2016 allcare pebb Formulary
AllCare PEBB Formulary FOREWORD
Foreword AllCare PEBB employs MedImpact, a pharmacy benefit management firm, MedImpact P & T Committee. to provide pharmacy services including formulary development. The All- This list is reviewed and updated periodically based on the clinical Care PEBB Formulary represents the efforts of the MedImpact Healthcare literature and pharmacokinetic characteristics of currently available Systems Pharmacy and Therapeutics (P & T) and Formulary Committees to versions of these drug products. provide prescribers and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness of commercially available drug products. A In situations where an FDA-approved generic equivalent is available, structured approach to the drug selection process is essential to ensuring brand names are listed for reference purposes only, and do not denote continuing patient access to rational drug therapies. coverage for the brand, unless specifically noted. The MedImpact P & T and Formulary Committees use the following criteria If a member or provider requests a brand name product in lieu of an in the evaluation of drug selection for the Standard Formulary: approved generic, the member, may be required to pay a higher copay • Drug safety profile than the generic medication. In some cases, a request for coverage • Drug efficacy may require using the medication Prior Authorization process. • Comparison of relevant therapeutic benefits to current formulary agents of similar use, minimizing therapeutic duplication when possible 2. Tier Benefit Design The Formulary is structured as a sliding benefit, where the member • Cost-effectiveness relative to comparable therapies shares the cost of prescription drug therapy based on the drug’s status Access to the most current version of the AllCare PEBB Formulary can be or tier. In general, copays increase with higher level tiers (with the obtained by visiting www.AllCarePEBB.com. exception of tier five), as follows: TIERS: How to Use the Formulary TIER 1: Preferred generic medications (formulary agents) The Formulary is a list of medications available to AllCare PEBB members TIER 2: Preferred brand medications (formulary agents) under their pharmacy benefit. All drugs are listed by their generic names TIER 3: Non-preferred medications (non-formularyagents) and most common proprietary (branded) name. The Formulary may be TIER 4: Specialty medications accessed by using the index, either by generic or proprietary name and by TIER 5: EHB Zero Copay/Preventative medications therapeutic drug category. In situations where an FDA-approved generic equivalent is available, brand names are listed for reference purposes only, Tier five is dedicated to essential health benefit/preventative medica- and do not denote coverage for the brand, unless specifically noted. tions and the copay is zero. All drugs are listed in each category in alphabetical order by generic name. 3. Medication Request Process For certain agents within the Formulary, a recommended prescribing Depending on plan benefit design, a medication request process may guideline may apply. These are denoted throughout the document using apply as follows: the following symbols: A. Coverage Exceptions: Drugs that are listed in the Formulary with associated Prior Au- AGE Age Edit Coverage may depend on patient age thorization (PA) require evaluation by an AllCare PEBB Physician G Gender Edit Coverage may depend on patient gender or Pharmacist reviewer prior to dispensing at a network pharmacy. PA Prior Authorization Requires specific provider request process Each request will be reviewed on an individual basis. If the re- QL Quantity Limit Coverage may be limited to specific quan- quest does not meet the guidelines established by the MedImpact tities P & T Committee, the request may not be approved and alterna- per prescription and/or time period tive therapy may be recommended. ST Step Therapy Coverage may depend on previous use of another drug In addition, a further review may be required if: 1) A member requests an exception to the recommended prescrib- Please refer to the prescribing guideline appendix within this document for ing guideline details regarding specific agents. 2) The medications require specific utilization management such Benefit Coverage and Limitations as This printed Formulary does not provide information regarding the specific age or gender edits, quantity limits, and/or step therapy coverage and limitations an individual member may be subject to. Members 3) The medication exceeds the AllCare PEBB Health Plan’s dollar may have specific benefit inclusions, exclusions, copays, or a lack of cover- limit age, which are not reflected in the Formulary. Please see the AllCAre PEBB per claim member handbook for more information. B. Obtaining Coverage Coverage, questions or information regarding the medication The Formulary applies only to outpatient drugs provided to members, request or formulary process may be obtained by contacting All- and does not apply to medications used in inpatient or office settings. If a Care PEBB Member Services at 541-474-PEBB (7322) or Toll Free: member has any specific questions regarding their coverage, they should 1 (888) 460-0185. contact AllCare PEBB Member Services at 541-474-PEBB (7322) or Toll Free: 1 (888) 460-0185. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical Depending upon a member’s specific coverage benefits, the following necessity. Prior Authorization is generally not available for drugs topics may apply: that are specifically excluded by benefit design. Please see the 1. Generic Substitution AllCare PEBB member handbook for more information. When available, FDA-approved generic drugs are to be used in all situations, regardless of the brand name indicated. Greater economy 4. General Exclusions is realized through the use of generic equivalents. This policy is not A. Over-the-Counter (OTC) medications or their equivalents, meant to preclude or supplant any state statutes that may exist. All except drugs that are or become available generically are subject to review for those OTC agents covered under the EHB tier. by MedImpact’s Pharmacy and Therapeutics Committee. Multi-source B. Drugs specifically listed as not covered. drugs are approved for addition to the MAC list based on the following C. Drug products used for cosmetic purposes. criteria: D. Experimental drug products or any drug product used in an • A multi-source drug product manufactured by at least one (1) experimental manner. nationally marketed company. E. Replacement of lost or stolen medication. • At least one (1) of the generic manufacturer’s products must have F. Non-self-administered injectable drug products unless other- an “A” rating or the generic product has been determined to be wise specified in the ormularyF listing. unassociated with efficacy, safety or bioequivalency concerns by G. Foreign sourced drugs or drugs not approved by the United the MedImpact P & T Committee. States • Drug product will be approved for generic substitution by the Food & Drug Administration, except in certain cases of drug shortage, when allowed under the individual’s pharmacy benefit.
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 3 TABLE OF CONTENTS ALLERGY ...... 6 ANTIEMESIS/ANTIVERTIGO ...... 7 ASTHMA AND COPD ...... 8 AUTONOMIC NERVOUS SYSTEM DISORDERS ...... 11 BEHAVIORAL HEALTH - ANTIDEPRESSANTS ...... 11 BEHAVIORAL HEALTH - OTHER ...... 13 CARDIOVASCULAR DISEASE - ARRHYTHMIA ...... 18 CARDIOVASCULAR DISEASE - CARDIAC STIMULANT ...... 18 CARDIOVASCULAR DISEASE - HYPERTENSION ...... 18 CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ...... 24 CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ...... 27 CARDIOVASCULAR DISEASE - VASODILATION ...... 27 CONTRACEPTION/OXYTOCICS ...... 28 COUGH AND COLD ...... 29 DERMATOLOGY - ACNE ...... 31 DERMATOLOGY - ANTIINFECTIVE ...... 32 DERMATOLOGY - ANTI-INFLAMMATORY ...... 36 DERMATOLOGY - ANTIPRURITIC DRUGS ...... 38 DERMATOLOGY - MISCELLANEOUS ...... 38 DERMATOLOGY - PIGMENTATION DISORDERS ...... 45 DERMATOLOGY - PSORIASIS/ECZEMA ...... 45 DIABETES ...... 46 EAR - GENERAL DISORDERS ...... 49 ELECTROLYTE REGULATION ...... 50 ENDOCRINE DISORDER - FERTILITY ...... 51 ENDOCRINE DISORDER - OTHER ...... 52 ENDOCRINE DISORDER - THYROID ...... 54 EYE - GENERAL DISORDERS ...... 55 EYE - GLAUCOMA ...... 58 EYE - MISCELLANEOUS ...... 59 GOUT AND RELATED DISEASES ...... 59
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 4 HEMATOLOGICAL DISORDERS ...... 60 HORMONAL DEFICIENCY ...... 64 IMMUNIZATION ...... 66 IMMUNOSUPPRESSION/MODULATION ...... 69 INFECTIOUS DISEASE - BACTERIAL ...... 70 INFECTIOUS DISEASE - FUNGAL ...... 75 INFECTIOUS DISEASE - MISCELLANEOUS ...... 76 INFECTIOUS DISEASE - PARASITIC ...... 77 INFECTIOUS DISEASE - VIRAL ...... 78 INFLAMMATORY DISEASE ...... 81 LOCAL ANESTHESIA ...... 86 LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT . . . . 86 LOWER GASTROINTESTINAL DISORDERS - OTHER ...... 87 MISCELLANEOUS AGENTS ...... 89 NEOPLASTIC DISEASE ...... 89 NEUROLOGICAL DISEASE - MISCELLANEOUS ...... 93 ORAL/PHARYNGEAL DISORDERS ...... 94 OTHER RESPIRATORY DISORDERS ...... 95 PAIN MANAGEMENT - ANALGESICS ...... 95 PARKINSONS DISEASE ...... 101 SEIZURE DISORDER ...... 102 SKELETAL MUSCLE DISORDER ...... 105 SMOKING CESSATION ...... 106 UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ...... 106 UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE . . . . . 106 UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ...... 107 URINARY TRACT - FUNCTIONAL DISORDERS ...... 108 VAGINAL DISORDERS ...... 109 VITAMIN AND/OR MINERAL DEFICIENCY ...... 109 WEIGHT REDUCTION ...... 139
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 5 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
ALLERGY CETIRIZINE-PSEUDOEPHED- cetirizine hcl/pseudoephedrine 1 RINE ER(OTC) fexofenadine/pseudoephedrine ALLERGY RELIEF-D(OTC) 1
loratadine/pseudoephedrine CLARITIN-D 12 HOUR(OTC) 1
loratadine/pseudoephedrine CLARITIN-D 24 HOUR(OTC) 1
fexofenadine/pseudoephedrine ALLEGRA-D 12 HOUR(OTC) 2
fexofenadine/pseudoephedrine ALLEGRA-D 24 HOUR(OTC) 2
desloratadine/pseudoephedrine CLARINEX-D 12 HOUR 3 XX
pseudoephedrine hcl/acrivas SEMPREX-D 3
grass pollen-timothy, std GRASTEK 2 X
gr pol-orc/sw ver/rye/kent/tim ORALAIR 2 X
weed pollen-short ragweed RAGWITEK 2 X
carbinoxamine maleate CARBINOXAMINE MALEATE 1 X
clemastine fumarate CLEMASTINE FUMARATE 1
cyproheptadine hcl CYPROHEPTADINE HCL 1
diphenhydramine hcl DIPHENHYDRAMINE HCL 1 HYDROXYZINE HCL(SOLU- hydroxyzine hcl 1 TION) hydroxyzine pamoate HYDROXYZINE PAMOATE 1
hydroxyzine pamoate VISTARIL 1
promethazine hcl PHENERGAN 1
promethazine hcl PROMETHAZINE HCL 1
carbinoxamine maleate KARBINAL ER 3 X X X
hydroxyzine hcl HYDROXYZINE HCL(TAB) 5
cetirizine hcl CETIRIZINE HCL 1
desloratadine CLARINEX(TAB) 1 X
desloratadine DESLORATADINE 1 XX
fexofenadine hcl FEXOFENADINE HCL 1
levocetirizine dihydrochloride XYZAL(SOLUTION) 1 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 6 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
levocetirizine dihydrochloride XYZAL(TAB) 1
desloratadine CLARINEX(SYRUP) 3 XX
budesonide RHINOCORT AQUA 1 XX
flunisolide FLUNISOLIDE 1 X
fluticasone propionate FLUTICASONE PROPIONATE 1 X
triamcinolone acetonide TRIAMCINOLONE ACETONIDE 1 X
beclomethasone dipropionate QNASL 2 XX
beclomethasone dipropionate QNASL CHILDREN 2 XX
mometasone furoate NASONEX 2 X
beclomethasone dipropionate BECONASE AQ 3 XX
ciclesonide OMNARIS 3 XX
ciclesonide ZETONNA 3 XX
fluticasone furoate VERAMYST 3 XX
azelastine hcl ASTEPRO 1 XX
azelastine hcl AZELASTINE HCL 1 X
olopatadine hcl PATANASE 1 XX
azelastine/fluticasone DYMISTA 3 XX
ANTIEMESIS/ANTIVERTIGO
dronabinol MARINOL 1 XX
granisetron hcl GRANISETRON HCL(TAB) 1 XX
granisetron hcl GRANISETRON HCL(VIAL) 1
granisetron hcl/pf GRANISETRON HCL 1
meclizine hcl ANTIVERT 1
ondansetron ZOFRAN ODT 1
ondansetron hcl ONDANSETRON HCL 1
ondansetron hcl ZOFRAN(SOLUTION) 1 X
ondansetron hcl ZOFRAN(TAB) 1
ondansetron hcl ZOFRAN(VIAL) 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 7 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
prochlorperazine COMPAZINE 1
promethazine hcl PHENERGAN 1
promethazine hcl PROMETHEGAN 1
trimethobenzamide hcl TIGAN 1
aprepitant EMEND(CAP DS PK) 2 X
aprepitant EMEND(CAP)(125 MG) 2 X
aprepitant EMEND(CAP)(40 MG) 2 X
aprepitant EMEND(CAP)(80 MG) 2 X
dolasetron mesylate ANZEMET(TAB)(100 MG) 3 XX
dolasetron mesylate ANZEMET(TAB)(50 MG) 3 XX
dolasetron mesylate ANZEMET(VIAL) 3
doxylamine/pyridoxine hcl DICLEGIS 3 X
granisetron SANCUSO 3 XX
nabilone CESAMET 3 XX
netupitant/palonosetron hcl AKYNZEO 3 X
ondansetron ZUPLENZ(FILM)(4 MG) 3 XX
ondansetron ZUPLENZ(FILM)(8 MG) 3 XX
rolapitant hydrochloride VARUBI 3
scopolamine TRANSDERM-SCOP 3
prochlorperazine maleate COMPAZINE 5
ASTHMA AND COPD
zileuton ZYFLO 3
zileuton ZYFLO CR 3
epinephrine EPINEPHRINE 1
glycopyrrolate SEEBRI NEOHALER 3
albuterol sulfate ALBUTEROL SULFATE 1
albuterol sulfate VOSPIRE ER 1
levalbuterol hcl XOPENEX 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 8 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
metaproterenol sulfate METAPROTERENOL SULFATE 1
arformoterol tartrate BROVANA 3 X
indacaterol maleate ARCAPTA NEOHALER 3 XX
levalbuterol tartrate XOPENEX HFA 3
albuterol sulfate PROAIR HFA 5
albuterol sulfate PROAIR RESPICLICK 5
albuterol sulfate PROVENTIL HFA 5
albuterol sulfate VENTOLIN HFA 5
formoterol fumarate FORADIL 5 XX
formoterol fumarate PERFOROMIST 5 X
olodaterol hcl STRIVERDI RESPIMAT 5 X
salmeterol xinafoate SEREVENT DISKUS 5 X
terbutaline sulfate TERBUTALINE SULFATE 5
ipratropium/albuterol sulfate IPRATROPIUM-ALBUTEROL 1
ipratropium/albuterol sulfate COMBIVENT RESPIMAT 2
indacaterol/glycopyrrolate UTIBRON NEOHALER 3
tiotropium br/olodaterol hcl STIOLTO RESPIMAT 5 X
umeclidinium brm/vilanterol tr ANORO ELLIPTA 5 XX
fluticasone/salmeterol ADVAIR HFA 2 X
budesonide/formoterol fumarate SYMBICORT 3 XX
fluticasone/salmeterol ADVAIR DISKUS 5 X
fluticasone/vilanterol BREO ELLIPTA 5 X
mometasone/formoterol DULERA 5 X
ipratropium bromide IPRATROPIUM BROMIDE 1
ipratropium bromide ATROVENT HFA 2 X SPIRIVA RESPIMAT(MIST IN- tiotropium bromide 2 X HAL)(1.25 MCG) aclidinium bromide TUDORZA PRESSAIR 3 XX
umeclidinium bromide INCRUSE ELLIPTA 3 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 9 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
tiotropium bromide SPIRIVA 5 X SPIRIVA RESPIMAT(MIST IN- tiotropium bromide 5 X HAL)(2.5 MCG) PULMICORT(AMPUL-NEB)(1 budesonide 1 X MG/2 ML) budesonide PULMICORT FLEXHALER 2 X ASMANEX(AER POW BA) mometasone furoate 2 X (220MCG(14)) ciclesonide ALVESCO 3 XX
flunisolide AEROSPAN 3 XX
fluticasone furoate ARNUITY ELLIPTA 3 XX
beclomethasone dipropionate QVAR 5 X PULMICORT(AMPUL-NEB) budesonide 5 X (0.25MG/2ML) PULMICORT(AMPUL-NEB)(0.5 budesonide 5 X MG/2ML) FLOVENT DISKUS(BLST W/ fluticasone propionate 5 XX DEV)(100 MCG) FLOVENT DISKUS(BLST W/ fluticasone propionate 5 XX DEV)(250 MCG) FLOVENT DISKUS(BLST W/ fluticasone propionate 5 XX DEV)(50 MCG) FLOVENT HFA(AER W/ADAP) fluticasone propionate 5 XX (110 MCG) FLOVENT HFA(AER W/ADAP) fluticasone propionate 5 XX (220 MCG) FLOVENT HFA(AER W/ADAP) fluticasone propionate 5 XX (44 MCG) mometasone furoate ASMANEX HFA 5 X ASMANEX(AER POW BA) mometasone furoate 5 X (110MCG(30)) ASMANEX(AER POW BA) mometasone furoate 5 X (220MCG 120) ASMANEX(AER POW BA) mometasone furoate 5 X (220MCG(30)) ASMANEX(AER POW BA) mometasone furoate 5 X (220MCG(60)) montelukast sodium SINGULAIR 5
zafirlukast ACCOLATE 5
cromolyn sodium CROMOLYN SODIUM 5
cromolyn sodium GASTROCROM 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 10 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
roflumilast DALIRESP 5 XX
caffeine citrated CAFFEINE CITRATE 1
theophylline anhydrous THEOPHYLLINE ANHYDROUS 1
theophylline anhydrous THEO-24 2
AUTONOMIC NERVOUS SYSTEM DISORDERS
memantine hcl NAMENDA(SOLUTION) 1 X
memantine hcl NAMENDA(TAB DS PK) 1 X
memantine hcl NAMENDA(TAB) 1 X
memantine hcl NAMENDA XR(CAP 24 DSPK) 2 X
memantine hcl NAMENDA XR(CAP SPR 24) 2 X
memantine hcl/donepezil hcl NAMZARIC 2 XX
donepezil hcl ARICEPT 1
galantamine hbr RAZADYNE 1 X
galantamine hbr RAZADYNE ER 1 X
pyridostigmine bromide MESTINON(TAB) 1
rivastigmine EXELON 1 X
rivastigmine tartrate EXELON 1
pyridostigmine bromide MESTINON(SYRUP) 2
BEHAVIORAL HEALTH - ANTIDEPRESSANTS
mirtazapine MIRTAZAPINE 5
mirtazapine REMERON 5
phenelzine sulfate NARDIL 1
tranylcypromine sulfate PARNATE 1
isocarboxazid MARPLAN 3
bupropion hbr APLENZIN 3 XX
bupropion hcl FORFIVO XL 3 XX
bupropion hcl WELLBUTRIN XL 5
paroxetine hcl PAXIL(ORAL SUSP) 2
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 11 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
fluoxetine hcl FLUOXETINE HCL 3
paroxetine mesylate BRISDELLE 3 XX
paroxetine mesylate PEXEVA 3 XX
citalopram hydrobromide CELEXA 5
citalopram hydrobromide CITALOPRAM HBR 5
escitalopram oxalate LEXAPRO 5
fluoxetine hcl SARAFEM 5
fluvoxamine maleate FLUVOXAMINE MALEATE 5
paroxetine hcl PAXIL CR 5
paroxetine hcl PAXIL(TAB) 5
sertraline hcl ZOLOFT 5
nefazodone hcl NEFAZODONE HCL 1
trazodone hcl OLEPTRO ER 3 XX
trazodone hcl TRAZODONE HCL 5
desvenlafaxine KHEDEZLA 1 XX
duloxetine hcl CYMBALTA 1 X
duloxetine hcl IRENKA 1 XX
desvenlafaxine succinate PRISTIQ ER 2 XX
desvenlafaxine DESVENLAFAXINE ER 3 XX DESVENLAFAXINE FUMARATE desvenlafaxine fumarate 3 XX ER levomilnacipran hydrochloride FETZIMA 3 XX
venlafaxine hcl EFFEXOR XR 5
venlafaxine hcl VENLAFAXINE HCL ER 5
vilazodone hydrochloride VIIBRYD 3 XX
vortioxetine hydrobromide BRINTELLIX 3 XX CHLORDIAZEPOXIDE-AMITRIP- amitrip hcl/chlordiazepoxide 1 TYLINE PERPHENAZINE-AMITRIPTY- perphenazine/amitriptyline hcl 1 LINE amoxapine AMOXAPINE 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 12 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
clomipramine hcl ANAFRANIL 1
desipramine hcl NORPRAMIN 1
doxepin hcl DOXEPIN HCL(CAP)(100 MG) 1
maprotiline hcl MAPROTILINE HCL 1
trimipramine maleate TRIMIPRAMINE MALEATE 1
trimipramine maleate SURMONTIL 3
amitriptyline hcl AMITRIPTYLINE HCL 5
doxepin hcl DOXEPIN HCL(CAP)(10 MG) 5
doxepin hcl DOXEPIN HCL(CAP)(150 MG) 5
doxepin hcl DOXEPIN HCL(CAP)(25 MG) 5
doxepin hcl DOXEPIN HCL(CAP)(50 MG) 5
doxepin hcl DOXEPIN HCL(CAP)(75 MG) 5
doxepin hcl DOXEPIN HCL(ORAL CONC) 5
imipramine hcl TOFRANIL 5
imipramine pamoate TOFRANIL-PM 5
nortriptyline hcl NORTRIPTYLINE HCL 5
nortriptyline hcl PAMELOR 5
protriptyline hcl PROTRIPTYLINE HCL 5
BEHAVIORAL HEALTH - OTHER DEXTROAMPHETAMINE SUL- dextroamphetamine sulfate 1 X FATE(TAB)(10 MG) DEXTROAMPHETAMINE SUL- dextroamphetamine sulfate 1 X FATE(TAB)(5 MG) dextroamphetamine sulfate PROCENTRA 1 X
dextroamphetamine/amphetamine ADDERALL 1 X
methamphetamine hcl DESOXYN 1 X
dextroamphetamine sulfate ZENZEDI(TAB)(2.5 MG) 2 XX
dextroamphetamine sulfate ZENZEDI(TAB)(7.5 MG) 2 XX
lisdexamfetamine dimesylate VYVANSE 2 XX
amphetamine sulfate EVEKEO 3 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 13 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
dextroamphetamine sulfate ZENZEDI(TAB)(15 MG) 3 X
dextroamphetamine sulfate ZENZEDI(TAB)(20 MG) 3 X
dextroamphetamine sulfate ZENZEDI(TAB)(30 MG) 3 X
acamprosate calcium ACAMPROSATE CALCIUM 1
disulfiram ANTABUSE 1
alprazolam XANAX 1
chlordiazepoxide hcl CHLORDIAZEPOXIDE HCL 1
clorazepate dipotassium CLORAZEPATE DIPOTASSIUM 1
clorazepate dipotassium TRANXENE T-TAB 1
diazepam DIAZEPAM 1
diazepam VALIUM 1
lorazepam ATIVAN 1
lorazepam LORAZEPAM 1
meprobamate MEPROBAMATE 1
oxazepam OXAZEPAM 1
alprazolam ALPRAZOLAM INTENSOL 2
buspirone hcl BUSPIRONE HCL 5
carbamazepine EQUETRO 3
lithium carbonate LITHIUM CARBONATE 5
lithium citrate LITHIUM 5
sodium oxybate XYREM 4 X X
chlorpromazine hcl CHLORPROMAZINE HCL 5
fluphenazine hcl FLUPHENAZINE HCL 5
perphenazine PERPHENAZINE 5
thioridazine hcl THIORIDAZINE HCL 5
trifluoperazine hcl TRIFLUOPERAZINE HCL 5
pimozide ORAP 1
aripiprazole ARIPIPRAZOLE 1 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 14 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
brexpiprazole REXULTI 3 XX
aripiprazole ABILIFY 5 XX
loxapine ADASUVE 4 X
loxapine succinate LOXAPINE 5
paliperidone INVEGA(TAB ER 24H)(1.5 MG) 1 XX
paliperidone INVEGA(TAB ER 24H)(3 MG) 1 XX
paliperidone INVEGA(TAB ER 24H)(6 MG) 1 XX
paliperidone INVEGA(TAB ER 24H)(9 MG) 1 XX
risperidone RISPERDAL(SOLUTION) 1 X
asenapine maleate SAPHRIS 3 XX
iloperidone FANAPT(TAB DS PK) 3 XX
iloperidone FANAPT(TAB) 3 XX
lurasidone hcl LATUDA(TAB)(120 MG) 3 XX
lurasidone hcl LATUDA(TAB)(20 MG) 3 XX
lurasidone hcl LATUDA(TAB)(40 MG) 3 XX
lurasidone hcl LATUDA(TAB)(60 MG) 3 XX
lurasidone hcl LATUDA(TAB)(80 MG) 3 XX
quetiapine fumarate SEROQUEL XR 3 XX
clozapine VERSACLOZ 4 XX
clozapine CLOZAPINE 5 X
clozapine CLOZARIL 5 X
olanzapine ZYPREXA 5 X
quetiapine fumarate SEROQUEL 5 X
risperidone RISPERDAL(TAB) 5 X
ziprasidone hcl GEODON 5 X
thiothixene THIOTHIXENE 5
haloperidol HALOPERIDOL 5
haloperidol lactate HALOPERIDOL LACTATE 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 15 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
molindone hcl MOLINDONE HCL 1
phenobarbital PHENOBARBITAL 1
butabarbital sodium BUTISOL SODIUM 3
secobarbital sodium SECONAL SODIUM 3
flibanserin ADDYI 3 X
ramelteon ROZEREM 3 XX
tasimelteon HETLIOZ 4 X X
selegiline EMSAM 3 X
modafinil PROVIGIL 1 X
armodafinil NUVIGIL 3 X
naloxone hcl NALOXONE HCL 1
naltrexone hcl REVIA 1
naloxone hcl EVZIO 3 X
naloxone hcl NARCAN 3
estazolam ESTAZOLAM 1
eszopiclone LUNESTA 1 X
flurazepam hcl FLURAZEPAM HCL 1
midazolam hcl MIDAZOLAM HCL 1
temazepam RESTORIL 1
triazolam HALCION 1
triazolam TRIAZOLAM 1
zaleplon SONATA 1 X
zolpidem tartrate AMBIEN(TAB)(5 MG) 1 X ZOLPIDEM TARTRATE(TAB) zolpidem tartrate 1 X (5MG) doxepin hcl SILENOR 3 XX
suvorexant BELSOMRA 3 XX
zolpidem tartrate EDLUAR 3 XX
zolpidem tartrate INTERMEZZO 3 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 16 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
zolpidem tartrate ZOLPIMIST 3 XX
zolpidem tartrate AMBIEN(TAB)(10 MG) 5 X ZOLPIDEM TARTRATE(TAB) zolpidem tartrate 5 X (10MG) olanzapine/fluoxetine hcl SYMBYAX 1 X
clonidine hcl KAPVAY 1 X
guanfacine hcl INTUNIV 1 X FOCALIN XR(CPBP 50-50)(10 dexmethylphenidate hcl 1 X MG) FOCALIN XR(CPBP 50-50)(15 dexmethylphenidate hcl 1 X MG) FOCALIN XR(CPBP 50-50)(20 dexmethylphenidate hcl 1 X MG) FOCALIN XR(CPBP 50-50)(30 dexmethylphenidate hcl 1 X MG) FOCALIN XR(CPBP 50-50)(40 dexmethylphenidate hcl 1 X MG) FOCALIN XR(CPBP 50-50)(5 dexmethylphenidate hcl 1 X MG) methylphenidate hcl METHYLIN(SOLUTION) 1
methylphenidate hcl METHYLIN(TAB CHEW) 1 X
methylphenidate hcl RITALIN 1 X FOCALIN XR(CPBP 50-50)(25 dexmethylphenidate hcl 2 X MG) FOCALIN XR(CPBP 50-50)(35 dexmethylphenidate hcl 2 X MG) methylphenidate hcl RITALIN LA 2 X
methylphenidate DAYTRANA 3 XX
methylphenidate hcl APTENSIO XR 3 XX
methylphenidate hcl QUILLIVANT XR 3 XX
atomoxetine hcl STRATTERA(CAP)(10 MG) 2 X
atomoxetine hcl STRATTERA(CAP)(100 MG) 2 X
atomoxetine hcl STRATTERA(CAP)(18 MG) 2 X
atomoxetine hcl STRATTERA(CAP)(25 MG) 2 X
atomoxetine hcl STRATTERA(CAP)(40 MG) 2 X
atomoxetine hcl STRATTERA(CAP)(60 MG) 2 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 17 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
atomoxetine hcl STRATTERA(CAP)(80 MG) 2 X
CARDIOVASCULAR DISEASE - ARRHYTHMIA
amiodarone hcl AMIODARONE HCL 1
disopyramide phosphate NORPACE 1
flecainide acetate FLECAINIDE ACETATE 1 LIDOCAINE HCL IN 5% DEX- lidocaine hcl/d5w/pf 1 TROSE mexiletine hcl MEXILETINE HCL 1
procainamide hcl PROCAINAMIDE HCL 1
propafenone hcl PROPAFENONE HCL 1
propafenone hcl RYTHMOL 1
quinidine gluconate QUINIDINE GLUCONATE 1
quinidine sulfate QUINIDINE SULFATE 1
disopyramide phosphate NORPACE CR 2
dofetilide TIKOSYN 2
dronedarone hcl MULTAQ 2
amiodarone in dextrose,iso-osm NEXTERONE 3
CARDIOVASCULAR DISEASE - CARDIAC STIMULANT
digoxin DIGOXIN 2
digoxin LANOXIN(TAB)(187.5 MCG) 3
digoxin LANOXIN(TAB)(62.5 MCG) 3
digoxin LANOXIN(TAB)(125 MCG) 5
digoxin LANOXIN(TAB)(250 MCG) 5
CARDIOVASCULAR DISEASE - HYPERTENSION
trandolapril/verapamil hcl TARKA 1
perindopril arg/amlodipine bes PRESTALIA 3 XX
amlodipine besylate/benazepril LOTREL 5 BENAZEPRIL-HYDROCHLORO- benazepril/hydrochlorothiazide 5 THIAZIDE
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 18 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
benazepril/hydrochlorothiazide LOTENSIN HCT 5 CAPTOPRIL-HYDROCHLORO- captopril/hydrochlorothiazide 5 THIAZIDE ENALAPRIL-HYDROCHLORO- enalapril/hydrochlorothiazide 5 THIAZIDE enalapril/hydrochlorothiazide VASERETIC 5 FOSINOPRIL-HYDROCHLORO- fosinopril/hydrochlorothiazide 5 THIAZIDE lisinopril/hydrochlorothiazide ZESTORETIC 5 MOEXIPRIL-HYDROCHLORO- moexipril/hydrochlorothiazide 5 THIAZIDE quinapril/hydrochlorothiazide ACCURETIC 5
doxazosin mesylate CARDURA XL 3
phenoxybenzamine hcl DIBENZYLINE 4 X
doxazosin mesylate CARDURA 5
prazosin hcl MINIPRESS 5
terazosin hcl TERAZOSIN HCL 5
carvedilol phosphate COREG CR 2
carvedilol COREG 5
labetalol hcl TRANDATE 5
olmesartan/amlodipin/hcthiazid TRIBENZOR 2 X
amlodipine/valsartan/hcthiazid EXFORGE HCT 5 X
olmesartan/hydrochlorothiazide BENICAR HCT 2 X
azilsartan med/chlorthalidone EDARBYCLOR 3 X
candesartan/hydrochlorothiazid ATACAND HCT 5
irbesartan/hydrochlorothiazide AVALIDE 5
losartan/hydrochlorothiazide HYZAAR 5
telmisartan/hydrochlorothiazid MICARDIS HCT 5
valsartan/hydrochlorothiazide DIOVAN HCT 5
amlodipine bes/olmesartan med AZOR 2 X
amlodipine/valsartan EXFORGE 5 X
telmisartan/amlodipine TWYNSTA 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 19 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
perindopril erbumine ACEON 1
perindopril erbumine PERINDOPRIL ERBUMINE 1
enalapril maleate EPANED 3 X X X
benazepril hcl BENAZEPRIL HCL 5
benazepril hcl LOTENSIN 5
captopril CAPTOPRIL 5
enalapril maleate VASOTEC 5
fosinopril sodium FOSINOPRIL SODIUM 5
lisinopril ZESTRIL 5
moexipril hcl MOEXIPRIL HCL 5
quinapril hcl ACCUPRIL 5
ramipril ALTACE 5
trandolapril MAVIK 5
olmesartan medoxomil BENICAR 2 X
azilsartan medoxomil EDARBI 3 X
candesartan cilexetil ATACAND 5
eprosartan mesylate EPROSARTAN MESYLATE 5 X
irbesartan AVAPRO 5
losartan potassium COZAAR 5
telmisartan MICARDIS 5
valsartan DIOVAN 5
mecamylamine hcl VECAMYL 3 X
metyrosine DEMSER 3
clonidine hcl/chlorthalidone CLORPRES 1
methyldopate hcl METHYLDOPATE HCL 1
clonidine CATAPRES-TTS 1 5
clonidine CATAPRES-TTS 2 5
clonidine CATAPRES-TTS 3 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 20 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
clonidine hcl CATAPRES 5
guanfacine hcl TENEX 5
methyldopa METHYLDOPA 5 METHYLDOPA-HYDROCHLO- methyldopa/hydrochlorothiazide 5 ROTHIAZIDE reserpine RESERPINE 5
hydralazine hcl HYDRALAZINE HCL 5
minoxidil MINOXIDIL 5
nebivolol hcl BYSTOLIC 2
penbutolol sulfate LEVATOL 3
propranolol hcl HEMANGEOL 3 X X X
propranolol hcl INDERAL XL 3 X
propranolol hcl INNOPRAN XL 3 X
sotalol hcl SOTALOL HCL 3
sotalol hcl SOTYLIZE 3 XX
acebutolol hcl SECTRAL 5
atenolol TENORMIN 5
betaxolol hcl BETAXOLOL HCL 5
bisoprolol fumarate ZEBETA 5
metoprolol succinate TOPROL XL 5
metoprolol tartrate LOPRESSOR 5
metoprolol tartrate METOPROLOL TARTRATE 5
nadolol CORGARD 5
pindolol PINDOLOL 5
propranolol hcl PROPRANOLOL HCL 5
sotalol hcl BETAPACE 5
sotalol hcl SOTALOL 5
timolol maleate TIMOLOL MALEATE 5
nadolol/bendroflumethiazide CORZIDE 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 21 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
metoprolol succinate/hctz DUTOPROL 3
atenolol/chlorthalidone TENORETIC 100 5
atenolol/chlorthalidone TENORETIC 50 5
bisoprolol fumarate/hctz ZIAC 5
metoprolol/hydrochlorothiazide LOPRESSOR HCT 5 METOPROLOL-HYDROCHLO- metoprolol/hydrochlorothiazide 5 ROTHIAZIDE PROPRANOLOL-HYDROCHLO- propranolol/hydrochlorothiazid 5 ROTHIAZID isradipine ISRADIPINE 1
nicardipine hcl NICARDIPINE HCL 1
nimodipine NIMODIPINE 1
nisoldipine NISOLDIPINE 1
nisoldipine SULAR 1
diltiazem hcl CARDIZEM LA 3
nicardipine hcl CARDENE SR 3
nimodipine NYMALIZE 4 X X
amlodipine besylate NORVASC 5
diltiazem hcl CARTIA XT 5
felodipine FELODIPINE ER 5
nifedipine ADALAT CC 5
nifedipine PROCARDIA XL 5
verapamil hcl CALAN SR 5
verapamil hcl VERAPAMIL ER 5
ammonium chloride AMMONIUM CHLORIDE 1
ethacrynic acid EDECRIN 3
bumetanide BUMETANIDE 5
furosemide FUROSEMIDE 5
furosemide LASIX 5
torsemide DEMADEX 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 22 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
mannitol RESECTISOL 3
triamterene DYRENIUM 3
amiloride hcl AMILORIDE HCL 5
eplerenone INSPRA 5
spironolactone ALDACTONE 5 TRIAMTERENE-HYDROCHLO- triamterene/hydrochlorothiazid 1 ROTHIAZID AMILORIDE-HYDROCHLORO- amiloride/hydrochlorothiazide 5 THIAZIDE spironolact/hydrochlorothiazid ALDACTAZIDE 5
triamterene/hydrochlorothiazid DYAZIDE 5
triamterene/hydrochlorothiazid MAXZIDE 5
triamterene/hydrochlorothiazid MAXZIDE-25 MG 5
riociguat ADEMPAS 4 X X
sildenafil citrate REVATIO(TAB) 1 X
sildenafil citrate REVATIO(SUSP RECON) 4 X X
tadalafil ADCIRCA 4 XXX
ambrisentan LETAIRIS 4 X X
bosentan TRACLEER 4 X X
macitentan OPSUMIT 4 X X
iloprost tromethamine VENTAVIS 4 X X
treprostinil TYVASO 4 X X
treprostinil diolamine ORENITRAM ER 4 X X
treprostinil sodium REMODULIN 4 X X
treprostinil/neb accessories TYVASO 4 X X
treprostinil/nebulizer/accesor TYVASO 4 X X
aliskiren hemifumarate TEKTURNA 3 X
aliskiren/amlodipine besylate TEKAMLO 3 X
aliskiren/hydrochlorothiazide TEKTURNA HCT 3 X
chlorothiazide CHLOROTHIAZIDE 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 23 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
chlorothiazide DIURIL 5
chlorthalidone CHLORTHALIDONE 5
hydrochlorothiazide HYDROCHLOROTHIAZIDE 5
hydrochlorothiazide MICROZIDE 5
indapamide INDAPAMIDE 5
methyclothiazide METHYCLOTHIAZIDE 5
metolazone METOLAZONE 5
isosorb dinit/hydralazine hcl BIDIL 2
CARDIOVASCULAR DISEASE - LIPID IRREGULARITY
ezetimibe/atorvastatin calcium LIPTRUZET(TAB)(10 MG-10MG) 3 XX
ezetimibe/atorvastatin calcium LIPTRUZET(TAB)(10 MG-20MG) 3 XX
ezetimibe/atorvastatin calcium LIPTRUZET(TAB)(10 MG-40MG) 3 XX
ezetimibe/atorvastatin calcium LIPTRUZET(TAB)(10 MG-80MG) 3 XX
ezetimibe/simvastatin VYTORIN(TAB)(10 MG-10MG) 3 XX
ezetimibe/simvastatin VYTORIN(TAB)(10 MG-20MG) 3 XX
ezetimibe/simvastatin VYTORIN(TAB)(10 MG-40MG) 3 XX
ezetimibe/simvastatin VYTORIN(TAB)(10 MG-80MG) 3 XX
mipomersen sodium KYNAMRO 4 X X
fluvastatin sodium LESCOL 1 XX
rosuvastatin calcium CRESTOR(TAB)(10 MG) 2 XX
rosuvastatin calcium CRESTOR(TAB)(20 MG) 2 XX
rosuvastatin calcium CRESTOR(TAB)(40 MG) 2 XX
rosuvastatin calcium CRESTOR(TAB)(5 MG) 2 XX
lovastatin ALTOPREV 3 XX
pitavastatin calcium LIVALO 3 XX
atorvastatin calcium LIPITOR 5
lovastatin LOVASTATIN 5
pravastatin sodium PRAVACHOL 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 24 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
pravastatin sodium PRAVASTATIN SODIUM 5
simvastatin ZOCOR(TAB)(10 MG) 5
simvastatin ZOCOR(TAB)(20 MG) 5
simvastatin ZOCOR(TAB)(40 MG) 5
simvastatin ZOCOR(TAB)(5 MG) 5
simvastatin ZOCOR(TAB)(80 MG) 5 X
lomitapide mesylate JUXTAPID(CAP)(10 MG) 4 X X
lomitapide mesylate JUXTAPID(CAP)(20 MG) 4 X X
lomitapide mesylate JUXTAPID(CAP)(30 MG) 4 X X
lomitapide mesylate JUXTAPID(CAP)(40 MG) 4 X X
lomitapide mesylate JUXTAPID(CAP)(5 MG) 4 X X
lomitapide mesylate JUXTAPID(CAP)(60 MG) 4 X X
alirocumab PRALUENT PEN 4 X X
alirocumab PRALUENT SYRINGE 4 X X
evolocumab REPATHA SURECLICK 4 X X
evolocumab REPATHA SYRINGE 4 X X SIMCOR(TBMP 24HR)(1000- niacin/simvastatin 2 XX 20MG) SIMCOR(TBMP 24HR)(1000-40 niacin/simvastatin 2 XX MG) SIMCOR(TBMP 24HR)(500MG- niacin/simvastatin 2 XX 20MG) SIMCOR(TBMP 24HR)(500MG- niacin/simvastatin 2 XX 40MG) SIMCOR(TBMP 24HR)(750MG- niacin/simvastatin 2 XX 20MG) ADVICOR(TBMP 24HR)(1000- niacin/lovastatin 3 XX 20MG) ADVICOR(TBMP 24HR)(1000- niacin/lovastatin 3 XX 40 MG) ADVICOR(TBMP 24HR)(500MG- niacin/lovastatin 3 XX 20MG) ADVICOR(TBMP 24HR)(750MG- niacin/lovastatin 3 XX 20MG) colesevelam hcl WELCHOL 2
colestipol hcl COLESTID(PACKET)(7.5 G) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 25 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
cholestyramine (with sugar) QUESTRAN 5
cholestyramine/aspartame PREVALITE 5
cholestyramine/aspartame QUESTRAN LIGHT 5
colestipol hcl COLESTID(GRANULES) 5
colestipol hcl COLESTID(PACKET)(5 G) 5
colestipol hcl COLESTID(TAB) 5
fenofibrate,micronized FENOFIBRATE 1
fenofibrate FENOGLIDE 1
fenofibrate LIPOFEN 1
fenofibrate nanocrystallized TRICOR 1
fenofibric acid FIBRICOR 1
fenofibric acid (choline) TRILIPIX 1
niacin NIASPAN 1 X
ezetimibe ZETIA 2 X
icosapent ethyl VASCEPA 2 X
fenofibrate,micronized ANTARA 3 X
methionine/inositol/choline/fa LIPOCHOL PLUS 3
fenofibrate,micronized LOFIBRA 5
fenofibrate LOFIBRA 5
fenofibrate nanocrystallized TRIGLIDE 5 X
gemfibrozil LOPID 5
omega-3 acid ethyl esters LOVAZA 5 X
niacinamide NIACINAMIDE(OTC) 1
niacin (inositol niacinate) NIACIN FLUSH FREE(OTC) 3
niacin (inositol niacinate) NIACIN(OTC) 3
niacin NIACIN(OTC) 5
niacin SLO-NIACIN(OTC) 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 26 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS
midodrine hcl MIDODRINE HCL 1
droxidopa NORTHERA 4 X X
sacubitril/valsartan ENTRESTO 3 X X RANEXA(TAB ER 12H)(1000 ranolazine 2 X MG) ranolazine RANEXA(TAB ER 12H)(500 MG) 2 X
ivabradine hcl CORLANOR 2 X X
amlodipine/atorvastatin CADUET 1 X
CARDIOVASCULAR DISEASE - VASODILATION
amyl nitrite AMYL NITRITE 1
isosorbide dinitrate ISORDIL 2
nitroglycerin NITRO-BID 2 NITRO-DUR(PATCH TD24)(0.3 nitroglycerin 2 MG/HR) NITRO-DUR(PATCH TD24) nitroglycerin 2 (0.8MG/HR) isosorbide dinitrate DILATRATE-SR 3
isosorbide dinitrate ISOCHRON 5
isosorbide dinitrate ISORDIL TITRADOSE 5
isosorbide dinitrate ISOSORBIDE DINITRATE 5
isosorbide mononitrate ISOSORBIDE MONONITRATE ER 5 NITRO-DUR(PATCH TD24) nitroglycerin 5 (0.1MG/HR) NITRO-DUR(PATCH TD24) nitroglycerin 5 (0.2MG/HR) NITRO-DUR(PATCH TD24) nitroglycerin 5 (0.4MG/HR) NITRO-DUR(PATCH TD24) nitroglycerin 5 (0.6MG/HR) nitroglycerin NITROSTAT 5
ergoloid mesylates ERGOLOID MESYLATES 1
isoxsuprine hcl ISOXSUPRINE HCL 1
papaverine hcl PAPAVERINE HCL 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 27 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
CONTRACEPTION/OXYTOCICS
etonogestrel/ethinyl estradiol NUVARING 5 XX
etonogestrel NEXPLANON 5 X
medroxyprogesterone acetate DEPO-PROVERA 5 X
medroxyprogesterone acetate DEPO-SUBQ PROVERA 104 5 X
nonoxynol 9 VCF(OTC) 5
nonoxynol 9 CONCEPTROL(OTC) 5
nonoxynol 9 GYNOL II(OTC) 5 TODAY CONTRACEPTIVE nonoxynol 9 5 SPONGE(OTC) desog-e.estradiol/e.estradiol AZURETTE 5
desogestrel-ethinyl estradiol APRI 5
drospir/eth estra/levomefol ca BEYAZ 5 X
drospir/eth estra/levomefol ca SAFYRAL 5 X
estradiol valerate/dienogest NATAZIA 5 X
ethinyl estradiol/drospirenone OCELLA 5 X
ethynodiol d-ethinyl estradiol KELNOR 1-35 5
l-norgest/e.estradion-e.estrad CAMRESE 5 X
l-norgest/e.estradion-e.estrad QUARTETTE 5
levonorgestrel MY WAY(OTC) 5
levonorgestrel-ethin estradiol LEVORA-28 5
levonorgestrel-ethin estradiol AMETHYST 5 X
noreth-ethinyl estradiol/iron GENERESS FE 5
norethindrone NORA-BE 5
norethindrone ac-eth estradiol LOESTRIN 5
norethindrone ac-eth estradiol MICROGESTIN 5
norethindrone-e.estradiol-iron MICROGESTIN FE 5
norethindrone-e.estradiol-iron LO LOESTRIN FE 5 X
norethindrone-e.estradiol-iron MINASTRIN 24 FE 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 28 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
norethindrone-ethinyl estrad NECON 5
norethindrone-ethinyl estrad ORTHO-NOVUM 5
norethindrone-mestranol NORINYL 1+50 5
norgestimate-ethinyl estradiol SPRINTEC 5
norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO 5 X
norgestrel-ethinyl estradiol CRYSELLE 5
ulipristal acetate ELLA 5
norelgestromin/ethin.estradiol ORTHO EVRA 5 X
diaphragms, wide seal WIDE SEAL DIAPHRAGM 5
cervical cap FEMCAP 5 METHYLERGONOVINE MALE- methylergonovine maleate 1 ATE dinoprostone CERVIDIL 3
dinoprostone PREPIDIL 3 PROSTIN E2 VAGINAL SUPPOS- dinoprostone 3 ITORY COUGH AND COLD
phenylephrine hcl/prometh hcl PROMETHAZINE VC 1 SUDOGEST SINUS & ALLER- pseudoephed/chlorpheniramine 1 GY(OTC) pseudoephedrine/brompheni- ramin Q-TAPP(OTC) 1
pseudoephedrine/triprolidine APRODINE(OTC) 1
chlorcyclizine/pseudoephedrine STAHIST AD(OTC) 3 pseudoephedrine/brompheni- ramin LODRANE D(OTC) 3
benzonatate BENZONATATE 1
benzonatate TESSALON PERLE 1
benzonatate ZONATUSS 1
guaifenesin/pseudoephedrne hcl ENTEX T(OTC) 1
guaifenesin/pseudoephedrne hcl DESPEC-TAB(OTC) 3
guaifenesin/pseudoephedrne hcl MUCINEX D(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 29 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
guaifenesin/pseudoephedrne hcl POLY-VENT IR(OTC) 3
guaifenesin/pseudoephedrne hcl RESPAIRE-30(OTC) 3
guaifenesin/pseudoephedrne hcl TUSNEL PEDIATRIC(OTC) 3 ADVIL COLD & SINUS(TAB) ibuprofen/pseudoephedrine hcl 1 (OTC) ADVIL COLD & SINUS(CAP) ibuprofen/pseudoephedrine hcl 3 (OTC) pseudoephedrine hcl SINUS 12 HOUR(OTC) 1
promethazine/phenyleph/codeine PROMETHAZINE VC-CODEINE 1
pseudoephed/hydrocodone/cpm ZUTRIPRO 1
hydrocodone/chlorphen p-stirex TUSSIONEX 1
promethazine hcl/codeine PROMETHAZINE-CODEINE 1
hydrocodone/chlorphen p-stirex TUSSICAPS 3
hydrocodone bit/homatrop me-br HYDROMET 1 BROMPHENIRAMINE-PSEUDO- d-methorphan hb/p-epd hcl/bpm 1 EPHED-DM dexbromphen/pseudoephedrine/ dm M-END DMX(OTC) 3
guaifenesin/dm/pseudoephedrine TUSNEL(OTC) 3
promethazine/dextromethorphan PROMETHAZINE-DM 1
guaifenesin/dm/pseudoephedrine DESPEC-DM(OTC) 1
guaifenesin/dm/pseudoephedrine CAPMIST DM(OTC) 3
guaifenesin/dm/pseudoephedrine ENTEX PAC(OTC) 3
guaifenesin/dm/pseudoephedrine MAXIFED DM(OTC) 3
guaifenesin/dm/pseudoephedrine POLY-VENT DM(OTC) 3
guaifenesin/dm/pseudoephedrine TUSNEL(OTC) 3
guaifenesin/dm/pseudoephedrine TUSNEL-DM PEDIATRIC(OTC) 3
tetrahydrozoline hcl TYZINE 3
pseudoephedrine hcl SUDOGEST(OTC) 1
pseudoephedrine sulfate 12 HOUR COLD RELIEF(OTC) 1
pseudoephedrine hcl NEXAFED(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 30 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
pseudoephedrine hcl SUDAFED 24-HOUR(OTC) 3
DERMATOLOGY - ACNE
isotretinoin CLARAVIS 1
isotretinoin ABSORICA 3 X
clindamycin phos/benzoyl perox BENZACLIN(GEL) 1
sulfacetamide sodium KLARON 1
clindamycin phos/benzoyl perox ACANYA 2
clindamycin/tretinoin ZIANA 2
adapalene/benzoyl peroxide EPIDUO 3 X X X
adapalene/benzoyl peroxide EPIDUO FORTE 3 X X X
azelaic acid AZELEX 3
clindamycin phos/benzoyl perox BENZACLIN(GEL W/PUMP) 3 X
clindamycin phos/benzoyl perox ONEXTON 3
clindamycin/benzoyl/emol cmb94 NEUAC 3
clindamycin/tretinoin VELTIN 3 X
dapsone ACZONE 3
bacitracin BACIIM 1 BUTYLATED HYDROXYTOLU- butylated hydroxytoluene 3 ENE(BHT) benzoyl peroxide/hydrocortison VANOXIDE-HC 2
metronidazole METROGEL 1
metronidazole METROLOTION 1
metronidazole METRONIDAZOLE 1
metronidazole ROSADAN 1
azelaic acid FINACEA 3
brimonidine tartrate MIRVASO 3 X
ivermectin SOOLANTRA 3
metronidazole NORITATE 3
metronidazole/skin cleansr #23 ROSADAN 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 31 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL HYDROCORTISONE-IODOQUI- hydrocortisone/iodoquinol 1 NOL hydrocortisone/iodoquinol/aloe VYTONE 1
iodine/potassium iodide LU G O L’ S 1
silver nitrate SILVER NITRATE 1
cadexomer iodine IODOFLEX 3
cadexomer iodine IODOSORB 3
clioquinol/hc/emollient cmb#88 DERMASORB AF 3
clioquinol/hydrocortisone ALA-QUIN 3
hydrocortisone/iodoquin/aloe#2 ALCORTIN A 3
iodoquinol/aloe polysacchar #1 ALOQUIN 3
silver ARIDA 3
silver SILVRSTAT 3
silver carbonate NORMLGEL AG 3
adapalene DIFFERIN 1 X
tretinoin ATRALIN 1 X
tretinoin RETIN-A 1 X
tretinoin microspheres RETIN-A MICRO 1 X RETIN-A MICRO PUMP(GEL W/ tretinoin microspheres 1 X PUMP)(0.04 %) RETIN-A MICRO PUMP(GEL W/ tretinoin microspheres 1 X PUMP)(0.1 %) tretinoin TRETIN-X 3 X RETIN-A MICRO PUMP(GEL W/ tretinoin microspheres 3 X PUMP)(0.08 %) tretinoin/emol cmb9/skin cln1 TRETIN-X 3 X
tazarotene FABIOR 2 X
DERMATOLOGY - ANTIINFECTIVE
nitazoxanide ALINIA 3
clindamycin phosphate CLEOCIN T 1
clindamycin phosphate CLINDACIN P 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 32 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
clindamycin phosphate EVOCLIN 1
erythromycin base/ethanol ERYGEL 1
erythromycin base/ethanol ERYTHROMYCIN 1
erythromycin/benzoyl peroxide BENZAMYCIN 1
gentamicin sulfate GENTAMICIN SULFATE 1
mupirocin BACTROBAN 1
mupirocin calcium BACTROBAN 1
erythromycin/benzoyl peroxide BENZAMYCINPAK 2
clindamycin phos/skin clnsr 19 CLINDACIN ETZ 3
clindamycin phos/skin clnsr 19 CLINDACIN PAC 3
clindamycin phosphate CLINDAGEL 3
mupirocin CENTANY AT 3 CLOTRIMAZOLE-BETAMETHA- clotrimazole/betamethasone dip 1 SONE clotrimazole/betamethasone dip LOTRISONE 1
ciclopirox CICLOPIROX 1
ciclopirox LOPROX 1
ciclopirox PENLAC 1
ciclopirox olamine CICLODAN 1
ciclopirox olamine CICLOPIROX 1
ciclopirox/ure/camph/menth/euc CICLODAN 1
clotrimazole CLOTRIMAZOLE 1
econazole nitrate ECONAZOLE NITRATE 1
gentian viol/brlnt grn/proflav TRIPLE DYE 1
ketoconazole KETOCONAZOLE 1
ketoconazole NIZORAL 1
naftifine hcl NAFTIN(CREAM)(1 %) 1
nystatin NYSTATIN 1
nystatin/triamcin NYSTATIN-TRIAMCINOLONE 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 33 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
sodium thiosulfate/sal acid EXODERM 1
naftifine hcl NAFTIN(CREAM)(2 %) 2
naftifine hcl NAFTIN(GEL)(1 %) 2
sulconazole nitrate EXELDERM 2
butenafine hcl MENTAX 3
ciclopirox/nail lacquer removr CNL 8 3
ciclopirox/skin cleanser no.28 CICLODAN 3
ciclopirox/urea PEDIPAK 3
econazole nitrate ECOZA 3
efinaconazole JUBLIA 3 X
ketoconazole EXTINA 3
ketoconazole XOLEGEL 3
luliconazole LUZU 3 XX
miconazole nitrate/zinc ox/pet VUSION 3
naftifine hcl NAFTIN(GEL)(2 %) 3
nystatin/emollient combo no.54 PEDIADERM AF 3
oxiconazole nitrate OXISTAT 3
sertaconazole nitrate ERTACZO 3
tavaborole KERYDIN 3 X
lindane LINDANE 1
malathion OVIDE 1
permethrin ELIMITE 1
spinosad NATROBA 1
crotamiton EURAX 2
benzyl alcohol ULESFIA 3
citric/citronellyl/hydrox/meth LYCELLE 3
ivermectin SKLICE 3
acyclovir ZOVIRAX(OINT) 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 34 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
acyclovir ZOVIRAX(CREAM) 2
penciclovir DENAVIR 3
acyclovir/hydrocortisone XERESE 3 XX
sinecatechins VEREGEN 3
retapamulin ALTABAX 3
silver sulfadiazine SILVER SULFADIAZINE 1 SODIUM SULFACETAMIDE-SUL- sulfacetamide sod/sulfur/urea 1 FUR sulfacetamide sodium/sulfur AVAR(CLEANSER) 1
sulfacetamide sodium/sulfur AVAR-E LS 1
sulfacetamide sodium/sulfur PLEXION(CLEANSER) 1
sulfacetamide sodium/sulfur PLEXION(CREAM) 1
sulfacetamide sodium/sulfur PLEXION(LOTION) 1
sulfacetamide sodium/sulfur ROSULA(MED PAD) 1 SODIUM SULFACETAMIDE-SUL- sulfacetamide sodium/sulfur 1 FUR sulfacetamide sodium/sulfur SS 10-2 1
sulfacetamide sodium/sulfur SUMADAN 1
sulfacetamide sodium/sulfur ZENCIA 1 SODIUM SULFACETAMIDE-SUL- sulfacetamide/sulfur/cleansr23 1 FUR sulfact sod/sulur/avob/otn/oct SUMADAN XLT 1
mafenide acetate SULFAMYLON 3
sulfacetamide sodium/sulfur AVAR LS 3
sulfacetamide sodium/sulfur AVAR(FOAM) 3
sulfacetamide sodium/sulfur AVAR(MED PAD) 3
sulfacetamide sodium/sulfur PLEXION(MED PAD) 3
sulfacetamide sodium/sulfur ROSANIL 3
sulfacetamide sodium/sulfur ROSULA(CLEANSER) 3
sulfacetamide/sulfur/cleansr23 SUMADAN 3
sulfacetamide/sulfur/cleansr23 SUMAXIN CP 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 35 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
DERMATOLOGY - ANTI-INFLAMMATORY
hc/mineral oil/petrolat,wht HYDROCORTISONE 1 ALCLOMETASONE DIPROPIO- alclometasone dipropionate 1 NATE amcinonide AMCINONIDE 1 BETAMETHASONE DIPROPIO- betamethasone dipropionate 1 NATE betamethasone valerate BETAMETHASONE VALERATE 1
betamethasone valerate LUXIQ 1
betamethasone/propylene glyc DIPROLENE 1
betamethasone/propylene glyc DIPROLENE AF 1
clobetasol propionate CLOBETASOL PROPIONATE 1
clobetasol propionate CLOBEX 1
clobetasol propionate CLODAN 1
clobetasol propionate OLUX 1
clobetasol propionate TEMOVATE 1
clobetasol propionate/emoll CLOBETASOL EMOLLIENT 1
clobetasol propionate/emoll TEMOVATE EMOLLIENT 1
clocortolone pivalate CLODERM 1
desonide DESONIDE 1
desonide DESOWEN 1
desoximetasone TOPICORT(CREAM) 1
desoximetasone TOPICORT(GEL) 1
desoximetasone TOPICORT(OINT) 1
diflorasone diacetate DIFLORASONE DIACETATE 1
diflorasone diacetate PSORCON 1
fluocinolone acetonide DERMA-SMOOTHE-FS 1
fluocinolone acetonide FLUOCINOLONE ACETONIDE 1
fluocinolone acetonide SYNALAR 1
fluocinolone/shower cap DERMA-SMOOTHE-FS 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 36 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
fluocinonide FLUOCINONIDE 1
fluocinonide VANOS 1
fluocinonide/emollient base FLUOCINONIDE-E 1
fluticasone propionate CUTIVATE 1
fluticasone propionate FLUTICASONE PROPIONATE 1
halobetasol propionate ULTRAVATE 1
hydrocortisone HYDROCORTISONE 1
hydrocortisone acetate/urea U-CORT 1
hydrocortisone butyrate LOCOID(CREAM) 1
hydrocortisone butyrate LOCOID(OINT) 1
hydrocortisone butyrate LOCOID(SOLUTION) 1
hydrocortisone butyrate/emoll LOCOID LIPOCREAM 1
hydrocortisone valerate HYDROCORTISONE VALERATE 1
mometasone furoate ELOCON 1
prednicarbate DERMATOP 1
triamcinolone acet/dimethicone DERMASILKRX SDS 1 XX
triamcinolone acetonide KENALOG 1
triamcinolone acetonide TRIAMCINOLONE ACETONIDE 1
diflorasone diacetate/emoll APEXICON E 2
flurandrenolide CORDRAN 2
hydrocort/sal acid/sulf/shmp#1 SCALACORT DK 2
hydrocortisone TEXACORT 2
hydrocortisone probutate PANDEL 2
clobetasol/skin cleanser #28 CLODAN 3
desonide DESONATE 3
desonide VERDESO 3
desoximetasone TOPICORT(SPRAY) 3 X
fluocinolone acetonide CAPEX SHAMPOO 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 37 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
fluocinolone/emol cmb#65 SYNALAR 3
fluocinolone/skin clnsr28 SYNALAR TS 3
halcinonide HALOG 3
halobetasol/lactic acid ULTRAVATE X 3
hydrocortisone acetate/aloe v NUCORT 3
hydrocortisone butyrate LOCOID(LOTION) 3
hydrocortisone/emol no.45 PEDIADERM HC 3
hydrocortisone/skin clnsr #25 AQUA GLYCOLIC HC 3
hydrocortisone/skin clnsr #35 DERMASORB HC 3
triamcinolone acet/dimethicone WHYTEDERM TDPAK 3
triamcinolone acet/dimethicone WHYTEDERM TRILASIL PAK 3
triamcinolone aceton/silicones DERMACINRX SILAZONE 3
triamcinolone/emollient cmb#45 PEDIADERM TA 3
triamcinolone/emollient cmb#86 DERMASORB TA 3
diclofenac sodium DICLOFENAC SODIUM 1
diclofenac sodium VOLTAREN 2
diclofenac epolamine FLECTOR 3
diclofenac sodium PENNSAID 3 X
neomycin/bacitra/polymyxin/hc CORTISPORIN 2
neomycin/polymyxin b sulf/hc CORTISPORIN 2
neomycin sulfate/fluocinolone NEO-SYNALAR 3 X
neomycin/fluocinolone/emol #65 NEO-SYNALAR 3 X
DERMATOLOGY - ANTIPRURITIC DRUGS
doxepin hcl PRUDOXIN 3
doxepin hcl ZONALON 3
na mg fl/na pho/nacl/ha/na hyp ALEVICYN 3
DERMATOLOGY - MISCELLANEOUS
aluminum chloride DRYSOL 2
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 38 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
emollient combination no.43 TL TRISEB 1
emollient combination no.85 LOUTREX 1
selenium sulfide SELENIUM SULFIDE 1
sulfacetamide sodium OVACE 1
sulfacetamide sodium SODIUM SULFACETAMIDE 1
sulfacetamide sodium OVACE PLUS(SHAMPOO) 2
emollient #43/skin cleanser#27 PROMISEB COMPLETE 3
emollient combination no.43 PROMISEB 3
selenium sulfide SELRX 3
selenium sulfide TERSI FOAM 3
sulfacetamide sodium OVACE PLUS(CLEANSR ER) 3
sulfacetamide sodium OVACE PLUS(CREAM) 3
sulfacetamide sodium OVACE PLUS(FOAM) 3
sulfacetamide sodium OVACE PLUS(LOTION) 3 X
guaiacol GUAIACOL 3
ammonium lactate AMMONIUM LACTATE 1 em#53/namgf/cyc/phos/nahc/ nacl MB HYDROGEL 1
emol53/namgfs/ha/nahypochlorit MB HYDROGEL 1
emollient combination no.10 PRUTECT 1
emollient combination no.32 EMULSION SB 1
emollient combination no.35 PRUMYX 1
emollient combination no.53 HPR PLUS(CREAM) 1
lactic acid LACTIC ACID 1
vite ac/grape/hyaluronic acid PRUCLAIR 1
emollient combination no.32 EPICERAM 3
emollient combination no.38 NEOSALUS 3
emollient combination no.44 HPR 3
emollient combination no.44 HYLATOPIC 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 39 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
emollient combination no.47 NEOSALUS 3
emollient combination no.47 NEOSALUS CP 3
emollient combination no.48 TROPAZONE 3
emollient combination no.53 HPR PLUS(FOAM) 3
emollient combination no.53 HYLATOPIC PLUS 3
emollient combination no.60 ALEVICYN ANTIPRURITIC SG 3
emollient combination no.60 ATRAPRO HYDROGEL 3
emollient combination no.60 CELACYN 3
emollient combination no.60 ZANABIN 3
emollient combination no.80 PRESERA 3
emollient combo no.47 & no.60 ATRAPRO CP 3
hyaluro/dl-e ac/e12/allan/shea XCLAIR 3
namgflu/cyclo/phos/nahco3/nacl AURSTAT 3
palm oil/hyaluronate sodium PEDIAPALM 3
water for irrigation,sterile WATER 1
acetic acid ACETIC ACID 1
mannitol/sorbitol solution SORBITOL-MANNITOL 1
neomycin su/polymyx b sulf NEOSPORIN G.U. IRRIGANT 1
ringers solution RINGERS IRRIGATION 1
sodium chloride irrig solution SODIUM CHLORIDE 1
sorbitol solution SORBITOL 1
ringers solution,lactated LACTATED RINGERS 3
organ preservation soln-belzer VIASPAN BELZER-UW 3
sodium chlor/hypochlorous acid VASHE WOUND THERAPY 3 SINELEE(ADH PATCH)(0.0375%- capsaicin/menthol 1 5%) capsaicin/menthol RELY Y T 3 SINELEE(ADH PATCH)(0.05%- capsaicin/menthol 3 5%) capsaicin/menthol SOLAICE 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 40 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
capsaicin/menthol/histamine SILMANIX 3
capsaicin/skin cleanser QUTENZA 3 X
benzoyl peroxide BPO 1
benzoyl peroxide microspheres BENZEPRO 1
podofilox CONDYLOX(SOLUTION) 1
podophyllum resin PODOCON-25 1
potassium hydroxide POTASSIUM HYDROXIDE 1
salicylic acid KER ALY T 1
salicylic acid SALACYN 1
salicylic acid SALEX 1
salicylic acid SALICYLIC ACID 1
salicylic acid VIRASAL 1
salicylic acid/ammon lact/aloe SALICYLIC ACID 1
salicylic acid/ceramide cmb #1 SALEX 1
silver nitrate applicator SILVER NITRATE APPLICATOR 1
urea ALUVEA 1
urea KERALAC 1
urea REA LO 40 1
urea UMECTA(NL FM SUSP) 1
urea URAMAXIN(CREAM) 1
urea URAMAXIN(GEL) 1
urea URAMAXIN(LOTION) 1
urea UREA 1
urea/hyaluronate sodium UREA 1
urea/lactic ac/zn undecylenate BP-50% UREA 1
urea/lactic acid/salicylic ac LATRIX 1
podofilox CONDYLOX(GEL) 2
benzoyl peroxide PACNEX HP 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 41 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
benzoyl peroxide PACNEX LP 3
benzoyl peroxide PACNEX MX 3
benzoyl peroxide/sulfur NUOX 3
benzoyl peroxide/vit e mix INOVA 3
salicylic ac/benzoyl per/vit e INOVA 4-1 3
salicylic ac/benzoyl per/vit e INOVA 8-2 3
salicylic acid BENSAL HP 3
salicylic acid KERALYT SCALP 3
salicylic acid ULTRASAL-ER 3
salicylic acid/urea SALVAX DUO PLUS 3
urea CARB-O-PHILIC 3
urea GORDO-UREA 3
urea HYDRO 35 3
urea KERAFOAM 3
urea UMECTA PD 3
urea UMECTA(EMULSN) 3
urea URAMAXIN(FOAM) 3
urea UREVAZ 3
urea UTOPIC 3
urea/emollient cmb no.18 DERMASORB XM 3
urea/emollient combination #65 URAMAXIN GT 3
hyp ac/sod chl/sod sul/sod pho ALEVICYN 3
hypoc acid/sod hypo/nacl/water ATRAPRO DERMAL SPRAY 3
hypoc acid/sod hypo/nacl/water MICROCYN 3
petrolatum,white VASELINE WHITE PETROLEUM 1
protect cmb2/ceramide 1,3,6-11 PR CREAM 1
bio/carb/equis/ethan/chit/msm GENADUR 3
carbit/equis xt/ethan/chit/msm GENADUR 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 42 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
di-me silox/dimethic/hexamethy BEAU RX 3 XX
hocl/na hy/namgf/na ph/nacl/wa MICROCYN HYDROGEL 3
hyaluron sod/allantoin/aloe xt RADIAPLEXRX 3
hyaluronate sodium BIONECT 3
hyaluronate sodium/he-cell/peg HYGEL 3
poly-ureaurethane NUVAIL 3
polydimethylsiloxanes/silicon RECEDO 3
protectives combination no.2 TETRIX 3
urea CARB-O-PHILIC 1 PRAMOSONE(CREAM)(2.5 %-1 hydrocortisone/pramoxine 1 %) lidocaine/hydrocortisone ac LIDOCAINE-HYDROCORTISONE 1
hydrocortisone/pramoxine ANALPRAM HC 2
hydrocortisone/pramoxine PRAMOSONE(CREAM)(1 %-1 %) 2
hydrocortisone/pramoxine PRAMOSONE(LOTION) 2
hydrocortisone/pramoxine PRAMOSONE(OINT) 2
hydrocortisone/pramoxine EPIFOAM 3
hydrocortisone/pramoxine/aloe NOVACORT 3
hydrocortisone/pramoxine/emoll PRAMOSONE E 3
diclofenac sodium SOLARAZE 1 X X
fluorouracil CARAC 1
fluorouracil EFUDEX 1
fluorouracil FLUOROURACIL 1
ingenol mebutate PICATO(GEL)(0.015 %) 2 X
ingenol mebutate PICATO(GEL)(0.05 %) 2 X
fluorouracil FLUOROPLEX 3
fluorouracil TOLAK 3
alitretinoin PANRETIN 4 X
bexarotene TARGRETIN 4 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 43 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
mechlorethamine hcl VALCHLOR 4 X X
cocaine hcl COCAINE HCL 1
ethyl chloride ETHYL CHLORIDE 1
lidocaine LIDOCAINE 1
lidocaine LIDODERM 1
lidocaine hcl LIDOCAINE HCL 1
lidocaine hcl LIDOPIN(CREAM)(3 %) 1
lidocaine hcl/menthol ZERUVIA 1
lidocaine/prilocaine EMLA 1
lidocaine/prilocaine RELADOR PAK PLUS 1
lidocaine/tetracaine PLIAGLIS 1
benzocaine ANACAINE 3
lidocain/zn/meadowsw xt/oak xt LDO PLUS 3
lidocaine LIDOVEX 3
lidocaine hcl LIDOPIN(CREAM)(3.25 %) 3
lidocaine hcl LIDORX 3
lidocaine hcl/collagen REGENECARE 3
lidocaine hcl/menthol PAIN RELIEF 3
lidocaine hcl/menthol SYNVEXIA TC 3
lidocaine/allantoin/petrolatum SCAR 3
lidocaine/allantoin/petrolatum VEXA 3
lidocaine/benzocain/me-sal/cap ADAZIN 3
lidocaine/capsaicin/menthol SILVERA 3
lidocaine/menthol RELY YKS 3
lidocaine/methyl sal/menthol VELMA 3
lidocaine/skin cleanser no.37 DERMASILKRX LIDORXKIT 3
lidocaine/tetracaine SYNERA 3
norflurane/hfc 245fa PAIN EASE 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 44 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
norflurane/hfc 245fa SPRAY AND STRETCH 3
tetracaine hcl PONTOCAINE 3
tetracaine/benzocaine/butamben CETACAINE 3
tetracaine/benzocaine/butamben CETACAINE ANESTHETIC 3
vit e/lidocain/alo ver/colagn REGENECARE 3
povidone-iodine BETADINE 3
trypsin/balsam peru/castor oil GRANULEX 1
collagenase clostridium hist. SANTYL 3
DERMATOLOGY - PIGMENTATION DISORDERS
methoxsalen OXSORALEN 2
DERMATOLOGY - PSORIASIS/ECZEMA
methoxsalen, rapid OXSORALEN-ULTRA 1
methoxsalen 8-MOP 2
acitretin SORIATANE 4 X
secukinumab COSENTYX (2 SYRINGES) 4 X X
secukinumab COSENTYX PEN 4 X X
secukinumab COSENTYX PEN (2 PENS) 4 X X
secukinumab COSENTYX SYRINGE 4 X X
calcipotriene CALCIPOTRIENE 1 X
calcipotriene DOVONEX 1 X
calcitriol VECTICAL 1 X
anthralin DRITHOCREME HP 2 X
tazarotene TAZORAC 2
anthralin ZITHRANOL-RR 3 X
anthralin micronized ZITHRANOL 3 X
calcipotriene SORILUX 3 X
pyrogallol PYROGALLIC ACID 3
urea GORDO-UREA 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 45 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
tacrolimus PROTOPIC 1 X X
pimecrolimus ELIDEL 3 X X
calcipotriene/betamethasone TACLONEX(OINT) 1 X
calcipotriene/betamethasone TACLONEX(SUSPENSION) 3 X
DIABETES
alogliptin benz/metformin hcl KAZANO 3 XX KOMBIGLYZE XR(TBMP 24HR) saxagliptin hcl/metformin hcl 3 XX (2.5-1000MG) KOMBIGLYZE XR(TBMP 24HR) saxagliptin hcl/metformin hcl 3 XX (5 MG-500MG) KOMBIGLYZE XR(TBMP 24HR) saxagliptin hcl/metformin hcl 3 XX (5MG-1000MG) linagliptin/metformin hcl JENTADUETO 5 X
sitagliptin phos/metformin hcl JANUMET 5 X JANUMET XR(TBMP 24HR)(100- sitagliptin phos/metformin hcl 5 X 1000MG) JANUMET XR(TBMP 24HR)(50- sitagliptin phos/metformin hcl 5 X 1000 MG) JANUMET XR(TBMP 24HR) sitagliptin phos/metformin hcl 5 X (50MG-500MG) alogliptin benz/pioglitazone OSENI 3 XX
albiglutide TANZEUM 3 XX BYETTA(PEN INJCTR) exenatide 3 XX (10MCG/0.04) BYETTA(PEN INJCTR) exenatide 3 XX (5MCG/0.02) exenatide microspheres BYDUREON 3 XX
exenatide microspheres BYDUREON PEN 3 XX
dulaglutide TRULICITY 5 XX
liraglutide VICTOZA 2-PAK 5 XX
liraglutide VICTOZA 3-PAK 5 XX
dapagliflozin propanediol FARXIGA 3 XX
empagliflozin JARDIANCE 3 XX
canagliflozin INVOKANA 5 XX
bromocriptine mesylate CYCLOSET 3 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 46 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
acarbose PRECOSE 1
miglitol GLYSET 3
pramlintide acetate SYMLINPEN 120 2
pramlintide acetate SYMLINPEN 60 2
alogliptin benzoate NESINA 3 XX
saxagliptin hcl ONGLYZA 3 XX
linagliptin TRADJENTA 5 X
sitagliptin phosphate JANUVIA 5 X
repaglinide PRANDIN 1
glyburide,micronized GLYNASE 5
chlorpropamide CHLORPROPAMIDE 5
glimepiride AMARYL 5
glipizide GLUCOTROL 5
glyburide GLYBURIDE 5
glyburide DIABETA 5
nateglinide STARLIX 5
tolazamide TOLAZAMIDE 5
tolbutamide TOLBUTAMIDE 5
rosiglitazone maleate AVANDIA 3 X
pioglitazone hcl ACTOS 5
empagliflozin/linagliptin GLY X AMBI 5 XX
metformin hcl RIOMET 2
metformin hcl GLUMETZA 3 X
metformin hcl GLUCOPHAGE 5
glipizide/metformin hcl GLIPIZIDE-METFORMIN 5
glyburide/metformin hcl GLUCOVANCE 5
glyburide/metformin hcl GLYBURIDE-METFORMIN HCL 5
repaglinide/metformin hcl PRANDIMET 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 47 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
pioglitazone hcl/glimepiride DUETACT 5 X
mifepristone KORLYM 4 X X
dapagliflozin/metformin hcl XIGDUO XR 3 XX
empagliflozin/metformin hcl SYNJARDY 3
canagliflozin/metformin hcl INVOKAMET 5 XX
pioglitazone hcl/metformin hcl ACTOPLUS MET XR 2 X
rosiglitazone/metformin hcl AVANDAMET 3 X
pioglitazone hcl/metformin hcl ACTOPLUS MET 5 X
becaplermin REGRANEX 2
diazoxide PROGLYCEM 3
insulin aspart NOVOLOG FLEXPEN 5 XX
insulin aspart NOVOLOG(CARTRIDGE) 5 XX
insulin aspart NOVOLOG(VIAL) 5 XX
insulin aspart protam & aspart NOVOLOG MIX 70-30 5 XX
insulin aspart protam & aspart NOVOLOG MIX 70-30 FLEXPEN 5 XX
insulin degludec TRESIBA FLEXTOUCH U-100 5
insulin degludec TRESIBA FLEXTOUCH U-200 5
insulin detemir LEVEMIR 5 XX
insulin detemir LEVEMIR FLEXTOUCH 5 XX
insulin glulisine APIDRA 5 XX
insulin glulisine APIDRA SOLOSTAR 5 XX
insulin lispro HUMALOG KWIKPEN U-100 5 X
insulin lispro HUMALOG KWIKPEN U-200 5 X
insulin lispro HUMALOG(CARTRIDGE) 5 X
insulin lispro HUMALOG(VIAL) 5 X
insulin nph hum/reg insulin hm HUMULIN 70-30(OTC) 5 X HUMULIN 70/30 KWIK- insulin nph hum/reg insulin hm 5 X PEN(OTC) insulin nph hum/reg insulin hm NOVOLIN 70-30(OTC) 5 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 48 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
insulin nph human isophane HUMULIN N KWIKPEN(OTC) 5 X
insulin nph human isophane HUMULIN N(OTC) 5 X
insulin nph human isophane NOVOLIN N(OTC) 5 XX
insulin npl/insulin lispro HUMALOG MIX 50-50 5 X
insulin npl/insulin lispro HUMALOG MIX 50-50 KWIKPEN 5 X
insulin npl/insulin lispro HUMALOG MIX 75-25 5 X
insulin npl/insulin lispro HUMALOG MIX 75-25 KWIKPEN 5 X
glucagon,human recombinant GLUCAGON EMERGENCY KIT 2
glucagon,human recombinant GLUCAGEN 3
insulin glargine,hum.rec.anlog LANTUS 5 X
insulin glargine,hum.rec.anlog LANTUS SOLOSTAR 5 X
insulin glargine,hum.rec.anlog TOUJEO SOLOSTAR 5 X AFREZZA(CART W/DEV)(4 insulin regular, human 5 X UNIT(30)) AFREZZA(CART W/DEV)(4 insulin regular, human 5 X UNIT(60)) AFREZZA(CART W/DEV)(4 insulin regular, human 5 X UNIT) AFREZZA(CART W/DEV)(8 insulin regular, human 5 X UNIT(60)) insulin regular, human HUMULIN R U-500 5 X
insulin regular, human HUMULIN R(OTC) 5 X
insulin regular, human NOVOLIN R(OTC) 5 XX
EAR - GENERAL DISORDERS
fluocinolone acetonide oil DERMOTIC 1
acetic acid ACETIC ACID 1
acetic acid/aluminum acetate ACETIC ACID-ALUMINUM 1 HYDROCORTISONE-ACETIC acetic acid/hydrocortisone 1 ACID hc/pramox hcl/cl-xylenol/water CORTANE-B 1
hc/pramoxine hcl/chloroxylenol OTICIN HC 1
hc/pramoxine hcl/chloroxylenol CORTANE-B 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 49 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
ciprofloxacin hcl CETRAXAL 1
neomycin/polymyxin b sulf/hc NEOMYCIN-POLYMYXIN-HC 1
neomycin su/colist/hc/thonzon COLY-MYCIN S 3
neomycin su/colist/hc/thonzon CORTISPORIN-TC 3
antipyrine/benzocaine ANTIPYRINE-BENZOCAINE 1
benzocaine PINNACAINE 1
antipyrine/benzocain/gly/zinc OTOZIN 3
antipyrine/benzocaine OTIC CARE 3
ciprofloxacin hcl/dexameth CIPRODEX 2
ciprofloxacin/hydrocortisone CIPRO HC 3
chloroxylenol/pramoxine hcl OTICIN 1
chloroxylenol/benzoc/hydrocort TRIOXIN 3
ELECTROLYTE REGULATION
tolvaptan SAMSCA(TAB)(15 MG) 3 X
tolvaptan SAMSCA(TAB)(30 MG) 3 X
calcium acetate CALCIUM ACETATE 1
calcium acetate PHOSLO 1
calcium carbonate/mag carb/fa MAGNEBIND 400 RX 1
sodium polystyrene sulfonate KIONEX 1
sevelamer carbonate RENVELA 2
sevelamer hcl RENAGEL 2
calcium acetate PHOSLYR A 3
ferric citrate AURYXIA 3 X
lanthanum carbonate FOSRENOL 3
patiromer calcium sorbitex VELTASSA 3
sucroferric oxyhydroxide VELPHORO 3
electrolyte-148 solution PLASMA-LYTE 148 3
electrolyte-a solution PLASMA-LYTE A PH 7.4 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 50 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
electrolyte-r (ph 7.4) NORMOSOL-R PH 7.4 3
electrolyte-s solution ISOLY TE S 3
pot chloride/pot bicarb/cit ac POTASSIUM CHLORIDE 1
potassium bicarbonate/cit ac KLOR-CON-EF 1
potassium chloride K-SOL 1
potassium chloride K-TAB ER 1
potassium chloride KLOR-CON(PACKET)(20 MEQ) 1
potassium chloride POTASSIUM CHLORIDE 1 POTASSIUM CHL-NORMAL SA- potassium chloride in 0.9%nacl 1 LINE potassium chloride-0.45% nacl POTASSIUM CHLORIDE-NACL 1
potassium bicarbonate/cit ac EFFER-K 3
potassium chloride KLOR-CON(PACKET)(25 MEQ) 3
0.9 % sodium chloride NORMAL SALINE FLUSH 1
sodium chloride 0.45 % SODIUM CHLORIDE 1
sodium chloride 3 % SODIUM CHLORIDE 1
sodium chloride 5 % SODIUM CHLORIDE 1
ENDOCRINE DISORDER - FERTILITY
sildenafil citrate VIAGRA 2 X X
tadalafil CIALIS(TAB)(10 MG) 2 X X
tadalafil CIALIS(TAB)(2.5 MG) 2 X X
tadalafil CIALIS(TAB)(20 MG) 2 X X
tadalafil CIALIS(TAB)(5 MG) 2 X X
vardenafil hcl STAXYN 2 X X
alprostadil CAVERJECT 3 X
alprostadil EDEX 3 X
alprostadil MUSE 3 X
avanafil STENDRA 3 X X
vardenafil hcl LEVITRA 3 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 51 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
clomiphene citrate SEROPHENE 1
menotropins MENOPUR 4 X
urofollitropin BRAVELLE 3
follitropin alfa, recomb GONAL-F 4 X
follitropin alfa, recomb GONAL-F RFF 4 X
follitropin alfa, recomb GONAL-F RFF REDI-JECT 4 X
follitropin beta,recomb FOLLISTIM AQ 4 X
chorionic gonadotropin, human CHORIONIC GONADOTROPIN 2
chorionic gonadotropin, human NOVAREL 2
chorionic gonadotropin, human PREGNYL 2
choriogonadotropin alfa OVIDREL 2
progesterone,micronized CRINONE 2
progesterone,micronized ENDOMETRIN 2
ENDOCRINE DISORDER - OTHER
desmopressin (nonrefrigerated) DDAVP 1
desmopressin acetate DDAVP 1
desmopressin acetate DESMOPRESSIN ACETATE 1
desmopressin acetate STIMATE 3
leuprolide acetate ELIGARD 4 X X
teriparatide FORTEO 4 X
alendronate sodium/vitamin d3 FOSAMAX PLUS D 2 ALENDRONATE SODIUM(SOLU- alendronate sodium 1 X TION) ibandronate sodium BONIVA(SYRINGE) 1 X
ibandronate sodium IBANDRONATE SODIUM 1 X
pamidronate disodium PAMIDRONATE DISODIUM 1
raloxifene hcl EVISTA 1 X X
risedronate sodium ACTONEL(TAB)(150 MG) 1 XX
risedronate sodium ACTONEL(TAB)(30 MG) 1 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 52 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
risedronate sodium ACTONEL(TAB)(35 MG) 1 XX
risedronate sodium ACTONEL(TAB)(5 MG) 1 XX
calcitonin,salmon,synthetic MIACALCIN(VIAL) 3
alendronate sodium BINOSTO 3 XX
denosumab PROLIA 4 X X
denosumab XGEVA 4 X X
zoledronic acid ZOMETA 4 X
zoledronic acid/mannitol&water RECLAST 4 X
zoledronic acid/mannitol&water ZOMETA 4 X
calcitonin,salmon,synthetic MIACALCIN(SPRAY/PUMP) 5
calcitonin,salmon,synthetic FORTICAL 5
alendronate sodium ALENDRONATE SODIUM(TAB) 5
alendronate sodium FOSAMAX 5
etidronate disodium ETIDRONATE DISODIUM 5
ibandronate sodium BONIVA(TAB) 5
cinacalcet hcl SENSIPAR 4 X
pegvisomant SOMAVERT(VIAL)(10 MG) 4 X
pegvisomant SOMAVERT(VIAL)(15 MG) 4 X
pegvisomant SOMAVERT(VIAL)(20 MG) 4 X
pegvisomant SOMAVERT(VIAL)(25 MG) 4 X
pegvisomant SOMAVERT(VIAL)(30 MG) 4 X
tesamorelin acetate EGRIFTA 4 X X
somatropin GENOTROPIN 4 X X
somatropin HUMATROPE 4 X X
somatropin NORDITROPIN FLEXPRO 4 X X
somatropin NORDITROPIN NORDIFLEX 4 X X
somatropin NUTROPIN AQ 4 X X
somatropin NUTROPIN AQ NUSPIN 4 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 53 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
somatropin OMNITROPE 4 X X
somatropin SAIZEN 4 X X
somatropin SEROSTIM 4 X X
somatropin ZOMACTON 4 X X
somatropin ZORBTIVE 4 X X
doxercalciferol HECTOROL 1
paricalcitol PARICALCITOL 1
paricalcitol ZEMPLAR(CAP) 1
paricalcitol ZEMPLAR(VIAL) 3
mecasermin INCRELEX 4 X X
metreleptin MYALEPT 4 X
histrelin ac VANTAS 4 X
nafarelin acetate SYNAREL 4 X
cetrorelix acetate CETROTIDE 4 X
ganirelix acetate GANIRELIX ACETATE 4 X
histrelin ac SUPPRELIN LA 4 X
ospemifene OSPHENA 3 X
parathyroid hormone NATPARA 4 X X
cabergoline CABERGOLINE 1
danazol DANAZOL 1
ENDOCRINE DISORDER - THYROID
methimazole TAPAZOLE 1
propylthiouracil PROPYLTHIOURACIL 1
potassium iodide SSKI 1
potassium iodide/iodine STRONG IODINE 1
thyroid,pork NATURE-THROID 1
levothyroxine sodium SYNTHROID 1
levothyroxine sodium UNITHROID 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 54 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
liothyronine sodium CYTOMEL 1
thyroid,pork ARMOUR THYROID 2
levothyroxine sodium TIROSINT 3
liotrix THYROLAR-1 3
liotrix THYROLAR-1/2 3
liotrix THYROLAR-1/4 3
liotrix THYROLAR-2 3
liotrix THYROLAR-3 3
EYE - GENERAL DISORDERS
neo/polymyx b sulf/dexameth MAXITROL 1 NEOMYCIN-BACITRACIN-PO- neomycin su/baci zn/poly/hc 1 LY-HC tobramycin/dexamethasone TOBRADEX(DROPS SUSP) 1
tobramycin/dexamethasone TOBRADEX(OINT) 2
tobramycin/lotepred etab ZYLET 2
gentamicin/prednisol ac PRED-G 3
tobramycin/dexamethasone TOBRADEX ST 3
azelastine hcl AZELASTINE HCL 1
epinastine hcl ELESTAT 1
olopatadine hcl PATANOL 1
olopatadine hcl PATADAY 2
alcaftadine LASTACAFT 3
bepotastine besilate BEPREVE 3
emedastine difumarate EMADINE 3
olopatadine hcl PAZEO 3 XX
bromfenac sodium BROMFENAC SODIUM 1 DEXAMETHASONE SODIUM dexamethasone sod phosphate 1 PHOSPHATE diclofenac sodium DICLOFENAC SODIUM 1
fluorometholone FML 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 55 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
flurbiprofen sodium OCUFEN 1
ketorolac tromethamine ACULAR 1
ketorolac tromethamine ACULAR LS 1
prednisolone acetate OMNIPRED 1 PREDNISOLONE SODIUM prednisolone sod phosphate 1 PHOSPHATE difluprednate DUREZOL 2
fluorometholone FML FORTE 2
fluorometholone FML S.O.P. 2
fluorometholone acetate FLAREX 2
loteprednol etabonate ALREX 2
loteprednol etabonate LOTEMAX 2
nepafenac ILEVRO 2
nepafenac NEVANAC 2
prednisolone acetate PRED MILD 2
bromfenac sodium PROLENSA 3
dexamethasone MAXIDEX 3
ketorolac tromethamine/pf ACUVAIL 3
rimexolone VEXOL 3
trifluridine VIROPTIC 1
ganciclovir ZIRGAN 2
benoxinate hcl/fluorescein na FLUROX 1
proparacaine hcl PROPARACAINE HCL 1
proparacaine/fluorescein sod FLUCAINE 1
tetracaine hcl TETCAINE 1
tetracaine hcl/pf TETRACAINE HCL 1
lidocaine hcl/pf AKTEN 3
tetracaine hcl TETRAVISC 3
tetracaine hcl TETRAVISC FORTE 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 56 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
sulfacetamide sodium SULFACETAMIDE SODIUM 1 SULFACETAMIDE-PREDNISO- sulfacetamide/prednisolone sp 1 LONE sulfacetm na/prednisol ac BLEPHAMIDE 2
sulfacetm na/prednisol ac BLEPHAMIDE S.O.P. 2
naphazoline hcl NAPHAZOLINE HCL 1
phenylephrine hcl PHENYLEPHRINE HCL 1
cyclosporine RESTASIS 2 X
bacitracin BACITRACIN 1
bacitracin/polymyxin b sulfate BACITRACIN-POLYMYXIN 1
ciprofloxacin hcl CILOXAN(DROPS) 1
erythromycin base ILOTYCIN 1
gatifloxacin ZYMAXID 1
gentamicin sulfate GARAMYCIN 1
levofloxacin LEVOFLOXACIN 1 NEOMYCIN-BACITRACIN-POLY- neomycin su/bacitra/polymyxin 1 MYXIN neomycin/polymyxn b/gramicidin NEOSPORIN 1
ofloxacin OCUFLOX 1
polymyxin b sulf/trimethoprim POLYTRIM 1
tobramycin TOBREX(DROPS) 1
besifloxacin hcl BESIVANCE 2
ciprofloxacin hcl CILOXAN(OINT) 2
moxifloxacin hcl MOXEZA 2
moxifloxacin hcl VIGAMOX 2
tobramycin TOBREX(OINT) 2
azithromycin AZASITE 3
natamycin NATACYN 3
cromolyn sodium CROMOLYN SODIUM 1
lodoxamide tromethamine ALOMIDE 2
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 57 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
nedocromil sodium ALOCRIL 2
hypochlorous acid/sodium chlor ACUICYN 3
hypochlorous acid/sodium chlor AVENOVA 3
EYE - GLAUCOMA
acetazolamide ACETAZOLAMIDE 5
acetazolamide DIAMOX SEQUELS 5
methazolamide NEPTAZANE 5
pilocarpine hcl ISOPTO CARPINE 1
timolol maleate TIMOPTIC 1
timolol maleate TIMOPTIC-XE 1
betaxolol hcl BETOPTIC S 2
bimatoprost LUMIGAN 2 X
brimonidine tartrate ALPHAGAN P(DROPS)(0.1 %) 2
brimonidine tartrate/timolol COMBIGAN 2
brinzolamide AZOPT 2
brinzolamide/brimonidine tart SIMBRINZA 2
timolol BETIMOL 2
travoprost TRAVATAN Z 2 X
apraclonidine hcl IOPIDINE(DROPERETTE) 3
dorzolamide/timolol/pf COSOPT PF 3 XX
echothiophate iodide PHOSPHOLINE IODIDE 3
tafluprost/pf ZIOPTAN 3 XX
timolol maleate ISTALOL 3
timolol maleate/pf TIMOPTIC OCUDOSE 3 XX
unoprostone isopropyl RESCULA 3 XX
apraclonidine hcl IOPIDINE(DROPS) 5
betaxolol hcl BETAXOLOL HCL 5
bimatoprost BIMATOPROST 5 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 58 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
brimonidine tartrate ALPHAGAN P(DROPS)(0.15 %) 5
brimonidine tartrate BRIMONIDINE TARTRATE 5
carteolol hcl CARTEOLOL HCL 5
dorzolamide hcl TRUSOPT 5
dorzolamide hcl/timolol maleat COSOPT 5
latanoprost XALATAN 5
levobunolol hcl BETAGAN 5
metipranolol METIPRANOLOL 5
travoprost (benzalkonium) TRAVOPROST 5 X
atropine sulfate ATROPINE SULFATE 1
atropine sulfate ISOPTO ATROPINE 1
cyclopentolate hcl CYCLOGYL(DROPS)(1 %) 1
cyclopentolate hcl CYCLOGYL(DROPS)(2 %) 1
homatropine hbr HOMATROPAIRE 1
tropicamide MYDRIACYL 1
tropicamide TROPICAMIDE 1
cyclopentolate hcl CYCLOGYL(DROPS)(0.5 %) 2
cyclopentolate/phenylephrine CYCLOMYDRIL 3
hydroxyamphetamine/tropicamide PAREMYD 3
mitomycin MITOSOL 3
EYE - MISCELLANEOUS
hydroxypropyl cellulose LACRISERT 3
gelatin GELFILM 3
cysteamine hcl CYSTARAN 4 X X
GOUT AND RELATED DISEASES
colchicine COLCRYS 1 X
colchicine/probenecid PROBENECID-COLCHICINE 1
colchicine MITIGARE 5 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 59 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
febuxostat ULORIC 2 XX
allopurinol ZYLOPRIM 5
probenecid PROBENECID 1
HEMATOLOGICAL DISORDERS
warfarin sodium COUMADIN 5
tranexamic acid CYKLOKAPRON 1
tranexamic acid LYSTEDA 1
aminocaproic acid AMICAR 3
antihemo.fviii,full length peg ADYNOVATE 4 X
antihemoph.fviii rec,fc fusion ELOCTATE 4 X
antihemoph.fviii,b-dom truncat NOVOEIGHT 4 X
antihemoph.fviii,b-domain del XYNTHA 4 X
antihemoph.fviii,b-domain del XYNTHA SOLOFUSE 4 X
antihemoph.fviii,full length ADVATE 4 X
antihemoph.fviii,full length ADVATE H 4 X
antihemoph.fviii,full length ADVATE L 4 X
antihemoph.fviii,full length ADVATE M 4 X
antihemoph.fviii,full length ADVATE SH 4 X
antihemoph.fviii,full length ADVATE UH 4 X
antihemoph.fviii,full length HELIXATE FS 4 X
antihemoph.fviii,full length KOGENATE FS 4 X
antihemoph.fviii,hek b-delete NUWIQ 4 X
antihemophilic factor, hum rec RECOMBINATE 4 X
antihemophilic factor, human HEMOFIL M 4 X
antihemophilic factor, human KOATE-DVI 4 X
antihemophilic factor, human MONOCLATE-P 4 X
coagulation factor viia,recomb NOVOSEVEN RT 4 X
anti-inhibitor coagulant comp. FEIBA NF 4 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 60 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
antihemophilic factor/vwf ALPHANATE 4 X
antihemophilic factor/vwf HUMATE-P 4 X
antihemophilic factor/vwf WILATE 4 X
factor xiii CORIFACT 4 X CITRATE PHOSPHATE DEX- citrate phosphate dextros soln 1 TROSE sodium citrate SODIUM CITRATE 1
dextrose/sod citrate/citric ac ACD 3
edoxaban tosylate SAVAYSA 3 X
apixaban ELIQUIS(TAB)(2.5 MG) 5 X
apixaban ELIQUIS(TAB)(5 MG) 5 X
rivaroxaban XARELTO(TAB DS PK) 5 X
rivaroxaban XARELTO(TAB)(10 MG) 5 X
rivaroxaban XARELTO(TAB)(15 MG) 5 X
rivaroxaban XARELTO(TAB)(20 MG) 5 X
factor ix cplx(pcc)#4, 3factor PROFILNINE 4 X
factor ix cplx(pcc)#6, 3factor BEBULIN 4 X
factor ix human recomb,thr 148 IXINITY 4 X
factor ix rec, fc fusion protn ALPROLIX 4 X
factor ix MONONINE 4 X
factor ix human recombinant RIXUBIS 4 X
coagulation factor x COAGADEX 4 X
factor xiii a-subunit,recomb TRETTEN 4 X ARANESP(SYRINGE) darbepoetin alfa in polysorbat 4 X X (100MCG/0.5) ARANESP(SYRINGE) darbepoetin alfa in polysorbat 4 X X (10MCG/0.4) ARANESP(SYRINGE) darbepoetin alfa in polysorbat 4 X X (150MCG/0.3) ARANESP(SYRINGE) darbepoetin alfa in polysorbat 4 X X (200MCG/0.4) ARANESP(SYRINGE) darbepoetin alfa in polysorbat 4 X X (25MCG/0.42)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 61 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL ARANESP(SYRINGE) darbepoetin alfa in polysorbat 4 X X (300MCG/0.6) ARANESP(SYRINGE)(40 darbepoetin alfa in polysorbat 4 X X MCG/0.4) ARANESP(SYRINGE)(500 MCG/ darbepoetin alfa in polysorbat 4 X X ML) ARANESP(SYRINGE) darbepoetin alfa in polysorbat 4 X X (60MCG/0.3) darbepoetin alfa in polysorbat ARANESP(VIAL) 4 X X
epoetin alfa EPOGEN 4 X X
epoetin alfa PROCRIT 4 X X
pentoxifylline PENTOXIFYLLINE 1
heparin sod,porcine/0.9 % nacl HEPARIN FLUSH 1
heparin sodium,porcine HEPARIN SODIUM 1
heparin sodium,porcine/d5w HEPARIN SODIUM-D5W 1
heparin sodium,porcine/ns/pf HEPARIN SODIUM-0.9% NACL 1
heparin sodium,porcine/pf HEPARIN FLUSH 1 MONOJECT PREFILL AD- heparin sodium,porcine/pf 1 VANCED HEPARIN SODIUM IN 0.45% heparin sod,pork in 0.45% nacl 3 NACL FRAGMIN(SYRINGE)(10000/ dalteparin sodium,porcine 4 X ML) FRAGMIN(SYRINGE) dalteparin sodium,porcine 4 X (12500/0.5) FRAGMIN(SYRINGE) dalteparin sodium,porcine 4 X (15000/0.6) FRAGMIN(SYRINGE) dalteparin sodium,porcine 4 X (18000/0.72) FRAGMIN(SYRINGE) dalteparin sodium,porcine 4 X (2500/0.2ML) FRAGMIN(SYRINGE) dalteparin sodium,porcine 4 X (5000/0.2ML) FRAGMIN(SYRINGE) dalteparin sodium,porcine 4 X (7500/0.3ML) dalteparin sodium,porcine FRAGMIN(VIAL) 4 X LOVENOX(SYRINGE)(100 MG/ enoxaparin sodium 4 X ML) LOVENOX(SYRINGE) enoxaparin sodium 4 X (120MG/.8ML) LOVENOX(SYRINGE)(150 MG/ enoxaparin sodium 4 X ML)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 62 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL LOVENOX(SYRINGE) enoxaparin sodium 4 X (30MG/0.3ML) LOVENOX(SYRINGE) enoxaparin sodium 4 X (40MG/0.4ML) LOVENOX(SYRINGE) enoxaparin sodium 4 X (60MG/0.6ML) LOVENOX(SYRINGE) enoxaparin sodium 4 X (80MG/0.8ML) enoxaparin sodium LOVENOX(VIAL) 4 X ARIXTRA(SYRINGE) fondaparinux sodium 4 X (10MG/0.8ML) ARIXTRA(SYRINGE)(2.5 fondaparinux sodium 4 X MG/0.5) ARIXTRA(SYRINGE) fondaparinux sodium 4 X (5MG/0.4ML) fondaparinux sodium ARIXTRA(SYRINGE)(7.5MG/0.6) 4 X
filgrastim NEUPOGEN 4 X X
filgrastim-sndz ZARXIO 4 X X
pegfilgrastim NEULASTA 4 X X
sargramostim LEUKINE 4 X X
tbo-filgrastim GRANIX 4 X X
aspirin/dipyridamole AGGRENOX 1
cilostazol PLETAL 1
clopidogrel bisulfate PLAVIX(TAB)(300 MG) 1 X
prasugrel hcl EFFIENT 2 X
ticagrelor BRILINTA 2 X
aspirin DURLAZA 3
vorapaxar sulfate ZONTIVITY 3 X
clopidogrel bisulfate PLAVIX(TAB)(75 MG) 5
dipyridamole PERSANTINE 5
ticlopidine hcl TICLOPIDINE HCL 5
oprelvekin NEUMEGA 4 X
anagrelide hcl ANAGRELIDE HCL 1
hydroxyurea DROXIA 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 63 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
desirudin IPRIVASK 4 X X
dabigatran etexilate mesylate PRADAXA 3 X
eltrombopag olamine PROMACTA 4 X X
thromb-ca-cell-dressing, hemos THROMBI-PAD 1
thrombin/ca/cmc/gel/dress, hem THROMBI-GEL 1
ferric subsulfate MONSEL’S 1
thrombin (bovine) THROMBIN-JMI 1
cellulose,oxidized OXYCEL 3
gelatin sponge,absorbable GELFOAM 3
ferric subsulfate ASTRINGYN 3
fibrinogen/thrombin(human der) EVARREST 3
fibrinogen/thrombin(human der) TACHOSIL 3
microfibrillar collagen ULTRAFOAM 3
microfibrillar collagen AVITENE 3
microfibrillar collagen ENDO-AVITENE 3
microfibrillar collagen SYRINGE AVITENE 3
thrombin (recombinant) RECOTHROM 3
thrombin(hum plas)/fib/apro/ca TISSEEL VHSD 3
phytonadione VITAMIN K1 1
phytonadione MEPHYTON 2
HORMONAL DEFICIENCY
fluoxymesterone ANDROXY 1 X
methyltestosterone TESTRED 1
oxandrolone OXANDRIN 1 X ANDROGEL(GEL PACKET) testosterone 1 X (25MG(1%)) testosterone FORTESTA 1 X
testosterone VOGELXO 1 X
testosterone cypionate DEPO-TESTOSTERONE 1 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 64 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
testosterone enanthate DELATESTRYL 1 X
methyltestosterone METHITEST 2
testosterone ANDROGEL(GEL MD PMP) 2 X ANDROGEL(GEL PACKET) testosterone 2 X (1.25G-1.62) ANDROGEL(GEL PACKET) testosterone 2 X (2.5G-1.62%) testosterone AXIRON 2 X
oxymetholone ANADROL-50 3 X
testosterone ANDRODERM 3 X
testosterone NATESTO 3 X
testosterone STRIANT 3 X
testosterone TESTOPEL 3
drospirenone/estradiol ANGELIQ 3
estrogens,conj/bazedoxifene DUAVEE 2 ESTROGEN-METHYLTESTOS- estrogen,ester/me-testosterone 1 TERONE estradiol CLIMARA 1 X
estradiol ESTRACE 1
estradiol VIVELLE-DOT 1 X ESTRADIOL-NORETHINDRONE estradiol/norethindrone acet 1 ACETAT estropipate ESTROPIPATE 1
estropipate OGEN 1
norethindrone ac-eth estradiol JINTELI 1
estrogen,con/m-progest acet PREMPHASE 2
estrogen,con/m-progest acet PREMPRO 2
estrogens, conjugated PREMARIN 2
estrogens,esterified MENEST 2
estradiol ALORA 2 X
estradiol MINIVELLE 2 X
estradiol/norethindrone acet COMBIPATCH 2 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 65 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
estrogens,conj.,synthetic b ENJUVIA 3
estradiol DIVIGEL 3
estradiol ELESTRIN 3
estradiol ESTROGEL 3
estradiol EVAMIST 3
estradiol MENOSTAR 3 X
estradiol/levonorgestrel CLIMARA PRO 3 X
estradiol/norgestimate PREFEST 3
leuprolide/norethindrone acet LUPANETA PACK 3
progesterone,micronized PROMETRIUM 1
medroxyprogesterone acetate PROVERA 1
norethindrone acetate AYGESTIN 1
progesterone PROGESTERONE 1
progesterone,micronized CRINONE 3
IMMUNIZATION
igg/hyaluronidase,recombinant HYQVIA 4 X X
lymphocyte ig, antithymocyte ATGAM 4 X
lymphocyte immu glob.,rabbit THYMOGLOBULIN 4 X
imm glob g (igg)/sorb/iga 0-50 FLEBOGAMMA DIF 4 X X
immun glob g (igg)/gly/iga 50+ BIVIGAM 4 X X
immun glob g (igg)/gly/iga 50+ GAMMAGARD LIQUID 4 X X
immun glob g (igg)/gly/iga 50+ GAMMAKED 4 X X
immun glob g (igg)/gly/iga 50+ GAMUNEX-C 4 X X
immun glob g(igg)/malt/iga 50+ OCTAGAM 4 X X
immun glob g(igg)/pro/iga 0-50 HIZENTRA 4 X X
immun glob g(igg)/pro/iga 0-50 PRIVIGEN 4 X X
immun glob g(igg)/sorb/iga 50+ FLEBOGAMMA DIF 4 X X
immun glob g/sorb/gly/iga 0-50 GAMMAPLEX 4 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 66 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
rotavirus vac,live att, 89-12 ROTARIX 3
rotavirus vaccine,live oral pv ROTATEQ 3
typhoid vacc,live,attenuated VIVOTIF 3
typhoid vacc,live,attenuated VIVOTIF BERNA 3
pneumoc 13-val conj-dip crm/pf PREVNAR 13 5 X X
pneumococcal 23-val p-sac vac PNEUMOVAX 23 5 X X FLUZONE QUAD PEDI 2015- flu vacc qs 2015 (6-35mos)/pf 2 2016 flu vacc ts 15-16 (18+)cell/pf EZ FLU 2015-2016 (FLUCELVAX) 2 FLUZONE QUAD PEDI 2014- flu vaccine 2014(6-35mos)/pf 2 2015 flu vaccine ts 2015-16 (5 yr+) AFLURIA 2015-2016 2
flu vaccine ts2015-16(4yr+)/pf EZ FLU 2015-2016 (FLUVIRIN) 2
flu vac tv 2014(18 yr+)rcm/pf FLUBLOK 2014-2015 5 X X
flu vac tv 2015(18 yr+)rcm/pf FLUBLOK 2015-2016 5 X X
flu vacc qs 2014-15(36mos+)/pf FLUARIX QUAD 2014-2015 5 X X
flu vacc qs 2014-15(36mos+)/pf FLULAVAL QUAD 2014-2015 5 X X
flu vacc qs 2014-15(36mos+)/pf FLUZONE QUAD 2014-2015 5 X X FLUZONE INTRADERM QUAD flu vacc qs 2015 (18-64yrs)/pf 5 X X 2015-16 flu vacc qs 2015-16(36mos+)/pf FLUARIX QUAD 2015-2016 5 X X
flu vacc qs 2015-16(36mos+)/pf FLUZONE QUAD 2015-2016 5 X X
flu vacc qv live 2014(2-49yrs) FLUMIST QUAD 2014-2015 5 X X
flu vacc qv live 2015(2-49yrs) FLUMIST QUAD 2015-2016 5 X X
flu vacc ts 14-15 (18+)cell/pf FLUCELVAX 2014-2015 5 X X
flu vacc ts 14-15 (18+)cell/pf SINGLE USE EZ FLU 2014-2015 5 X X
flu vacc ts 15-16 (18+)cell/pf FLUCELVAX 2015-2016 5 X X FLUZONE INTRADERMAL 2014- flu vacc ts 2014 (18-64yrs)/pf 5 X X 2015 FLUZONE HIGH-DOSE 2014- flu vacc ts 2014-15 (65yr+)/pf 5 X X 2015 flu vacc ts 2014-15(36mos+)/pf FLUARIX 2014-2015 5 X X
flu vacc ts 2014-15(36mos+)/pf FLUZONE 2014-2015 5 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 67 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL FLUZONE HIGH-DOSE 2015- flu vacc ts 2015-16 (65yr+)/pf 5 X X 2016 flu vaccine qs 2014-15(36mos+) FLULAVAL QUAD 2014-2015 5 X X
flu vaccine qs 2014-15(6mos+) FLUZONE QUAD 2014-2015 5 X X
flu vaccine qs 2015-16 (6mos+) FLUZONE QUAD 2015-2016 5 X X
flu vaccine qs 2015-16(36mos+) FLULAVAL QUAD 2015-2016 5 X X
flu vaccine ts 2014-15 (4 yr+) FLUVIRIN 2014-2015 5 X X
flu vaccine ts 2014-15 (5 yr+) AFLURIA 2014-2015 5 X X
flu vaccine ts 2014-15(36mos+) FLULAVAL 2014-2015 5 X X
flu vaccine ts 2014-15(6 mos+) FLUZONE 2014-2015 5 X X
flu vaccine ts 2015-16(6 mos+) FLUZONE 2015-2016 5 X X
flu vaccine ts 2015-2016(4yr+) FLUVIRIN 2015-2016 5 X X
flu vaccine ts2014-15(4yr+)/pf FLUVIRIN 2014-2015 5 X X
flu vaccine ts2014-15(5yr+)/pf AFLURIA 2014-2015 5 X X
flu vaccine ts2015-16(4yr+)/pf FLUVIRIN 2015-2016 5 X X
flu vaccine ts2015-16(5yr+)/pf AFLURIA 2015-2016 5 X X
diph,pertuss(acell),tet vac/pf ADACEL TDAP 5 X X
diphth,pertuss(acell),tet vac BOOSTRIX TDAP 5 X X
measles,mumps&rubella vacc/pf M-M-R II VACCINE 5 X X
measles,mumps,rub,varicella/pf PROQUAD 5 X X TETANUS DIPHTHERIA TOX- tetanus & diphtheria tox,adult 5 X X OIDS tetanus and diphtheria tox/pf TENIVAC 5 X X ADENOVIRUS TYPE 4 AND adenovirus vac live type-4 & 7 3 TYPE 7 adenovirus vaccine live type-4 ADENOVIRUS TYPE 4 3
adenovirus vaccine live type-7 ADENOVIRUS TYPE 7 3
human papilomvirus vac,qval/pf GARDASIL 5 X
hepatitis b virus vaccine/pf ENGERIX-B ADULT 5 X X
hepatitis b virus vaccine/pf RECOMBIVAX HB 5 X X
human papillomav vacc bival/pf CERVARIX 5 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 68 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
varicella vaccine live/pf VARIVAX VACCINE 5 X X
zoster vaccine live/pf ZOSTAVAX 5 X X
IMMUNOSUPPRESSION/MODULATION
imiquimod ALDARA 1 X X
imiquimod ZYCLARA(CREAM PACK) 3 X X
imiquimod ZYCLARA(CRM MD PMP)(2.5 %) 3 X X ZYCLARA(CRM MD PMP)(3.75 imiquimod 3 X X %) interferon alfa-2b,recomb. INTRON A 4 X X
interferon gamma-1b,recomb. ACTIMMUNE 4 X
interferon alfa-n3 ALFERON N 4 X
basiliximab SIMULECT 4 X
azathioprine AZASAN 3
belatacept NULOJIX 4 X
cyclosporine SANDIMMUNE(AMPUL) 4 X
cyclosporine SANDIMMUNE(SOLUTION) 4 X
everolimus ZORTRESS 4 X
mycophenolate mofetil hcl CELLCEPT 4 X
sirolimus RAPAMUNE(SOLUTION) 4 X
tacrolimus ASTAGRAF XL 4 X
tacrolimus ENVARSUS XR 4 X
tacrolimus PROGRAF(AMPUL) 4 X
cyclosporine, modified NEORAL 5 X
azathioprine IMURAN 5
cyclosporine SANDIMMUNE(CAP) 5 X
mycophenolate mofetil CELLCEPT 5
mycophenolate sodium MYFORTIC 5
sirolimus RAPAMUNE(TAB) 5 X
tacrolimus PROGRAF(CAP) 5 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 69 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
INFECTIOUS DISEASE - BACTERIAL
sulfamethoxazole/trimethoprim BACTRIM 1
sulfamethoxazole/trimethoprim BACTRIM DS 1 SULFAMETHOXAZOLE-TRI- sulfamethoxazole/trimethoprim 1 METHOPRIM aztreonam lysine CAYSTON 4 X X
imipenem/cilastatin sodium PRIMAXIN 1
meropenem MERREM 1
doripenem DORIBAX 3
ertapenem sodium INVANZ 3
ceftaroline fosamil acetate TEFLARO 3
cefazolin sodium/dextrose,iso CEFAZOLIN 1
cefadroxil CEFADROXIL 1
cefazolin sodium CEFAZOLIN SODIUM 1
cephalexin CEPHALEXIN 1
cephalexin KEFLEX 1
cefotetan disod/dextrose,iso CEFOTETAN & DEXTROSE 1
cefoxitin sodium/dextrose,iso CEFOXITIN SODIUM 1
cefaclor CEFACLOR 1
cefotetan disodium CEFOTETAN 1
cefoxitin sodium CEFOXITIN 1
cefprozil CEFPROZIL 1
cefuroxime axetil CEFTIN(TAB) 1
cefuroxime sodium ZINACEF(VIAL) 1
cefuroxime axetil CEFTIN(SUSP RECON) 2
cefoxitin sodium/d5w MEFOXIN 3
cefuroxime sodium ZINACEF(VIAL PORT) 3
cefuroxime sodium/water ZINACEF 3
ceftriaxone na/dextrose,iso CEFTRIAXONE 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 70 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
cefdinir CEFDINIR 1
cefditoren pivoxil CEFDITOREN PIVOXIL 1
cefditoren pivoxil SPECTRACEF 1 SUPRAX(SUSP RECON)(100 cefixime 1 MG/5ML) SUPRAX(SUSP RECON)(200 cefixime 1 MG/5ML) cefotaxime sodium CLAFORAN 1
cefpodoxime proxetil CEFPODOXIME PROXETIL 1
ceftazidime CEFTAZIDIME 1
ceftibuten CEDAX 1
ceftriaxone sodium CEFTRIAXONE 1
cefixime SUPRAX(CAP) 2 SUPRAX(SUSP RECON)(500 cefixime 2 MG/5ML) cefixime SUPRAX(TAB CHEW) 2 FORTAZ IN ISO-OSMOTIC DEX- ceftazidime na/dextrose,iso 3 TROSE ceftazidime FORTAZ 3
ceftazidime in dextrose5%water CEFTAZIDIME 3
cefepime hcl MAXIPIME(VIAL) 1
cefepime hcl/dextrose, iso-osm CEFEPIME 3
cefepime hcl MAXIPIME(VIAL PORT) 3
cefepime hcl/d5w CEFEPIME-DEXTROSE 3
methen/m-blue/sal/na phos/hyos UTA 1
methen/sod phos/meth blue/hyos UROGESIC-BLUE 1
methenam/me blue/ba/salicy/hyo HYOPHEN 1
methenamine hippurate HIPREX 1
methenamine mandelate METHENAMINE MANDELATE 1
mth/me blue/sod phos/phen/hyos URIBEL 1
trimethoprim TRIMETHOPRIM 1
methenam/me blue/ba/salicy/hyo PROSED-DS 2
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 71 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
mth/me blue/sod phos/phen/hyos PHOSPHASAL 2
mth/me blue/sod phos/phen/hyos URETRON D-S 2
mth/me blue/sod phos/phen/hyos URIN D.S. 2
trimethoprim PRIMSOL 2
fosfomycin tromethamine MONUROL 3
sulbutiamine ARKALIOX(OTC) 3
daptomycin CUBICIN 3
tigecycline TYGACIL 3
telithromycin KETEK 2
azithromycin AZITHROMYCIN 1
azithromycin ZITHROMAX 1
azithromycin ZITHROMAX TRI-PAK 1
clarithromycin BIAXIN 1
clarithromycin CLARITHROMYCIN 1
erythromycin base ERYTHROMYCIN 1
erythromycin ethylsuccinate ERYPED 200 1
erythromycin stearate ERYTHROCIN STEARATE 1
azithromycin ZMAX 2
erythromycin base ERY-TAB 2
erythromycin base PCE 2
erythromycin ethylsuccinate ERYPED 400 2
fidaxomicin DIFICID 2 XX
erythromycin lactobionate ERYTHROCIN LACTOBIONATE 3
nitrofurantoin FURADANTIN 1
nitrofurantoin macrocrystal MACRODANTIN 1
nitrofurantoin monohyd/m-cryst MACROBID 1
linezolid ZYVOX 1
tedizolid phosphate SIVEXTRO 2 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 72 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
nafcillin in dextrose,iso-osm NAFCILLIN 1
oxacillin sodium/dextrose,iso OXACILLIN 1
amoxicillin AMOXICILLIN 1 AMOXICILLIN-CLAVULANATE amoxicillin/potassium clav 1 POTASS amoxicillin/potassium clav AUGMENTIN ES-600 1 AUGMENTIN(SUSP RECON) amoxicillin/potassium clav 1 (250-62.5/5) amoxicillin/potassium clav AUGMENTIN(TAB) 1
ampicillin sodium AMPICILLIN SODIUM 1
ampicillin sodium/sulbactam na AMPICILLIN-SULBACTAM 1
ampicillin sodium/sulbactam na UNASYN 1
ampicillin trihydrate AMPICILLIN TRIHYDRATE 1
dicloxacillin sodium DICLOXACILLIN SODIUM 1
nafcillin sodium NAFCILLIN SODIUM 1
oxacillin sodium OXACILLIN SODIUM 1 PENICILLIN GK-ISO-OSM DEX- pen g pot/dextrose-water 1 TROSE penicillin g potassium PFIZERPEN 1
penicillin g procaine PENICILLIN G PROCAINE 1
penicillin g sodium PENICILLIN G SODIUM 1
penicillin v potassium PENICILLIN V POTASSIUM 1
piperacillin sodium/tazobactam PIPERACILLIN-TAZOBACTAM 1
piperacillin sodium/tazobactam ZOSYN 1 AUGMENTIN(SUSP RECON) amoxicillin/potassium clav 2 (125-31.25/) piperacillin-tazo-dextrose,iso ZOSYN 3
pen g benz/pen g procaine BICILLIN C-R 3
penicillin g benzathine BICILLIN L-A 3
ciprofloxacin CIPRO 1
ciprofloxacin hcl CIPRO 1
ciprofloxacin hcl CIPROFLOXACIN HCL 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 73 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
ciprofloxacin/ciprofloxa hcl CIPRO XR 1
levofloxacin LEVAQUIN 1
moxifloxacin hcl AVELOX 1
ofloxacin OFLOXACIN 1
gemifloxacin mesylate FACTIVE 3
demeclocycline hcl DEMECLOCYCLINE HCL 1
doxycycline hyclate DORYX(TAB DR)(150 MG) 1 XX
doxycycline hyclate DOXYCYCLINE HYCLATE 1 XX
doxycycline hyclate VIBRAMYCIN 1 XX
doxycycline monohydrate ADOXA 1 XX
doxycycline monohydrate AVIDOXY 1 XX DOXYCYCLINE MONOHY- doxycycline monohydrate 1 X DRATE(TAB)(150 MG) DOXYCYCLINE MONOHY- doxycycline monohydrate 1 XX DRATE(TAB)(50 MG) DOXYCYCLINE MONOHY- doxycycline monohydrate 1 X DRATE(TAB)(75 MG) doxycycline monohydrate MONODOX(CAP)(100 MG) 1 X
doxycycline monohydrate MONODOX(CAP)(50 MG) 1 X
doxycycline monohydrate MONODOX(CAP)(75 MG) 1 XX
doxycycline monohydrate VIBRAMYCIN 1
minocycline hcl MINOCIN 1
minocycline hcl MINOCYCLINE HCL 1
tetracycline hcl TETRACYCLINE HCL 1
doxycycline calcium VIBRAMYCIN 2
doxycycline hyclate ACTICLATE 3 XX
doxycycline hyclate DORYX(TAB DR)(200 MG) 3 XX
doxycycline hyclate DORYX(TAB DR)(50 MG) 3 XX
doxycycline/benzoyl peroxide BENOXYLDOXY 30 3 XX
doxycycline/benzoyl peroxide BENOXYLDOXY 60 3 XX
doxycycline/benzoyl peroxide BENZODOX 30 3 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 74 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
doxycycline/benzoyl peroxide BENZODOX 60 3 XX
doxycycline/salicy/oct/zinc ox AVIDOXY DK 3 XX
doxycycline/skin cleanser #19 MORGIDOX 3 XX
minocycline hcl SOLODYN 3 X X X
minocycline hcl/skin cl no.4 MINOCIN 3
INFECTIOUS DISEASE - FUNGAL
fluconazole in nacl/iso-osm FLUCONAZOLE-NACL 1
clotrimazole CLOTRIMAZOLE 1
fluconazole DIFLUCAN 1
flucytosine ANCOBON 1
itraconazole SPORANOX(CAP) 1
ketoconazole KETOCONAZOLE 1
terbinafine hcl LAMISIL(TAB) 1
voriconazole VFEND 1
voriconazole VFEND IV 1
itraconazole SPORANOX(SOLUTION) 2
terbinafine hcl LAMISIL(GRAN PACK) 2
isavuconazonium sulfate CRESEMBA 3
itraconazole ONMEL 3
miconazole ORAVIG 3
posaconazole NOXAFIL 3
griseofulvin, microsize GRIFULVIN V 1
griseofulvin, microsize GRISEOFULVIN 1
amphotericin b AMPHOTERICIN B 1
griseofulvin ultramicrosize GRIS-PEG 1
nystatin NYSTATIN 1
amphotericin b lipid complex ABELCET 3
amphotericin b liposome AMBISOME 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 75 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
anidulafungin ERAXIS (WATER DILUENT) 3
caspofungin acetate CANCIDAS 3
micafungin sodium MYCAMINE 3
INFECTIOUS DISEASE - MISCELLANEOUS
gentamicin in nacl, iso-osm GENTAMICIN SULFATE IN NS 1
amikacin sulfate AMIKACIN SULFATE 1
gentamicin sulfate GENTAMICIN SULFATE 1
gentamicin sulfate/pf GENTAMICIN SULFATE 1
neomycin sulfate NEOMYCIN SULFATE 1
streptomycin sulfate STREPTOMYCIN SULFATE 1
tobramycin sulfate TOBRAMYCIN SULFATE 1
tobramycin/sodium chloride TOBRAMYCIN SULFATE IN NS 1
tobramycin BETHKIS 4 X X
tobramycin TOBI PODHALER 4 X X
tobramycin in 0.225% nacl TOBI 4 X X
tobramycin/nebulizer KITABIS PAK 4 X X
ethambutol hcl ETHAMBUTOL HCL 1
ethambutol hcl MYAMBUTOL 1
isoniazid ISONIAZID 1
pyrazinamide PYRAZINAMIDE 1
rifabutin MYCOBUTIN 1
aminosalicylic acid PASER 3
ethionamide TRECATOR 3
glycine urologic solution GLYCINE 1
dapsone DAPSONE 1
thalidomide THALOMID 4 X X
cycloserine CYCLOSERINE 1
rifampin RIFADIN 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 76 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
rifampin/isoniazid RIFAMATE 2
capreomycin sulfate CAPASTAT SULFATE 3
rifamp/isoniazid/pyrazinamide RIFATER 3
rifapentine PRIFTIN 3
bedaquiline fumarate SIRTURO 4 X X CHLORAMPHENICOL SOD SUC- chloramphenicol sod succ 1 CINATE clindamycin hcl CLEOCIN HCL 1
clindamycin palmitate hcl CLINDAMYCIN PALMITATE HCL 1
clindamycin phosphate CLEOCIN PHOSPHATE 1
clindamycin phosphate/d5w CLEOCIN PHOSPHATE IN D5W 1
lincomycin hcl LINCOCIN 3
polymyxin b sulfate POLYMYXIN B SULFATE 1
rifaximin XIFAXAN(TAB)(550 MG) 2 X
rifaximin XIFAXAN(TAB)(200 MG) 3 X
vancomycin hcl VANCOCIN HCL 1 X
vancomycin hcl VANCOMYCIN HCL 1
vancomycin hcl/d5w VANCOMYCIN HCL 1
telavancin hcl VIBATIV 3
INFECTIOUS DISEASE - PARASITIC
tinidazole TINDAMAX 1
paromomycin sulfate PAROMOMYCIN SULFATE 1
metronidazole FLAGYL 1
metronidazole/sodium chloride METRO IV 1
metronidazole FLAGYL ER 2
ivermectin STROMECTOL 1
praziquantel BILTRICIDE 2
albendazole ALBENZA 3
atovaquone/proguanil hcl MALARONE 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 77 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
chloroquine phosphate CHLOROQUINE PHOSPHATE 1
hydroxychloroquine sulfate PLAQUENIL 1
mefloquine hcl MEFLOQUINE HCL 1
quinine sulfate QUALAQUIN 1
primaquine phosphate PRIMAQUINE 2
pyrimethamine DARAPRIM 2
artemether/lumefantrine COARTEM 3
atovaquone MEPRON 1
pentamidine isethionate NEBUPENT 2
INFECTIOUS DISEASE - VIRAL
acyclovir ZOVIRAX 1
acyclovir sodium ACYCLOVIR SODIUM 1
cidofovir VISTIDE 1
famciclovir FAMVIR 1
foscarnet sodium FOSCAVIR 1
rimantadine hcl FLUMADINE 1
valacyclovir hcl VALTREX 1
valganciclovir hcl VALCYTE(TAB) 1
oseltamivir phosphate TAMIFLU(CAP)(30 MG) 2 X
oseltamivir phosphate TAMIFLU(CAP)(45 MG) 2 X
oseltamivir phosphate TAMIFLU(CAP)(75 MG) 2 X
oseltamivir phosphate TAMIFLU(SUSP RECON) 2 X
ribavirin VIRAZOLE 2
acyclovir SITAVIG 3 XX
valganciclovir hcl VALCYTE(SOLN RECON) 3
zanamivir RELENZA 3 X
darunavir ethanolate PREZISTA(ORAL SUSP) 4 X
darunavir ethanolate PREZISTA(TAB)(150 MG) 4 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 78 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
darunavir ethanolate PREZISTA(TAB)(400 MG) 4 X
darunavir ethanolate PREZISTA(TAB)(600 MG) 4 X
darunavir ethanolate PREZISTA(TAB)(75 MG) 4 X
darunavir ethanolate PREZISTA(TAB)(800 MG) 4 X
darunavir/cobicistat PREZCOBIX 4 X
tipranavir APTIVUS 4 X X
tipranavir/vitamin e tpgs APTIVUS 4 X X
emtricitabine/tenofovir TRUVADA 4 X
abacavir sulfate/lamivudine EPZICOM 4 X
abacavir/lamivudine/zidovudine TRIZIVIR 4 X X
lamivudine/zidovudine COMBIVIR 4 X
maraviroc SELZENTRY 4 X
enfuvirtide FUZEON 4 XX
nevirapine VIRAMUNE(ORAL SUSP) 1 X
nevirapine VIRAMUNE(TAB) 1 X
delavirdine mesylate RESCRIPTOR 2
efavirenz SUSTIVA 4 X
etravirine INTELENCE 4 X X
rilpivirine hcl EDURANT 4 X X
didanosine VIDEX EC(CAP DR)(125 MG) 1 X
didanosine VIDEX EC(CAP DR)(200 MG) 1 X
didanosine VIDEX EC(CAP DR)(250 MG) 1
didanosine VIDEX EC(CAP DR)(400 MG) 1
lamivudine EPIVIR(SOLUTION) 1 X
lamivudine EPIVIR(TAB)(150 MG) 1 X
lamivudine EPIVIR(TAB)(300 MG) 1 X
stavudine ZERIT(CAP) 1 X
stavudine ZERIT(SOLN RECON) 1 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 79 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
zidovudine RETROVIR(CAP) 1 X
zidovudine RETROVIR(SYRUP) 1 X
zidovudine ZIDOVUDINE 1 X
didanosine VIDEX 2 X
emtricitabine EMTRIVA(CAP) 2 X
emtricitabine EMTRIVA(SOLUTION) 2 X
abacavir sulfate ZIAGEN(TAB) 4 X
abacavir sulfate ZIAGEN(SOLUTION) 4 X
tenofovir disoproxil fumarate VIREAD(POWDER) 4 X
tenofovir disoproxil fumarate VIREAD(TAB) 4 X
lopinavir/ritonavir KALETRA(SOLUTION) 4 X
lopinavir/ritonavir KALETRA(TAB)(100MG-25MG) 4 X
lopinavir/ritonavir KALETRA(TAB)(200MG-50MG) 4 X
indinavir sulfate CRIXIVAN 2
atazanavir sulfate REYATAZ 4 X
atazanavir sulfate/cobicistat EVOTAZ 4 X
fosamprenavir calcium LEXIVA 4 X
nelfinavir mesylate VIRACEPT 4 X
ritonavir NORVIR(CAP) 4 X
ritonavir NORVIR(SOLUTION) 4 X
ritonavir NORVIR(TAB) 4 X
saquinavir mesylate INVIRASE(CAP) 4 XX
saquinavir mesylate INVIRASE(TAB) 4 XX
dolutegravir sodium TIVICAY 4 X X
elvitegravir VITEKTA 4 XX
raltegravir potassium ISENTRESS 4 X
efavirenz/emtricitab/tenofovir ATRIPLA 4 X
emtricitab/rilpivirine/tenofov COMPLERA 4 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 80 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
elviteg/cobi/emtric/tenofo ala GENVOYA 4 X
elvitegr/cobicist/emtric/tenof STRIBILD 4 X
abacavir/dolutegravir/lamivudi TRIUMEQ 4 X
cobicistat TYBOST 2 X
ledipasvir/sofosbuvir HARVONI 4 X X
sofosbuvir SOVALDI 4 X X
lamivudine EPIVIR HBV(TAB) 1
lamivudine EPIVIR HBV(SOLUTION) 2
adefovir dipivoxil HEPSERA 4 X
entecavir BARACLUDE 4 X
telbivudine TYZEKA 4 X
ribavirin RIBASPHERE(CAP) 1
ribavirin RIBASPHERE(TAB)(200 MG) 1
ribavirin RIBASPHERE(TAB)(400 MG) 1 X
ribavirin RIBASPHERE(TAB)(600 MG) 1 X
ribavirin REBETOL 2
peginterferon alfa-2a PEGASYS 4 X X
peginterferon alfa-2a PEGASYS PROCLICK 4 X X
peginterferon alfa-2b PEGINTRON 4 X X
peginterferon alfa-2b PEGINTRON REDIPEN 4 X X
daclatasvir dihydrochloride DAKLINZA 4 X X
ombita/paritap/riton/dasabuvir VIEKIRA PAK 4 X X
simeprevir sodium OLYSIO 4 X X
ombitasvir/paritaprev/ritonav TECHNIVIE 4 X X
INFLAMMATORY DISEASE
penicillamine CUPRIMINE 2
penicillamine DEPEN 2
methotrexate sodium RHEUMATREX 2
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 81 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL OTREXUP(AUTO INJECT) methotrexate/pf 4 XX (10MG/0.4ML) OTREXUP(AUTO INJECT) methotrexate/pf 4 XX (15MG/0.4ML) OTREXUP(AUTO INJECT) methotrexate/pf 4 XX (20MG/0.4ML) OTREXUP(AUTO INJECT) methotrexate/pf 4 XX (25MG/0.4ML) OTREXUP(AUTO INJECT)(7.5 methotrexate/pf 4 XX MG/0.4) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (10MG/0.2ML) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (12.5/0.25) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (15MG/0.3ML) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (17.5/0.35) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (20MG/0.4ML) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (22.5/0.45) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (25MG/0.5ML) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (27.5/0.55) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (30MG/0.6ML) RASUVO(AUTO INJECT) methotrexate/pf 4 XX (7.5MG/0.15) anakinra KINERET 4 X X
rilonacept ARCALYST 4 X
adalimumab HUMIRA PEDIATRIC CROHN’S 4 X X
adalimumab HUMIRA PEN 4 X X
adalimumab HUMIRA PEN CROHN’S-UC-HS 4 X X
adalimumab HUMIRA PEN PSORIASIS 4 X X HUMIRA(SYRINGE KIT) adalimumab 4 X X (10MG/0.2ML) HUMIRA(SYRINGE KIT) adalimumab 4 X X (20MG/0.4ML) HUMIRA(SYRINGE KIT) adalimumab 4 X X (40MG/0.8ML) etanercept ENBREL 4 X X
golimumab SIMPONI 4 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 82 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
leflunomide ARAVA 1
apremilast OTEZLA 4 X X
abatacept ORENCIA 4 X X
abatacept/maltose ORENCIA 4 X X
icatibant acetate FIRAZYR 4 X X
c1 esterase inhibitor, recomb RUCONEST 4 X X
c1 esterase inhibitor BERINERT 4 X X
c1 esterase inhibitor CINRYZE 4 X X
budesonide ENTOCORT EC 1
cortisone acetate CORTISONE ACETATE 1
dexamethasone DEXAMETHASONE 1 DEXAMETHASONE SODIUM dexamethasone sod phosphate 1 PHOSPHATE DEXAMETHASONE SODIUM dexamethasone sod phosphate/pf 1 PHOSPHATE hydrocortisone CORTEF 1
methylprednisolone MEDROL(TAB DS PK) 1
methylprednisolone MEDROL(TAB)(16 MG) 1
methylprednisolone MEDROL(TAB)(32 MG) 1
methylprednisolone MEDROL(TAB)(4 MG) 1
methylprednisolone MEDROL(TAB)(8 MG) 1
prednisolone PREDNISOLONE 1
prednisolone sod phosphate PEDIAPRED 1 PREDNISOLONE SODIUM prednisolone sod phosphate 1 PHOSPHATE prednisone PREDNISONE(TAB DS PK) 1
prednisone PREDNISONE(TAB)(10 MG) 1
methylprednisolone MEDROL(TAB)(2 MG) 2
prednisolone MILLIPRED 2
prednisolone MILLIPRED DP 2
prednisone PREDNISONE INTENSOL 2
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 83 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
budesonide UCERIS 3 X
dexamethasone DEXAMETHASONE INTENSOL 3
dexamethasone DEXPAK 3
hydrocortisone sod succ/pf SOLU-CORTEF 3
prednisolone acetate FLO-PRED 3
prednisolone sod phosphate MILLIPRED 3
prednisolone sod phosphate VERIPRED 20 3
prednisone RAYOS 3 X
prednisone PREDNISONE(SOLUTION) 5
prednisone PREDNISONE(TAB)(1 MG) 5
prednisone PREDNISONE(TAB)(2.5 MG) 5
prednisone PREDNISONE(TAB)(20 MG) 5
prednisone PREDNISONE(TAB)(5 MG) 5
prednisone PREDNISONE(TAB)(50 MG) 5
auranofin RIDAURA 4 X
tocilizumab ACTEMRA 4 X X
tofacitinib citrate XELJANZ 4 X X
fludrocortisone acetate FLUDROCORTISONE ACETATE 1
ustekinumab STELARA 4 X X
ketorolac tromethamine SPRIX 3 X
ibuprofen/famotidine DUEXIS 3 XX
naproxen/esomeprazole mag VIMOVO 3 X
diclofenac sodium/misoprostol ARTHROTEC 50 1
diclofenac sodium/misoprostol ARTHROTEC 75 1
celecoxib CELEBREX 1
diclofenac potassium DICLOFENAC POTASSIUM 1
diclofenac sodium DICLOFENAC SODIUM 1
etodolac ETODOLAC 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 84 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
fenoprofen calcium FENOPROFEN CALCIUM(TAB) 1
flurbiprofen FLURBIPROFEN 1
ibuprofen IBUPROFEN 1
ketoprofen KETOPROFEN 1
ketorolac tromethamine KETOROLAC TROMETHAMINE 1
meclofenamate sodium MECLOFENAMATE SODIUM 1
mefenamic acid PONSTEL 1
meloxicam MOBIC 1
nabumetone NABUMETONE 1
naproxen NAPROXEN(ORAL SUSP) 1
naproxen sodium ANAPROX 1
naproxen sodium ANAPROX DS 1
oxaprozin DAYPRO 1
piroxicam FELDENE 1
sulindac SULINDAC 1
tolmetin sodium TOLMETIN SODIUM 1
fenoprofen calcium FENOPROFEN CALCIUM(CAP) 2
indomethacin INDOCIN 2
indomethacin/submicronized TIVORBEX 3 XX
meloxicam/submicronized VIVLODEX 3
diclofenac potassium ZIPSOR 3 XX
diclofenac submicronized ZORVOLEX 3 XX
naproxen sodium NAPRELAN 3
indomethacin INDOMETHACIN 5
naproxen EC-NAPROSYN 5
naproxen NAPROSYN 5
naproxen NAPROXEN(TAB) 5
naproxen/capsaicin/menthol NAPROPAX 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 85 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
diclofenac/capsicum DERMASILKRX DICLOPAK 3
ibuprofen/irr cnt-irrit cmb #2 COMFORT PAC-IBUPROFEN 3
meloxicam/irr cntr-irr cmb #2 COMFORT PAC-MELOXICAM 3
naproxen sodium/menthol NAPROPAK COOL 3
naproxen/irr cntr-irrit cmb #2 COMFORT PAC-NAPROXEN 3
LOCAL ANESTHESIA
lidocaine hcl LIDOCAINE HCL VISCOUS 1
b-caine/zinc cl/pine/cpyrd BUCALSEP 3
LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT
sulfadiazine SULFADIAZINE 1
mesalamine SFROWASA 1
mesalamine w/cleansing wipes ROWASA 1
mesalamine CANASA 2
balsalazide disodium COLAZAL 1
sulfasalazine SULFASALAZINE 1
mesalamine APRISO 2
mesalamine LIALDA 2
mesalamine PENTASA 2
balsalazide disodium GIAZO 3 X
mesalamine ASACOL HD 3 X
mesalamine DELZICOL 3 X
olsalazine sodium DIPENTUM 3 X
certolizumab pegol CIMZIA 4 X X
infliximab REMICADE 4 X X
hydrocort/pramoxin/emol/pram#1 ANALPRAM E 1
hydrocortisone/lidocaine/aloe LIDOCAINE-HYDROCORTISONE 1 ANALPRAM HC(CREAM/APPL) hydrocortisone/pramoxine 1 (1 %-1 %)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 86 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL ANALPRAM HC(CREAM/APPL) hydrocortisone/pramoxine 1 (2.5 %-1 %) ANALPRAM HC(CREAM/APPL) hydrocortisone/pramoxine 1 (2.5-1%(4G)) lidocaine/hydrocortisone ac LIDOCAINE-HYDROCORTISONE 1 ANALPRAM HC(CREAM/APPL) hydrocortisone/pramoxine 2 (1 %-1 %) hydrocortisone/pramoxine ANALPRAM HC(LOTION) 2
hydrocortisone/pramoxine PROCTOFOAM-HC 2
hydrocort/pramoxn/skn clnsr#16 ZYPRAM 3
hydrocortisone/lidocaine/aloe ANA-LEX 3
hydrocortisone/pramoxine PROCORT 3
lidocaine/hydrocortisone ac ANA-LEX 3
eluxadoline VIBERZI 3 X
linaclotide LINZESS 2 X
nitroglycerin RECTIV 3
hydrocortisone PROCTOZONE-HC 1
hydrocortisone acetate HEMMOREX-HC 1
hydrocortisone acetate PROCTOCORT 1
hydrocortisone CORTENEMA 1
budesonide UCERIS 3 X
hydrocortisone acetate CORTIFOAM 3
LOWER GASTROINTESTINAL DISORDERS - OTHER
lactulose GENERLAC 1
acetohydroxamic acid LITHOSTAT 3
carglumic acid CARBAGLU 4 X
glycerol phenylbutyrate RAVICTI 4 X X
sodium phenylbutyrate BUPHENYL 4 X
crofelemer FULYZAQ 3 XX
diphenoxylate hcl/atropine DIPHENOXYLATE-ATROPINE 1
diphenoxylate hcl/atropine LOMOTIL 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 87 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
loperamide hcl LOPERAMIDE 1
opium tincture OPIUM TINCTURE 1
paregoric PAREGORIC 1
dextranomer/hyaluronate/nacl SOLESTA 3
difenoxin hcl/atropine sulfate MOTOFEN 3
ursodiol ACTIGALL 1
ursodiol URSO 1
ursodiol URSO FORTE 1
chenodiol CHENODAL 3
cholic acid CHOLBAM 4 X X
alosetron hcl LOTRONEX 1
bisac/nacl/nahco3/kcl/peg 3350 PEG-PREP 1
lactulose LACTULOSE 1
polyethylene glycol 3350 POLYETHYLENE GLYCOL 3350 1
lactulose KRISTALOSE 2
lubiprostone AMITIZA 2 X
naphos m-b m-h/na phos,di-ba OSMOPREP 3
peg 3350-bowel 2,two part prep SUCLEAR 3
peg 3350/na sulf,bicarb,cl/kcl COLYTE WITH FLAVOR PACKS 3
sod picosulf/mag ox/citric ac PREPOPIK 3
peg 3350/na sulf,bicarb,cl/kcl GAVILYTE-C 5
peg 3350/na sulf,bicarb,cl/kcl GOLY TELY 5
sodium potassium &mag sulfates SUPREP 5
peg3350/sod sul/nacl/asb/c/kcl MOVIPREP 5
sodium chloride/nahco3/kcl/peg GAVILYTE-N 5
methylnaltrexone bromide RELISTOR 2 X
naloxegol oxalate MOVANTIK 2 X
alvimopan ENTEREG 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 88 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
teduglutide GATTEX 4 X X
MISCELLANEOUS AGENTS
epinephrine ADRENACLICK 1
epinephrine EPIPEN 2-PAK 2
epinephrine EPIPEN JR 2-PAK 2
epinephrine AUVI-Q 3 X
liver extract (beef-pork) NEXAVIR 3
bethanechol chloride URECHOLINE 1
cevimeline hcl EVOXAC 1
guanidine hcl GUANIDINE HCL 1
pilocarpine hcl SALAGEN 1
alpha-1-proteinase inhibitor ARALAST NP 4 X
alpha-1-proteinase inhibitor PROLASTIN C 4 X
alpha-1-proteinase inhibitor ZEMAIRA 4 X
NEOPLASTIC DISEASE
hydroxyurea HYDREA 1 X
melphalan ALKERAN 2 X
altretamine HEXALEN 4 X
busulfan BUSULFEX 4 X
busulfan MYLERAN 4 X
carmustine in polifeprosan 20 GLIADEL 4 X
chlorambucil LEUKERAN 4 X
cyclophosphamide CYCLOPHOSPHAMIDE 4 X
lomustine GLEOSTINE(CAP)(100 MG) 4 X
lomustine LOMUSTINE 4 X
lomustine GLEOSTINE(CAP)(10 MG) 4 X
lomustine GLEOSTINE(CAP)(40 MG) 4 X
lomustine GLEOSTINE(CAP)(5 MG) 4 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 89 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
melphalan hcl ALKERAN 4 X
temozolomide TEMODAR 4 X X
ofatumumab ARZERRA 4 X
rituximab RITUXAN 4 X X
bicalutamide CASODEX 1
flutamide FLUTAMIDE 1
abiraterone acetate ZYTIGA 4 X X
enzalutamide XTANDI 4 X X
nilutamide NILANDRON 4 X
streptozocin ZANOSAR 4 X
fluorouracil FLUOROURACIL 1
mercaptopurine MERCAPTOPURINE 1
methotrexate sodium METHOTREXATE(TAB) 1 X
methotrexate sodium METHOTREXATE(VIAL) 1
methotrexate sodium/pf METHOTREXATE SODIUM 1
methotrexate sodium TREXALL 2 X
capecitabine XELODA(TAB)(150 MG) 4 X X
capecitabine XELODA(TAB)(500 MG) 4 X X
fludarabine phosphate FLUDARABINE PHOSPHATE 4 X
mercaptopurine PURIXAN 4 XX
thioguanine TABLOID 4 X
trifluridine/tipiracil hcl LONSURF 4 X X
anastrozole ARIMIDEX 1
exemestane AROMASIN 1 X X
letrozole FEMARA 1
sonidegib phosphate ODOMZO 4 X X
vismodegib ERIVEDGE 4 X X
ruxolitinib phosphate JAKAFI 4 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 90 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
cobimetinib fumarate COTELLIC 4 X X
everolimus AFINITOR DISPERZ 4 X X
everolimus AFINITOR(TAB)(10 MG) 4 X X
everolimus AFINITOR(TAB)(2.5 MG) 4 X X
everolimus AFINITOR(TAB)(5 MG) 4 X X
everolimus AFINITOR(TAB)(7.5 MG) 4 X X
temsirolimus TORISEL 4 X X
topotecan hcl TOPOTECAN HCL 4 X
topotecan hcl HYCAMTIN 4 X
ziv-aflibercept ZALTRAP 4 X X
lenalidomide REVLIMID 4 X X
peginterferon alfa-2b SYLATRON 4 X
pomalidomide POMALYST 4 X X
degarelix acetate FIRMAGON(VIAL)(120 MG) 4 X
degarelix acetate FIRMAGON(VIAL)(80 MG) 4 X
afatinib dimaleate GILOTRIF 4 X X
alectinib hydrochloride ALECENSA 4 X
axitinib INLYTA(TAB)(1 MG) 4 X X
axitinib INLYTA(TAB)(5 MG) 4 X X
bosutinib BOSULIF(TAB)(100 MG) 4 X X
bosutinib BOSULIF(TAB)(500 MG) 4 X X
cabozantinib s-malate COMETRIQ 4 X X
ceritinib ZYKADIA 4 X X
crizotinib XALKORI 4 X X
dabrafenib mesylate TAFINLAR 4 X X
dasatinib SPRYCEL(TAB)(100 MG) 4 X X
dasatinib SPRYCEL(TAB)(140 MG) 4 X X
dasatinib SPRYCEL(TAB)(20 MG) 4 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 91 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
dasatinib SPRYCEL(TAB)(50 MG) 4 X X
dasatinib SPRYCEL(TAB)(70 MG) 4 X X
dasatinib SPRYCEL(TAB)(80 MG) 4 X X
erlotinib hcl TARCEVA 4 X X
gefitinib IRESSA 4 X X
ibrutinib IMBRUVICA 4 X X
idelalisib ZYDELIG 4 X X
imatinib mesylate GLEEVEC 4 X X
ixazomib citrate NINLARO 4 X X
lapatinib ditosylate TYKERB 4 X X
lenvatinib mesylate LENVIMA 4 X X
nilotinib hcl TASIGNA 4 X X
olaparib LYNPARZA 4 X X
osimertinib mesylate TAGRISSO 4 X X
palbociclib IBRANCE 4 X X
pazopanib hcl VOTRIENT 4 X X
ponatinib hcl ICLUSIG(TAB)(15 MG) 4 X X
ponatinib hcl ICLUSIG(TAB)(45 MG) 4 X X
regorafenib STIVARGA 4 X X
sorafenib tosylate NEXAVAR 4 X X
sunitinib malate SUTENT 4 X X
trametinib dimethyl sulfoxide MEKINIST 4 X X
vandetanib CAPRELSA(TAB)(100 MG) 4 X X
vandetanib CAPRELSA(TAB)(300 MG) 4 X X
vemurafenib ZELBORAF 4 X X
panobinostat lactate FARYDAK 4 X X
vorinostat ZOLINZA 4 X
etoposide ETOPOSIDE(CAP) 1 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 92 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
etoposide ETOPOSIDE(VIAL) 1
etoposide phosphate ETOPOPHOS 3
mitotane LYSODREN 4 X
mitoxantrone hcl MITOXANTRONE HCL 4 X X
omacetaxine mepesuccinate SYNRIBO 4 X X
procarbazine hcl MATULANE 4 X
tretinoin TRETINOIN 4 X
amifostine crystalline AMIFOSTINE 1
leucovorin calcium LEUCOVORIN CALCIUM 1
mesna MESNEX 3
glucarpidase VORAXAZE 4 X
ipilimumab YERVOY 4 X X
talc STERILE TALC 1
talc SCLEROSOL 3
methoxsalen UVADEX 3
aminolevulinic acid hcl LEVULAN 3
tamoxifen citrate SOLTAMOX 2
toremifene citrate FARESTON 4 X X
tamoxifen citrate TAMOXIFEN CITRATE 5
bexarotene TARGRETIN 4 X X
megestrol acetate MEGESTROL ACETATE 1
estramustine phosphate sodium EMCYT 4 X
NEUROLOGICAL DISEASE - MISCELLANEOUS
dimethyl fumarate TECFIDERA 4 X X
fingolimod hcl GILENYA 4 X X
glatiramer acetate COPAXONE 4 X X
interferon beta-1a AVONEX 4 X X
interferon beta-1a AVONEX PEN 4 X X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 93 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL AVONEX ADMINISTRATION interferon beta-1a/albumin 4 X X PACK interferon beta-1a/albumin REBIF 4 X X
interferon beta-1a/albumin REBIF REBIDOSE 4 X X
interferon beta-1b BETASERON 4 X X
interferon beta-1b EXTAVIA 4 X X
peginterferon beta-1a PLEGRIDY 4 X X
peginterferon beta-1a PLEGRIDY PEN 4 X X
teriflunomide AUBAGIO 4 X X
dalfampridine AMPYRA 4 X X
riluzole RILUTEK 4 X
milnacipran hcl SAVELLA 2
natalizumab TYSABRI 4 X X
gabapentin enacarbil HORIZANT(TAB ER)(300 MG) 3 XX
gabapentin enacarbil HORIZANT(TAB ER)(600 MG) 3 XX
tetrabenazine XENAZINE 4 X
gabapentin GRALISE(TAB ER 24H)(300 MG) 3 XX GRALISE(TAB ER 24H)(300- gabapentin 3 XX 600 MG) gabapentin GRALISE(TAB ER 24H)(600 MG) 3 XX
dextromethorphan hbr/quinidine NUEDEXTA 3 X
ORAL/PHARYNGEAL DISORDERS
chlorhexidine gluconate CHLORHEXIDINE GLUCONATE 1
triamcinolone acetonide TRIAMCINOLONE ACETONIDE 1
dental suction/chlor/swb#1/mth Q-CARE RX 3
dental suction/chlorhx/swab #1 Q-CARE RX 3
palifermin KEPIVANCE 4 X
mupirocin calcium BACTROBAN NASAL 2
ipratropium bromide ATROVENT 1
minocycline hcl microspheres ARESTIN 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 94 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
OTHER RESPIRATORY DISORDERS
pirfenidone ESBRIET 4 X X
ivacaftor KALYDECO(GRAN PACK) 4 X X
ivacaftor KALYDECO(TAB) 4 X X
lumacaftor/ivacaftor ORKAMBI 4 X X
beractant SURVANTA 3
calfactant INFASURF 3
lucinactant SURFAXIN 3
poractant alfa CUROSURF 3
acetylcysteine ACETYLCYSTEINE 1
dornase alfa PULMOZYME 4 X X
nintedanib esylate OFEV 4 X X
PAIN MANAGEMENT - ANALGESICS
butalbital/acetaminophen BUTALBITAL-ACETAMINOPHEN 1
butalbital/acetaminophen BUPAP 3
butalbital/aspirin/caffeine FIORINAL 1 BUTALBITAL-ACETAMINO- butalb/acetaminophen/caffeine 1 PHEN-CAFFE butalb/acetaminophen/caffeine ESGIC 1
butalb/acetaminophen/caffeine FIORICET 1
butalb/acetaminophen/caffeine VANATOL LQ 3
choline sal/mag salicylate CHOLINE MAG TRISALICYLATE 1
diflunisal DIFLUNISAL 1
salsalate DISALCID 1
asa/salicylam/acetaminoph/caff LEVACET 3
aspirin ASPIRIN EC(OTC) 5 acetaminophen/pyrilam/pam- abrom MENSTRUAL PAIN RELIEF(OTC) 1
hydrocodone/ibuprofen HYDROCODONE-IBUPROFEN 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 95 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
hydrocodone/ibuprofen VICOPROFEN 1
ibuprofen/oxycodone hcl OXYCODONE HCL-IBUPROFEN 1
butorphanol tartrate BUTORPHANOL TARTRATE 1
codeine sulfate CODEINE SULFATE 1 CARISOPRODOL COM- codeine/carisoprodol/aspirin 1 POUND-CODEINE dhcodeine bt/acetaminophn/caff TREZIX 1 X
dihydrocodeine/aspirin/caffein SYNALGOS-DC 1
fentanyl DURAGESIC 1 X X
fentanyl FENTANYL 1 X X
fentanyl citrate ACTIQ 1 X
hydrocodone/acetaminophen HYCET 1 X HYDROCODONE-ACETAMINO- hydrocodone/acetaminophen 1 X PHEN(SOLUTION)(10-325/15) HYDROCODONE-ACETAMINO- hydrocodone/acetaminophen 1 X PHEN(SOLUTION)(2.5-167/5) HYDROCODONE-ACETAMINO- hydrocodone/acetaminophen 1 X PHEN(SOLUTION)(5-163/7.5) HYDROCODONE-ACETAMINO- hydrocodone/acetaminophen 1 X PHEN(TAB)(10MG-300MG) HYDROCODONE-ACETAMINO- hydrocodone/acetaminophen 1 X PHEN(TAB)(10MG-325MG) HYDROCODONE-ACETAMINO- hydrocodone/acetaminophen 1 X PHEN(TAB)(5 MG-325MG) HYDROCODONE-ACETAMINO- hydrocodone/acetaminophen 1 X PHEN(TAB)(5MG-300MG) HYDROCODONE-ACETAMINO- hydrocodone/acetaminophen 1 X PHEN(TAB)(7.5-300MG) HYDROCODONE-ACETAMINO- hydrocodone/acetaminophen 1 X PHEN(TAB)(7.5-325MG) hydrocodone/acetaminophen VERDROCET 1
hydromorphone hcl DILAUDID 1
hydromorphone hcl HYDROMORPHONE HCL 1
hydromorphone hcl/pf DILAUDID 1
hydromorphone hcl/pf DILAUDID-HP(AMPUL) 1
hydromorphone hcl/pf HYDROMORPHONE HCL 1
levorphanol tartrate LEVORPHANOL TARTRATE 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 96 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
meperidine hcl DEMEROL 1 X
meperidine hcl MEPERIDINE HCL(CARTRIDGE) 1
meperidine hcl MEPERIDINE HCL(SOLUTION) 1 X
meperidine hcl MEPERIDINE HCL(TAB) 1 X
methadone hcl DOLOPHINE HCL 1
methadone hcl METHADONE HCL 1
morphine sulfate KADIAN(CAP ER PEL)(10 MG) 1 X
morphine sulfate KADIAN(CAP ER PEL)(100 MG) 1 X
morphine sulfate KADIAN(CAP ER PEL)(20 MG) 1 X
morphine sulfate KADIAN(CAP ER PEL)(30 MG) 1 X
morphine sulfate KADIAN(CAP ER PEL)(50 MG) 1 X
morphine sulfate KADIAN(CAP ER PEL)(60 MG) 1 X
morphine sulfate KADIAN(CAP ER PEL)(80 MG) 1 X MORPHINE SULFATE ER(CPMP morphine sulfate 1 X 24HR)(120 MG) MORPHINE SULFATE ER(CPMP morphine sulfate 1 X 24HR)(30 MG) MORPHINE SULFATE ER(CPMP morphine sulfate 1 X 24HR)(45 MG) MORPHINE SULFATE ER(CPMP morphine sulfate 1 X 24HR)(60 MG) MORPHINE SULFATE ER(CPMP morphine sulfate 1 X 24HR)(75 MG) MORPHINE SULFATE ER(CPMP morphine sulfate 1 X 24HR)(90 MG) morphine sulfate MS CONTIN 1 X MORPHINE SULFATE-0.9% morphine sulfate in 0.9 % nacl 1 NACL morphine sulfate/pf MORPHINE SULFATE 1
nalbuphine hcl NALBUPHINE HCL 1
opium/belladonna alkaloids BELLADONNA-OPIUM 1
oxycodone hcl OXYCODONE HCL 1
oxycodone hcl ROXICODONE 1
oxycodone hcl/acetaminophen PERCOCET 1 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 97 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
oxycodone hcl/aspirin OXYCODONE HCL-ASPIRIN 1
oxymorphone hcl OPANA(TAB) 1
pentazocine hcl/naloxone hcl PENTAZOCINE-NALOXONE HCL 1
tramadol hcl ULTRAM 1
tramadol hcl/acetaminophen ULTRACET 1
buprenorphine BUTRANS 2 X
morphine sulfate MORPHINE SULFATE 2 OXYCONTIN(TAB ER 12H)(10 oxycodone hcl 2 X MG) OXYCONTIN(TAB ER 12H)(15 oxycodone hcl 2 X MG) OXYCONTIN(TAB ER 12H)(20 oxycodone hcl 2 X MG) OXYCONTIN(TAB ER 12H)(30 oxycodone hcl 2 X MG) OXYCONTIN(TAB ER 12H)(40 oxycodone hcl 2 X MG) OXYCONTIN(TAB ER 12H)(60 oxycodone hcl 2 X MG) OXYCONTIN(TAB ER 12H)(80 oxycodone hcl 2 X MG) tapentadol hcl NUCYNTA 2 X
tapentadol hcl NUCYNTA ER 2 X
buprenorphine hcl BELBUCA 3
buprenorphine hcl BUPRENEX 3
fentanyl SUBSYS 3 X
fentanyl citrate ABSTRAL 3 X
fentanyl citrate FENTORA 3 X
fentanyl citrate LAZANDA 3 X
fentanyl hcl IONSYS 3
hydrocodone bitartrate HYSINGLA ER 3 X
hydrocodone bitartrate ZOHYDRO ER 3 X
hydrocodone/acetaminophen LORTAB 3
hydrocodone/acetaminophen ZAMICET 3 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 98 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
hydromorphone hcl/pf DILAUDID-HP(VIAL) 3
meperidine hcl/pf DEMEROL 3
morphine sulfate KADIAN(CAP ER PEL)(200 MG) 3 X
morphine sulfate KADIAN(CAP ER PEL)(40 MG) 3 X EMBEDA(CAP ER PO)(100MG- morphine sulfate/naltrexone 3 X 4MG) EMBEDA(CAP ER PO)(20MG- morphine sulfate/naltrexone 3 X 0.8MG) EMBEDA(CAP ER PO)(30MG- morphine sulfate/naltrexone 3 X 1.2MG) EMBEDA(CAP ER PO)(50 MG-2 morphine sulfate/naltrexone 3 X MG) EMBEDA(CAP ER PO)(60MG- morphine sulfate/naltrexone 3 X 2.4MG) EMBEDA(CAP ER PO)(80MG- morphine sulfate/naltrexone 3 X 3.2MG) oxycodone hcl OXAYDO 3
oxycodone hcl OXECTA 3
oxycodone hcl/acetaminophen PRIMLEV 3 X
oxycodone hcl/acetaminophen XARTEMIS XR 3 X
oxymorphone hcl OPANA(AMPUL) 3
pentazocine lactate TALWIN 3
almotriptan malate AXERT 1 XX
dihydroergotamine mesylate D.H.E.45 1 X DIHYDROERGOTAMINE dihydroergotamine mesylate 1 MESYLATE dihydroergotamine mesylate MIGRANAL 1 X ISOMETHEPT-DICHLORALP-AC- isomethept/dichlphn/acetaminop 1 ETAMIN ISOMETHEPT-CAFF-ACETAMIN- isomethepten/caf/acetaminophen 1 OPHEN naratriptan hcl AMERGE 1 X
rizatriptan benzoate MAXALT 1 X
rizatriptan benzoate MAXALT MLT 1 X
sumatriptan IMITREX 1 X
sumatriptan succinate IMITREX(CARTRIDGE) 1 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 99 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
sumatriptan succinate IMITREX(PEN INJCTR) 1 X
sumatriptan succinate IMITREX(TAB) 1 X
sumatriptan succinate IMITREX(VIAL) 1 X
zolmitriptan ZOMIG(TAB) 1 XX
ergotamine tartrate/caffeine CAFERGOT 2 X
zolmitriptan ZOMIG(SPRAY)(2.5 MG) 2 XX
zolmitriptan ZOMIG(SPRAY)(5 MG) 2 XX
diclofenac potassium CAMBIA 3 X
eletriptan hbr RELPAX 3 XX
ergotamine tartrate ERGOMAR 3 X
ergotamine tartrate/caffeine MIGERGOT 3 X
frovatriptan succinate FROVA 3 XX
sumatriptan succ/naproxen sod TREXIMET 3 XX
sumatriptan succinate ALSUMA 3 X SUMAVEL DOSEPRO(NDL FR sumatriptan succinate 3 XX INJ)(4 MG/0.5ML) SUMAVEL DOSEPRO(NDL FR sumatriptan succinate 3 XX INJ)(6 MG/0.5ML) sumatriptan succinate ZECUITY 3 BUTALB-CAFF-ACETAMI- butalbit/acetamin/caff/codeine 1 NOPH-CODEIN codeine/butalbital/asa/caffein FIORINAL WITH CODEINE #3 1
acetaminophen with codeine ACETAMINOPHEN-CODEINE 1
acetaminophen with codeine TYLENOL-CODEINE NO.3 1
acetaminophen with codeine TYLENOL-CODEINE NO.4 1
acetaminophen with codeine CAPITAL W-CODEINE 2
buprenorphine hcl BUPRENORPHINE HCL 1
buprenorphine hcl/naloxone hcl BUPRENORPHINE-NALOXONE 1 X
buprenorphine hcl/naloxone hcl SUBOXONE 2 X
buprenorphine hcl BUPRENEX 3
buprenorphine hcl/naloxone hcl BUNAVAIL 3 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 100 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
buprenorphine hcl/naloxone hcl ZUBSOLV 3 X
PARKINSONS DISEASE
benztropine mesylate BENZTROPINE MESYLATE 1
benztropine mesylate COGENTIN 1
trihexyphenidyl hcl TRIHEXYPHENIDYL HCL 1
amantadine hcl AMANTADINE 1
bromocriptine mesylate PARLODEL 1
carbidopa/levodopa CARBIDOPA-LEVODOPA 1
carbidopa/levodopa SINEMET 10-100 1
carbidopa/levodopa SINEMET 25-100 1
carbidopa/levodopa SINEMET 25-250 1
carbidopa/levodopa/entacapone STALEVO 100 1
carbidopa/levodopa/entacapone STALEVO 125 1
carbidopa/levodopa/entacapone STALEVO 150 1
carbidopa/levodopa/entacapone STALEVO 200 1
carbidopa/levodopa/entacapone STALEVO 50 1
carbidopa/levodopa/entacapone STALEVO 75 1
entacapone COMTAN 1
pramipexole di-hcl MIRAPEX 1
ropinirole hcl REQUIP 1
selegiline hcl ELDEPRYL 1
selegiline hcl SELEGILINE HCL 1
tolcapone TASMAR 1 XX
rasagiline mesylate AZILECT 2 X
rotigotine NEUPRO 2 XX
carbidopa/levodopa DUOPA 3 X
carbidopa/levodopa RYTARY 3 XX
pramipexole di-hcl MIRAPEX ER 3 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 101 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
selegiline hcl ZELAPAR 3 X
apomorphine hcl APOKYN 4 X X
carbidopa LODOSYN 1
SEIZURE DISORDER
clonazepam CLONAZEPAM 1
clonazepam KLONOPIN 1
diazepam DIASTAT 1 X
diazepam DIASTAT ACUDIAL 1 X
divalproex sodium DEPAKOTE ER 1
fosphenytoin sodium CEREBYX 1
gabapentin GABAPENTIN 1
gabapentin NEURONTIN(CAP)(300 MG) 1
lamotrigine LAMICTAL (BLUE) 1
phenytoin sodium PHENYTOIN SODIUM 1
valproic acid (as sodium salt) VALPROIC ACID 1
carbamazepine TEGRETOL XR 2
lamotrigine LAMICTAL (GREEN) 2
lamotrigine LAMICTAL (ORANGE) 2
phenytoin sodium extended DILANTIN(CAP)(30 MG) 2
pregabalin LYRICA 2
clobazam ONFI(ORAL SUSP) 3 XX
clobazam ONFI(TAB) 3 XX
eslicarbazepine acetate APTIOM(TAB)(200 MG) 3 XX
eslicarbazepine acetate APTIOM(TAB)(400 MG) 3 XX
eslicarbazepine acetate APTIOM(TAB)(600 MG) 3 XX
eslicarbazepine acetate APTIOM(TAB)(800 MG) 3 XX
ethotoin PEGANONE 3
ezogabine POTIGA(TAB)(200 MG) 3 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 102 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
ezogabine POTIGA(TAB)(300 MG) 3 XX
ezogabine POTIGA(TAB)(400 MG) 3 XX
ezogabine POTIGA(TAB)(50 MG) 3 XX
lacosamide VIMPAT(SOLUTION) 3 XX
lacosamide VIMPAT(TAB) 3 XX
lacosamide VIMPAT(VIAL) 3
lamotrigine LAMICTAL XR (BLUE) 3 X
lamotrigine LAMICTAL XR (GREEN) 3 X
lamotrigine LAMICTAL XR (ORANGE) 3 X
lamotrigine LAMICTAL(TB CHW DSP)(2 MG) 3
methsuximide CELONTIN 3 OXTELLAR XR(TAB ER 24H) oxcarbazepine 3 XX (150 MG) OXTELLAR XR(TAB ER 24H) oxcarbazepine 3 XX (300 MG) OXTELLAR XR(TAB ER 24H) oxcarbazepine 3 XX (600 MG) perampanel FYCOMPA(TAB)(10 MG) 3 XX
perampanel FYCOMPA(TAB)(12 MG) 3 XX
perampanel FYCOMPA(TAB)(2 MG) 3 XX
perampanel FYCOMPA(TAB)(4 MG) 3 XX
perampanel FYCOMPA(TAB)(6 MG) 3 XX
perampanel FYCOMPA(TAB)(8 MG) 3 XX
rufinamide BANZEL(ORAL SUSP) 3 XX
rufinamide BANZEL(TAB)(200 MG) 3 XX
rufinamide BANZEL(TAB)(400 MG) 3 XX
tiagabine hcl GABITRIL(TAB)(12 MG) 3 XX
tiagabine hcl GABITRIL(TAB)(16 MG) 3 XX TROKENDI XR(CAP ER 24H) topiramate 3 XX (100 MG) TROKENDI XR(CAP ER 24H) topiramate 3 XX (200 MG)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 103 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL TROKENDI XR(CAP ER 24H)(25 topiramate 3 XX MG) TROKENDI XR(CAP ER 24H)(50 topiramate 3 XX MG) vigabatrin SABRIL 3 X
carbamazepine CARBAMAZEPINE 5
carbamazepine CARBATROL 5
carbamazepine TEGRETOL 5
ethosuximide ZARONTIN 5
felbamate FELBATOL(ORAL SUSP) 5 XX
felbamate FELBATOL(TAB)(400 MG) 5 XX
felbamate FELBATOL(TAB)(600 MG) 5 XX
gabapentin NEURONTIN(CAP)(100 MG) 5
gabapentin NEURONTIN(CAP)(400 MG) 5
gabapentin NEURONTIN(SOLUTION) 5
gabapentin NEURONTIN(TAB) 5
lamotrigine LAMICTAL(TAB) 5 LAMICTAL(TB CHW DSP)(25 lamotrigine 5 MG) lamotrigine LAMICTAL(TB CHW DSP)(5 MG) 5
levetiracetam KEPPRA 5
levetiracetam LEVETIRACETAM 5
oxcarbazepine TRILEPTAL 5
phenytoin DILANTIN 5
phenytoin DILANTIN-125 5
phenytoin PHENYTOIN 5
phenytoin sodium extended DILANTIN(CAP)(100 MG) 5
phenytoin sodium extended PHENYTEK 5
primidone MYSOLINE 5
tiagabine hcl GABITRIL(TAB)(2 MG) 5 XX
tiagabine hcl GABITRIL(TAB)(4 MG) 5 XX
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 104 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
topiramate TOPAMAX 5
valproic acid DEPAKENE 5
valproic acid (as sodium salt) DEPAKENE 5
zonisamide ZONEGRAN 5
zonisamide ZONISAMIDE 5
SKELETAL MUSCLE DISORDER
dichlorphenamide KEVEYIS 4 X X
baclofen BACLOFEN 1
carisoprodol SOMA 1
carisoprodol/aspirin CARISOPRODOL-ASPIRIN 1
chlorzoxazone PARAFON FORTE DSC 1
cyclobenzaprine hcl CYCLOBENZAPRINE HCL 1
cyclobenzaprine hcl FEXMID 1
dantrolene sodium DANTRIUM 1
dantrolene sodium DANTROLENE SODIUM 1
metaxalone METAXALONE 1
metaxalone SKELAXIN 1
methocarbamol ROBAXIN 1
methocarbamol ROBAXIN-750 1
orphenadrine citrate ORPHENADRINE CITRATE 1
tizanidine hcl TIZANIDINE HCL 1
tizanidine hcl ZANAFLEX 1
chlorzoxazone LORZONE 3
cyclobenzaprine hcl AMRIX 3
cyclobenzaprine/capsai/menthol FLEXEPAX 1 COMFORT PAC-CYCLOBEN- cyclobenz hcl/irr cntr-irr cb2 3 ZAPRINE tizanidine/irr cntr-irr cmb #2 COMFORT PAC-TIZANIDINE 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 105 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
SMOKING CESSATION
nicotine NICODERM CQ(OTC) 5 X X NICOTINE PATCH(PATCH TD24) nicotine 5 X X (OTC) nicotine NICOTINE PATCH(PATCH)(OTC) 5 X
nicotine NICOTROL 5 X X X
nicotine NICOTROL NS 5 X X X
nicotine polacrilex NICORETTE(OTC) 5 X X
varenicline tartrate CHANTIX 5 X X
bupropion hcl BUPROBAN 5 X X
UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE
sacrosidase SUCRAID 4 X X
lipase/protease/amylase PANCRELIPASE 5,000 1
lipase/protease/amylase CREON 2
lipase/protease/amylase ZENPEP 2
lipase/protease/amylase PANCREAZE 3
lipase/protease/amylase PERTZYE 3
lipase/protease/amylase ULTRESA 3
lipase/protease/amylase VIOKACE 3
UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE
dicyclomine hcl BENTYL 1
dicyclomine hcl DICYCLOMINE HCL 1
hyoscyamine sulfate HYOSCYAMINE SULFATE 1
hyoscyamine sulfate SYMAX-SL 1
methscopolamine bromide METHSCOPOLAMINE BROMIDE 1
phenobarb/hyoscy/atropine/scop DONNATAL 2
hyoscyamine sulfate SYMAX DUOTAB 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 106 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE
misoprostol CYTOTEC 1
sucralfate CARAFATE(TAB) 1
sucralfate CARAFATE(ORAL SUSP) 2
lansoprazole/amoxiciln/clarith PREVPAC 1 X
bismuth/metronid/tetracycline PYLERA 3
omeprazole/clarith/amoxicillin OMECLAMOX-PAK 3
chlordiazepoxide/clidinium br LIBRAX 1
glycopyrrolate ROBINUL 1
glycopyrrolate ROBINUL FORTE 1
propantheline bromide PROPANTHELINE BROMIDE 1
glycopyrrolate CUVPOSA 3
mepenzolate bromide CANTIL 3
cimetidine CIMETIDINE 1
cimetidine hcl CIMETIDINE 1
famotidine PEPCID 1
nizatidine NIZATIDINE 1
ranitidine hcl RANITIDINE HCL 1
ranitidine hcl ZANTAC 1
famotidine PEPCID RPD 3
metoclopramide hcl METOCLOPRAMIDE HCL 1
metoclopramide hcl REGLAN 1
omeprazole/sodium bicarbonate ZEGERID(CAP) 1 XX
rabeprazole sodium ACIPHEX 1 X
esomeprazole magnesium NEXIUM(SUSP DR PKT) 2 X
lansoprazole PREVACID(TAB RAP DR) 2 X
dexlansoprazole DEXILANT 3 XX
omeprazole magnesium PRILOSEC 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 107 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
omeprazole/sodium bicarbonate ZEGERID(PACKET) 3 XX
pantoprazole sodium PROTONIX(GRANPKT DR) 3 X
rabeprazole sodium ACIPHEX SPRINKLE 3 XX
esomeprazole magnesium NEXIUM(CAP DR) 5 X
lansoprazole PREVACID(CAP DR) 5
omeprazole PRILOSEC 5
pantoprazole sodium PROTONIX(TAB DR) 5
URINARY TRACT - FUNCTIONAL DISORDERS
alfuzosin hcl UROXATRAL 1
dutasteride AVODART 1 X X
finasteride PROSCAR 1
tamsulosin hcl FLOMAX 1
silodosin RAPAFLO 3 X X
dutasteride/tamsulosin hcl JALYN 1 X X
cysteamine bitartrate CYSTAGON 3
cysteamine bitartrate PROCYSBI 4 X X
tiopronin THIOLA 4 X
mirabegron MYRBETRIQ 2 XX
phosphorus #1 PHOSPHA 250 NEUTRAL 1
potassium citrate UROCIT-K 1
na phos,m-b/k phos,monob K-PHOS NO.2 3
potassium phosphate,monobasic K-PHOS ORIGINAL 3
citric acid/g-lactone/mag carb RENACIDIN 3
methen mand/naphos m-b m-h UROQID-ACID NO.2 3
pentosan polysulfate sodium ELMIRON 2
phenazopyridine hcl PYRIDIUM 1
solifenacin succinate VESICARE 2 X
darifenacin hydrobromide ENABLEX 3 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 108 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
flavoxate hcl FLAVOXATE HCL 1
oxybutynin chloride OXYBUTYNIN CHLORIDE 1
tolterodine tartrate DETROL LA 1 X
trospium chloride TROSPIUM CHLORIDE 1 X
fesoterodine fumarate TOVIAZ 2 X
oxybutynin GELNIQUE 3 X
oxybutynin OXYTROL 3 X
oxybutynin chloride GELNIQUE 3 X
VAGINAL DISORDERS
clindamycin phosphate CLEOCIN(CREAM/APPL) 1
metronidazole METROGEL-VAGINAL 1
metronidazole VANDAZOLE 2
clindamycin phosphate CLEOCIN(SUPP VAG) 3
clindamycin phosphate CLINDESSE 3
metronidazole NUVESSA 3
miconazole nitrate MICONAZOLE 3 1
terconazole TERAZOL 3 1
terconazole TERAZOL 7 1
terconazole TERCONAZOLE 1
butoconazole nitrate GYNAZOLE 1 2
estrogens, conjugated PREMARIN 2
estradiol ESTRACE 2
estradiol VAGIFEM 2
estradiol ESTRING 3 X
estradiol acetate FEMRING 3 X
sulfanilamide AVC 2
VITAMIN AND/OR MINERAL DEFICIENCY
vit a,c & e/lutein/minerals I-VITE(OTC) 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 109 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
antiox #11/om3/dha/epa/lut/zea 50+ ADULT EYE HEALTH(OTC) 1
antiox#10/om3/dha/epa/lut/zeax I-CAPS(OTC) 1
beta-carotene(a) w-c & e/zn/cu VISION-VITE + ZINC(OTC) 1
mv-mn/om3/dha/epa/fish/lut/zea LIPOTRIAD VISIONARY(OTC) 1 EYE VITAMIN & MINER- vit a/c/e ac/znox/cupric oxide 1 ALS(OTC) PRESERVISION AREDS(TAB) vit a/vit c/vit e/zinc/copper 1 (OTC) antiox#12/om3/dha/epa/lut/zean MACULAR BENEFITS(OTC) 3
fa/vit c/e/zinc/copper/lut/zea MACUVEX 3
fa/vit c/e/zinc/copper/lut/zea MACUZIN 3
fa/vit c/e/zinc/copper/lut/zea OCUVEL 3
multivit w-mn/fa/lycop/lut/ala MULTI-BETIC(OTC) 3
vit a/vit c/vit e/selenium yst ANTIOXIDANT FORMULA(OTC) 3 PRESERVISION AREDS(CAP) vit a/vit c/vit e/zinc/copper 3 (OTC) vit c/vit e/lutein/min/omega-3 OCUVITE(OTC) 3
vit c/vite ac/lut/copper/znox PRESERVISION LUTEIN(OTC) 3
bioflav,lemon/vit bcomp,c LIPOFLAVOVIT(OTC) 1
hesperidin/diosmin BIOFLONEX(OTC) 1
inositol/choline/biofla/vitb&c EAR HEALTH PLUS(OTC) 1
bioflavonoids, citrus CITRUS BIOFLAVONOIDS(OTC) 3
hesperidin met chalcon/diosmin VASOFLEX D1(OTC) 3
hesperidin/diosmin/grape seed VENALIV(OTC) 3
rutin RUTIN(OTC) 3 BONE MEAL WITH VITAMIN A & bone meal/vitamin d2 1 D(OTC) ca carb & gluc/mag ox & gluc CALCIUM MAGNESIUM(OTC) 1
ca citrate/mgox/vit d3/b6/min CALCIUM CITRATE + D(OTC) 1
ca/d3/mag ox/zinc/cop/mang/bor CALCIUM 600 + VIT D(OTC) 1
calc/d3/mag/zn/copp/mang/bo- CALCIUM PLUS VITAMIN 1 ron D(OTC)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 110 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
calcium carb & citrate/vit d3 CITRACAL + D(OTC) 1
calcium carb & lact/vitamin d3 CALCET PETITES(OTC) 1 PARVA-CAL 500(TAB)(500 MG- calcium carb &gluconate/vit d2 1 200)(OTC) calcium carb/d3/mag aa chelate CORAL CALCIUM(OTC) 1 CALCIUM-MAGNE- calcium carb/d3/magnesium/zinc 1 SIUM-ZINC-VIT D(OTC) CALCIUM-MAGNE- calcium carb/mag ox/zinc gluc 1 SIUM-ZINC(OTC) CALCIUM-MAGNE- calcium carb/mag ox/zinc sulf 1 SIUM-ZINC(OTC) CALCIUM-MAGNE- calcium carb/mag oxide/cu/znox 1 SIUM-ZINC(OTC) CALCIUM-MAGNE- calcium carb/mag oxide/zinc ox 1 SIUM-ZINC(OTC) CALCIUM MAGNESIUM + calcium carb/magnesium oxid/d3 1 D(OTC) CALCIUM 600+D & MINER- calcium carb/vit d3/minerals 1 ALS(OTC) calcium carb/vitamin d2/soyb CALCIUM 600 WITH SOY(OTC) 1
calcium carb/vitamin d3/soyb SOY FORMULA(OTC) 1
calcium carb/vitamin d3/vit k1 VIACTIV(OTC) 1
calcium carbonate OYSTER SHELL CALCIUM(OTC) 1
calcium carbonate/boron gluc CALCIUM WITH BORON(OTC) 1 OYSTER SHELL CALCIUM-MAG- calcium carbonate/magnesium ox 1 NESIUM(OTC) OYSTER SHELL CALCIUM W-VIT calcium carbonate/vitamin d2 1 D(OTC) OYSTER SHELL CALCIUM W-VIT calcium carbonate/vitamin d3 1 D(OTC) calcium chloride CALCIUM CHLORIDE 1 CALCIUM CITRATE MALATE calcium cit malate/vitamin d3 1 WITH D(OTC) calcium cit/mag/d3/zn/cop/mang CALCIUM CITRATE PLUS(OTC) 1
calcium citrate CALCITRATE(OTC) 1
calcium citrate/vitamin d2 CAL-CITRATE(OTC) 1
calcium citrate/vitamin d3 CITRUS CALCIUM + D(OTC) 1
calcium glubionate CALCIONATE(OTC) 1
calcium gluconate CALCIUM GLUCONATE 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 111 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
calcium gluconate CALCIUM GLUCONATE(OTC) 1 CALCIUM GLUCONATE-0.9% calcium gluconate in 0.9% nacl 1 NACL CALCIUM LACTATE(TAB)(650 calcium lactate 1 MG)(OTC) CALCIUM LACTATE(TAB)(84 calcium lactate 1 MG(648))(OTC) CHILDREN’S CALCIUM GUM- calcium phos tribas/vitamin d2 1 MIES(OTC) calcium phosphate dibas/vit d3 RISACAL-D(OTC) 1 CALCIUM + VITAMIN D3(TAB calcium phosphate trib/vit d3 1 CHEW)(250MG-400)(OTC) BONE DENSITY CALCIUM + calcium/d3/argnin/inos/silicon 1 D(OTC) CORAL CALCIUM(CAP)(185-50- calcium/mag oxide/vitamin d3 1 100)(OTC) calcium/mag/d3/b12/fa/b6/boron FOLGARD OS 1
calcium/magnesium CALCIUM-MAGNESIUM(OTC) 1 CALCIUM-MAGNE- calcium/magnesium/zinc 1 SIUM-ZINC(OTC) calcium/multivitamins w-iron FOSFREE(OTC) 1 CALTRATE + D3 PLUS MINER- ca carb/d3/mag ox/cop/mang/zn 3 ALS(OTC) ca/d3/mag/zinc/copp/mang/mg- CALTRATE 600+D3 PLUS MIN- 3 bor ERALS(OTC)
cal cit/d3/k/mag ox/stron/bor PROSTEON(OTC) 3
cal cit/d3/k/mag ox/stron/bor THERACAL(OTC) 3 CITRACAL-VIT D + MAGNE- cal cit/mag/d3/zn/cop/mang/bor 3 SIUM(OTC) cal phos/mag hydrx/c & d3/phos PRO-CAL(OTC) 3
cal/fa/b/d3/e/bioflav/soy xt CALCI-MAX(OTC) 3
calc/mag ox/d2/mang/boron/sil FEM-CAL CITRATE(OTC) 3 CALCIUM AMINO ACID CHE- calcium amino acid chelate 3 LATE(OTC) calcium carb &cit/mag cit &gly LOCALNESIUM(OTC) 3
calcium carb &cit/magnesium ox CALMAG THINS(OTC) 3
calcium carb &gluconate/vit d2 PARVA-CAL 250(OTC) 3 PARVA-CAL 500(TAB)(500 MG- calcium carb &gluconate/vit d2 3 200)(OTC)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 112 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL CITRACAL D + HEART calcium carb&cit/d3/phytostrol 3 HEALTH(OTC) calcium carb/d3/magnesium/zinc CAL MAG ZINC + D(OTC) 3
calcium carb/mag oxide/vit c LOCALNESIUM-C(OTC) 3
calcium carb/mag/vitamin d3 CORAL CALCIUM(OTC) 3
calcium carb/magnesium cmb #10 CAL-MAG(OTC) 3
calcium carb/mgox/vit d2/biofl ACTICAL(OTC) 3
calcium carb/vitamin d3/vit k1 CITRACAL(OTC) 3
calcium carbonate CAL-MINT(OTC) 3
calcium carbonate CALCIUM CARBONATE(OTC) 3
calcium carbonate/vitamin d3 C AL- Q U ICK(OTC) 3
calcium carbonate/vitamin d3 CALCIUM PETITES(OTC) 3
calcium carbonate/vitamin d3 CALCIUM(OTC) 3
calcium carbonate/vitamin d3 CALTRATE 600 + D(OTC) 3
calcium carbonate/vitamin d3 LIQUID CALCIUM-VIT D(OTC) 3
calcium carbonate/vitamin d3 OSTEO-PORETICAL(OTC) 3
calcium citrate/vitamin d3 CALCET(OTC) 3
calcium citrate/vitamin d3 CITRACAL + D MAXIMUM(OTC) 3
calcium citrate/vitamin d3 UPCAL D(OTC) 3 CITRACAL + BONE DENSI- calcium crb&cit/d3/min34/genis 3 TY(OTC) CALCIUM LACTATE(TAB)(100 calcium lactate 3 MG)(OTC) calcium phosphate CALCIUM PHOSPHATE(OTC) 3 CALCIUM + VITAMIN D3(TAB calcium phosphate trib/vit d3 3 CHEW)(250 MG-200)(OTC) calcium phosphate trib/vit d3 CALCIUM-VITAMIN D3(OTC) 3
calcium phosphate trib/vit d3 CALTRATE GUMMY BITES(OTC) 3 FLINTSTONES BONE SUP- calcium phosphate trib/vit d3 3 PORT(OTC) calcium/d3/k/fa/b12/c/minerals ORTHO-TABS(OTC) 3 CORAL CALCIUM(CAP)(250 calcium/mag oxide/vitamin d3 3 MG-100)(OTC)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 113 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
calcium/magnesium/vit d3 CALCIUM 500(OTC) 3
calcium/mineral/d3/k2/silicon ADVANCED CALCIUM(OTC) 3
calcium/vit d3/mgox/fa/vit k1 BIOCAL(OTC) 3
calcium/vit e/fa/vit b6/herbs MEN’S POTENT FORMULA(OTC) 3
calcium/vits d3/c/k2/minerals BONE ESSENTIALS(OTC) 3
vits a/c/e/b complx/min/lutein LIPOTRIAD(OTC) 3 FLUORIDEX SENSITIVITY RE- sodium fluoride/potassium nit 1 LIEF stannous fluoride G EL- K AM (OTC) 1
sodium fluoride FLUORITAB 2
sodium fluoride FLURA-DROPS 2
sodium fluoride CLINPRO 5000 3
sodium fluoride FLUOR-A-DAY 3
sodium fluoride FLUORABON 3
sodium fluoride PHOS-FLUR(OTC) 3
sodium fluoride PREVIDENT 3
sodium fluoride PREVIDENT 5000 3 PREVIDENT 5000 ENAMEL sodium fluoride/potassium nit 3 PROTECT sodium fluoride/potassium nit PREVIDENT 5000 SENSITIVE 3
sodium fluoride/vitamin d3 FLORIVA 3
sodium fluoride/xylitol FLUOR-A-DAY 3
sodium fluoride FLUORIDE 5
sodium fluoride LUDENT FLUORIDE 5
folic acid FOLIC ACID 1
multivit-min/fa/lycopen/lutein BIOCEL(OTC) 1
fa#7/pc,pe dha/nac/pap/if/mv46 PURALOR CI 3
fa/multivit-min/yhbk/gin/dam UROSEX(OTC) 3
folic acid FOLIC ACID(OTC) 3
b1,b2,b3,b6,b12/dexpan/zn/mang ELDERTONIC(OTC) 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 114 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
multivitamin w/iron, minerals SPECTRAVITE SENIOR(OTC) 1
mv, min #36/iron,carbonyl/fa GERITOL COMPLETE(OTC) 1
b1/b2/b3/b5/b6/iron/meth/choln GERITOL TONIC(OTC) 1
folic acid/multivit-min/lutein SPECTRAVITE ADULT 50+(OTC) 1 CERTAVITE SENIOR-ANTIOXI- multivit-min/fa/lycopen/lutein 1 DANT(OTC) multivitamin w-minerals/lutein CEROVITE SENIOR(OTC) 1
multivitamin with minerals ELLIS TONIC(OTC) 1
mv, min cmb#16/fa/lutein/lycop REQ49+ 3
b comp/ferrous gluc/lysin/znox APETIGEN PLUS(OTC) 1
cholecalciferol (vitamin d3) DIALYVITE VITAMIN D(OTC) 1 STRESS FORMULA WITH vit b comp/c/fa/iron sulf/vite 1 IRON(OTC) STRESS FORMULA WITH vit b comp/c/fa/iron/vit e 1 IRON(OTC) CHILDREN’S FERROUS SUL- ferrous sulfate 5 FATE(OTC) magnesium MAGNESIUM(OTC) 1
magnesium amino acid chelate MAGNESIUM(OTC) 1
magnesium chloride MAG64(OTC) 1
magnesium gluconate MAG-G(OTC) 1
magnesium l-lactate MAG-TAB SR(OTC) 1
magnesium oxide MAGNESIUM OXIDE(OTC) 1
magnesium oxide MAGOX 400(OTC) 1
magnesium oxide/mag aa chelate MAGNESIUM(OTC) 1
magnesium oxide/pyridoxine hcl BEELITH(OTC) 1
magnesium sulfate MAGNESIUM SULFATE 1
magnesium sulfate in water MAGNESIUM SULFATE 1
magnesium sulfate/d5w MAGNESIUM SULFATE-D5W 1
magnesium aspartate hcl MAGINEX(OTC) 3
magnesium carbonate MAGONATE(OTC) 3
magnesium chloride MAGNESIUM DR(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 115 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
magnesium citrate MAGNESIUM CITRATE(OTC) 3
magnesium gluconate MAGNESIUM GLUCONATE(OTC) 3
magnesium glycinate MAG GLYCINATE(OTC) 3
magnesium oxide MAGNESIUM(OTC) 3
magnesium oxide/mag aa chelate MG-PLUS-PROTEIN(OTC) 3
magnesium sulfate MAGNESIUM SULFATE(OTC) 3 CHROMIUM PICOLINATE chrom pico/chrom hist/min aa 1 PLUS(OTC) chromic chloride CHROMIUM 1 CHROMIUM PICOLINATE(CAP) chromium picolinate 1 (200 MCG)(OTC) CHROMIUM PICOLINATE(TAB) chromium picolinate 1 (OTC) copper gluconate COPPER(CAP)(OTC) 1
cupric chloride COPPER CHLORIDE 1
manganese chloride MANGANESE 1
manganese sulfate MANGANESE SULFATE 1
selenium SELENIUM 1
selenium SELENIUM(OTC) 1
trace elements comb no.1 ADDAMEL N 1
zinc sulf/cuso4 p-hyd/mn/cr/se MULTITRACE-5 1
zn/cu/mang/selen/fluor/pot iod PEDITRACE 1
znso4/cuso4/mang su/chromic cl MULTITRACE-4 1
chromium amino acid chelate CHROMIUM(OTC) 3
chromium chel/manganese/zinc CRO-MAN-ZIN(OTC) 3 CHROMIUM PICOLINATE(CAP) chromium picolinate 3 (200 MCG)(OTC) copper gluconate COPPER(TAB)(OTC) 3
iodine KELP(OTC) 3
minerals/protein supplement PROVIMIN(OTC) 3
na m-fluorophos/calcium carb MONOCAL(OTC) 3
selenomethionine SELENIUM(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 116 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
sodium fluoride/calcium carb FLORICAL(OTC) 3
amino acids/mv,th w-fe,mn BIOTECT PLUS(OTC) 1 FATIGUE RELIEF COMPLEX- bcomp,c/st.jhn wrt/s.ginsg/kgn 1 (OTC) fa/mv,ca,iron,min/lycopene/lut MULTIVITAL(OTC) 1
fe fumarate/fa/vit bcomp,c DIALYVITE 800 WITH IRON 1
folic acid/mv,fe,other min ONE DAILY MAXIMUM(OTC) 1
folic acid/mv,fe,other min/lut CERTA PLUS(OTC) 1 MULTIVITAMINS W-CALCI- multivit with calcium,iron,min 1 UM-IRON(OTC) multivit, iron, min #5, fa STROVITE FORTE 1
multivit, min cmb#20/iron/fa BACMIN 1 ONE-A-DAY multivit,ca,iron,min/fa/hrb145 1 WEIGHTSMART(OTC) multivit,ca,iron,min/fa/hrb146 DAILY ENERGY(OTC) 1 DIABETES HEALTH SUP- multivit,ca,mins/fa/bioflav#4 1 PORT(OTC) multivit,ther iron,ca,fa & min THERA-M(OTC) 1
multivitamin w/iron, minerals MULTILEX(OTC) 1
multivitamins,ther w-minerals VITAMIN AND MINERALS(OTC) 1
multivitamins,therapeutic THERA(OTC) 1
multivits w-fe,other min/lut THERATRUM COMPLETE(OTC) 1
multivits,ca,min/iron/fa/lycop SPECTRAVITE MEN’S(OTC) 1
multivits,ca,minerals/iron/fa THERA-M(OTC) 1
multivits,stress formula STRESS FORMULA(OTC) 1 STRESS FORMULA WITH multivits,stress formula/zinc 1 ZINC(OTC) multivits,th w-ca,fe,oth min THERAPEUTIC M(OTC) 1
multivits,th w-fe,other min THEREMS-M(OTC) 1
mv, min, ca, iron& amino acids K-PAX(OTC) 1
mv,ca,iron,min/fa/phytosterol CENTRAL-VITE CARDIO(OTC) 1
mv,ca,min/iron fum/fa/lyco/lut COMPLETE(OTC) 1
mv,ca,min/iron fum/fa/vit k MULTI FOR HER(OTC) 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 117 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
mv,ca,min/iron gluc/fa/biotin HAIR, SKIN & NAILS(OTC) 1 ONE DAILY DIET SUP- mv,ca,min/iron/fa/egcg/caffein 1 PORT(OTC) mv,ca,min/iron/fa/guarana/caff ONE-A-DAY WOMEN’S(OTC) 1
mv,fe,other min/gr tea lfxt DAILY MULTIPLE(OTC) 1
mv,iron,min/fa/inos/chol/paba VITAMINS FOR HAIR(OTC) 1
mv,iron,min/folic acid/biotin HAIR FORMULA(OTC) 1
mv,minerals/fa/lycopene/ginkgo DAILY MULTIPLE(OTC) 1
a/c/e/zinc/sod selenate/copper PROSIGHT(OTC) 1
a/d3/e/tocophersolan/vit k1 DEKAS ESSENTIAL(OTC) 1
alpha lipoic acid/fa/mv-mn/lut DIABETES HEALTH(OTC) 1 VITAMIN B-COMPLEX WITH VIT b complex with vitamin c 1 C(OTC) beta-carotene(a) w-c & e/min OCUTABS(OTC) 1
cal/mag/b comp/vit d3/hrb61 WOMEN’S COMPLEX(OTC) 1
folic acid/multivit-min/lutein ESSENTIAL WOMAN 50+(OTC) 1
folic acid/multivit-minerals ONE DAILY ESSENTIAL(OTC) 1 KELP-LECITHIN-B-6-VINE- lecithin/pyridoxine/kelp 1 GAR(OTC) multivit & min no.49/iron/fa PROTECT PLUS NF(OTC) 1 COMPLETE MULTIVITAMIN-MIN- multivit &minerals/ferrous fum 1 ERAL(OTC) ONE DAILY WOMEN’S multivit-min/fa/calcium/vit k1 1 50+(OTC) multivit-min/fa/lycopen/lutein CENTRUM SILVER(OTC) 1
multivit-min/folic acid/vit k1 TRUEPLUS MULTIVITAMIN(OTC) 1
multivit/folic acid/zinc/vit c DECUBI VITE(OTC) 1
multivitamin TAB-A-VITE(OTC) 1
multivitamin no.44/vit d3/k MULTIVITAMINS-A,B,D,E,K,ZN 1
multivitamin w-minerals/herbs MEN’S BIOMULTIPLE(OTC) 1
multivitamin with folic acid QUINTABS(OTC) 1 MULTIVITAMINS WITH MINER- multivitamin with minerals 1 ALS(OTC)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 118 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL MULTI-DAY PLUS MINER- multivitamin-min/iron/fa/vit k 1 ALS(OTC) multivitamin/ferrous gluconate MULTI-DELYN(OTC) 1 CEROVITE ADVANCED FORMU- multivitamin/iron/folic acid 1 LA(OTC) multivitamins with iron TAB-A-VITE WITH IRON(OTC) 1
multivitamins with min no.7/fa V-C FORTE 1
multivitamins-min/fa/ginkgo DAILY MULTIPLE(OTC) 1
multivits w-min/ferrous gluc CERTAVITE-ANTIOXIDANT(OTC) 1 MENS 50+ ADVANCED ONE multivits-min/fa/k/lycopene 1 DAILY(OTC) CENTURY ENERGY METABO- multivits-min/iron/fa/ginseng 1 LISM(OTC) SPECTRAVITE ULTRA WOM- multivits-min/iron/fa/lutein 1 EN’S(OTC) ONE-A-DAY MEN’S(TAB)(400- multivits-minerals/fa/lycopene 1 300MCG)(OTC) mv w-ca/iron/fa/lutein/hrb#179 MEGA MULTIVITAMIN(OTC) 1
mv-min/iron fum/fa/k/lyco/lutn SUNVITE(OTC) 1 THERAGRAN-M PREMIER 50 mv-mn/fa/coq10/lycopene/lutein 1 PLUS(OTC) mv-mn/fa/lycopene/lut/hb#178 MEGA MULTI(OTC) 1
mv-mn/fe picolin/fa/cal/d3/aa K-PAX IMMUNE SUPPORT(OTC) 1
mv/gnk bi ex/k.ginsg CENTRAL VITE(OTC) 1
om-3/calcium/d3/fa/mv cmb 13 ADVANCED AM/PM 1
om-3/dha/epa/b12/fa/b6/phytost VIT 3 1
om-3/dha/epa/d3/b12/fa/b-6/phy ANIMI-3 1
vit a/vit c/vit e/zinc/copper ICAPS(OTC) 1
vit b comp & c/calcium carb B-COMPLEX(OTC) 1 B COMPLEX WITH VITAMIN vitamin b complex & vit c no.3 1 C(OTC) vitamins a and d VITAMIN A AND D(OTC) 1 STRESS FORMULA ENER- vitb&c/iron fum/fa/vit e/aa#16 1 GY(OTC) b2/vit a,c & e/lut/zeaxanth/mn ICAPS(OTC) 3
bioflavonoids/mv,fe,other min LIFE-PACK(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 119 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
folic acid/mv,fe,other min NUTRICAP 3
iron,carbonyl/fa/multivit-min OPURITY MULTIVITAMIN(OTC) 3 ONE-A-DAY MENOPAUSE FOR- multivit, ca, min/fa/soy isofl 3 MULA(OTC) multivit, calc, min/folic acid ULTRA FREEDA(OTC) 3
multivit, iron, min #4, fa MULTICHEW 3
multivit, iron, min #7, fa OPTISOURCE(OTC) 3
multivit, min no.21/folic acid SUPERVITE EC 3 ONE-A-DAY WOMEN’S PE- multivits,ca,minerals/iron/fa 3 TITES(OTC) multivits,ca,minerals/iron/fa ONE-A-DAY WOMEN’S(OTC) 3
multivits,ca,minerals/iron/fa QUINTABS-M(OTC) 3
mv, min cmb #6/fa/lut/lyco/q10 CORVITE FREE 3
mv, min cmb#24/iron ps cmp/fa PROTECT IRON 3
mv, min cmb#9/fa/saw palmet xt UDAMIN SP 3 CENTRUM SPECIALIST mv,ca,iron,min/fa/phytosterol 3 HEART(OTC) BODY, HAIR, SKIN & mv,ca,iron,mn/fa/chol/ino/paba 3 NAILS(OTC) mv,ca,iron,mn/fa/lut/lyc/hb153 BIO-35(OTC) 3
mv,ca,min/iron fum/fa/vit k OPTISOURCE(OTC) 3 ONE-A-DAY WOMEN’S mv,ca,min/iron/fa/lutein 3 HEALTHY SKIN(OTC) SPECTRAVITE CARDIO mv,ca,min/iron/fa/lyc/lut/phyt 3 HEALTH(OTC) mv,fe/fa/d3/om-3/dha/epa/fish PRORENAL QD(OTC) 3 SUPER MULTIPLE-LOW mv,iron,min/fa/dietary cmb.24 3 IRON(OTC) mv,iron,min/folic acid/biotin HAIR, SKIN & NAILS(OTC) 3
mv,min #10/fa/d3/alip acid/lut STROVITE ONE 3
mv,minerals/fa/lycopene/ginkgo ONE-A-DAY MEN’S 50+(OTC) 3
mvi, adult no.1 with vit k M.V.I. ADULT 3
mvi, adult no.2 without vit k M.V.I.-12 3
mvi, adult no.4 with vit k INFUVITE ADULT 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 120 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
prenatal vit #76/iron,carb/fa THRIVITE RX 3
a/c/e/zinc ox/cupric ox/lutein MACUVITE EYE CARE(OTC) 3
b&c/fa/zinc/copper oxide/vit e STRESS B-COMPLEX(OTC) 3 HEARTBURN & ACID REFLUX- ca comb no.1/d3/b-6/fa/b12/av 3 (OTC) ca comb no.1/d3/b-6/fa/b12/av VITAMIN D3-ALOE(OTC) 3 HEARTBURN & ACID REFLUX- ca comb no.1/vit d3/b-6/fa/b12 3 (OTC) ca comb no.1/vit d3/b-6/fa/b12 VITAMIN D3(OTC) 3 FOLIC ACID-VIT B-6-VIT calcium/vit b12/fa/pyridoxine 3 B-12(OTC) fa/mu-vits-min th/lycopene/lut CORVITA 3
fa/mu-vits-min th/lycopene/lut CORVITE 3 CENTRUM FLAVOR BURST folic acid/multivit-minerals 3 ADULT(OTC) ONE-A-DAY MEN VI- folic acid/multivit-minerals 3 TACRAVES(OTC) ONE-A-DAY WOMEN VI- folic acid/multivit-minerals 3 TACRAVES(OTC) iron fum/fa/b complex & c/min PARVLEX(OTC) 3
iron/lysine/vit b comp/fa NUTRIVIT(OTC) 3
lmefolate/b3/copp/zn/sel/chrom NICOMIDE 3
m-tetrahyrofolate/niacin/cu/zn NICOMIDE 3
multivit with min #53/fa/k/q10 DEKAS PLUS(OTC) 3
multivit&min/fa/lycopene/boron BLADDER 2.2(OTC) 3 BIOTIN PLUS-CALCIUM & VIT multivit-min/cal/biotin/d3/fa 3 D3(OTC) ONE-A-DAY WOMEN’S multivit-min/fa/calcium/vit k1 3 50+(OTC) multivit-min/fa/guarana/caff BEROCCA(OTC) 3 ALIVE WOMEN’S GUMMY VITA- multivit-min/fa/herbal no.245 3 MINS(OTC) multivit-min/fa/lutein/zeaxant ICAPS MV(OTC) 3
multivit-min/fa/lutein/zeaxant MACULAR VITAMIN(OTC) 3 CENTRUM SILVER ULTRA multivit-min/fa/lycopen/lutein 3 MEN’S(OTC) multivit-min/fa/lycopen/lutein ESSENTIAL MAN 50+(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 121 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
multivit-min/fa/lycopen/lutein ESSENTIAL MAN(OTC) 3
multivit-min/folic acid/biotin HAIR, SKIN & NAILS(OTC) 3 WOMEN’S MULTIVITAMIN W-BI- multivit-min/folic acid/biotin 3 OTIN(OTC) multivit-min/folic acid/vit k1 MULTI FOR HER 50 PLUS(OTC) 3
multivit-min/folic acid/vit k1 SOLO(OTC) 3
multivit-min/glutathione/cyst OXI-FREEDA(OTC) 3
multivit-min/iron fum/folic ac FREEDAVITE(OTC) 3
multivit-min/iron fum/folic ac MONOCAPS(OTC) 3 MULTI-VITAMIN WITH MINER- multivit-min/iron fum/folic ac 3 ALS(OTC) ONE-A-DAY VITACRAVES EN- multivit-minerals/fa/caffeine 3 ERGY(OTC) multivit/iron/fa/k/herb no.244 ALIVE WOMEN’S ENERGY(OTC) 3 SUPER GINSENG MULTIVITA- multivitamin w-minerals/gin 3 MIN(OTC) multivitamin-min/iron/fa/vit k MULTI FOR HER(OTC) 3 ONE-DAILY MULTI-VITA- multivitamin/ferrous sulfate 3 MIN-IRON(OTC) ONE-A-DAY VITACRAVES OME- multivitamin/folic acid/dha 3 GA-3(OTC) multivits-min/fa/dietary no 19 SUPER MULTIPLE(OTC) 3
multivits-min/fa/k/lycopene ONE-A-DAY MEN’S(OTC) 3 CENTRUM SILVER WOM- multivits-min/iron/fa/lutein 3 EN(OTC) ONE-A-DAY MEN’S(TAB)(400- multivits-minerals/fa/lycopene 3 300MCG)(OTC) mv-min/fa/d3/om-3/dha/epa/fish CARDIAMIN(OTC) 3
mv-min/mfol/coq10/dha/epa/#27 PROTECT CARDIO AF(OTC) 3
mv-min/mfolat/coq10/diet no.26 PROTECT PLUS SO(OTC) 3
mv-mn/fa/inosi/choline/bioflav THERAMILL FORTE(OTC) 3
mv-mn/fa/vit k/lycop/lut/coq10 DAILY MULTIVITAMIN(OTC) 3
mv-mn/fa/vit k1/lycop/lut/zeax OCUVITE EYE + MULTI(OTC) 3 THERANATAL LACTATION SUP- mv-mn/fe/fa/k/d3/chol/dha/fish 3 PORT(OTC) mv-mn/iron/fa/ca carb/vit k ONE-A-DAY WOMEN’S(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 122 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
mv-mn/iron/fa/k/green tea xt PROCERV HP(OTC) 3
mv-mn/iron/fa/lut/lyc/herb#175 BIO-35(OTC) 3 CENTRUM SPECIALIST ENER- mv-mn/iron/fa/vit k/k.ginseng 3 GY(OTC) mv. min cmb#51/fa/vit k1/ubi AQUADEKS(OTC) 3
mv. min cmb#52/fa/vit k1/ubi AQUADEKS(OTC) 3
mv/dietary 4/dna/rna FORTAVIT 3
mv/k/o3/d3/mag/c/ala/grn t/chr DIABETES HEALTH PACK(OTC) 3
pedi multivit #40/phytonadione AQUADEKS(OTC) 3
vit a/beta-carot/d2/e/selenium VITAMINS A-D-E(OTC) 3 CALCIUM PANTOTHEN- calcium pantothenate 1 ATE(OTC) pantothenic acid PANTOTHENIC ACID(OTC) 1
fluoride/iron/vit a,c&d TRI-VIT WITH FLUORIDE-IRON 5
iron/fluoride/vits a, c, & d3 MYKIDZ IRON FL 5
iron/vitamins a, c, and d3 MYKIDZ IRON(OTC) 5
multivitamin w/iron, minerals CEROVITE JR(OTC) 5
mvi, pedi no.1 with vit k INFUVITE 5
mvi, pedi no.2 with vit k M.V.I. PEDIATRIC 5
ped mv a,c,d3 #21 w-fluoride TRI-VITAMIN WITH FLUORIDE 5
ped mv a,c,d3 #38 w-fluoride TRI-VI-FLOR 5
pedi multivits a,c,&d3 no.21 TRI-VITAMIN(OTC) 5 CHILD’S OMEGA-3 DHA MULTI- vit a,c,d3,e/omega-3/ala/dha 5 VITAM(OTC) FLINTSTONES PLUS CALCI- calcium carbonate/multivitamin 5 UM(OTC) multivitamin CHILD CHEW VITAMIN(OTC) 5
multivitamins with iron CHILD CHEW + IRON(OTC) 5
ped multivit #17/iron fumarate KID’S VITAMINS + IRON(OTC) 5 ANIMAL SHAPES COM- ped multivit #38/iron fumarate 5 PLETE(OTC) ped multivit #43/iron fumarate FLINTSTONES COMPLETE(OTC) 5
ped multivit #46/iron sulfate POLYVITAMIN WITH IRON(OTC) 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 123 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
ped multivit#108/iron/fluoride TEXAVITE LQ 5
pedi m.vit no.17 with fluoride MULTIVITAMIN WITH FLUORIDE 5
pedi multivit #22/vit d3/vit k MULTIVITAMINS-A,B,D,E,K,ZN 5
pedi multivit #37 w-fluoride POLY-VI-FLOR 5
pedi multivit #47/iron/fluorid ESCAVITE 5 COMPLETE FORMULATION pedi multivit #61/vit d3/vit k 5 MULTIVIT(OTC) COMPLETE FORMULATION pedi multivit #61/vit d3/vit k 5 D3000 pedi multivit #62/vit d3/vit k CHOICEFUL VITAMINS(OTC) 5
pedi multivit #63 w-fluoride QUFLORA 5
pedi multivit #64/vit d3/vit k CHOICEFUL VITAMINS(OTC) 5
pedi multivit #65/vit d3/vit k MULTIVITAMINS-A,B,D,E,K,ZN 5 COMPLETE FORMULATION pedi multivit #77/vit d3/vit k 5 PEDIATRIC pedi multivit #78/iron/fluorid ESCAVITE D 5 ONE-A-DAY TEEN HIM VI- pedi multivit #89/vit d3/vit k 5 TACRAVES(OTC) pedi multivit #90 w-fluoride POLY-VI-FLOR FS 5 ONE-A-DAY TEEN HER VI- pedi multivit #99/vit d3/vit k 5 TACRAVES(OTC) KIDS VITAMINS COM- pedi multivit 9/iron/fa 5 PLETE(OTC) MULTIVITAMINS WITH FLUO- pedi multivit no.2 w-fluoride 5 RIDE FLINTSTONES WITH EXTRA pedi multivit no.27/folic acid 5 C(OTC) pedi multivit no.7/folic acid FLINTSTONES(OTC) 5 FLINTSTONES MULTI-VIT GUM- pedi multivit no.7/folic acid 5 MIES(OTC) pedi multivit no.85/fluoride FLORIVA 5
pedi multivit#86/iron/fluoride ESCAVITE LQ 5
pedi mv #37 w-fluoride & iron POLY-VI-FLOR WITH IRON 5 MULTIVITAMINS W-FLUO- pedi mv #45/fluoride/iron 5 RIDE-IRON MULTIVITAMINS W-FLUO- pedi mv #75/fluoride/iron 5 RIDE-IRON CHILDREN’S CHEW VITA- pedi mv no.114/iron fumarate 5 MIN-IRON(OTC)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 124 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL CHILD COMPLETE MULTIVITA- pedi mv no.58/ferrous fumarate 5 MIN(OTC) CHILDREN’S COMPLETE VITA- pedi mv no.67/ferrous fumarate 5 MIN(OTC) pedi mv no.68/iron carbonyl CENTRUM KIDS(OTC) 5
pedi mv no.79/ferrous fumarate FLINTSTONES WITH IRON(OTC) 5
pedi mv no.83 with fluoride QUFLORA 5
pedi mv no.84 with fluoride QUFLORA 5 CHILDREN’S CHEW MULTIV- pedi mv no.91/iron fumarate 5 IT-IRON(OTC) pedi mv no.94/iron fumarate NANOVM 9-18(OTC) 5
pedi mv#88/iron polysac complx NOVAFERRUM PEDIATRIC(OTC) 5
pedi mvi no.12/sodium fluoride MVC-FLUORIDE 5 MULTIVITAMINS WITH FLUO- pedi mvi no.16 with fluoride 5 RIDE pedi mvi no.33 with fluoride POLY-VI-FLOR 5 MULTIVITAMINS WITH FLUO- pedi mvi no.82 with fluoride 5 RIDE pediatric multivit #128/vit k DEKAS PLUS(OTC) 5
pediatric multivit #14/iron/fa NANO VM 1-3(OTC) 5
pediatric multivit #15/iron/fa NANO VM 4-8(OTC) 5
pediatric multivit #17/iron CHILDREN’S CHEWABLES(OTC) 5
pediatric multivit #24/iron/fa ZOO FRIENDS COMPLETE(OTC) 5
pediatric multivit #31/iron/fa CHILDREN’S CHEWABLE(OTC) 5
pediatric multivit #36/iron VITALETS(OTC) 5 CHILDREN’S MULTI-VIT GUM- pediatric multivit comb #19/fa 5 MIES(OTC) FLINTSTONES MULTI-VIT GUM- pediatric multivit comb #19/fa 5 MIES(OTC) pediatric multivit comb #23/fa CHILDREN’S CHEWABLES(OTC) 5
pediatric multivit comb #25/fa CHILDREN’S CHEWABLES(OTC) 5
pediatric multivit comb #25/fa FLINTSTONES(OTC) 5 KIDS MULTIVITAMIN-MINER- pediatric multivit comb 11/fa 5 ALS(OTC) pediatric multivit comb 8/fa KIDS VITAMINS(OTC) 5
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 125 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL CHILDREN’S MULTIVITA- pediatric multivit comb no.101 5 MIN(OTC) pediatric multivit comb no.111 ZOO FRIENDS(OTC) 5 CENTRUM FLAVOR BURST pediatric multivit comb no.117 5 KIDS(OTC) TROPICAL LIQUID NUTRI- pediatric multivit comb no.118 5 TION(OTC) CHILDREN’S MULTIVITA- pediatric multivit comb no.119 5 MIN(OTC) CHILDREN’S MULTIVITA- pediatric multivit comb no.120 5 MIN(OTC) pediatric multivit comb no.127 EMERGEN-C KIDZ(OTC) 5
pediatric multivit comb no.20 POLY-VITAMIN(OTC) 5
pediatric multivit comb no.28 CHILD MULTIVITAMINS(OTC) 5 GUMMIES GIRLS’ MULTIVITA- pediatric multivit comb no.29 5 MINS(OTC) CHILD’S GUMMY VITAMIN-MIN- pediatric multivit comb no.42 5 ERAL(OTC) pediatric multivit comb no.42 FLINTSTONES(OTC) 5
pediatric multivit comb no.48 ONE-A-DAY KID’S(OTC) 5
pediatric multivit comb no.48 SCOOBY-DOO(OTC) 5
pediatric multivit comb no.53 ZOO FRIENDS(OTC) 5 CHILDREN’S MULTIVITA- pediatric multivit comb no.73 5 MIN(OTC) pediatric multivit comb no.76 GUMMY DINOS(OTC) 5
pediatric multivit comb no.76 FLINTSTONES COMPLETE(OTC) 5
pediatric multivit comb. no.49 FLINTSTONES GUMMIES(OTC) 5 LITTLE ANIMALS PLUS pediatric multivit no.28/iron 5 IRON(OTC) pediatric multivit no.50/dha FLINTSTONES(OTC) 5
pediatric multivit no.93/iron NANOVM T/F(OTC) 5 GUMMIES CHILDREN MULTIVI- pediatric multivitamin comb#30 5 TAMIN(OTC) pediatric mv #33 w-fluoride&fe POLY-VI-FLOR WITH IRON 5
vit a palmitate/vit c/vit d3 TRI-VI-SOL(OTC) 5
vitamin a/c/d3/cod liver oil KIDS COD LIVER OIL +D(OTC) 5
pn vit.w-o ca #7, iron,fa,dha ELITE OB DHA 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 126 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
pnv no.66/iron,carbonyl/fa/dha ACTIVE OB 1
pnv no12/iron,carb/fa/dss/om-3 OBTREX DHA 1 WOMEN’S PRENATAL + pnv with ca,no.61/iron/fa/dha 1 DHA(OTC) pnv with ca,no.62/iron/fa/dha TRIVEEN-ONE 1
pnv with ca,no.70/iron/fa/dha NATELLE ONE 1
pnv with ca,no.72/iron,carb/fa PRENATAL PLUS 1
pnv with ca,no.72/iron/fa PRENATAL PLUS 1
pnv with ca,no63/iron/fa/b6 TARON-BC 1
pnv,ca,no.35/iron/fa/ds/omeg-3 ULTIMATECARE ONE NF 1
pnv,ca42/iron/fa/lmefol ca/dha PNV-DHA PLUS 1
pnv/iron,carbonyl/docusate/fa MYNATAL 1
pnv34/iron,carbonyl/fa/dss/dha VP-CH-PNV 1
pnv59/iron,carb&fum/fa/dss/dha CITRANATAL HARMONY 1
pnv59/iron,carbonyl/fa/dss/dha VP-CH PLUS 1
pnv69/iron,carbonyl/fa/dss/dha PRENAISSANCE PLUS 1
pnv72/iron,carb&glu/fa/dss/dha CITRANATAL 90 DHA 1
pnv73/iron,carb&glu/fa/dss/dha CITRANATAL ASSURE 1
prenatal vit #76/iron,carb/fa VO L-TAB R X 1
prenatal vit w-ca,fe,fa(<1 mg) PRENATAL VITAMINS(OTC) 1
pn w-ca64/iron cb&gl/fa/dss/dh PRENAISSANCE 90 DHA 1
pnv #14/ferrous fum/folic acid COMPLETENATE 1
pnv #19/iron ps&heme/folic/dha PREFERA-OB ONE 1
pnv #8/iron ps cmp&aspg/fa/dha PAIRE OB PLUS DHA 1
pnv #87/iron bisgly/fa/dha NESTABS DHA 1
pnv 11-iron fum-folic acid-om3 C-NATE DHA 1
pnv comb.no.44/iron/folic acid VITASPIRE 1
pnv combo #22/iron/fa/om3/dha HEMENATAL OB + DHA 1
pnv combo#47/iron/fa #1/dha PNV-DHA 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 127 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
pnv no.115/iron fumarate/fa PRENATAL 19 1
pnv no.118/iron fumarate/fa PRENATAL 19(OTC) 1
pnv no.15/iron fum & ps cmp/fa CONCEPT OB 1
pnv no.22/iron cbn&gluc/fa/dss VINACAL 1
pnv no.23-iron ps complex-fa EZFE FORTE(OTC) 1
pnv no.25/iron fumarate/fa/dha PRENATAL-1(OTC) 1
pnv no10/iron fum&p/fa/omega-3 SE-TAN DHA 1
pnv w-ca #40/iron fum/fa cmb#1 PNV-SELECT 1
pnv w-ca no.37/iron/fa/omega-3 ULTIMATECARE ONE 1
pnv w-ca8/iron/fa/lmefolate ca PNV-IRON 1
pnv w-o ca no5/fe fumarate/fa PRENATAL-U 1
pnv with ca #68/iron/fa#1/dha VIRT-PN PLUS 1
pnv with ca no.36/iron/fa PERRY PRENATAL(OTC) 1
pnv with ca no.65/iron poly/fa MARNATAL-F 1
pnv with ca#74/iron/folic acid VO L- PLUS 1
pnv#16/iron fum & ps/fa/om-3 CONCEPT DHA 1
pnv#21/iron ps& heme polyp/fa HEMENATAL OB 1
pnv#64/iron/lmfolate/algal/soy NEEVODHA 1
pnv#71/iron/folic acid/dha VITAPEARL 1 ONE A DAY WOMEN’S PRENA- pnv#75/iron fum/fa/om3/dha/epa 1 TAL DHA(OTC) pnv#75/iron fum/fa/om3/dha/epa ONE DAILY PRENATAL(OTC) 1
pnv#79/iron/fa/lmfolate ca/dha VINATE DHA 1
pnv/ferrous fumarate/doss/fa MYNATE 90 PLUS 1
pnv/ferrous fumarate/fa/se VINATE-M 1
pnv100/iron edta&ps/fa/omega3 BAL-CARE DHA ESSENTIAL 1
pnv103/fa/omega3/dha/fish oil PRENATAL(OTC) 1
pnv115/iron fumarate/fa/dss PRENATAL 19 1
pnv119/iron fumarate/fa/dss SE-NATAL 19 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 128 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
pnv17/iron/fa/fish oil/dha/om ELITE-OB 400 1
pnv19/iron bg hc&succ-p/fa/om3 PR NATAL 400 EC 1
pnv22/iron cbn&gluc/fa/dss/dha PNV OB+DHA 1
pnv38/iron cbn&gluc/fa/dss/dha PRENAISSANCE PROMISE 1
pnv39/iron fumarate/fa/dss/dha TARON-PREX PRENATAL 1
pnv53/iron b-g hcl-p/fa/omega3 TRIVEEN-DUO DHA 1
pnv54/iron b-g hcl-p/fa/omega3 PR NATAL 430 1
pnv55/iron bg hc&succ-p/fa/om3 PR NATAL 430 EC 1
pnv62/fa/om3/dha/epa/fish oil PRENATAL(OTC) 1
pnv66/iron fumarate/fa/dss/dha VIRTPREX 1
pnv7/fe asp gly/docusate/fa VINATE PN CARE 1
pnv77/sod iron edta& ps/fa/om3 VENATAL COMPLETE DHA 1
pnv80/iron fumarate/fa/dss/dha PRENAISSANCE 1
pnv81/sod iron edta& ps/fa/om3 BAL-CARE DHA 1
pnv95/ferrous fumarate/fa PRENATAL VITAMINS(OTC) 1
prenat vit comb.10/iron/fa/dha VITAFOL-OB+DHA 1
prenatal #48/iron cb&glu/fa/b6 CITRANATAL B-CALM(OTC) 1
prenatal #57/iron/fa/dss/dha EXTRA-VIRT PLUS DHA 1
prenatal comb no.42/folic acid VITAMEDMD REDICHEW RX 1
prenatal no.13/iron ps/fa cb#1 SELECT-OB 1
prenatal no.40/iron/fa/dha PRENATAL MULTI + DHA(OTC) 1
prenatal no.52/iron/fa/dha VP-PNV-DHA 1
prenatal no.75/iron/folate #1 VITAFOL NANO 1
prenatal no.82/iron/folate #2 TL FOLATE 1
prenatal vit #108/iron/fa PRENATAL ONE(OTC) 1
prenatal vit #91/fe fum/fa/dha PRENATAL + DHA(OTC) 1
prenatal vit 15/iron cb/fa/dss VIRT-ADVANCE 1
prenatal vit 16/iron cb/fa/dss VIRT-VITE GT 1
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 129 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
prenatal vit 18/iron cb/fa/dss INATAL ULTRA 1
prenatal vit no.109/iron/fa VINATE CARE 1
prenatal vit no.124/iron/fa PRENATAL VITAMIN(OTC) 1
prenatal vit no.73/iron/fa TRINATE 1
prenatal vit no.78/iron/fa PRENATABS FA 1
prenatal vit#4/iron fum &ps/fa PUREFE OB PLUS 1
prenatal vit#86/iron bisgly/fa NESTABS 1
prenatal vit#96/ferrous fum/fa PRENATAL(OTC) 1
prenatal vit/iron bisglycin/fa VINATE II 1
prenatal vit/iron fumarate/fa PRENATAL VITAMINS(OTC) 1
prenatal vit27&calcium/iron/fa TRINATAL RX 1 1
prenatal vits #90/iron fum/fa PRENATAL FORMULA(OTC) 1
prenatal vits#4/iron fum/fa PUREFE PLUS 1
pv w-o cal/iron ps cplx/fa SELECT-OB 1
pnv 18/fe,carb/fa/dss/ubi/dha PREQUE 10 3
pnv comb.no43/iron,carb/fa/dss ATABEX EC 3
pnv no.63/iron,carbonyl/fa/dha STUART ONE(OTC) 3
pnv no.88/iron ps,heme/fa/dha PREFERA-OB PLUS DHA 3
pnv76/iron,carb&glu/fa/dss/dha CITRANATAL DHA 3
pnv83/iron,carb/iron asp gl/fa OB COMPLETE PREMIER 3
pv w-o cal/fe,carbonyl/doss/fa OBSTETRIX EC 3
pn85/iron cb&asp g/fa/dha/fish OB COMPLETE ONE 3
pnv #116/iron fumarate/fa/dha EXPECTA PRENATAL(OTC) 3
pnv #30/iron carb&aspg/fa/om3 OB COMPLETE WITH DHA 3
pnv #35/iron/fa #6/dha PRENATE ESSENTIAL 3
pnv #38/iron fum/folate/dha PRENATE DHA 3
pnv #56/iron carb&aspg/fa/dha OB COMPLETE PETITE 3
pnv #78/iron asp gly/fa#1/dha PRENATE DHA 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 130 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
pnv #86/iron poly/fa/dha/epa NESTABS ABC 3
pnv cmb#21/iron/folic acid PRENATAL COMPLETE(OTC) 3
pnv comb no.3/iron fum&gluc/fa MAXINATE 3
pnv no.100/iron/fa/dha/epa THERANATAL ONE(OTC) 3
pnv no.122/iron/folic acid PRENATAL MULTI(OTC) 3
pnv no.23-iron ps complex-fa PROFE FORTE(OTC) 3
pnv no.28/ferrous fumarate/fa THERANATAL(OTC) 3
pnv no.74/iron fum/fa/coq10 THERANATAL OVAVITE(OTC) 3
pnv no.74/iron fum/fa/dha THERANATAL PLUS(OTC) 3
pnv no.80/iron/mfolate/dss/dha FOLET ONE 3
pnv no.81/iron cbn&gluc/fa/dss CITRANATAL RX 3
pnv no.86/iron/mfolate/dss/dha FOLET DHA 3
pnv no.90/iron fum & ps/fa/dha PROVIDA DHA 3
pnv#102/iron/fa/dha/lutein SIMILAC PRENATAL(OTC) 3
pnv#102/iron/folate #1/dss/dha VITAFOL FE+ 3
pnv#20/iron/fa/ds/fish/dha/epa TRICARE PRENATAL DHA ONE 3 PRENATAL DHA+COMPLETE pnv#24/iron aa chel/fa/dha 3 PRENATAL(OTC) pnv#26/iron poly/fa/dha VITAFOL-ONE 3
pnv#67/iron ps/fa cmb#1/dha VITAFOL ULTRA 3
pnv106/iron/fa/om3/dha/epa DUET DHA 400 3
pnv117/iron/fa/om3/dha/epa DUET DHA BALANCED 3
pnv119/iron fumarate/fa/dss PRENATAL 19(OTC) 3 ONE-A-DAY WOMEN’S PRENA- pnv123/iron car/fa/om3/dha/epa 3 TAL 1(OTC) pnv2/iron b-g suc-p/fa/omega-3 COMPLETE NATAL DHA 3
pnv2/iron b-g suc-p/fa/omega-3 TRUST NATAL DHA 3
pnv51/iron fum/fa/om-3/dha/epa PRENATAL MULTI + DHA(OTC) 3
pnv53/iron fum/fa/docusate/dha NEXA PLUS 3
pnv55/iron fum & bisgly/fa NATACHEW 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 131 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
prenatal #103/iron fumarate/fa TRICARE 3
prenatal #79/iron asp gly/fa#1 PRENATE ELITE 3
prenatal #92/iron/fa #8/ps-dha ENBRACE HR 3 PRENATAL VITAMIN + prenatal cmb#95/iron/fa/dha 3 DHA(OTC) prenatal no.25/iron/fa #6/dha VITAMEDMD ONE RX 3
prenatal no.39/iron/fa #6/dha VITAMEDMD PLUS RX 3
prenatal no.77/iron asp gly/fa PRENATE STAR 3
prenatal no.93/iron/fa #9/dha TRISTART DHA 3
prenatal vit #105/iron/fa/dha VITATRUE 3
prenatal vit #49/iron fum/fa MINI PRENATAL(OTC) 3
prenatal vit #68/iron/fa#6/dha PRENATE ENHANCE 3
prenatal vit #69/iron/fa#6/dha PRENATE RESTORE 3
prenatal vit #83/iron/fa#6/dha CADEAU DHA 3
prenatal vit comb.10/iron/fa VITAFOL-OB 3
prenatal vit no.112/folic acid PRENATE CHEWABLE 3
prenatal vit no.114/fa/ginger PRENATE AM 3
prenatal vit no.44/iron/fa/dha PRENATE MINI 3
prenatal vit no.87/iron/fa/dha PRENATE MINI 3 CENTRUM SPECIALIST PRENA- prenatal vit#101/iron/fa/dha 3 TAL(OTC) prenatal vit#36/iron/fa cmb#6 PRENATE ELITE 3
prenatal vit#65/iron fum&ps/fa PROVIDA OB 3
prenatal vit#84/iron/fa#1/dha PRENATE ESSENTIAL 3
prenatal vit#85/iron/fa#1/dha PRENATE PIXIE 3
prenatal vit#98/ferrous fum/fa KPN(OTC) 3
prenatal vit/iron fumarate/fa NATALVIT 3
prenatal vit37/iron/folic acid PRENATA 3
prenatal vits #32/iron/fa/dha THERANATAL COMPLETE(OTC) 3
prenatal vits #33/iron/fa/dha SELECT-OB + DHA 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 132 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
prenatal vits #93/iron fum/fa PRENATAL FORMULA(OTC) 3
pv w-o cal/ferrous fumarate/fa M-VIT 3
pnv w-o iron/fa/calcium/b6/b12 FOLBECAL 1
pnv/fa/b6/calcium carb/ginger PRENAISSANCE NEXT-B 1
pnv/fa/b6/calcium phos/ginger VP-GGR-B6 1
vit a palm,d3 in cod liver oil COD LIVER OIL(OTC) 1
vit a & d3 in cod liver oil COD LIVER OIL(OTC) 1
vitamin a/vitamin d3 VITAMIN A & D(OTC) 1
beta-carotene BETA CAROTENE(OTC) 1
lycopene LYCOPENE(OTC) 1
vitamin a VITAMIN A(OTC) 1 VITAMIN A(CAP)(10000 UNIT) vitamin a palmitate 1 (OTC) vitamin a palmitate/vitamin d2 VITAMINS A & D(OTC) 1
vitamin a/vit c/vit e/selenium PREVENT(OTC) 1
vitamin a/vit c/zinc/propolis ZINC(OTC) 1 NORWEGIAN COD LIVER vitamin a/vitamin d2 1 OIL(OTC) beta-carotene LUMITENE(OTC) 3
vitamin a palmitate AQUASOL A 3 VITAMIN A(CAP)(10000 UNIT) vitamin a palmitate 3 (OTC) VITAMIN A & BETA CARO- vitamin a palmitate/b-carotene 3 TENE(OTC) folic acid/vit bcomp,c NEPHRO-VITE(OTC) 1
folic acid/vit bcomp,c/cu/znox FOLBEE PLUS CZ 1
vitamins b1,b2,b3,b5,& b6 B-COMPLEX 1
b cmplx 4/vit d3/c/fa/zinc ox VITAL- D R X 1
b complex & c no.10/folic acid NEPHRONEX(OTC) 1
b complex & c no.20/folic acid NEPHROCAPS 1
cyanocobalamin/fa/pyridoxine FOLBEE 1 VITAMIN B-COMPLEX WITH VIT fa/vit b complex & c/rice bran 1 C(OTC)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 133 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
fa/vit bcomp&c/se/min aa/zn DIALYVITE 3000 1
folic acid/b complex & c no.17 VIRT-VITE PLUS 1
lysine hcl/vitamin b complex ALBA-LYBE(OTC) 1
vit b cmplx 3/fa/vit c/biotin RENA-VITE RX 1
vit b cmplx no3/fa/c/biot/zinc NEPHPLEX RX 1
vit b comp/c/fa/iron/vit e VITAMIN B COMPLEX(OTC) 1 NATURAL BALANCED vit b complex 100 cmb #2/herbs 1 B-100(OTC) vit b complex 100 cmb #3/herbs BALANCED B-100(OTC) 1
vit b cplx #11/fa/c/biot/zn ox DIALYVITE ZINC 1 B COMPLEX WITH VITAMIN vit b1 mn/b2/b3/b5/b6/b12/c/fa 1 C(OTC) vitamin b complex VITAMIN B COMPLEX(OTC) 1
vitamin b complex & vit c no.4 SUPER B COMPLEX(OTC) 1
vitamin b complex 100 no.2 BALANCED B-100(OTC) 1
vitamin b complex no.12/niacin RABANO YODADO(OTC) 1
vitamin b complex/folic acid VITAMIN B-100 COMPLEX(OTC) 1 MEDTYCHOLL-B COMPLEX vitamin b complex/liver ext 1 W-LIVER(OTC) vitamin b complex/lysine APETIGEN(OTC) 1
vitamin b complex/minerals STRESS FORMULA(OTC) 1 BREWER’S YEAST(TAB)(500 yeast 1 MG)(OTC) fa/vit bcomp,c/zinc/vitamin d3 DIALYVITE 800-ULTRA D(OTC) 3
multivit, mincmb#11/folic acid DIALYVITE 5000 3
multivitamin, min cmb#25/fa/d3 DIALYVITE SUPREME D 3
b&c/ferrous fum/fa/d3/zinc ox PRORENAL(OTC) 3
b1/b2/niacin/b12/protease B-COMPLEX WITH B-12(OTC) 3
biotin BIOTIN(OTC) 3
calcium carb/vit b comp/fa COMPLEX B-50(OTC) 3
cyanocobalamin/fa/pyridoxine B COMPLEX-FOLIC ACID(OTC) 3 HOMOCYSTEINE FORMU- cyanocobalamin/fa/pyridoxine 3 LA(OTC)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 134 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
cyanocobalamin/fa/pyridoxine VITA-RESPA 3
leucovorin/pyridox/mecobalamin FOLINIC-PLUS(OTC) 3
lysine hcl/vit b comp/fa/zinc SUPERVITE 3
potassium aminobenzoate POTABA 3
vit b comp&c/folic acid/vit d3 DIALYVITE 800 PLUS D(OTC) 3
vit b complex & c no.13/fa/d3 NEPHROCAPS QT 3
vit b1/b2/b6/fa/mecobalamin METHAVER 3
vit b2/niacin/b-6/b-12/d-panth B COMPLEX WITH B-12(OTC) 3
vit d3/folic acid/b2/b6/b12 FOLGARD(OTC) 3
vitamin b comp and c/fa/zinc QUIN B STRONG(OTC) 3 DIALYVITE 800 WITH vitamin b comp and c/fa/zn cit 3 ZINC(OTC) vitamin b complex/folic acid B-STRESS(OTC) 3 BREWER’S YEAST(TAB)(680 yeast 3 MG)(OTC) thiamine hcl VITAMIN B-1(OTC) 1
thiamine mononitrate VITAMIN B-1(OTC) 1
cyanocobalamin (vitamin b-12) CYANOCOBALAMIN INJECTION 1
cyanocobalamin/cobamamide B-12(LOZENGE)(OTC) 1
cyanocobalamin/folic acid B-12(OTC) 1
cyanocobalamin/mecobalamin NEURIN-SL 1
hydroxocobalamin HYDROXOCOBALAMIN 1 B-12(TAB RDP DIS)(5000 MCG) mecobalamin 1 (OTC) vit b12/pyridoxine/thiamine NEURO VITE(OTC) 1
cyanocobalamin (vitamin b-12) B-12 COMPLIANCE 3
cyanocobalamin (vitamin b-12) B-12(OTC) 3
cyanocobalamin (vitamin b-12) NASCOBAL 3
cyanocobalamin (vitamin b-12) PHYSICIANS EZ USE B-12 3
cyanocobalamin (vitamin b-12) VITAMIN B-12(OTC) 3
cyanocobalamin (vitamin b-12) VITAMIN B12(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 135 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL
cyanocobalamin/cobamamide B-12(TAB SUBL)(OTC) 3 B-12(TAB RDP DIS)(1000 MCG) mecobalamin 3 (OTC) mecobalamin/folic acid OPURITY(OTC) 3
vit b12/intrins fact/fa cmb #2 INTRINSI B12-FOLATE(OTC) 3
vit b12/pyridoxine/thiamine APATATE(OTC) 3
riboflavin VITAMIN B-2(OTC) 1
pyridoxine hcl VITAMIN B-6(OTC) 1
pyridoxine hcl B-NATAL(OTC) 3 CHROMIUM PICOLINATE KL- pyridoxine/chromium picolinate 3 B6(OTC) vit c/rutin/hes/biofl,lem/rose FLEVOXIN(OTC) 1
ascorbate calcium VITAMIN C(TAB)(OTC) 1 ESTER-C(TAB)(500-200 MG) ascorbate calcium/bioflavonoid 1 (OTC) ascorbate calcium/multivit-min VITAMIN C(OTC) 1
ascorbic acid VITAMIN C(OTC) 1
ascorbic acid/ascorbate ca FRUIT C-100(OTC) 1
ascorbic acid/ascorbate sodium ACEROLA C(OTC) 1 VITAMIN C-BIOFLAVI- ascorbic acid/bioflavonoids 1 NOIDS-RH(OTC) ascorbic acid/cod liver oil COD LIVER OIL(OTC) 1
ascorbic acid/multivit-min ESSENCE C(OTC) 1
ascorbic acid/vit b12/zinc ZINC PLUS(OTC) 1 CRANBERRY URINARY COM- ascorbic acid/vitamin e 1 FORT(OTC) ascorbic acid/zinc ZINC WITH VITAMIN C(OTC) 1
vit c/ascorbate ca/ascorb sod VITAMIN C(OTC) 1
vit c/hesp meth chal/hesp cm PERIDIN-C(OTC) 1
ascorbic acid/mv, min cmb#18 ULTRA POTENT-C(OTC) 3
vit c/rut/hesp cmp/bioflav,cit SPECIAL C(OTC) 3
ascorbate calcium VITAMIN C(POWDER)(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 136 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL ESTER-C(TAB)(1000-200MG) ascorbate calcium/bioflavonoid 3 (OTC) ascorbic acid/bioflavonoids SPAN C(OTC) 3 EMERGEN-C IMMUNE ascorbic acid/multivit-min 3 PLUS(OTC) vit c/hesperidin/bioflavonoids PAN-C 500(OTC) 3
calcitriol CALCITRIOL 1
calcitriol ROCALTROL 1
cod liver oil COD LIVER OIL(OTC) 1
ergocalciferol (vitamin d2) DRISDOL 1
cholecalciferol (vitamin d3) CHILDREN’S REPLESTA(OTC) 3
cholecalciferol (vitamin d3) DECARA(OTC) 3 DIALYVITE VITAMIN D3 MAX- cholecalciferol (vitamin d3) 3 (OTC) cholecalciferol (vitamin d3) REPLESTA NX(OTC) 3
cholecalciferol (vitamin d3) REPLESTA(OTC) 3
cholecalciferol (vitamin d3) SUPER DAILY D3(OTC) 3
cholecalciferol (vitamin d3) THERA-D(OTC) 3
cholecalciferol (vitamin d3) VITAMIN D3(OTC) 3
ergocalciferol (vitamin d2) VITAMIN D2(OTC) 3
vitamin d3/folic acid CIFEREX 3
vitamin d3/folic acid DERMACINRX PUREFOLIX 3
vitamin d3/folic acid DURACHOL 3
vitamin d3/folic acid ORTHO D 3
vitamin d3/folic acid REVESTA 3
vitamin d3/folic acid ZAVARA 3
vitamin d3/soy isoflavone ISO D3(OTC) 3
vitamin d3/vitamin k2 D3 + K2 DOTS(OTC) 3
vitamin d3/vitamin k2 (mk4) K2 PLUS D3(OTC) 3
fish oil/dha/epa FISH OIL(OTC) 5 VITAMIN E(CAP)(100 UNIT) vitamin e (dl,tocopheryl acet) 1 (OTC)
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 137 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL VITAMIN E(CAP)(1000 UNIT) vitamin e (dl,tocopheryl acet) 1 (OTC) VITAMIN E(CAP)(200 UNIT) vitamin e (dl,tocopheryl acet) 1 (OTC) VITAMIN E(CAP)(400 UNIT) vitamin e (dl,tocopheryl acet) 1 (OTC) vitamin e (dl,tocopheryl acet) VITAMIN E(DROPS)(OTC) 1
vit e ac/cu/se/znox/pyg/saw p PROSTAMEN(OTC) 1
vitamin e VITAMIN E(CAP)(OTC) 1
vitamin e VITAMIN E(DROPS)(OTC) 1
vitamin e acetate VITAMIN E(OTC) 1
vitamin e acetate/selenium VITAMIN E(OTC) 1
vitamin e mixed VITAMIN E(CAP)(OTC) 1
wheat germ oil WHEAT GERM OIL(OTC) 1 VITAMIN E(CAP)(400 UNIT) vitamin e (dl,tocopheryl acet) 3 (OTC) tocophersolan LIQUI-E(OTC) 3
vit e/vit c/magnesium/zinc ECEE PLUS(OTC) 3
vitamin e VITAMIN E(LIQUID)(OTC) 3
vitamin e acid succinate VITAMIN E(OTC) 3
vitamin e mixed VITAMIN E(TAB)(OTC) 3
vitamin e mixed/tocotrienol AQUA-E(OTC) 3 ZINC WITH VIT C-ECHI- ascorbate sodium/zn/echin purp 1 NACEA(OTC) vit a acet/vit c/znox/propolis ZINC LOZENGE(OTC) 1
zinc ZINC(OTC) 1
zinc amino acid chelate ZINC(OTC) 1
zinc chloride ZINC CHLORIDE 1
zinc gluconate ZINC(OTC) 1
zinc sulfate ZINC SULFATE 1
zinc sulfate ZINC SULFATE(OTC) 1
zinc gluconate-zinc picolinate ZINC(OTC) 3
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCare PEBB/AllCare Health Plan, Inc./Formulary Revised December 30, 2015 138 Restrictions GENERIC NAME BRAND NAME TIER AL QL ST PA GL VITAMELTS FAST DIS- zinc oxide 3 SOLVE(OTC) zinc sulfate ORAZINC(OTC) 3
zinc sulfate ZINC-15(OTC) 3
WEIGHT REDUCTION
benzphetamine hcl BENZPHETAMINE HCL 1
diethylpropion hcl DIETHYLPROPION HCL ER 1
phendimetrazine tartrate BONTRIL PDM 1
phendimetrazine tartrate PHENDIMETRAZINE TARTRATE 1
phentermine hcl ADIPEX-P 1
phentermine hcl PHENTERMINE HCL 1
am ac/mv-mn/dietary/prt supp OPTIFAST 70(OTC) 3
benzphetamine hcl REGIMEX 3
phentermine hcl SUPRENZA ODT 3 X
phentermine/topiramate QSYMIA 3 X
resve/chrom/grn tea/egcg/dig#3 RESVERATROL DIET(OTC) 3
naltrexone hcl/bupropion hcl CONTRAVE 3 X
liraglutide SAXENDA 3 X
orlistat ALLI(OTC) 3
orlistat XENICAL 3
lorcaserin hcl BELVIQ 3 X
RESTRICTIONS KEY: AL = Age Limit; QL = Quality Limit; ST = Step Therapy; PA = Prior Authorization; GL = Gender Limitations
AllCarePEBB.com AllCare PEBB/AllCare Health Plan, Inc./Formulary 139 Grants Pass 740 SE 7th Street, Grants Pass, OR 97526 Tel (541) 471-4106 Medford 3629 Aviation Way, Medford, OR 97504 Tel (541) 734-5520
Toll-free 1 (888) 460-0185 TTY 1 (800) 735-2900 Fax (541) 471-3784 AllCareAdvantageHP.comAllCarePEBB.com