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Open Formulary for Web W Spclty V2 (Updated 11-11-2016).Xlsx HOSPITALITY RX OPEN FORMULARY Prior Quantity Step Drug Class Drug Description Drug Name Tier Authorization Limit Therapy ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREXIANTS Amphetamine‐Dextroamphetamine Adderall Oral Tablet 10 MG Tier 3 MEDICAL DEVICES AND SUPPLIES Lancets 1st Choice Lancets Super Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets 1st Choice Lancets Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets 1st Choice Lancets Ultra Thin Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 29G X 12MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 31G X 5 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 31G X 6 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 31G X 8 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Insulin Pen Needle 1st Tier Unifine Pentips Plus Miscellaneous 32G X 4 MM Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets 1st Tier Unilet ComforTouch Miscellaneous Tier 2 CHEMICALS 2‐Deoxy‐D‐Glucose 2‐Deoxy‐D‐Glucose Powder Tier 3 CHEMICALS Hydroxytryptophan 5‐HTP Powder Tier 3 CHEMICALS Hydroxytryptophan 5‐Hydroxy‐L‐Tryptophan Powder Tier 3 CHEMICALS 5‐Methyltetrahydrofolate Calcium 5‐Methyltetrahydrofolate Calc Powder Tier 3 CHEMICALS 7‐Ketodehydroepiandrosterone (7‐Keto DHEA) 7‐Keto DHEA Powder Tier 3 DERMATOLOGICALS Methoxsalen 8‐Mop Oral Capsule 10 MG Tier 3 DERMATOLOGICALS Amantadine‐Amitriptyline‐Gabapentin‐Cyclobenzaprine A.A.G.C. Kit in TeroDerm External Cream 8‐4‐10‐4 % Tier 3 ANTIVIRALS Abacavir Sulfate Abacavir Sulfate Oral Tablet 300 MG Tier 1 x ANTIVIRALS Abacavir Sulfate‐Lamivudine‐Zidovudine Abacavir‐Lamivudine‐Zidovudine Oral Tablet 300‐150‐300 MG Tier 1 x HEMATOPOIETIC AGENTS Cyanocobalamin‐Methylcobalamin Abaneu‐SL Sublingual Tablet Sublingual 600‐600 MCG Tier 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Maintena Intramuscular Suspension Reconstituted 300 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Maintena Intramuscular Suspension Reconstituted 400 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 10 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 15 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 2 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 20 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 30 MG Tier 3 xx ANTIPSYCHOTICS/ANTIMANIC AGENTS Aripiprazole Abilify Oral Tablet 5 MG Tier 3 xx DIAGNOSTIC PRODUCTS Gadofosveset Trisodium Ablavar Intravenous Solution 244 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 100 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 200 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 300 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 400 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 600 MCG Tier 3 x x ANALGESICS ‐ OPIOID Fentanyl Citrate Abstral Sublingual Tablet Sublingual 800 MCG Tier 3 x x CHEMICALS Saccharomyces Cerevisiae Extract AC Dermapeptide Liquid Tier 3 PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. Acamprosate Calcium Acamprosate Calcium Oral Tablet Delayed Release 333 MG Tier 1 x DERMATOLOGICALS Clindamycin Phosphate‐Benzoyl Peroxide Acanya External Gel 1.2‐2.5 % Tier 3 x ANTIDIABETICS Acarbose Acarbose Oral Tablet 100 MG Tier 1 ANTIDIABETICS Acarbose Acarbose Oral Tablet 25 MG Tier 1 ANTIDIABETICS Acarbose Acarbose Oral Tablet 50 MG Tier 1 ANTIASTHMATIC AND BRONCHODILATOR AGENTS Zafirlukast Accolate Oral Tablet 10 MG Tier 3 x ANTIASTHMATIC AND BRONCHODILATOR AGENTS Zafirlukast Accolate Oral Tablet 20 MG Tier 3 x DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek Active In Vitro Strip Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek Aviva In Vitro Strip Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek Aviva Plus In Vitro Strip Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek Compact Plus In Vitro Strip Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek FastClix Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek Multiclix Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Accu‐Chek Nano SmartView Kit w/Device Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek Safe‐T Pro Lancets Miscellaneous Tier 2 DIAGNOSTIC PRODUCTS Glucose Blood Accu‐Chek SmartView In Vitro Strip Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek Soft Touch Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Lancets Accu‐Chek Softclix Lancets Miscellaneous Tier 2 MEDICAL DEVICES AND SUPPLIES Blood Glucose Monitoring Supplies Accu‐Chek Voicemate Kit Tier 2 ANTIHYPERTENSIVES Quinapril HCl Accupril Oral Tablet 10 MG Tier 3 ANTIHYPERTENSIVES Quinapril HCl Accupril Oral Tablet 20 MG Tier 3 ANTIHYPERTENSIVES Quinapril HCl Accupril Oral Tablet 40 MG Tier 3 ANTIHYPERTENSIVES Quinapril HCl Accupril Oral Tablet 5 MG Tier 3 ANTIHYPERTENSIVES Quinapril‐Hydrochlorothiazide Accuretic Oral Tablet 10‐12.5 MG Tier 3 ANTIHYPERTENSIVES Quinapril‐Hydrochlorothiazide Accuretic Oral Tablet 20‐12.5 MG Tier 3 ANTIHYPERTENSIVES Quinapril‐Hydrochlorothiazide Accuretic Oral Tablet 20‐25 MG Tier 3 DIAGNOSTIC PRODUCTS Glucose Blood Accutrend Glucose In Vitro Strip Tier 2 BETA BLOCKERS Acebutolol HCl Acebutolol HCl Oral Capsule 200 MG Tier 1 BETA BLOCKERS Acebutolol HCl Acebutolol HCl Oral Capsule 400 MG Tier 1 ANTIHYPERTENSIVES Perindopril Erbumine Aceon Oral Tablet 4 MG Tier 3 ANTIHYPERTENSIVES Perindopril Erbumine Aceon Oral Tablet 8 MG Tier 3 ANTIDOTES Acetylcysteine (Antidote) Acetadote Intravenous Solution 200 MG/ML Tier 3 x ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine #2 Oral Tablet 300‐15 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine #3 Oral Tablet 300‐30 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine #4 Oral Tablet 300‐60 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine Oral Solution 120‐12 MG/5ML Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine Oral Tablet 300‐15 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine Oral Tablet 300‐30 MG Tier 1 ANALGESICS ‐ OPIOID Acetaminophen w/ Codeine Acetaminophen‐Codeine Oral Tablet 300‐60 MG Tier 1 OTIC AGENTS Hydrocortisone w/Acetic Acid Acetasol HC Otic Solution 2‐1 % Tier 1 DIURETICS Acetazolamide AcetaZOLAMIDE ER Oral Capsule Extended Release 12 Hour 500 MG Tier 1 DIURETICS Acetazolamide AcetaZOLAMIDE Oral Tablet 125 MG Tier 2 DIURETICS Acetazolamide AcetaZOLAMIDE Oral Tablet 250 MG Tier 1 DIURETICS Acetazolamide Sodium AcetaZOLAMIDE Sodium Injection Solution Reconstituted 500 MG Tier 1 x GENITOURINARY AGENTS ‐ MISCELLANEOUS Acetic Acid Acetic Acid Irrigation Solution 0.25 % Tier 1 OTIC AGENTS Acetic Acid (Otic) Acetic Acid Otic Solution 2 % Tier 1 OTIC AGENTS Acetic Acid‐Aluminum Acetate Acetic Acid‐Aluminum Acetate Otic Solution 2 % Tier 2 CHEMICALS Acetone Acetone Solution Tier 3 ANALGESICS ‐ NonNarcotic Aspirin Acetyl Salicylic Acid Powder Tier 3 COUGH/COLD/ALLERGY Acetylcysteine Acetylcysteine Inhalation Solution 10 % Tier 1 COUGH/COLD/ALLERGY Acetylcysteine Acetylcysteine Inhalation Solution 20 % Tier 1 ANTIDOTES Acetylcysteine (Antidote) Acetylcysteine Intravenous Solution 200 MG/ML Tier 1 x COUGH/COLD/ALLERGY Acetylcysteine Acetylcysteine Powder Tier 3 CHEMICALS Acetyl‐D‐Glucosamine Acetyl‐D‐Glucosamine Powder Tier 3 CHEMICALS Lactobacillus Acidophilus Acidophilus Lactobacillus Powder Tier 3 ULCER DRUGS Rabeprazole Sodium Aciphex Oral Tablet Delayed Release 20 MG Tier 3 x x ULCER DRUGS Rabeprazole Sodium AcipHex Sprinkle Oral Capsule Sprinkle 10 MG Tier 3 x x ULCER DRUGS Rabeprazole Sodium AcipHex Sprinkle Oral Capsule Sprinkle 5 MG Tier 3 x x DERMATOLOGICALS Acitretin Acitretin Oral Capsule 10 MG Tier 1 DERMATOLOGICALS Acitretin Acitretin Oral Capsule 17.5 MG Tier 1 DERMATOLOGICALS Acitretin Acitretin Oral Capsule 25 MG Tier 1 DERMATOLOGICALS Alclometasone Dipropionate Aclovate External Cream 0.05 % Tier 3 DERMATOLOGICALS Benzoyl Peroxide Acne Medication 5 External Gel 5 % Tier 1 BIOLOGICALS MISC Acremonium Acremonium Subcutaneous Solution 20000 PNU/ML Tier 3 x ANALGESICS ‐ ANTI‐INFLAMMATORY Tocilizumab Actemra Subcutaneous Solution Prefilled Syringe 162 MG/0.9ML Tier 2 x ENDOCRINE AND METABOLIC AGENTS ‐ MISC. Corticotropin Acthar HP Injection Gel 80 UNIT/ML Tier 2 x VACCINES Haemophilus B Polysac Conj Vac ActHIB Intramuscular Solution Reconstituted Tier 3 x DERMATOLOGICALS Permethrin Acticin External Cream 5 % Tier 1 TETRACYCLINES Doxycycline Hyclate Acticlate Oral Tablet 150 MG Tier 3 x TETRACYCLINES Doxycycline Hyclate Acticlate Oral Tablet 75 MG Tier 3 x DERMATOLOGICALS Silver Acticoat
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