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Empirx Health 2018 Basic Plus Formulary List

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Empirx Health 2018 Basic Plus Formulary List EmpiRx Health 2018 Basic Plus Formulary List The 2018 Basic Plus Formulary drug list is shown below. The formulary is the list of drugs included in your prescription drug benefit plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes. PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for your prescription drug benefit program. For specific questions about your coverage, please call the phone number printed on your member ID card. KEY For the member: Generic medications contain the same active [INJ] – Injectable Drug ingredients as their corresponding brand-name medications, although [OTC] – Over-the-counter Product they may look different in color or shape. They have been FDA-approved [SP] – Specialty Drug under strict standards. Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY For the physician: Please prescribe preferred products and allow generic Generic drugs are listed in lower-case letters. Example: ibuprofen substitutions when medically appropriate. A adapalene/benzoyl peroxide alyacen apraclonidine eye solution ADCETRIS [INJ] [SP] amabelz aprepitant abacavir [SP] ADCIRCA [SP] amantadine apri abacavir/lamivudine [SP] ADDAMEL N [INJ] AMBISOME [INJ] APTIVUS [SP] abacavir/lamivudine/zidovudine [SP] adefovir amcinonide AQUASOL A [INJ] ABELCET [INJ] ADEMPAS [SP] amethia ARALAST NP [INJ] [SP] ABILIFY MAINTENA [INJ] adenosine [INJ] amethia lo aranelle ABRAXANE [INJ] [SP] ADVAIR DISKUS amethyst ARANESP [INJ] [SP] ABSORICA ADVAIR HFA AMICAR arbinoxa acamprosate delayed-release advanced am/pm amifostine [INJ] ARCALYST [INJ] [SP] ACANYA ADVATE [INJ] [SP] amikacin [INJ] ARCAPTA NEOHALER acarbose ADYNOVATE [INJ] [SP] amiloride aripiprazole ACCU-CHEK FASTCLIX LANCETS AFINITOR [SP] amiloride/hydrochlorothiazide aripiprazole orally disintegrating tablets [OTC] AFINITOR DISPERZ [SP] amino acid [INJ] ARISTADA [INJ] ACCU-CHEK MULTICLIX LANCET KIT AFLURIA [INJ] aminocaproic acid [INJ] ARISTOSPAN [INJ] [OTC] AFLURIA QUAD [INJ] aminophylline [INJ] armodafinil ACCU-CHEK MULTICLIX LANCETS AFSTYLA [INJ][SP] AMINOSYN [INJ] ARMONAIR RESPICLICK [OTC] AKYNZEO amiodarone ARMOUR THYROID ACCU-CHEK SOFTCLIX LANCET KIT ALBENZA amiodarone [INJ] ARNUITY ELLIPTA [OTC] albumin human [INJ] AMITIZA ARRANON [INJ] [SP] ACCU-CHEK SOFTCLIX LANCETS albuterol amitriptyline ARZERRA [INJ] [SP] [OTC] albuterol ext-release amitriptyline/chlordiazepoxide ASACOL HD acebutolol albuterol nebulization solution amlodipine ascorbic acid [INJ] acetaminophen/codeine alclometasone amlodipine/atorvastatin ashlyna acetazolamide ALDURAZYME [INJ] [SP] amlodipine/benazepril ASMANEX HFA acetazolamide ext-release ALECENSA [SP] amlodipine/olmesartan ASMANEX TWISTHALER acetazolamide sodium [INJ] alendronate amlodipine/valsartan aspirin/dipyridamole ext-release acetic acid ear solution alfentanil [INJ] amlodipine/valsartan/hydrochlorothiazide atenolol acetic acid irrigation solution ALFERON N [INJ] ammonium lactate 12% topical atenolol/chlorthalidone acetic acid/aluminum acetate ear alfuzosin ext-release amoxapine ATGAM [INJ] solution ALIMTA [INJ] amoxicillin atomoxetine acetic acid/hydrocortisone ear solution ALINIA amoxicillin/potassium clavulanate atorvastatin acetic acid/oxyquinoline vaginal allopurinol amoxicillin/potassium clavulanate ext- atovaquone acetylcysteine [INJ] allopurinol sodium [INJ] release atovaquone/proguanil acetylcysteine inhalation solution almotriptan amphotericin [INJ] ATRIPLA [SP] acitretin alosetron ampicillin atropine [INJ] ACTEMRA [INJ] [SP] ALOXI [INJ] ampicillin sodium [INJ] atropine sulfate eye ointment ACTHAR H.P. [INJ] [SP] ALPHAGAN P 0.1% ampicillin sodium/sulbactam [INJ] atropine sulfate eye solution ACTHIB [INJ] ALPHANATE [INJ] [SP] AMPYRA [SP] ATROVENT HFA ACTHREL [INJ] ALPHANINE SD [INJ] [SP] AMYTAL [INJ] aubra ACTIMMUNE [INJ] [SP] alphaquin hp anagrelide AUGMENTIN 125-31.25 MG/5 ML ACTIVASE [INJ] alprazolam anastrozole AVASTIN [INJ] [SP] acyclovir alprazolam ext-release ANDRODERM AVELOX IV [INJ] acyclovir ointment alprazolam orally disintegrating tablets ANDROGEL 1.62% aviane acyclovir sodium [INJ] ALPROLIX [INJ] [SP] ANORO ELLIPTA avo cream ADACEL [INJ] alprostadil [INJ] anthralin AVONEX [INJ] [SP] ADAGEN [INJ] [SP] ALREX APLISOL [INJ] AVYCAZ [INJ] adapalene altavera APOKYN [INJ] [SP] azacitidine [INJ] [SP] EmpiRx Health Basic Plus Formulary AZACTAM-ISO-OSMOTIC DEXTROSE blisovi fe camrese chlorcyclizine/pseudoephedrine/codeine [INJ] BOOSTRIX [INJ] camrese lo chlordiazepoxide AZASITE BOSULIF [SP] CANASA chlordiazepoxide/clidinium azathioprine [SP] BOTOX [INJ] [SP] CANCIDAS [INJ] chlorhexidine gluconate azathioprine sodium [INJ] [SP] bp vit 3 candesartan chloroquine azelastine eye solution BREO ELLIPTA candesartan/hydrochlorothiazide chlorothiazide azelastine nasal spray BREVITAL [INJ] CAPASTAT SULFATE [INJ] chlorothiazide sodium [INJ] azithromycin briellyn capecitabine [SP] chlorpheniramine/phenylephrine/ azithromycin [INJ] BRILINTA CAPRELSA [SP] dextromethorphan aztreonam [INJ] brimonidine eye solution captopril chlorpromazine azuphen mb BRINEURA [INJ] [SP] captopril/hydrochlorothiazide chlorpromazine [INJ] azurette BRISDELLE CARAC chlorthalidone bromfenac eye solution CARAFATE SUSPENSION chlorzoxazone B bromocriptine carbachol [INJ] CHOLBAM [SP] bacitracin [INJ] brompheniramine/pseudoephedrine/ CARBAGLU [SP] cholestyramine bacitracin eye ointment codeine carbamazepine cholestyramine light bacitracin/polymyxin eye ointment brompheniramine/pseudoephedrine/ carbamazepine ext-release choline salicylate/magnesium salicylate baclofen dextromethorphan carbidopa CHORIONIC GONADOTROPIN [INJ] BAL IN OIL [INJ] budesonide ext-release carbidopa/levodopa [SP] balanced salt eye irrigation solution budesonide nebulization suspension carbidopa/levodopa ext-release chromium chloride [INJ] bal-care dha prenatal vitamins bumetanide carbidopa/levodopa orally disintegrating CIALIS balsalazide bumetanide [INJ] tablets ciclopirox balziva bupivacaine [INJ] carbidopa/levodopa/entacapone ciclopirox shampoo BANZEL bupivacaine/dextrose [INJ] carbinoxamine cidofovir [INJ] BARACLUDE SOLUTION bupivacaine/epinephrine [INJ] carboplatin [INJ] ciferex BAVENCIO [INJ] [SP] buprenorphine carteolol eye solution cilostazol b-complex [INJ] buprenorphine [INJ] carvedilol cimetidine BEBULIN [INJ] [SP] buprenorphine/naloxone caspofungin [INJ] CINRYZE [INJ] [SP] bekyree bupropion CATHFLO ACTIVASE [INJ] CIPRODEX benazepril bupropion ext-release CAVERJECT [INJ] ciprofloxacin benazepril/hydrochlorothiazide bupropion ext-release (smoking CAYSTON [SP] ciprofloxacin ear solution BENDEKA [INJ] [SP] deterrent) caziant ciprofloxacin ext-release BENEFIX [INJ] [SP] buspirone cefaclor ciprofloxacin eye solution BENLYSTA [INJ] [SP] busulfan [INJ] cefaclor ext-release ciprofloxacin lactate [INJ] benoxinate/fluorescein eye solution butalbital/acetaminophen cefadroxil ciprofloxacin lactate/dextrose [INJ] benzonatate butalbital/acetaminophen/caffeine cefazolin [INJ] cisplatin [INJ] benzoyl peroxide butalbital/acetaminophen/caffeine/ cefdinir citalopram benzphetamine codeine cefditoren citric acid/sodium citrate benztropine butalbital/aspirin/caffeine cefepime [INJ] cladribine [INJ] benztropine [INJ] butalbital/aspirin/caffeine/codeine cefepime/dextrose [INJ] clarithromycin BEPREVE butorphanol [INJ] cefixime clarithromycin ext-release BERINERT [INJ] [SP] butorphanol nasal cefotaxime [INJ] clemastine BESPONSA [INJ] [SP] BUTRANS cefotetan [INJ] clindamycin hcl betamethasone acetate/betamethasone BYDUREON [INJ] cefoxitin [INJ] clindamycin palmitate sodium phosphate [INJ] BYETTA [INJ] cefoxitin/dextrose [INJ] clindamycin phosphate [INJ] betamethasone dipropionate BYSTOLIC cefpodoxime clindamycin phosphate topical betamethasone dipropionate augmented BYVALSON cefprozil clindamycin phosphate vaginal ceftazidime [INJ] clindamycin phosphate/benzoyl peroxide betamethasone valerate C BETASERON [INJ] [SP] CEFTAZIDIME/DEXTROSE [INJ] clindamycin phosphate/dextrose [INJ] betaxolol cabergoline ceftibuten clindamycin phosphate/tretinoin betaxolol eye solution CABOMETYX [SP] ceftriaxone [INJ] CLINIMIX [INJ] bethanechol caffeine citrated ceftriaxone/dextrose [INJ] CLINIMIX E [INJ] BETHKIS [SP] caffeine citrated [INJ] cefuroxime axetil clobetasol propionate BEVESPI AEROSPHERE caffeine/sodium benzoate [INJ] cefuroxime sodium [INJ] clobetasol propionate shampoo bexarotene [SP] calcipotriene celacyn clobetasol propionate/emollient BEXSERO [INJ] calcipotriene/betamethasone celecoxib clofarabine [INJ] bicalutamide dipropionate CELONTIN clomiphene citrate BICILLIN C-R [INJ] calcitonin salmon nasal centratex clomipramine BICILLIN L-A [INJ] calcitriol cephalexin clonazepam BICNU [INJ] calcitriol [INJ] CEPROTIN [INJ] [SP] clonazepam orally disintegrating tablets BILTRICIDE calcitriol ointment CERDELGA [SP] clonidine bimatoprost eye solution calcium acetate CEREZYME [INJ] [SP] clonidine [INJ] BIOTHRAX [INJ] calcium chloride [INJ] cetirizine syrup clonidine ext-release bisoprolol CALCIUM DISODIUM VERSENATE CETROTIDE [INJ] [SP] clonidine patches bisoprolol/hydrochlorothiazide [INJ] cevimeline clonidine/chlorthalidone bivalirudin [INJ] calcium gluconate
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