG




Antagonists

TEMAZEPAM CAP


TEMAZEPAM CAP

22.5MG Not on 2017 formulary trazodone, Silenor Sleep Disorder Agents Benzodiazepines

TEMAZEPAM CAP


Pg. 301 of 331



TEMAZEPAM CAP


TERAZOSIN CAP

10MG




Agents

TERAZOSIN CAP 1MG




Agents

TERAZOSIN CAP 2MG




Agents

TERAZOSIN CAP 5MG




Agents

TERBUTALINE INJ

1MG/ML Not on 2017 formulary terbutaline tablets Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

TERCONAZOLE SUP

80MG On formulary, tier change tier 1 to tier 2 Genitourinary Agents Vaginal Products

TESTOST CYP INJ

100MG/ML



Hormonal Agents,


Modifying (Sex


TESTOST CYP INJ

200MG/ML



Hormonal Agents,


Modifying (Sex


TESTOST ENAN INJ

200MG/ML



Hormonal Agents,


Modifying (Sex


TESTOSTERONE GEL

1%(25MG)



Hormonal Agents,


Modifying (Sex


Pg. 302 of 331



TESTOSTERONE GEL

1%(25MG)


limit may apply 90 packets per 30 days

Hormonal Agents,


Modifying (Sex


TESTOSTERONE GEL

1%(50MG)



Hormonal Agents,


Modifying (Sex


TESTOSTERONE GEL

1%(50MG)


limit may apply 60 packets per 30 days

Hormonal Agents,


Modifying (Sex


TESTOSTERONE GEL

PUMP 1%



Hormonal Agents,


Modifying (Sex


TESTOSTERONE GEL

PUMP 1%


limit may apply

4 pump bottles per 30

days

Hormonal Agents,


Modifying (Sex


TESTRED CAP 10MG Not on 2017 formulary

methyltestosterone 10 mg


requires prior

authorization. To


form, please visit

www.MyPrime.com or




Hormonal Agents,


Modifying (Sex


Pg. 303 of 331



TETANUS TOX INJ 5LF

ADS



TETRABENAZIN TAB

12.5MG




Agents

Central Nervous System,

Other

TETRABENAZIN TAB

12.5MG




Agents


Other

TETRABENAZIN TAB

25MG




Agents


Other

TETRABENAZIN TAB

25MG




Agents


Other

TEVETEN HCT TAB 600-



hiazide,


zide,


de,


azide,



Antihypertensive

Combinations

THALOMID CAP

100MG



THALOMID CAP

100MG





THALOMID CAP

150MG



Pg. 304 of 331



THALOMID CAP

150MG





THALOMID CAP

200MG



THALOMID CAP

200MG





THALOMID CAP 50MG



THALOMID CAP 50MG





THIORIDAZINE TAB


THIORIDAZINE TAB


THIORIDAZINE TAB


THIORIDAZINE TAB


THIOTHIXENE CAP

10MG





Pg. 305 of 331



THIOTHIXENE CAP

1MG





THIOTHIXENE CAP


THIOTHIXENE CAP

2MG





THIOTHIXENE CAP

5MG





TICLOPIDINE TAB


clopidogrel 75 mg tablet,

Effient



TIER UNI PLS MIS


TIKOSYN CAP

125MCG Not on 2017 formulary dofetilide 125 mcg Cardiovascular Agents Antiarrhythmics

TIKOSYN CAP


TIKOSYN CAP


TIMOLOL MAL TAB



Agents

TIMOLOL MAL TAB



Agents

TIMOLOL MAL TAB 5MG On formulary, tier change tier 1 to tier 4 Cardiovascular Agents


Agents

TIS-U-SOL SOL Not on 2017 formulary sterile water for irrigation Miscellaneous Miscellaneous

Pg. 306 of 331



TIVICAY TAB 10MG



TIVICAY TAB 25MG



TIVICAY TAB 50MG



TOBRADEX OIN 0.3-

0.1% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

TOBRADEX ST SUS 0.3-



e solution,



ointment,





ointment,



Ophthalmic Anti-

inflammatories

TOBRAMYCIN NEB

300/5ML On formulary, tier change tier 2 to tier 5 Antibacterials Aminoglycosides

TOLAZAMIDE TAB




TOLAZAMIDE TAB




TOLBUTAMIDE TAB




TOLMETIN SOD CAP

400MG



Nonsteroidal Anti-

inflammatory Drugs

Pg. 307 of 331



TOLMETIN SOD TAB

600MG Not on 2017 formulary tolmetin 400 mg tablets Anti-inflammatory Agents

Nonsteroidal Anti-

inflammatory Drugs

TOLTERODINE TAB

1MG



TOLTERODINE TAB

2MG



TOPIRAMATE CAP ER






Glutamate Reducing

Agents

TOPIRAMATE CAP ER






Glutamate Reducing

Agents

TOPIRAMATE CAP ER






Glutamate Reducing

Agents

TOPIRAMATE CAP ER






Glutamate Reducing

Agents

TOPIRAMATE CAP ER






Glutamate Reducing

Agents

TOPOTECAN INJ 4MG On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics

TOPOTECAN INJ


TORISEL SOL


Pg. 308 of 331



TPN ELECTROL INJ Not on 2017 formulary lactated ringers inj



Electrolyte/Mineral

Replacement

TRACLEER TAB

125MG



Pulmonary

Antihypertensives

TRACLEER TAB

125MG



Pulmonary

Antihypertensives

TRACLEER TAB

62.5MG



Pulmonary

Antihypertensives

TRACLEER TAB

62.5MG



Pulmonary

Antihypertensives

TRADJENTA TAB 5MG On formulary, tier change tier 3 to tier 4 Blood Glucose Regulators Antidiabetic Agents

TRADJENTA TAB 5MG



TRAMADL/APAP TAB

37.5-325




acting

TRANDOLAPRIL TAB




TRANDOLAPRIL TAB




TRANDOLAPRIL TAB




TRANSDERM-SC DIS

1MG Not on 2017 formulary check with your doctor Antiemetics Antiemetics, Other

TRAVASOL INJ 10% Not on 2017 formulary

Premasol 6%,

Hepatamine 8%,

Aminosyn-HF 8%,


SF 15%



Pg. 309 of 331



TRAVOPROST DRO


latanoprost, Lumigan,

Travatan Z Ophthalmic Agents

Ophthalmic

Prostaglandin and

Prostamide Analogs

TREANDA INJ


TREANDA INJ

45/0.5ML On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

TRETINOIN CAP 10MG On formulary, tier change tier 1 to tier 5 Antineoplastics Antineoplastics

TRETINOIN CAP 10MG





TREXALL TAB 10MG Not on 2017 formulary

methotrexate 2.5 mg

tablet Immunological Agents Immune Suppressants


methotrexate 2.5 mg



methotrexate 2.5 mg


TREXALL TAB 7.5MG Not on 2017 formulary

methotrexate 2.5 mg


TRIAMCINOLON CRE


TRIAMCINOLON CRE


TRIAMCINOLON CRE


TRIAMCINOLON OIN


Pg. 310 of 331



TRIAMT/HCTZ CAP 50-


triamterene/hydrochlorothi

azide (37.5/25mg,

75/50mg) Cardiovascular Agents

Antihypertensive

Combinations

TRIAZOLAM TAB


TRIAZOLAM TAB


TRIBENZOR20- TAB 5-


amlodipine/valsartan/hydr

ochlorothiazide Cardiovascular Agents

Antihypertensive

Combinations

TRIBENZOR40- TAB 10-




Antihypertensive

Combinations

TRIBENZOR40- TAB 10-




Antihypertensive

Combinations

TRIBENZOR40- TAB 5-




Antihypertensive

Combinations

TRIBENZOR40- TAB 5-




Antihypertensive

Combinations

TRIDERM CRE 0.1% On formulary, tier change tier 1 to tier 2 Dermatological Agents Dermatological Agents

TRIFLUOPERAZ TAB

10MG





TRIFLUOPERAZ TAB

1MG





TRIFLUOPERAZ TAB

2MG





Pg. 311 of 331



TRIFLUOPERAZ TAB

5MG





TRIHEXYPHEN ELX


selegiline,

carbidopa/levodopa,

ropinirole, pramipexole,

entacapone Antiparkinson Agents Anticholinergics

TRIHEXYPHEN TAB


selegiline,

carbidopa/levodopa,



TRIHEXYPHEN TAB


selegiline,

carbidopa/levodopa,



TRINTELLIX TAB 10MG



TRINTELLIX TAB 20MG



TRINTELLIX TAB 5MG



TRIUMEQ TAB On formulary, tier change tier 4 to tier 5 Antivirals

Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


TRIUMEQ TAB



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


Pg. 312 of 331



TROKENDI XR CAP






Glutamate Reducing

Agents

TROKENDI XR CAP






Glutamate Reducing

Agents

TROKENDI XR CAP






Glutamate Reducing

Agents

TROKENDI XR CAP






Glutamate Reducing

Agents

TRUVADA TAB 100-

150



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


TRUVADA TAB 133-

200



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


TRUVADA TAB 167-

250



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


Pg. 313 of 331



TRUVADA TAB 200-

300



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


TYBOST TAB 150MG




nucleoside Reverse


TYGACIL INJ 50MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other

TYKERB TAB 250MG



TYKERB TAB 250MG





TYSABRI INJ

300/15ML





TYZINE PED DRO

0.05% Not on 2017 formulary check with your doctor Respiratory Tract Agents Nasal Agents

UCERIS TAB 9MG Not on 2017 formulary

Apriso, Asacol HD,

balsalazide, Delzicol,

Dipentum, Lialda,

Pentasa, sulfasalazine (IR

tablet or delayed-release

tablet)

Hormonal Agents,


Modifying (Adrenal)


orticoids

ULTICARE MIS


ULTICARE MIS


ULTICARE MIS


Pg. 314 of 331



ULTICARE PAD


UNFINE PNTP MIS


UNIFINE PNTP MIS


UNIFINE PNTP MIS


UNIFINE PNTP MIS


UNIFINE PNTP MIS


UNIFINE PNTP MIS


UNIFINE PNTP MIS


UNIFINE PNTP MIS


UNIFINE PNTP MIS


UNIFINE PNTP MIS


UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

Pg. 315 of 331



UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITH DIRECT TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

Pg. 316 of 331



UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

UNITHROID TAB


Hormonal Agents,


Modifying (Thyroid)

Hormonal Agents,


Modifying (Thyroid)

Pg. 317 of 331



URSODIOL TAB

250MG Not on 2017 formulary ursodiol 300 mg capsules Gastrointestinal Agents


Other

URSODIOL TAB

500MG Not on 2017 formulary ursodiol 300 mg capsules Gastrointestinal Agents


Other

VALCHLOR GEL

0.016% On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

VALGANCICLOV TAB


Anti-cytomegalovirus

(CMV) Agents

VALPROATE INJ

100MG/ML On formulary, tier change tier 1 to tier 2 Anticonvulsants

Gamma-aminobutyric


Agents

VALPROATE INJ

500/5ML On formulary, tier change tier 1 to tier 2 Anticonvulsants

Gamma-aminobutyric


Agents

VALSART/HCTZ TAB 160-

12.5 On formulary, tier change tier 2 to tier 6 Blood Glucose Regulators Antidiabetic Agents


12.5





Antihypertensive

Combinations


25MG



Antihypertensive

Combinations



Antihypertensive

Combinations


12.5



Antihypertensive

Combinations



Antihypertensive

Combinations


25MG



Antihypertensive

Combinations

Pg. 318 of 331





Antihypertensive

Combinations


12.5



Antihypertensive

Combinations

VALSARTAN TAB



Antagonists

VALSARTAN TAB

160MG




Antagonists

VALSARTAN TAB



Antagonists

VALSARTAN TAB

320MG




Antagonists

VALSARTAN TAB



Antagonists

VALSARTAN TAB

40MG




Antagonists

VALSARTAN TAB



Antagonists

VALSARTAN TAB

80MG




Antagonists

VANCOMYCIN CAP


VECTIBIX INJ 100MG On formulary, tier change tier 4 to tier 5 Antineoplastics Antineoplastics

VENLAFAXINE CAP

150MG ER




Reuptake Inhibitors

VENLAFAXINE CAP

37.5 ER




Reuptake Inhibitors

VENLAFAXINE CAP

75MG ER




Reuptake Inhibitors

VENLAFAXINE TAB

100MG




Reuptake Inhibitors

Pg. 319 of 331



VENLAFAXINE TAB

150MG ER




Reuptake Inhibitors

VENLAFAXINE TAB






Reuptake Inhibitors

VENLAFAXINE TAB

25MG




Reuptake Inhibitors

VENLAFAXINE TAB 37.5

ER




Reuptake Inhibitors

VENLAFAXINE TAB

37.5MG




Reuptake Inhibitors

VENLAFAXINE TAB

50MG




Reuptake Inhibitors

VENLAFAXINE TAB

75MG




Reuptake Inhibitors

VENLAFAXINE TAB

75MG ER




Reuptake Inhibitors

VENTAVIS SOL

10MCG/ML On formulary, tier change tier 4 to tier 5 Respiratory Tract Agents

Pulmonary

Antihypertensives

VENTAVIS SOL

10MCG/ML



Pulmonary

Antihypertensives

VENTAVIS SOL

10MCG/ML


limit may apply 270 mLs per 30 days Respiratory Tract Agents

Pulmonary

Antihypertensives

VENTAVIS SOL

20MCG/ML On formulary, tier change tier 4 to tier 5 Respiratory Tract Agents

Pulmonary

Antihypertensives

VENTAVIS SOL

20MCG/ML



Pulmonary

Antihypertensives

VENTAVIS SOL

20MCG/ML


limit may apply 270 mLs per 30 days Respiratory Tract Agents

Pulmonary

Antihypertensives

VENTOLIN HFA AER



Bronchodilators,

Sympathomimetic

Pg. 320 of 331



VERAPAMIL INJ

2.5MG/ML Not on 2017 formulary verapamil IR tablet Cardiovascular Agents


Agents

VERDROCET TAB 2.5-



hen (5/300, 7.5/300,

10/300, 5/325, 7.5/325,

10/325) Analgesics


acting

VERIPRED 20 SOL

20MG/5ML



Hormonal Agents,


Modifying (Adrenal)


orticoids

VERSACLOZ SUS

50MG/ML On formulary, tier change tier 4 to tier 5 Antipsychotics Treatment-Resistant

VERSACLOZ SUS

50MG/ML


limit may apply 540 mls per 30 days Antipsychotics Treatment-Resistant

VERSACLOZ SUS

50MG/ML





VESICARE TAB 10MG Not on 2017 formulary







VESICARE TAB 5MG Not on 2017 formulary







VICTOZA INJ

18MG/3ML


limit may apply 1 package per 30 days Blood Glucose Regulators Antidiabetic Agents

Pg. 321 of 331



VIDEX SOL 2GM On formulary, tier change tier 3 to tier 4 Antivirals

Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


VIDEX SOL 2GM



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


VIDEX SOL 4GM On formulary, tier change tier 3 to tier 4 Antivirals

Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


VIDEX SOL 4GM



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


VIIBRYD KIT On formulary, tier change tier 3 to tier 4 Antidepressants Antidepressants, Other

VIIBRYD KIT



VIIBRYD KIT

STARTER On formulary, tier change tier 3 to tier 4 Antidepressants Antidepressants, Other

VIIBRYD KIT

STARTER


limit may apply 1 kit per 30 days Antidepressants Antidepressants, Other

VIIBRYD TAB 10MG On formulary, tier change tier 3 to tier 4 Antidepressants Antidepressants, Other

VIIBRYD TAB 10MG




VIIBRYD TAB 20MG




Pg. 322 of 331



VIIBRYD TAB 40MG



VINBLASTINE INJ


VINCASAR PFS INJ

1MG/ML



VINCRISTINE INJ

1MG/ML



VIRACEPT TAB

250MG




Inhibitors

VIRACEPT TAB

625MG




Inhibitors

VIRAMUNE XR TAB


nevirapine SR 100 mg

tablet Antivirals


nucleoside Reverse


VIRAZOLE INH 6GM On formulary, tier change tier 4 to tier 5 Antivirals Anti-influenza Agents

VIREAD POW

40MG/GM


limit may apply 240 grams per 30 days Antivirals

Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


VIREAD TAB 150MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


VIREAD TAB 200MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


Pg. 323 of 331



VIREAD TAB 250MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


VIREAD TAB 300MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


VOLTAREN GEL 1% Not on 2017 formulary

diclofenac 1% gel* *This

drug requires prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Dermatological Agents Dermatological Agents

VORICONAZOLE INJ

200MG



VORICONAZOLE SUS

40MG/ML



VORICONAZOLE TAB

200MG



VOTRIENT TAB

200MG



VOTRIENT TAB

200MG





VPRIV INJ 400UNIT On formulary, tier change tier 4 to tier 5 Miscellaneous Miscellaneous

Pg. 324 of 331



VRAYLAR CAP 1.5-


Vraylar capsules (1.5 mg,

3 mg, 4.5 mg, 6 mg)*


authorization. To


form, please visit

www.MyPrime.com or




VYFEMLA TAB 0.4-35 On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Sex


WEBCOL PREP PAD

LARGE On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

WEBCOL PREP PAD

MEDIUM On formulary, tier change tier 1 to tier 3 Blood Glucose Regulators Antidiabetic Agents

XALKORI CAP 200MG



XALKORI CAP 250MG



XARELTO TAB 10MG





XARELTO TAB 15MG





XARELTO TAB 20MG





XARELTO STAR TAB

15/20MG





Pg. 325 of 331



XELJANZ TAB 5MG Not on 2017 formulary

methotrexate tablets,

leflunomide Immunological Agents Immune Suppressants

XENAZINE TAB


tetrabenzine 12.5mg*


authorization. To


form, please visit

www.MyPrime.com or





Agents


Other

XENAZINE TAB 25MG Not on 2017 formulary

tetrabenazine 25 mg*


authorization. To


form, please visit

www.MyPrime.com or





Agents


Other

XIFAXAN TAB 550MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other

XOLAIR SOL 150MG




Other

XTANDI CAP 40MG



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XULANE DIS 150-35 Not on 2017 formulary check with your doctor

Hormonal Agents,


Modifying (Sex


XYREM SOL

500MG/ML


prior authorization check with your doctor Sleep Disorder Agents Sleep Disorders, Other

XYREM SOL

500MG/ML


limit may apply 540 mls per 30 days Sleep Disorder Agents Sleep Disorders, Other

ZALEPLON CAP 10MG On formulary, tier change tier 2 to tier 3 Sleep Disorder Agents

GABA Receptor

Modulators

ZALEPLON CAP 5MG On formulary, tier change tier 2 to tier 3 Sleep Disorder Agents

GABA Receptor

Modulators

ZAZOLE SUP 80MG On formulary, tier change tier 1 to tier 2 Genitourinary Agents Vaginal Products

ZELBORAF TAB

240MG



ZELBORAF TAB

240MG





ZEMPLAR INJ

2MCG/ML Not on 2017 formulary paricalcitol 2 mcg/ml inj


Agents


Agents

ZEMPLAR INJ

5MCG/ML Not on 2017 formulary paricalcitol 5 mcg/ml inj


Agents


Agents

ZENCHENT TAB On formulary, tier change tier 1 to tier 2

Hormonal Agents,


Modifying (Sex


ZENZEDI TAB 10MG




Agents

Attention Deficit



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ZENZEDI TAB 5MG




Agents

Attention Deficit



ZETIA TAB 10MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents Dyslipidemics, Other

ZETIA TAB 10MG



ZIAGEN SOL

20MG/ML



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


ZIDOVUDINE CAP

100MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


ZIDOVUDINE SYP

50MG/5ML



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


ZIDOVUDINE TAB

300MG



Anti-HIV Agents,

Nucleoside and

Nucleotide Reverse


ZIPRASIDONE CAP

20MG


limit may apply 60 capsules per 30 days Antipsychotics 2nd Generation/Atypical

ZIPRASIDONE CAP

20MG





ZIPRASIDONE CAP

40MG



Pg. 328 of 331



ZIPRASIDONE CAP

40MG





ZIPRASIDONE CAP

60MG



ZIPRASIDONE CAP

60MG





ZIPRASIDONE CAP

80MG



ZIPRASIDONE CAP

80MG





ZIRGAN GEL 0.15% Not on 2017 formulary trifluridine 1% solution Ophthalmic Agents Ophthalmic Anti Infectives

ZOLINZA CAP 100MG



ZOLINZA CAP 100MG





ZOLPIDEM TAB 10MG On formulary, tier change tier 2 to tier 4 Sleep Disorder Agents

GABA Receptor

Modulators

ZOLPIDEM TAB 5MG On formulary, tier change tier 2 to tier 4 Sleep Disorder Agents

GABA Receptor

Modulators

ZOMETA INJ

4MG/100 On formulary, tier change tier 4 to tier 5


Agents


Agents

ZOSTAVAX INJ


limit may apply 1 vaccine per lifetime Immunological Agents Vaccines

Pg. 329 of 331



ZYDELIG TAB 100MG



ZYDELIG TAB 100MG





ZYDELIG TAB 150MG



ZYDELIG TAB 150MG





ZYFLO TAB 600MG Not on 2017 formulary montelukast, zafirlukast Respiratory Tract Agents Antileukotrienes

ZYFLO CR TAB

600MG Not on 2017 formulary montelukast, zafirlukast Respiratory Tract Agents Antileukotrienes

ZYKADIA CAP 150MG



ZYKADIA CAP 150MG





ZYPREXA RELP INJ

210MG



ZYPREXA RELP INJ

210MG





ZYPREXA RELP INJ


ZYPREXA RELP INJ

300MG



Pg. 330 of 331



ZYPREXA RELP INJ

300MG





ZYPREXA RELP INJ


ZYPREXA RELP INJ

405MG


limit may apply 1 vial per 28 days Antipsychotics 2nd Generation/Atypical

ZYPREXA RELP INJ

405MG





ZYTIGA TAB 250MG



ZYTIGA TAB 250MG





ZYVOX SOL

2MG/ML Not on 2017 formulary linezolid injection 2mg/ml Antibacterials Antibacterials, Other

Pg. 331 of 331

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