NIHB Formulary List for FNHA Updated July 5, 2018

Clients Enrolled in Plan W

To ensure continuity of therapies, NIHB will continue to cover a small number of drugs. Drugs on this list will be covered by NIHB.

Category Chemical/Strength/Dose Brand Name Item/DIN Number CETIRIZINE 20MG TAB MAR-CETIRIZINE 20MG TAB 2427141 ANTIHISTAMINE DRUGS CETIRIZINE 20MG TAB PMS-CETIRIZINE 20MG TAB 2315963 CETIRIZINE 20MG TAB REACTINE 20MG TAB 1900978 HYDROXYZINE HCL 10MG CAP APO-HYDROXYZINE 10MG CAP 646059 HYDROXYZINE HCL 25MG CAP APO-HYDROXYZINE 25MG CAP 646024 MISC HYDROXYZINE HCL 50MG CAP APO-HYDROXYZINE 50MG CAP 646016 ANXIOLYTICS/SEDATIVES/H HYDROXYZINE HCL 10MG/5ML O/L ATARAX SYRUP 2MG/ML 24694 YP HYDROXYZINE HCL 25MG CAP NOVO-HYDROXYZIN 25MG CAP 738832 HYDROXYZINE HCL 10MG/5ML O/L PMS-HYDROXYZINE 10MG/5ML SYR 741817 LEVOCABASTINE HCL 0.05% NAS SPR LIVOSTIN 0.5MG/ML NAS SPR 2020017 LODOXAMIDE TROMETHAMINE 0.1% OP SOL ALOMIDE 0.1% OP SOL 893560 NEDOCROMIL SODIUM 2% OP SOL ALOCRIL 2% OP SOL 2241407 OLOPATADINE HCL 0.1% OP SOL ACT-OLOPATADINE 0.1% OP SOL 2403986 OLOPATADINE HCL 0.2% OP SOL ACT-OLOPATADINE 0.2% OP SOL 2404095 EENT-ANTIALLERGIC OLOPATADINE HCL 0.1% OP SOL APO-OLOPATADINE 0.1% OP SOL 2305054 AGENTS/MISC OLOPATADINE HCL 0.2% OP SOL APO-OLOPATADINE 0.2% OP SOL 2402823 OLOPATADINE HCL 0.1% OP SOL MINT-OLOPATADINE 0.1% OP SOL 2422727 OLOPATADINE HCL 0.1% OP SOL PATANOL 0.1% OP SOL 2233143 OLOPATADINE HCL 0.1% OP SOL SDZ-OLOPATADINE 0.1% OP SOL 2358913 OLOPATADINE HCL 0.2% OP SOL SDZ-OLOPATADINE 0.2% OP SOL 2420171 GATIFLOXACIN 3MG/ML OP SOL ZYMAR 3MG/ML OP SOL 2257270 MOXIFLOXACIN 0.5% SOL ACT MOXIFLOXACIN 0.5% OP SOL 2404656 MOXIFLOXACIN 0.5% SOL APO-MOXIFLOXACIN 0.5% OP SOL 2406373 EENT-ANTIBACTERIALS MOXIFLOXACIN 0.5% SOL PMS-MOXIFLOXACIN 0.5% OP SOL 2432218 MOXIFLOXACIN 0.5% SOL SANDOZ MOXIFLOXACIN 0.5% OP SO 2411520 MOXIFLOXACIN 0.5% SOL VIGAMOX 0.5% OP SOL 2252260 POLYMYXIN B-TRIMETHOPRIM PMS-POLYTRIMETHOPRIM OP SOL 2240363 EENT-ANTI-INFLAMMATORY NEPAFENAC 0.3% OP SOL ILEVRO 0.3% OP SOL 2411393 AGENTS NEPAFENAC 0.1% OP SOL NEVANAC 0.1% OP SOL 2308983 IPRATROPIUM BROMIDE 0.03% NAS SPR ATROVENT 0.03% NAS SPR 2163705 EENT- IPRATROPIUM BROMIDE 0.06% NAS SPR ATROVENT 0.06% NAS SPR 2163713 ANTIMUSCARINICS/ANTISP IPRATROPIUM BROMIDE 0.06% NAS SOL IPRAVENT 0.06% NAS SOL 2246084 ASMODICS IPRATROPIUM BROMIDE 0.03% NAS SPR PMS-IPRATROPIUM 0.03% NAS SPR 2239627 FLUTICASONE PROPIONATE 50MCG NAS SPR APO-FLUTICASONE 50MCG/ACT NAS 2294745 FLUTICASONE PROPIONATE 50MCG NAS SPR FLONASE 50MCG NAS SPR 2213672 EENT - CORTICOSTEROIDS FLUTICASONE PROPIONATE 50MCG NAS SPR RATIO-FLUTICASONE 50MCG/ACT 2296071 TRIAMCINOLONE ACETONIDE 55MCG NAS SPR NASACORT AQ 55MCG NAS SPR 2213834 CHLORHEXIDINE GLUCONATE 0.12% MWH G.U.M. PAROEX 0.12% ORAL RINSE 2384272 EENT-MOUTHWASHES AND CHLORHEXIDINE GLUCONATE 0.12% MWH PERICHLOR 0.12% ORAL RINSE 2240433 GARGLES CHLORHEXIDINE GLUCONATE 0.12% MWH PERIDEX 0.12% ORAL RINSE 2237452 CHLORHEXIDINE GLUCONATE 0.12% MWH PERIOGARD 0.12% ORAL RINSE 2207796 ETHINYL ESTRADIOL-ETONOGESTREL 2.6/11.4MG DEVICE NUVARING VAG RING 2253186 ETHINYL ESTRADIOL-LEVONORGES 0.03/0.15 TAB SEASONALE 0.15/0.03MG TAB 2296659 ETHINYL ESTRADIOL-LEVONORGES Undefined TAB SEASONIQUE TAB 2346176 ETHINYL ESTRADIOL-NORETHINDRON 1/0.01MG TAB LOLO 28'S TAB 2417456 LEVONORGESTREL 13.5MG INSERT JAYDESS 13.5MG INSERT 2408295 ETHINYL ESTRADIOL-NORELGESTROM 0.6/6MG PATCH EVRA 0.6/6MG PATCH 2248297 CONTRACEPTIVES AND CYPROTERONE-ETHINYL ESTRADIOL 2MG/35MCG TAB CYESTRA-35 2/0.035MG TAB 2290308 HORMONES CYPROTERONE-ETHINYL ESTRADIOL 2MG/35MCG TAB DIANE-35 TAB 2233542 CYPROTERONE-ETHINYL ESTRADIOL 2MG/35MCG TAB NOVO-CYPROTERONE/ETHIN ESTRAD 2309556 CYPROTERONE-ETHINYL ESTRADIOL 2MG/35MCG TAB RAN-CYPROTERONE/ETHIN ESTRAD 2425017 ESTRADIOL 2MG DEVICE ESTRING 2MG VAGINAL RING 2168898 ESTRADIOL 10MCG TAB VAG VAGIFEM LD 10MCG TAB VAG 2325462 ESTRADIOL-LEVONORGESTREL 4.4/1.39MG PATCH CLIMARA PRO 4.4/1.39MG PATCH 2250616 ESTRONE 0.1% CR VAG ESTRAGYN 1MG/G VAG CR 727369

1 NIHB Formulary List for FNHA Updated July 5, 2018

Clients Enrolled in Plan W

Category Chemical/Strength/Dose Brand Name Item/DIN Number BENZOYL PEROXIDE-ERYTHROMYCIN 5/3% GEL BENZAMYCIN GEL 2225271 CLINDAMYCIN PHOSPHATE 1% LIQ DALACIN T 1% SOL 582301 CLINDAMYCIN-BENZOYL PEROXIDE 1/5% GEL BENZACLIN TOPICAL GEL 2248472 CLINDAMYCIN-BENZOYL PEROXIDE 1/5% GEL CLINDAMYCIN-BENZOYL PEROXIDE 2440180 SKIN&MUCOUS CLINDAMYCIN-BENZOYL PEROXIDE 1/3% GEL CLINDOXYL ADV GEL 2382822 MEMBRAINE CLINDAMYCIN-BENZOYL PEROXIDE 1/5% GEL CLINDOXYL GEL 2243158 MUPIROCIN 2% CR BACTROBAN 2% CR 2239757 MUPIROCIN 2% OINT BACTROBAN 2% OINT 1916947 MUPIROCIN 2% OINT TARO-MUPIROCIN 2% OINT 2279983 BETAMETHASONE-CLOTRIMAZOLE 0.05%/1% CR LOTRIDERM CR 611174 SKIN&MUCOUS MEMB - NYSTATIN 25,000U/G CR VAG NYADERM VAG CR 25,000U VAG CR 716901 ANTIFUNGALS KETOCONAZOLE 2% CR KETODERM 2% CR 2245662 TERBINAFINE HCL 1% CR LAMISIL 1% CR 2031094 CHOLECALCIFEROL 10,000U TAB (D-3) D-TABS 10000U TAB 821772 CHOLECALCIFEROL 10,000U CAP EURO-D 10000U CAP 2253178 CHOLECALCIFEROL 10,000U CAP JAMP-VITAMIN D 10,000U CAP 2449099 VITAMIN D CHOLECALCIFEROL 10,000U TAB JAMP-VITAMINE D 10000U TAB 2379007 CHOLECALCIFEROL 10,000U TAB VIDEXTRA 10000U TAB 2417685 CHOLECALCIFEROL 10,000U CAP VITAMIN D 10000U CAP 2417995 10mg Inhaler NICORETTE 2241742 5mg Patch NICOTROL TRANSDERMAL 2028697 7mg Patch HABITROL 1943057 7mg Patch NICOTINE TRANSDERMAL 80044393 8.3mg/10cm² Patch NICOTROL TRANSDERMAL 2065738 10mg Patch NICOTROL TRANSDERMAL 2029405 14mg Patch HABITROL 1943065 14mg Patch NICOTINE TRANSDERMAL 80044392 14mg Patch NICOTINE TRANSDERMAL 80013549 15mg Patch NICOTROL TRANSDERMAL 2029413 16.6mg/20cm² Patch NICOTROL TRANSDERMAL 2065754 17.5mg Patch TRANSDERMAL NICOTINE 2241227 21mg Patch HABITROL 1943073 21mg Patch NICOTINE TRANSDERMAL 80044389 MISCELLANEOUS 21mg Patch NICOTINE TRANSDERMAL 80014250 AUTONOMIC DRUGS 24.9mg/30cm² Patch NICOTROL TRANSDERMAL 2065762 35mg Patch TRANSDERMAL NICOTINE 2241226 36mg Patch NICODERM 2093111 52.5mg Patch TRANSDERMAL NICOTINE 2241228 78mg Patch NICODERM 2093138 114mg Patch NICODERM 2093146 2mg Gum NICORETTE 2091933 2mg Gum NICOTINE 80015240 4mg Gum NICORETTE PLUS 2091941 4mg Gum NICOTINE GUM 80000118 2mg Gum THRIVE 80000396 4mg Gum THRIVE 80000402 1mg Lozenge THRIVE 80007461 2mg Lozenge THRIVE 80007464 NALOXONE HCL 0.4MG/ML INJ S.O.S. NALOXONE HYDROCHLORIDE 2453258 NALOXONE HCL 0.4MG/ML INJ NALOXONE 0.4MG/ML INJ 2148706 NALOXONE HCL 0.4MG/ML INJ NALOXONE 0.4MG/ML INJ 2382482 NALOXONE HCL 0.4MG/ML INJ NALOXONE 0.4MG/ML INJ 2382601 OPIATE ANTAGONISTS NALOXONE HCL 0.4MG/ML INJ NALOXONE 0.4MG/ML INJ 2393034 NALOXONE HCL Undefined INJ NALOXONE KIT 2 VIALS/AMPS 9991460 NALOXONE HCL Undefined INJ NALOXONE KIT 3VIALS/AMPS 9991488 NALOXONE NASAL SPRAY KIT NALOXONE NASAL SPRAY KIT 9991475 NARCAN NASAL SPRAY NARCAN NASAL SPRAY 2458187 SHARPS CONTAINER BC SHARPS CONTAINER 1.4L 99401026 SHARPS CONTAINER SHARPS NESTABLE YLW LRG 22.7L 99401033 MISCELLANEOUS NUTRITIONAL SUPPLEMENTATION Nutritional Supplementation Call FNHA VISCOSUPPLEMENTATION Viscosupplementation Call FNHA BLOOD GLUCLOSE TEST STRIPS TEST STRIP FOR FNHA CLIENT (ONE BOX) 9991549

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