Ryan White Part A Formulary

Updated ƵŐƵƐƚ 2019 Ryan White Part A Pharmacy Formulary - Updated 8/19/19 Tier 1: In order to access Tier 1, clients must qualify for the Ryan White Part A Program based on eligiblity requirements. Generic Name Brand Name Drug Classification Tier Acetazolamide Diamox CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Acetic Acid Vosol Otic Anti-Infectives 1 Acetic Acid/HC Vosol HC Otic Anti-Infectives 1 Al, Mg, Simethicone Mylanta DS Gastrointest/Antacid 1 Albuterol tab Ventolin Respiratory, Cough & Cold Allergy/BetaAgonist Oral 1 Allopurinol Zyloprim Misc/Other 1 Alpha-Linoleic Acid Omega 3 Antihyperlipidemic Agents- Dietary Source 1 Amiiodarone Cordarone Cardiac & Anti-Hypertensive/Antiarrythmic 1 Ammonium lact Lac-Hydrin Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Amoxicillin Amoxil Antiinfectives/Antiviral/Antibacterial 1 Amoxicillin/Clavulanate Potassium Augmentin Antiinfectives/Antiviral/Antibacterial 1 Artificial tears Tearisol Ophthalmic/Misc/Other 1 Aspirin Clopidogrel *Aspirin may only be dispensed with Clopidogrel Plavix Cardiac & Anti-Hypertensive/Antiplatelet 1 Baclofen Lioresal CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1 Benzonatate Tessalon Antitussives 1 Benztropine Cogentin CNS, Anxiety, Psych, Neuro, & Autonomic/Misc 1 Betamethasone Diprosone Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Betaxolol Betoptic S Ophthalmic/Betablocker 1 Bimatoprost Lumigan Ophthalmic/Glaucoma 1 B-Plex with C Antioxidant Vitamins & Nutritional/Vitamins 1 Brimonide Alphagan Ophthalmic/Glaucoma 1 Brinzolamide Azopt Ophthalmic/Glaucoma 1 Budesonide Rhinocort Nasal 1 Bumetanide Bumex Cardiac & Anti-Hypertensive/Diuretic 1 Buspirone Buspar CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1 Butalbitol/Acetaminophen/Caffeine Fioricet CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1 Calcium Acetate Calcium Minerals, Electrolytes/Phosphate Binders 1 Carbamazepine Tegretol CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Carbamide Peroxide Debrox Otic 1 Carbidopa/Levodopa Sinemet CNS, Anxiety, Psych, Neuro, & Autonomic/Antiparkinson 1 Carbinoxamine/Pseudoephedrine Cardec, Cardec DM, Cardec S Respiratory, Cough & Cold Allergy/Antihist/Decongestant 1 Carisoprodol Soma CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1 Carvedilol Coreg Cardiac & Anti-Hypertensive/AlphaBeta Blocker 1 Cefdinir Omnicef Antiinfectives/Antiviral/Antibacterial 1 Ceftriaxone INJ Rocephin Antiinfectives/Antiviral/Antibacterial 1 Cefuroxime Ceftin Antiinfectives/Antiviral/Antibacterial 1 Generic Name Brand Name Drug Classification Tier Celebrex Celecoxib CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1 Cephalexin Keflex Antiinfectives/Antiviral/Antibacterial 1 Chlorhexidine 12% Solution Peridex Oral Rinse Misc/Other 1 Chlorpromazine Thorazine CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1 Ciprofloxacin Ciloxin Ophthalmic/Antibiotic 1 Ciprofloxacin Cipro Antiinfectives/Antiviral/Antibacterial 1 Ciprofloxacin/Hydrocortisone Cipro HC Otic Steroids 1 Clindamycin Cleocin Antiinfectives/Antiviral/Antibacterial 1 Clindamycin Cleocin Vag Topical, Dermatology, Rectal, Vaginal/Antibacterial 1 Clobetasol Temovate Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Clonazepam Klonopin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Clonidine Catapres Cardiac & Anti-Hypertensive/Alpha Blockers 1 Colchicine Colchicine Misc/Other 1 Cyclobenzaprine Flexeril CNS, Anxiety, Psych, Neuro, & Autonomic/Muscle Relaxant 1 Cycloserine Seromycin Antiinfectives/Antitubercular 1 Cyproheptadine Periactin Wasting 1 Danocrine Danazol Misc/Other 1 Dexamethasone Decadron Antiinfectives/Antiinflammatory 1

Dexamethasone/Neomycin/ Polymyxin B Dexacidin Ophthalmic/Antibiotic 1 Diazepam Valium CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1 Diclofenac Topical Voltaren (gel) Topical Non-Steroidal Anti-Inflammatories 1 Dicyclomine Bentyl Gastrointest/Antispasmotic 1 Diflorasone Psorcon Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Docusate sodium Colace Gastrointest/Laxative 1 Docusate/Casanth Peri-Colace Gastrointest/Laxative 1 Dorzolamide+Timolol Cosopt Ophthalmic/Glaucoma 1 Doxycycline Vibramycin Antiinfectives/Antiviral/Antibacterial 1 Dutasteride Avodart 5-Alpha-Reductase Inhibitors/BPH 1 Erythomycin / Benzoyl perox Benzagel Topical, Dermatology, Rectal, Vaginal/Antibacterial 1 Erythromycin E-Mycin Ophthalmic/Antibiotic 1 Erythromycin base Ery-tab Antiinfectives/Antiviral/Antibacterial 1 Estrogen Conjugated Premarin GYN/OB 1 Ethinyl Estradiol/Norgestimate Ortho-Tricyclen 28 GYN/OB 1 Ethinyl Estradiol/Norgestrel Lo-Ovral 28 GYN/OB 1 Ethosuximide Zarontin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Ferrous Sulfate/Fumerate Feosol Vitamins & Nutritional/Vitamins 1 Fiberlax Fibercon Gastrointest/Laxative 1 Fluocinolone Dermasmoothe Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Generic Name Brand Name Drug Classification Tier Fluorometholone FML Ophthalmic/Steroid 1 Formoterol/Mometasone Dulera Bronchodilator Combinations 1 Guaifen/Codeine/Pseudoephedrine Robitussin DAC Respiratory, Cough & Cold Allergy/Antitussive 1 Guaifen/Dextromethorphan Robitussin DM Respiratory, Cough & Cold Allergy/Antitussive 1 Guaifenesin Robitussin Respiratory, Cough & Cold Allergy/Antitussive 1 Guaifenesin/Codeine Robitussin AC Respiratory, Cough & Cold Allergy/Antitussive 1 Haloperidol Haldol CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1 HCTZ HydroDiuril Cardiac & Anti-Hypertensive/Diuretic 1 HCTZ/Triamterene Dyazide Cardiac & Anti-Hypertensive/Diuretic 1 Hydrocodone/Acetaminophen Vicodin,VicodinES CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Hydrocortisone Cream Hytone Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Hydrocortisone Suppository Anusol-HC Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Hydroxyzine Vistaril,Atarx CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1

Irbesartan Avapro Cardiac & Anti-Hypertensive/Angiotensin Receptor Blocker (ARB) 1 Isoniazid/Rifampin Rifamate Antiinfectives/Antitubercular 1 Isosorbide Mononitrate Imdur Cardiac & Anti-Hypertensive/Nitrates 1 Labetalol Normodyne Cardiac & Anti-Hypertensive/Beta Blockers 1 Lansoprazole Prevacid Gastrointest/PPI 1 Latanoprost Xalatan Ophthalmic/Glaucoma 1 Leuprolide Lupron Gonadotropin Releasing Hormones 1 Lindane Kwell Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Lithium Carb Lithonate CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1 Lodoxamide Alomide Ophthalmic/Misc/Other 1 Loperamide Paregoric Imodium Gastrointest/Antidiarrheal 1 Lorazepam Ativan CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1 MAGIC Mouthwash MAGIC Mouthwash Misc/Other 1 Methadone Methadone CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Methocarbamol Robaxin Skeletal Muscle Relaxants 1 Methyprednisolone Medrol dosepak Antiinfectives/Antiinflammatory 1 Montileukast Singulair Respiratory, Cough & Cold Allergy/Other 1 MSContin, MSIR Morphine CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Mupirocin Bactroban Topical Antibiotic 1 Naphazoline Vasocon Ophthalmic/Misc/Other 1 Neo/Gramic/Poly Neosporin Topical, Dermatology, Rectal, Vaginal/Antibacterial 1 Neo/Poly/Bacit Neosporin Ophthalmic/Antibiotic 1 Neomycin / HC Cortisporin Otic 1 Neurontin Gabapentin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Nitrofurantoin Macrodantin Antiinfectives/Antiviral/Antibacterial 1 Generic Name Brand Name Drug Classification Tier Nystatin Mycostatin Topical, Dermatology, Rectal, Vaginal/Antifungal 1 Nystatin/Triamcin Mycolog Topical, Dermatology, Rectal, Vaginal/Antifungal 1 Olopatadine Ophthalmic Pataday Ophthalmic Antihistamines and Decongestants 1 Oxybutinin Ditropan Misc/Other 1 Oxycodone/Acet Percocet CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Oxycodone/ASA Percodan CNS, Anxiety, Psych, Neuro, & Autonomic/Narcotic Analgesic 1 Pancrealipase Ultrace MT Gastrointest/Digestive Enzyme 1 Paromomycin Humatin Antiinfectives/Other 1 Pen Needles Pen Needles *for Lantus/Levemir Medication Administration 1 Penicililn VK PenVK Antiinfectives/Antiviral/Antibacterial 1 Penicillin Benzath Bicillin LA Antiinfectives/Antiviral/Antibacterial 1 Permethrin Elimite Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Perphenazine Trilafon CNS, Anxiety, Psych, Neuro, & Autonomic/Antipsychotic 1 Phenazopyridine Pyridium Misc/Other 1 Phenobarbital Phenobarbital CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Phenytoin Dilantin CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Pilocarpine Pilocar Ophthalmic/Miotic 1 Podophilox Condylox Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Polyethylene Glycol Electrolyte GoLytely/Colyte Gastrointest/Misc/Other 1 Pramipexole Mirapex Dopaminergic Antiparkinaonism Agents 1 Prednisolone Pred Forte Ophthalmic/Steroid 1 Prednisone Deltasone Antiinfectives/Antiinflammatory 1 Promethazine Suppos Promethazine Suppos Gastrointest/Antiemetic 1 Propranolol Inderal Cardiac & Anti-Hypertensive/Beta Blockers 1 Pseudoephedrine Sudafed Respiratory, Cough & Cold Allergy/Antihist/Decongestant 1 Rivaroxaban Xarelto Anticoagulant/Factor Xa Inhibitors 1 Salmeterol Discus Serevent Respiratory, Cough & Cold Allergy/BetaAgonist Inhaled 1 Selenium Selsun Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Simethicone Mylicon Gastrointest/Antiflatulant 1 Sodium Chloride Ocean Nasal Nasal 1 Sodium Chloride for Irrigation Normal Saline Misc/Other 1 Spironolactone Aldactone Cardiac & Anti-Hypertensive/Diuretic 1 Sucralfate Carafate Gastrointest/Misc/Other 1 Sulfacetamide Sulamyd Ophthalmic/Antibiotic 1 Sumatriptan Imitrex (Oral Only) CNS, Anxiety, Psych, Neuro, & Autonomic/Antimigraine 1 Td Tetanus/Diptheria Injection Vaccines 1 Temazepam Restoril CNS, Anxiety, Psych, Neuro, & Autonomic/Antianxiety/Hypnotic 1 Terbinafine Lamisil Antiinfectives/Antifungal 1 Terbinafine Lamisil Topical, Dermatology, Rectal, Vaginal/Antifungal 1 Generic Name Brand Name Drug Classification Tier Tetracycline Achromycin Antiinfectives/Antiviral/Antibacterial 1 Theophylline Theo-Dur Respiratory, Cough & Cold Allergy/Xanthine 1 Therapeutic Multivitamins Therapeutic Multivitamins Vitamins & Nutritional/Vitamins 1 Timolol Timoptic Ophthalmic/Betablocker 1 TMP-SMX ds TMP-SMX ds Opportunistic Infections (OIs) 1 Tobramycin Tobrex Ophthalmic/Antibiotic 1 Topiramate Topamax CNS, Anxiety, Psych, Neuro, & Autonomic/Anticonvulsant 1 Triamcinolone Kenalog Topical, Dermatology, Rectal, Vaginal/Antifungal 1 Triamcinolone crm Kenalog Topical, Dermatology, Rectal, Vaginal/Corticosteroid 1 Trifluridine Viroptic Ophthalmic/Misc/Other 1 Trimethoprim Proloprim Antiinfectives/Antiviral/Antibacterial 1 Ultram Tramadol CNS, Anxiety, Psych, Neuro, & Autonomic/Analgesic 1 Urea, misc Amino-Cerv Topical, Dermatology, Rectal, Vaginal/Topical: Misc/Other 1 Wellbutrin Bupropion CNS, Anxiety, Psych, Neuro, & Autonomic/Antidepressant 1 Lidocaine , Xylocaine Oint, Jelly, Visc, Xylocaine/Lidocaine Patch Topical, Dermatology, Rectal, Vaginal/Anaesthetic 1 Zoster Vaccine Live Zostavax Vaccines 1 Ryan White Part A Pharmacy Formulary - Updated 8/19/2019 Tier 2: In order to access Tier Two, clients must be screened every six (6) months for the State AIDS Drugs Assistance Program (ADAP) eligibility and must be ineligible and meet the Ryan Part A eligibility requirements prior to the use of this formulary.

Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier Nucleoside reverse transcriptase abacavir (ABC) Ziagen® Antiretroviral inhibitor (NRTI) 2 abacavir/lamivudine (ABC/3TC) Epzicom® Antiretroviral NRTI combo 2 abacavir/lamivudine/zidovud ine (ABC/3TC/AZT) Trizivir® Antiretroviral NRTI combo 2 acetaminophen Tylenol® Analgesic Prostaglandin inhibitor 2 acyclovir Zovirax® Anti‐infective, antiviral Antiviral 2 albuterol Albuterol Respiratory Beta‐2 Agonist 2 albuterol HFA ProAir HFA®, Proventil HFA®, Ventolin Respiratory Beta‐2 Agonist 2 Anticholinergic + Beta‐2 Agonist, oral albuterol/ipratropium Combivent Respimat® Respiratory inhaled 2 alendronate Fosamax® Osteoporosis Bisphosphonate 2 Central nervous system, amitriptyline Elavil® antidepressant Tricyclic antidepressant (TCA) 2 amlodipine Norvasc® Cardiovascular Calcium channel blocker 2 aripiprazole Abilify® Central nervous system Antipsychotic, atypical 2 aspirin Bayer®, Ecotrin® Analgesic Salicylate 2 atazanavir (ATV) Reyataz® Antiretroviral Protease inhibitor (PI) 2 atazanavir/cobicistat 2 (ATV/COBI) Evotaz® Antiretroviral PI/PK Enhancer atenolol Tenormin® Cardiovascular Beta‐blocker 2 Cardiovascular, atorvastatin Lipitor® antihyperlipidemic HMG‐CoA Reductase inhibitor 2 Atorvastatin Generic Lipitor Cardiovascular agents, antihype HMG‐CoA Reductase inhibitor 2 atovaquone Mepron® Antio‐infective, amebicide Amebicide 2 azithromycin Zithromax® Anti‐infective, antibiotic Macrolide 2 baloxavir marboxil Xofluza™ Anti‐infective, antiviral Anti‐influenza 2

Generic Name Brand Name Classification Pharmacologic Classification Tier beclomethasone (nasal Qnasl® Respiratory Corticosteroid, nasal spray) 2 beclomethasone (oral inhaler) Qvar® Respiratory Corticosteroid, oral inhaled 2 Angiotensin converting enzyme (ACE) benazepril Lotensin® Cardiovascular inhibitor 2 benzoyl peroxide topical Benzoyl peroxide topical Skin/Mucous membrane Antibiotic + keratolytic 2 betamethasone dipropionate Diprolene® Skin/Mucous membrane Corticosteroid, topical 2 betamethasone valerate Betaderm® Skin/Mucous membrane Corticosteroid, topical 2 bictegravir/emtricitabine/ten ofovir alafenamide (BIC/FTC/TAF) budesonide/formoterol inhaler Biktarvy® Antiretroviral INSTI/NRTI combo 2 budesonide/formoterol Corticosteroid + Long acting Beta‐2 inhaler Symbicort® Respiratory Agonist, oral inhaled 2 Antidepressant‐miscellaneous, bupropion Wellbutrin® Central nervous system aminoketone 2 Antidepressant‐miscellaneous, bupropion SR Wellbutrin® SR Central nervous system aminoketone 2 Antidepressant‐miscellaneous, bupropion XL Wellbutrin® XL Central nervous system aminoketone 2 calcium carbonate Caltrate® Vitamin Vitamin 2 calcium with vitamin D Calcitrate + D®, Caltrate + D® Vitamin Vitamin 2 capsaicin topical Zostrix® Skin/Mucous membrane Analgesic, topical 2 cetirizine Zyrtec® Respiratory Antihistamine 2 cholecalciferol Vitamin D3 Vitamin Vitamin 2 Central nervous system, Selective serotonin reuptake inhibitor citalopram Celexa® antidepressant (SSRI) 2 clarithromycin Biaxin® Anti‐infective, antibiotic Macrolide 2 clotrimazole Mycelex® Troche Anti‐infective, antifungal Azole 2 Clotrimazole Lotrimin Anti-infective, antifungal Azole 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier cobicistat (COBI) Tybost® Antiretroviral Pharmacokinetic enhancer 2 Codeine/Acetaminophen Tylenol#3 Analgesic Prostaglandin inhibitor 2 crofelemer Mytesi® Gastrointestinal Antidiarrheal 2 cyanocobalamin (vitamin B 2 12) Cyanocobalamin Vitamin Vitamin cyanocobalamin (vitamin B 2 12), intranasal Nascobal® Vitamin Vitamin dapsone Dapsone Anti‐infective, antibiotic Sulfone 2 darunavir (DRV) Prezista® Antiretroviral Protease inhibitor (PI) 2 darunavir, cobicistat, emtricitabine, and tenofovir alafenamide Symtuza® Antiretroviral PI/NRTI combo 2 darunavir/cobicistat (DRV/COBI) Prezcobix® Antiretroviral PI/PK Enhancer 2 Nucleoside reverse transcriptase didanosine (ddI) Videx® Antiretroviral inhibitor (NRTI) 2 Nucleoside reverse transcriptase didanosine EC (ddI) Videx® EC Antiretroviral inhibitor (NRTI) 2 digoxin Lanoxin® Cardiovascular Cardiac glycoside 2 diltiazem Cardizem® Cardiovascular Calcium channel blocker 2 diltiazem CD Cardizem CD® Cardiovascular Calcium channel blocker 2 diltiazem SR Cardizem SR® Cardiovascular Calcium channel blocker 2 diphenhydramine Benadryl® Respiratory Antihistamine 2 diphenoxylate atropine Lomotil®* Gastrointestinal Antidiarrheal 2 divalproex sodium Depakote® Central nervous system Anticonvulsant, mood stabilizer 2 Integrase strand transfer inhibitor dolutegravir (DTG) Tivicay® Antiretroviral (INSTI) 2 dolutegravir / lamivudine Dovato® Antiretroviral INSTI/NRTI combo 2 dolutegravir/abacavir/lamivu dine (DTG/ABC/3TC) Triumeq® Antiretroviral INSTI/NRTI combo 2 dolutegravir/rilpivirine (DTG/RPV) Juluca® Antiretroviral INSTI/NRTI combo 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier Non‐nucleoside reverse transcriptase doravirine (DOR) Pifeltro™ Antiretroviral inhibitor (NNRTI) 2 Cardiovascular, doxazosin Cardura® antihypertensive Alpha‐blocker 2 Cardiovascular, doxazosin XL Cardura XL® antihypertensive Alpha‐blocker 2 doxepin Silenor® Central nervous system Tricyclic antidepressant (TCA) 2 Doxepin Sinequan Central nervous system Tricyclic antidepressant (TCA) 2 Gastrointestinal, appetite dronabinol Marinol®* stimulant Cannabinoid 2 Central nervous system, Serotonin‐norepinephrine reuptake duloxetine Cymbalta® antidepressant inhibitor 2 efavirenz (EFV) Sustiva® Antiretroviral inhibitor (NNRTI) 2 efavirenz/emtricitabine/tenof ovir disoproxil fumarate (EFV/FTC/TDF) elbasvir/grazoprevir Atripla® Antiretroviral NNRTI/NRTI combo 2 elbasvir/grazoprevir Zepatier® Anti‐infective, antiviral Hepatitis C agent 2 elvitegravir/cobicistat/emtric itabine /tenofovir alafenamide (EVG/COBI/FTC/TAF) Genvoya® Antiretroviral INSTI/NRTI combo 2 elvitegravir/cobicistat/emtric itabine /tenofovir disoproxil fumarate (EVG/COBI/FTC/ TDF) Stribild® Antiretroviral INSTI/NRTI combo 2 Nucleoside reverse transcriptase emtricitabine (FTC) Emtriva® Antiretroviral inhibitor (NRTI) 2 emtricitabine/tenofovir alafenamide (FTC/TAF) Descovy® Antiretroviral NRTI combo 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) Truvada® Antiretroviral NRTI combo 2 Angiotensin converting enzyme (ACE) 2 enalapril Vasotec® Cardiovascular inhibitor enfuvirtide (ENF, T‐20) Fuzeon® Antiretroviral Fusion inhibitor 2 entecavir Baraclude® Anti‐infective, antiviral Hepatitis B agent 2 Blood formation and epoetin alfa Epogen®, Procrit® coagulation Erythropoeisis stimulating agent 2 ergocalciferol Vitamin D2 Vitamin Vitamin 2 Central nervous system, Selective serotonin reuptake inhibitor escitalopram Lexapro® antidepressant (SSRI) 2 ethambutol Myambutol® Anti‐infective Antimycobacterial 2 Non‐nucleoside reverse transcriptase etravirine Intelence® Antiretroviral inhibitor (NNRTI) 2 famotidine Pepcid® Gastrointestinal, acid reducer Histamine 2 receptor blocker 2 Cardiovascular, fenofibrate Tricor® antihyperlipidemic Fibric acid derivative 2 ferrous sulfate Slow Iron® Vitamin Vitamin 2 filgrastim Neupogen® Blood formation and Granulocyte stimulating agent coagulation 2 finasteride Proscar® Genitourinary 5‐Alpha Reducte Inhibitor 2 fluconazole Diflucan® Anti‐infective, antifungal Azole flunisolide nasal Nasarel® Respiratory Corticosteroid, nasal 2 Central nervous system, Selective serotonin reuptake inhibitor fluoxetine Prozac® antidepressant (SSRI) 2 folic acid Folic acid Vitamin Vitamin 2 fosamprenavir (FPV) Lexiva® Antiretroviral Protease inhibitor (PI) 2 furosemide Lasix® Cardiovascular Loop diuretic 2 gabapentin Neurontin® Central nervous system Anticonvulsant, mood stabilizer 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier gemifibrozil Lopid® Cardiovascular, Fibric acid derivative antihyperlipidemic 2 glecaprevir/pibrentasvir Mavyret® Anti‐infective, antiviral Hepatitis C agent 2 glimepiride Amaryl® Antidiabetic Sulfonylurea 2 glipizide Glucotrol® Antidiabetic Sulfonylurea 2 glipizide ER Glucotrol XL® Antidiabetic Sulfonylurea 2 glyburide Diabeta® Antidiabetic Sulfonylurea 2 hepatitis A vaccine Havrix® Vaccine Viral vaccine 2 hepatitis A/B vaccine Twinrix® Vaccine Viral vaccine 2 hepatitis B vaccine Engerix‐B®, Heplisav‐B®, Recombivax HVaccine Viral vaccine 2 hepatitis b vaccine (recombinant, adjuvanted) Heplisav-B® Vaccines Viral vaccine 2 human papilloma virus vaccine Gardasil®9 Vaccine Viral vaccine 2 hydrochlorothiazide Microzide® Cardiovascular Thiazide diuretic 2 ibalizumab‐uiyk injection Trogarzo™ Anti‐infective, antiviral CD4 post‐attachment HIV‐1 inhibitor 2 ibuprofen Advil®, Motrin® Analgesic Nonsteroidal antiinflamatory drug 2 imiquimod Aldara® Topical, antiviral Antiviral, topical 2 indinavir (IDV) Crixivan® Antiretroviral Protease inhibitor (PI) 2 influenza vaccine, Fluzone®, Fuzone® High‐Dose Vaccine Viral vaccine 2 inactivated (including high dose) Insulin Analog Humalog Antidiabetic Insulin-rapid acting 2 Insulin Detemir Levemir Antidiabetic Insulin intermediate to long acting 2 insulin glargine Lantus® Antidiabetic Insulin‐long acting 2 insulin isophane Humulin N®, Novolin N® Antidiabetic Insulin‐intermediate acting 2 insulin lispro Humalog® Antidiabetic Insulin‐rapid acting 2 insulin NPH and insulin regular Humulin 70/30®, Novolin 70/30® Antidiabetic Insulin‐70/30 2 insulin regular Humulin R®, Novolin R® Antidiabetic Insulin‐short acting 2 ipratropium Atrovent® Respiratory Anticholinergic, oral inhaled 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier isoniazid Isoniazid Anti‐infective Antimycobacterial 2 itraconazole Sporanox® Anti‐infective, antifungal Azole 2 ketoconazole Nizoral® Anti‐infective, antifungal Azole 2 ketoconazole (cream, shampoo) Nizoral® Topical, antifungal Azole, topical 2 lactulose Constulose®, Enulose®, Generlac® Gastrointestinal Laxative, osmotic 2 Nucleoside reverse transcriptase lamivudine (3TC) Epivir® Antiretroviral inhibitor (NRTI) 2 lamivudine/zidovudine Combivir® Antiretroviral NRTI combo (3TC/AZT) 2 lamotrigine Lamictal® Central nervous system Anticonvulsant, mood stabilizer 2 ledipasvir/sofosbuvir Harvoni® Anti‐infective, antiviral Hepatitis C agent 2 leucovorin Leucovorin Vitamin Vitamin 2 levetiracetam Keppra® Central nervous system Anticonvulsant, mood stabilizer 2 levofloxacin Levaquin® Anti‐infective, antibiotic Quinolone 2 levothyroxine Levothroid®, Levoxyl®, Synthroid® Hormanal Thyroid supplement 2 Angiotensin converting enzyme (ACE) lisinopril Prinivil®, Zestril® Cardiovascular inhibitor 2 lithium carbonate Lithobid® Central nervous system Mood stabilizer 2 lopinavir/ritonavir (LPV/RTV) Kaletra® Antiretroviral PI/PK Enhancer 2 loratadine Claritin® Respiratory Antihistamine 2 losartan Cozaar® Cardiovascular Angiotensin II receptor blocker (ARB) 2 maraviroc (MVC) Selzentry® Antiretroviral CCR5 antagonist 2 meclizine Antivert® Central nervous system Antivertigo, antiemetic 2 medroxyprogesterone injection Depo‐Provera® Hormanal Progesterone 2 Gastrointestinal, appetite megestrol Megace® stimulant Hormonal, progesterone derivative 2 Meningococcal Conjugate Vaccine Menactra Vaccines Bacterial vaccine 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier meningococcal serogroups A, C, Y, W vaccine Menactra®, Menveo® Vaccine Bacterial vaccine 2 metformin Glucophage® Antidiabetic Biguanide 2 Fortamet, Glucophage, Glumetza, 2 Metformin Riomet Antidiabetic Biguanide metformin ER Glucophage XR® Antidiabetic Biguanide 2 metformin/glyburide Glucovance® Antidiabetic Sulfonylureas/Biguanides 2 metoclopramide Reglan® Gastrointestinal Antiemetic, prokinetic 2 metoprolol succinate Toprol XL® Cardiovascular Beta‐blocker 2 metoprolol tartrate Lopressor® Cardiovascular Beta‐blocker 2 metronidazole Flagyl® Anti‐infective Amebicide, trichomonaside 2 Metronidazole Metrogel Anti-infective Amebicide, trichomonaside 2 mirtazapine Remeron® Central nervous system Tetracyclic antidepressant 2 multivitamin Multivitamin Vitamin Vitamin 2 multivitamin prenatal Multivitamin prenatal Vitamin Vitamin 2 multivitamins B complex Multivitamins B complex Vitamin Vitamin 2 naproxen Naprosyn® Analgesic Nonsteroidal antiinflamatory drug 2 nelfinavir (NFV) Viracept® Antiretroviral Protease inhibitor (PI) 2 Non‐nucleoside reverse transcriptase nevirapine (NVP) Viramune® Antiretroviral inhibitor (NNRTI) 2 Non‐nucleoside reverse transcriptase nevirapine XR (NVP) Viramune XR® Antiretroviral inhibitor (NNRTI) 2 Cardiovascular, niacin Niaspan® antihyperlipidemic Vitamin, lipotropic 2 nifedipine Procardia® Cardiovascular Calcium channel blocker 2 nifedipine XL Adalat CC®, Procardia XL® Cardiovascular Calcium channel blocker 2 nitroglycerin capsules Nitroglycerin capsules Cardiovascular Vasodilator 2 nitroglycerin sublingual Nitrostat® Cardiovascular Vasodilator 2 nortriptyline Pamelor® Central nervous system, Tricyclic antidepressant (TCA) antidepressant 2 olanzapine Zyprexa® Central nervous system Antipsychotic, antimanic 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier Cardiovascular, omega 3 Lovaza®, Vascepa® antihyperlipidemic Lipotropic 2 omeprazole Prilosec® Gastrointestinal, acid reducer Proton pump inhibitor 2 ondansetron Zofran®, Zofran ODT®, Zuplenz® Central nervous system Anti‐nausea 2 oseltamivir Tamiflu® Anti‐infective, antiviral Anti‐influenza 2 oxandrolone Oxandrin®* Gastrointestinal, appetite Hormonal, testosterone derivative stimulant 2 pantoprazole Protonix® Gastrointestinal, acid reducer Proton pump inhibitor 2 Central nervous system, Selective serotonin reuptake inhibitor paroxetine Paxil® antidepressant (SSRI) 2 2 pneumococcal 13‐valent conjugate vaccine (PCV13) Prevnar 13® Vaccine Bacterial vaccine pneumococcal 23‐valent 2 polysaccharide vaccine (PPSV23) Pneumovax 23® Vaccine Bacterial vaccine potassium chloride Klor‐Con® Cardiovascular Electrolyte replacement 2 Potassium Chloride Ten-K Cardiovascular Electrolyte replacement 2 Cardiovascular, pravastatin Pravachol® antihyperlipidemic HMG‐CoA Reductase inhibitor 2 pregabalin Lyrica®* Central nervous system Anticonvulsant, mood stabilizer 2 primaquine Primaquine Anti‐infective, antibiotic Antimalarial 2 promethazine Phenergan® Gastrointestinal Antihistamine, antiemetic 2 pyrazinamide Pyrazinamide Anti‐infective Antimycobacterial 2 pyridoxine (vitamin B6) Pyridoxine Vitamin Vitamin 2 pyrimethamine Daraprim® Anti‐infective, antibiotic Antimalarial 2 quetiapine Seroquel® Central nervous system Antipsychotic, antimanic 2 Integrase strand transfer inhibitor raltegravir (RAL) Isentress® Antiretroviral (INSTI) 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier Integrase strand transfer inhibitor raltegravir HD (RAL HD) Isentress HD® Antiretroviral (INSTI) 2 ranitidine Zantac® Gastrointestinal, acid reducer Histamine 2 receptor blocker 2 ribavirin Riba‐Pak 600®, Ribasphere® Anti‐infective, antiviral Hepatitis C agent 2 rifabutin Mycobutin® Anti‐infective Antimycobacterial 2 rifampin Rifadin® Anti‐infective Antimycobacterial 2 Non‐nucleoside reverse transcriptase rilpivirine (RPV) Edurant® Antiretroviral inhibitor (NNRTI) 2 rilpivirine /emtricitabine/ tenofovir disoproxil fumarate (RPV/FTC/TDF) Complera® Antiretroviral NNRTI/NRTI combo 2 rilpivirine/emtricitabine/teno fovir alafenamide (RPV/FTC/TAF) Odefsey® Antiretroviral NNRTI/NRTI combo 2 risperidone Risperdal® Central nervous system Antipsychotic, atypical 2 ritonavir (RTV) Norvir® Antiretroviral Pharmacokinetic enhancer 2 Cardiovascular, rosuvastatin Crestor® antihyperlipidemic HMG‐CoA Reductase inhibitor 2 saquinavir (SQV) Invirase® Antiretroviral Protease inhibitor (PI) 2 Selective serotonin reuptake inhibitor sertraline Zoloft® Central nervous system (SSRI) 2 sitagliptin Januvia® Antidiabetic Dipeptidyl Peptidase‐4 Inhibitor 2 Nucleoside reverse transcriptase stavudine (d4T) Zerit® Antiretroviral inhibitor (NRTI) 2 sulfadiazine Sulfadiazine Anti‐infective, antibiotic Sulfonamide 2 sulfamethoxazole/trimethopr Bactrim®, Septra® Anti‐infective, antibiotic Sulfonamide im (SMX/TMP) 2 sulfamethoxazole/trimethopr im (SMX/TMP) DS Bactrim DS®, Septra DS® Anti‐infective, antibiotic Sulfonamide 2 tamsulosin Flomax® Genitourinary Alpha‐blocker 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier tenofovir disoproxil Viread® Antiretroviral Nucleotide reverse transcriptase fumarate (TDF) inhibitor (NRTI) 2 Cardiovascular, terazosin Hytrin® antihypertensive Alpha‐blocker 2 terconazole Terazol® Topical, antifungal Azole, topical 2 testosterone gel (injection is 2 non‐formulary) Androgel®* Hormonal Androgen 2 testosterone patch (injection is non‐formulary) Tenivac® Vaccine Bacterial vaccine tetanus and diphtheria toxoids (Td) Adacel®, Boostrix® Vaccine Bacterial vaccine 2 tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) tipranavir (TPV) Aptivus® Antiretroviral Protease inhibitor (PI) 2 Central nervous system, trazodone Desyrel® antidepressant Serotonin reuptake inhibitor 2 valacyclovir Valtrex® Anti‐infective, antiviral Antiherpetic agent 2 valganciclovir Valcyte® Anti‐infective, antiviral Antiherpetic agent (CMV) 2 valproic acid Depakene® Central nervous system Anticonvulsant, mood stabilizer 2 varenicline Chantix® Smoking cessation Partial Nicotine Agonist 2 Central nervous system, Serotonin‐norepinephrine reuptake venlafaxine Effexor® antidepressant inhibitor 2 Central nervous system, Serotonin‐norepinephrine reuptake venlafaxine XR Effexor XR® antidepressant inhibitor 2 verapamil Calan® Cardiovascular Calcium channel blocker 2 verapamil SR Calan SR® Cardiovascular Calcium channel blocker 2 Blood formation and warfarin Coumadin® coagulation Vitamin K antagonist 2 Nucleoside reverse transcriptase zidovudine (AZT) Retrovir® Antiretroviral inhibitor (NRTI) 2 Therapeutic Generic Name Brand Name Classification Pharmacologic Classification Tier ziprasidone Geodon® Central nervous system Antipsychotic, atypical 2 zoster vaccine, recombinant Shingrix® Vaccine Viral vaccine (RZV) 2