ENHANCED FORMULARY 2021 Comprehensive Medication List
Effective Date: July 1, 2021 This document has information about the drugs covered in your plan. Please read carefully.
2006 CR 020_03 06/2021 How We Create Our Formulary QL – Quantity Limits We want to make sure our formulary (drug list) reflects Covered only for a limited number of doses over a certain clinical standards and gives our members the best value. To amount of time. To learn more about QL on a certain drug, call do this, we work with a Pharmacy and Therapeutics (P&T) OptumRx at 877.629.3118. Committee to review new FDA-approved drugs and those already on the market. Doctors, pharmacists and nurses make ST – Step Therapy up the committee. They choose the drugs based on safety, Requires use of some other drug first before it is covered. effectiveness and cost compared to other drugs in their class. Starts with the most cost-effective and safest drugs and moves on to other more costly ones only if needed. Examples are Formulary Design muscle relaxants and some specialty drugs. Our Enhanced formulary includes these types of drugs: generic, preferred and non-preferred, specialty and Affordable Care Act Formulary Changes (ACA)-approved preventive drugs. It is a closed formulary. This The P&T Committee meets often to review new information. means that coverage is limited to those drugs listed in each of This means the formulary may be changed. Some reasons for 4 tiers, along with the preventive drugs. changes include: • Generic forms of the brand drug now exist. The brand-name Tier 1 drug may no longer be covered if a generic is available. The Lowest member cost share. Most, but not all, generic generic may be covered at a lower copayment or cost share. medications are in Tier 1. • New drugs may be added to the list. • A drug may be taken off the market by the Food and Drug Tier 2 Administration (FDA) Contains some higher-cost generic and preferred brand- • A drug no longer requires a prescription. Often, over-the- name drugs. Preferred brand-name drugs often have lower counter drugs are not covered. copayments than non-preferred brand-name ones. Note: Always check the most current formulary at Tier 3 QualChoice.com. Mostly non-preferred brand-name drugs, though it may contain some higher-cost generics. Non-pre- ferred drugs often Exceptions to the Formulary have higher copayments than preferred brand-name drugs. You, someone you approve or a prescriber can ask for an exception. If there are good reasons why you cannot take a Tier 5 drug according to the coverage requirements*, you may ask for This tier contains specialty drugs and has the highest an exception. You may also ask for it if you: copayment and cost. These drugs are used to treat complex or • have tried all formulary alternatives, or rare health problems. • there are good medical reasons why the alternatives would not work for you, and ACA Preventive Drugs • the requested drug is medically necessary, and May be covered with no copayment if they meet ACA • the drug is not on the formulary requirements for age, gender and/or risk factors. The request can be made by email, fax, mail or telephone. We Medical Management will let you and your prescriber know the decision in writing. We work to make sure our members get the right care and the The Formulary Override Exceptions Request form can be found right medication for all health issues, in all care settings. Utilization at QualChoice.com . management determines if a medicine is medically necessary. A drug may include one of these labels on how it is to be used: *step therapy, quantity limits, etc.
PA – Pre-authorization Appeal Process Covered only if pre-authorized (pre-approved). You or your You have the right to appeal any decision by QualChoice to not doctor must have approval before filling the prescription. If provide or pay for a medication. You may file an appeal by filling you don’t get approval, your medication may not be covered. out the Member Appeal Request Form at QualChoice.com. You Call OptumRx at 877.629.3118 to start the pre=authorization may also call us at 501.228.7111 or 800.235.7111 and ask for a process. Your doctor must provide the needed information to copy to be mailed to you. OptumRx for review.
PV – Preventive Medication These medications may be available at no member cost share as specified by the United States Preventive Services Taskforce (USPSTF).
Enhanced Formulary Comprehensive Medication List – 2021 | 2 Table of Contents
Analgesics – Drugs for Pain...... 5 Analgesics – Drugs for Pain and Inflammation ...... 5 Anesthetics...... 6 Anti-Addiction/Substance Abuse Treatment Agents...... 6 Antibacterials...... 7 Anticoagulants...... 8 Anticonvulsants – Drugs for Seizures...... 8 Antidementia Agents – Drugs for Alzheimer’s Disease and Dementia...... 9 Antidepressants...... 9 Antiemetics – Drugs for Nausea and Vomiting...... 9 Antifungals...... 10 Antigout Agents...... 10 Antimigraine Agents ...... 10 Antimyasthenic Agents...... 11 Antimycobacterials ...... 11 Antineoplastics – Drugs for Cancer ...... 11 Antiparasitics...... 13 Antiparkinson Agents ...... 13 Antiplatelets...... 13 Antipsychotics – Drugs for Mood Disorders ...... 13 Antivirals...... 14 Anxiolytics – Drugs for Anxiety...... 15 Bipolar Agents – Drugs for Mood Disorders ...... 15 Blood Products and Modifiers – Drugs for Blood Disorders...... 15 Cardiovascular Agents – Drugs for Heart and Circulation Conditions...... 16 Central Nervous System Agents – Drugs for Attention Deficit Disorder...... 18 Central Nervous System Agents – Drugs for Multiple Sclerosis...... 19 Central Nervous System Agents – Miscellaneous...... 19 Dental and Oral Agents – Drugs for Mouth and Throat Conditions...... 19 Dermatological Agents – Drugs for Skin Conditions...... 19 Diabetes – Antidiabetic Agents...... 22 Diabetes – Glucose Monitoring ...... 22
Enhanced Formulary Comprehensive Medication List – 2021 | 3 Diabetes – Glycemic Agents...... 23 Diabetes – Insulins...... 23 Electrolytes/Minerals/Metals/Vitamins...... 24 Gastrointestinal Agents – Drugs for Acid Reflux and Ulcer...... 25 Gastrointestinal Agents – Drugs for Bowel, Intestine and Stomach Conditions...... 25 Genetic or Enzyme Disorder – Drugs for Replacement, Modification, Treatment...... 26 Genitourinary Agents – Drugs for Bladder, Genital and Kidney Conditions...... 26 Genitourinary Agents – Drugs for Prostate Conditions...... 27 Hormonal Agents – Adrenal...... 27 Hormonal Agents – Men’s Health...... 27 Hormonal Agents – Osteoporosis...... 27 Hormonal Agents – Pituitary...... 27 Hormonal Agents – Prostaglandins ...... 28 Hormonal Agents – Sex Hormones and Birth Control...... 28 Hormonal Agents – Thyroid ...... 31 Immunological Agents – Drugs for Immune System Stimulation or Suppression ...... 31 Immunological Agents – Drugs for Vaccination...... 32 Inflammatory Bowel Disease Agents...... 33 Metabolic Bone Disease Agents – Drugs for Osteoporosis...... 33 Metabolic Bone Disease Agents – Other...... 33 Miscellaneous Therapeutic Agents...... 33 Ophthalmic Agents – Drugs for Eye Allergy, Infection and Inflammation...... 34 Ophthalmic Agents – Drugs for Glaucoma...... 35 Ophthalmic Agents – Drugs for Miscellaneous Eye Conditions...... 35 Otic Agents – Drugs for Ear Conditions...... 36 Respiratory Tract/Pulmonary Agents – Drugs for Allergies, Cough, Cold...... 36 Respiratory Tract/Pulmonary Agents – Drugs for Asthma and Other Lung Conditions. . . .36 Respiratory Tract/Pulmonary Agents – Drugs for Cystic Fibrosis...... 37 Respiratory Tract/Pulmonary Agents – Drugs for Pulmonary Hypertension...... 37 Skeletal Muscle Relaxants – Drugs for Muscle Pain and Spasm...... 37 Sleep Disorder Agents...... 38
Enhanced Formulary Comprehensive Medication List – 2021 | 4 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Analgesics – Drugs for Pain morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 acetaminophen-codeine 1 QL 1 PA mg, 20 mg, 30 mg, 50 mg, acetaminophen-codeine #2 1 QL 60 mg, 80 mg acetaminophen-codeine #3 1 QL morphine sulfate er oral capsule 1 acetaminophen-codeine #4 1 QL extended release 24 hour 40 mg ascomp-codeine 1 morphine sulfate er oral tablet 1 PA bac 1 extended release buprenorphine transdermal patch morphine sulfate oral 1 weekly 10 mcg/hr, 15 mcg/hr, 1 morphine sulfate rectal 1 20 mcg/hr, 5 mcg/hr oxycodone hcl oral capsule 1 butalbital-acetaminophen oral tablet 1 oxycodone hcl oral concentrate 100 50-325 mg 1 mg/5ml butalbital-apap-caff-cod 1 oxycodone hcl oral solution 1 butalbital-apap-caffeine 1 oxycodone hcl oral tablet 1 butalbital-asa-caff-codeine 1 oxycodone-acetaminophen oral butalbital-aspirin-caffeine 1 tablet 10-325 mg, 2.5-325 mg, 5-325 1 QL butorphanol tartrate nasal 1 QL mg, 7.5-325 mg carisoprodol-aspirin-codeine 1 oxycodone-aspirin 1 codeine sulfate 1 oxymorphone hcl 1 endocet 1 QL oxymorphone hcl er 1 PA fentanyl citrate buccal lozenge pentazocine-naloxone hcl 1 1 PA; QL on a handle tramadol hcl er (biphasic) 1 PA fentanyl transdermal patch tramadol hcl er oral tablet extended 1 PA 72 hour 100 mcg/hr, 12 mcg/hr, 1 PA; QL release 24 hour 25 mcg/hr, 50 mcg/hr, 75 mcg/hr tramadol hcl oral tablet 50 mg 1 hydrocodone-acetaminophen 1 QL tramadol-acetaminophen 1 QL hydrocodone-ibuprofen 1 XTAMPZA ER 2 PA hydromorphone hcl er 1 PA Analgesics – Drugs for Pain and Inflammation hydromorphone hcl oral 1 adult aspirin regimen 1 PV hydromorphone hcl rectal 1 aspirin adult low strength 1 PV LORTAB 3 aspirin childrens 1 PV meperidine hcl injection 1 aspirin ec low dose 1 PV meperidine hcl oral 1 aspirin ec low strength 1 PV methadone hcl intensol 1 aspirin ec oral tablet delayed release 1 PV methadone hcl oral 1 325 mg methadose oral tablet soluble 1 aspirin low dose 1 PV morphine sulfate (concentrate) oral aspirin oral tablet 1 PV solution 100 mg/5ml, 1 aspirin oral tablet delayed release 1 PV 20 mg/ml celecoxib oral capsule 100 mg, 200 2 QL morphine sulfate er beads 1 PA mg, 50 mg DICLOFENAC PATCH 1.3% 3 PA; QL
Enhanced Formulary Comprehensive Medication List – 2021 | 5 Drug Name Drug Tier Notes Drug Name Drug Tier Notes diclofenac potassium 1 bupivacaine hcl injection solution 1 diclofenac sodium er 1 0.25%, 0.5% diclofenac sodium bupivacaine-epinephrine 1 1 QL external gel 1% bupivacaine-epinephrine (pf) 1 diclofenac sodium external solution 1 chloroprocaine hcl (pf) 1 diclofenac sodium oral 1 ethyl chloride 1 diclofenac-misoprostol 1 glydo 1 diflunisal oral 1 lidocaine external ointment 5% 3 QL etodolac 1 lidocaine external patch 5% 1 FLECTOR 3 PA; QL lidocaine hcl (pf) 1 flurbiprofen oral 1 lidocaine hcl external cream 3% 1 goodsense aspirin low dose 1 PV lidocaine hcl external lotion 1 ibuprofen 1 lidocaine hcl external solution 1 INDOCIN 3 lidocaine hcl injection solution 1 indomethacin er 1 lidocaine hcl urethral/mucosal 1 indomethacin oral capsule 1 lidocaine-epinephrine injection 1 25 mg, 50 mg lidocaine-prilocaine 1 ketoprofen er 1 lidopin external cream 3% 1 ketoprofen oral capsule 50 mg, 1 polocaine 1 75 mg polocaine-mpf 1 ketorolac tromethamine injection 1 premium lidocaine 3 QL ketorolac tromethamine 1 ropivacaine hcl injection solution intramuscular 1 7.5 mg/ml ketorolac tromethamine oral 1 QL sensorcaine-mpf injection solution meclofenamate sodium oral 1 1 0.25%, 0.5% mefenamic acid oral 1 SENSORCAINE-MPF/EPINEPHRINE meloxicam oral tablet 1 INJECTION SOLUTION 3 nabumetone oral 1 0.75-1:200000% naproxen oral tablet 1 Anti-Addiction/Substance Abuse Treatment Agents naproxen sodium oral tablet 275 mg, 1 550 mg acamprosate calcium 1 oxaprozin 1 buprenorphine hcl sublingual 1 buprenorphine hcl-naloxone hcl piroxicam oral 1 1 sublingual tablet sublingual salsalate oral 1 bupropion hcl er (smoking det) 1 PV; QL sulindac oral 1 CHANTIX 3 PA; QL tolmetin sodium 1 CHANTIX CONTINUING MONTH PAK 3 PA; QL Anesthetics CHANTIX STARTING MONTH PAK 3 PA; QL bupivacaine fisiopharma 1 disulfiram oral 1 bupivacaine hcl (pf) injection solution 1 naloxone hcl injection 1 0.25%, 0.5%
Enhanced Formulary Comprehensive Medication List – 2021 | 6 Drug Name Drug Tier Notes Drug Name Drug Tier Notes naltrexone hcl oral 1 clarithromycin er 1 VIVITROL 5 PA clarithromycin oral 1 Antibacterials CLEOCIN VAGINAL SUPPOSITORY 3 AEMCOLO 3 PA; QL clindamycin hcl oral 1 ALTABAX 3 clindamycin palmitate hcl 1 amikacin sulfate injection 1 clindamycin phosphate vaginal 1 amoxicillin 1 colistimethate sodium (cba) 5 amoxicillin-potassium clavulanate er 1 demeclocycline hcl 1 amoxicillin-potassium clavulanate 1 dicloxacillin sodium 1 oral DIFICID ORAL SUSPENSION 3 PA ampicillin 1 RECONSTITUTED ARIKAYCE 5 PA DIFICID ORAL TABLET 3 PA; QL AUGMENTIN ORAL SUSPENSION 3 doxycycline hyclate oral capsule 1 RECONSTITUTED 125-31.25 MG/5ML doxycycline hyclate oral tablet 1 avidoxy 1 100 mg, 20 mg azithromycin oral 1 doxycycline monohydrate oral 1 bacitracin intramuscular 1 capsule 100 mg, 50 mg, 75 mg doxycycline monohydrate oral BAXDELA ORAL 3 1 suspension reconstituted benzalkonium chloride external 1 doxycycline monohydrate oral tablet solution 1 100 mg, 50 mg, 75 mg cefaclor 1 erythromycin base 1 cefaclor er 1 erythromycin ethylsuccinate oral 1 cefadroxil 1 erythromycin oral 1 cefdinir 1 fosfomycin tromethamine 1 cefixime 1 gentamicin sulfate external 1 cefpodoxime proxetil 1 gentamicin sulfate injection 1 cefprozil 1 hydrogen peroxide 1 ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 1 iodine tincture external tincture 2% 1 500 mg levofloxacin oral 1 ceftriaxone sodium intravenous 1 linezolid oral 1 QL solution reconstituted 1 gm, 2 gm mafenide acetate external 1 cefuroxime axetil 1 methenamine hippurate 1 cephalexin oral capsule 1 methenamine mandelate oral 1 250 mg, 500 mg metronidazole oral 1 cephalexin oral suspension 1 reconstituted metronidazole vaginal 1 cephalexin oral tablet 1 minocycline hcl oral capsule 1 CIPRO ORAL SUSPENSION mondoxyne nl 1 3 RECONSTITUTED morgidox oral 1 ciprofloxacin hcl oral 1 moxifloxacin hcl oral 1
Enhanced Formulary Comprehensive Medication List – 2021 | 7 Drug Name Drug Tier Notes Drug Name Drug Tier Notes mupirocin calcium 1 fondaparinux sodium 5 QL mupirocin external 1 FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, neomycin sulfate oral 1 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 5 QL neomycin-polymyxin b gu 1 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, nitrofurantoin 1 7500 UNIT/0.3ML nitrofurantoin macrocrystal 1 jantoven 1 nitrofurantoin monohydrate PRADAXA 3 QL 1 macrocrystals warfarin sodium oral 1 ofloxacin oral 1 XARELTO 2 QL paromomycin sulfate oral 1 XARELTO STARTER PACK 2 QL penicillin g procaine 1 Anticonvulsants – Drugs for Seizures penicillin v potassium 1 BRIVIACT ORAL 3 PA polymyxin b sulfate injection 1 carbamazepine er 1 PRIMSOL 3 carbamazepine oral 1 silver nitrate external 1 CELONTIN 3 silver sulfadiazine external 1 clobazam 1 PA SIVEXTRO ORAL 3 QL diazepam rectal gel 10 mg, 20 mg 2 QL ssd 1 diazepam rectal gel 2.5 mg 1 QL streptomycin sulfate intramuscular 1 DILANTIN 3 sulfadiazine oral 1 DILANTIN INFATABS 3 sulfamethoxazole-trimethoprim oral 1 divalproex sodium er 1 SULFAMYLON EXTERNAL CREAM 3 divalproex sodium oral 1 sulfatrim pediatric 1 EPIDIOLEX 3 PA SUPRAX ORAL TABLET CHEWABLE 3 epitol 1 tinidazole oral 1 ethosuximide oral 1 tobramycin sulfate injection solution felbamate 1 1 10 mg/ml, 80 mg/2ml FINTEPLA 5 PA trimethoprim oral 1 FYCOMPA 3 PA vancomycin hcl oral capsule 1 gabapentin oral 1 vancomycin hcl oral solution 3 lamotrigine er 1 reconstituted lamotrigine oral 1 vandazole 1 levetiracetam er 1 VIBRAMYCIN ORAL SYRUP 3 levetiracetam oral 1 XENLETA ORAL 3 QL oxcarbazepine 1 XIFAXAN ORAL TABLET 200 MG 3 phenobarbital oral 1 XIFAXAN ORAL TABLET 550 MG 3 PA phenytoin infatabs 1 Anticoagulants phenytoin oral 1 ELIQUIS 2 QL phenytoin sodium extended 1 ELIQUIS DVT/PE STARTER PACK 2 QL primidone oral 1 enoxaparin sodium 5 QL
Enhanced Formulary Comprehensive Medication List – 2021 | 8 Drug Name Drug Tier Notes Drug Name Drug Tier Notes roweepra 1 duloxetine hcl oral capsule delayed 2 QL rufinamide 1 release particles 20 mg, 30 mg, 60 mg duloxetine hcl oral capsule delayed subvenite 1 1 release particles 40 mg tiagabine hcl 1 EMSAM 3 QL topiramate er 1 escitalopram oxalate 1 topiramate oral 1 fluoxetine hcl oral capsule 1 valproic acid oral 1 fluoxetine hcl oral capsule delayed 1 QL VALTOCO 3 release vigabatrin 1 fluoxetine hcl oral solution 1 vigadrone 1 fluvoxamine maleate 1 VIMPAT ORAL 3 fluvoxamine maleate er 1 QL XCOPRI 3 PA imipramine hcl oral 1 zonisamide oral 1 imipramine pamoate 1 Antidementia Agents – maprotiline hcl 1 Drugs for Alzheimer’s Disease and Dementia MARPLAN 3 donepezil hcl oral tablet 10 mg, 5 mg 1 mirtazapine oral 1 donepezil hcl oral tablet 23 mg 2 nefazodone hcl 1 donepezil hcl oral tablet dispersible 1 nortriptyline hcl oral 1 galantamine hydrobromide 1 olanzapine-fluoxetine hcl 1 QL galantamine hydrobromide er 1 paroxetine hcl 1 memantine hcl er 1 QL paroxetine hcl er 1 memantine hcl oral 1 perphenazine-amitriptyline 1 rivastigmine 1 phenelzine sulfate oral 1 rivastigmine tartrate 1 protriptyline hcl 1 Antidepressants sertraline hcl oral 1 amitriptyline hcl oral 1 tranylcypromine sulfate 1 amoxapine 1 trazodone hcl oral 1 bupropion hcl er (sr) 1 trimipramine maleate oral 1 bupropion hcl er (xl) oral tablet venlafaxine hcl 1 QL extended release 24 hour 150 mg, 1 venlafaxine hcl er oral capsule 300 mg 1 extended release 24 hour bupropion hcl oral 1 VIIBRYD 3 PA chlordiazepoxide-amitriptyline 1 VIIBRYD STARTER PACK 3 PA citalopram hydrobromide 1 Antiemetics – Drugs for Nausea and Vomiting clomipramine hcl oral 1 aprepitant 1 QL desipramine hcl oral 1 compro 1 DESVENLAFAXINE ER 3 QL dronabinol 1 QL desvenlafaxine succinate er 1 QL droperidol injection 1 doxepin hcl oral capsule 1 doxepin hcl oral concentrate 1
Enhanced Formulary Comprehensive Medication List – 2021 | 9 Drug Name Drug Tier Notes Drug Name Drug Tier Notes EMEND ORAL SUSPENSION ketoconazole oral 1 PA 3 QL RECONSTITUTED ketodan external foam 1 granisetron hcl oral 1 QL MENTAX 3 meclizine hcl oral tablet 1 miconazole 3 1 12.5 mg, 25 mg naftifine hcl external gel 1 metoclopramide hcl oral solution 1 NOXAFIL ORAL SUSPENSION 3 PA metoclopramide hcl oral tablet 1 nyamyc 1 ondansetron hcl oral tablet 24 mg 1 QL nystatin external 1 ondansetron hcl oral tablet 1 4 mg, 8 mg nystatin mouth/throat 1 ondansetron odt 1 nystatin oral 1 perphenazine oral 1 nystatin-triamcinolone 1 prochlorperazine 1 nystop 1 prochlorperazine maleate oral 1 ORAVIG 3 PA scopolamine 1 oxiconazole nitrate 1 QL SYNDROS 3 PA; QL OXISTAT EXTERNAL LOTION 3 QL trimethobenzamide hcl oral 1 posaconazole 1 PA SULCONAZOLE NITRATE EXTERNAL VARUBI (180 MG DOSE) 3 QL 3 CREAM Antifungals terbinafine hcl oral 1 QL ciclodan 1 terconazole 1 ciclopirox external 1 voriconazole oral 1 ciclopirox olamine external 1 XOLEGEL 3 ciclopirox treatment 1 Antigout Agents clotrimazole external 1 allopurinol oral 1 clotrimazole mouth/throat 1 COLCHICINE ORAL CAPSULE 3 clotrimazole-betamethasone 1 colchicine oral tablet 1 CRESEMBA ORAL 5 PA colchicine-probenecid 1 econazole nitrate external 1 febuxostat 1 ERTACZO 3 MITIGARE 3 EXELDERM 3 probenecid 1 fluconazole oral suspension 1 reconstituted Antimigraine Agents fluconazole oral tablet 100 mg, 200 AIMOVIG SUBCUTANEOUS SOLUTION 1 mg, 50 mg AUTO-INJECTOR 140 MG/ML, 2 PA; QL 70 MG/ML fluconazole oral tablet 150 mg 1 QL almotriptan malate 2 ST; QL flucytosine oral 1 dihydroergotamine mesylate nasal 3 QL griseofulvin microsize oral 1 PA; ST; eletriptan hydrobromide 1 griseofulvin ultramicrosize 1 QL GYNAZOLE-1 3 EMGALITY 2 PA; QL itraconazole oral 1 EMGALITY (300 MG DOSE) 2 PA; QL ketoconazole external 1 ERGOMAR 3 Enhanced Formulary Comprehensive Medication List – 2021 | 10 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ergotamine-caffeine 1 AYVAKIT 5 PA frovatriptan succinate 2 ST; QL BALVERSA 5 PA MIGERGOT 3 bexarotene 5 PA naratriptan hcl 1 QL bicalutamide 1 NURTEC 2 PA; QL BOSULIF 5 PA rizatriptan benzoate 1 QL BRAFTOVI 5 PA sumatriptan nasal 1 QL BRUKINSA 5 PA sumatriptan succinate oral 1 QL CABOMETYX 5 PA sumatriptan succinate refill 1 QL CALQUENCE 5 PA sumatriptan succinate subcutaneous capecitabine 5 1 QL solution CAPRELSA ORAL TABLET 100 MG 5 PA; QL sumatriptan succinate subcutaneous 1 QL CAPRELSA ORAL TABLET 300 MG 5 PA solution auto-injector COMETRIQ 5 PA UBRELVY 2 PA; QL COPIKTRA 5 PA ZOLMITRIPTAN NASAL 3 QL COTELLIC 5 PA zolmitriptan oral 1 QL cyclophosphamide oral capsule 5 ZOMIG NASAL 3 QL CYCLOPHOSPHAMIDE ORAL TABLET 2 Antimyasthenic Agents DAURISMO 5 PA GUANIDINE HCL 1 DROXIA 3 pyridostigmine bromide er 1 EMCYT 5 pyridostigmine bromide oral solution 1 ERIVEDGE 5 PA pyridostigmine bromide oral tablet 1 60 mg ERLEADA 5 PA erlotinib hcl oral tablet Antimycobacterials 5 PA 100 mg, 150 mg cycloserine oral 1 erlotinib hcl oral tablet 25 mg 5 PA; QL dapsone oral 1 etoposide oral 5 ethambutol hcl oral 1 everolimus oral tablet 5 PA; QL isoniazid oral 1 2.5 mg, 5 mg, 7.5 mg PASER 3 exemestane 5 PRIFTIN 3 FARYDAK 5 PA pyrazinamide oral 1 flutamide 5 rifabutin 1 fulvestrant 5 rifampin oral 1 GAVRETO 5 PA TRECATOR 3 GILOTRIF 5 PA; QL Antineoplastics – Drugs for Cancer GLEOSTINE 5 abiraterone acetate 5 PA HYCAMTIN ORAL 3 AFINITOR ORAL TABLET 10 MG 5 PA; QL hydroxyurea oral 1 ALECENSA 5 PA IBRANCE 5 PA ALUNBRIG 5 PA; QL ICLUSIG ORAL TABLET 5 PA anastrozole oral 1 10 MG, 30 MG, 45 MG
Enhanced Formulary Comprehensive Medication List – 2021 | 11 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ICLUSIG ORAL TABLET 15 MG 5 PA; QL ODOMZO 5 PA IDHIFA 5 PA; QL ONUREG 5 PA imatinib mesylate 5 PA PANRETIN 3 IMBRUVICA 5 PA PEMAZYRE 5 PA INLYTA 5 PA PIQRAY 5 PA INREBIC 5 PA POMALYST 5 PA IRESSA 5 PA QINLOCK 5 PA JAKAFI ORAL TABLET 10 MG 5 PA; QL RETEVMO 5 PA JAKAFI ORAL TABLET 15 MG, 20 MG, 5 PA REVLIMID 5 25 MG, 5 MG ROZLYTREK 5 PA KISQALI FEMARA 5 PA RUBRACA 5 PA KISQALI ORAL TABLET THERAPY PACK 5 PA RYDAPT 5 PA 200 MG SIKLOS ORAL TABLET 100 MG 3 KOSELUGO 5 PA SIKLOS ORAL TABLET 1000 MG 3 QL lapatinib ditosylate 5 PA SOLTAMOX 3 LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 10 MG, SPRYCEL 5 PA 10 MG & 2 X 4 MG, 2 X 10 MG, 5 PA STIVARGA 5 PA 2 X 10 MG & 4 MG, 2 X 4 MG, SUTENT 5 PA 3 X 4 MG, 4 MG TABLOID 5 letrozole oral 1 TABRECTA 5 PA leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 1 TAFINLAR 5 PA 350 mg, 50 mg TAGRISSO ORAL TABLET 40 MG 5 PA; QL leucovorin calcium oral 1 TAGRISSO ORAL TABLET 80 MG 5 PA LEUKERAN 3 TALZENNA 5 PA LONSURF 5 PA tamoxifen citrate oral 1 PV LORBRENA 5 PA TARGRETIN EXTERNAL 3 LYNPARZA 5 PA TASIGNA 5 PA LYSODREN 3 TAZVERIK 5 PA MATULANE 5 temozolomide 5 MEKINIST 5 PA TEPMETKO 5 PA; QL MEKTOVI 5 PA THALOMID 5 melphalan 1 TIBSOVO 5 PA mercaptopurine oral 1 toremifene citrate 5 MESNEX ORAL 3 tretinoin oral 5 MYLERAN 3 TUKYSA 5 PA NERLYNX 5 PA; QL TURALIO 5 PA NEXAVAR 5 PA UKONIQ 5 PA; QL nilutamide 5 VENCLEXTA 5 PA NINLARO 5 PA VENCLEXTA STARTING PACK 5 PA NUBEQA 5 PA VERZENIO 5 PA
Enhanced Formulary Comprehensive Medication List – 2021 | 12 Drug Name Drug Tier Notes Drug Name Drug Tier Notes VITRAKVI 5 PA primaquine phosphate 1 VIZIMPRO 5 PA pyrimethamine oral 1 VOTRIENT 5 PA quinine sulfate oral 1 XALKORI 5 PA spinosad 3 XOSPATA 5 PA sulfurated lime 1 XPOVIO (100 MG ONCE WEEKLY) 5 PA Antiparkinson Agents XPOVIO (40 MG ONCE WEEKLY) 5 PA amantadine hcl oral 1 XPOVIO (40 MG TWICE WEEKLY) 5 PA benztropine mesylate oral 1 XPOVIO (60 MG ONCE WEEKLY) 5 PA bromocriptine mesylate oral 1 XPOVIO (60 MG TWICE WEEKLY) 5 PA carbidopa oral 1 XPOVIO (80 MG ONCE WEEKLY) 5 PA carbidopa-levodopa 1 XPOVIO (80 MG TWICE WEEKLY) 5 PA carbidopa-levodopa er 1 XTANDI 5 PA carbidopa-levodopa-entacapone 1 YONSA 5 PA entacapone 1 ZEJULA 5 PA INBRIJA 3 PA ZELBORAF 5 PA KYNMOBI 3 ZOLINZA 5 PA KYNMOBI TITRATION KIT 3 ZYDELIG 5 PA NEUPRO 3 PA Antiparasitics pramipexole dihydrochloride 1 albendazole oral 1 QL ALINIA ORAL SUSPENSION pramipexole dihydrochloride er 1 3 RECONSTITUTED rasagiline mesylate oral 1 ARAKODA 3 ropinirole hcl 1 atovaquone oral 1 ropinirole hcl er 1 atovaquone-proguanil hcl 1 selegiline hcl oral 1 BENZNIDAZOLE 3 PA tolcapone 1 chloroquine phosphate oral 1 trihexyphenidyl hcl 1 COARTEM 3 ZELAPAR 3 crotan 1 Antiplatelets hydroxychloroquine sulfate oral 1 aspirin-dipyridamole er 1 ivermectin oral 1 BRILINTA 3 KRINTAFEL 3 cilostazol 1 LAMPIT 3 PA clopidogrel bisulfate oral 1 lindane 1 dipyridamole oral 1 malathion 1 prasugrel hcl 1 mefloquine hcl 1 ZONTIVITY 3 nitazoxanide 1 Antipsychotics – Drugs for Mood Disorders pentamidine isethionate 1 ABILIFY MAINTENA 3 permethrin external 1 aripiprazole 1 QL praziquantel oral 1 ARISTADA 3
Enhanced Formulary Comprehensive Medication List – 2021 | 13 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ARISTADA INITIO 3 abacavir-lamivudine-zidovudine 1 asenapine maleate 1 PA; QL acyclovir external 1 chlorpromazine hcl oral 1 acyclovir oral 1 clozapine 1 QL adefovir dipivoxil 5 FANAPT 3 QL APTIVUS 3 FANAPT TITRATION PACK 3 QL atazanavir sulfate 1 fluphenazine decanoate injection 1 BARACLUDE ORAL SOLUTION 5 QL fluphenazine hcl oral 1 BIKTARVY 3 haloperidol decanoate intramuscular 1 CABENUVA 5 PA haloperidol lactate oral 1 CIMDUO 3 haloperidol oral 1 COMPLERA 3 INVEGA SUSTENNA 3 CRIXIVAN 3 INVEGA TRINZA 3 DELSTRIGO 3 LATUDA 3 QL DESCOVY 3 loxapine succinate 1 DOVATO 3 NUPLAZID ORAL CAPSULE 3 EDURANT 3 NUPLAZID ORAL TABLET 3 PA efavirenz 1 olanzapine oral 1 QL efavirenz-emtricitab-tenofovir 1 paliperidone er 1 QL efavirenz-lamivudine-tenofovir 1 PERSERIS 3 emtricitabine 1 pimozide 1 emtricitabine-tenofovir df 1 quetiapine fumarate 1 QL EMTRIVA ORAL SOLUTION 3 quetiapine fumarate er 1 QL entecavir 5 QL REXULTI 3 PA; QL EPIVIR HBV ORAL SOLUTION 5 RISPERDAL CONSTA 5 EVOTAZ 3 risperidone 1 QL famciclovir oral 1 SECUADO 3 PA fosamprenavir calcium 1 thioridazine hcl oral 1 FUZEON 5 thiothixene 1 GENVOYA 3 trifluoperazine hcl 1 INTELENCE 2 VRAYLAR ORAL CAPSULE 1.5 MG, 3 3 PA; QL MG, 4.5 MG INTRON A 5 VRAYLAR ORAL CAPSULE 6 MG 3 QL INVIRASE 2 VRAYLAR ORAL CAPSULE THERAPY ISENTRESS 3 3 PA; QL PACK ISENTRESS HD 3 ziprasidone hcl 1 QL KALETRA ORAL TABLET 2 ZYPREXA RELPREVV 3 lamivudine oral solution 1 Antivirals lamivudine oral tablet 100 mg 5 abacavir sulfate 1 lamivudine oral tablet 150 mg, 300 1 abacavir sulfate-lamivudine 1 mg
Enhanced Formulary Comprehensive Medication List – 2021 | 14 Drug Name Drug Tier Notes Drug Name Drug Tier Notes lamivudine-zidovudine 1 VIREAD ORAL TABLET 2 LEXIVA ORAL SUSPENSION 3 150 MG, 200 MG, 250 MG VOSEVI 5 PA; QL lopinavir-ritonavir 1 zidovudine 1 MAVYRET 5 PA; QL Anxiolytics – Drugs for Anxiety nevirapine 1 alprazolam intensol 1 QL nevirapine er 1 ST alprazolam oral tablet 1 QL NORVIR ORAL PACKET 2 buspirone hcl oral 1 NORVIR ORAL SOLUTION 2 chlordiazepoxide hcl 1 QL ODEFSEY 3 clonazepam oral 1 QL oseltamivir phosphate oral 1 QL clorazepate dipotassium 1 PEGASYS 5 diazepam intensol 1 PEGINTRON 5 diazepam oral 1 PIFELTRO 3 estazolam 1 QL PREVYMIS ORAL 5 hydroxyzine hcl intramuscular 1 PREZCOBIX 3 solution 50 mg/ml PREZISTA 2 hydroxyzine hcl oral 1 RELENZA DISKHALER 3 QL hydroxyzine pamoate oral 1 REYATAZ ORAL PACKET 2 lorazepam injection 1 ribavirin oral 5 lorazepam intensol 1 QL rimantadine hcl 1 lorazepam oral concentrate 2 mg/ml 1 QL ritonavir 1 lorazepam oral tablet 1 QL RUKOBIA 3 PA meprobamate 1 SELZENTRY 3 oxazepam 1 QL SOFOSBUVIR-VELPATASVIR 5 PA; QL quazepam 1 QL stavudine 1 triazolam 1 QL STRIBILD 3 Bipolar Agents – Drugs for Mood Disorders SYMTUZA 3 EQUETRO 3 TEMIXYS 3 lithium 1 tenofovir disoproxil fumarate 1 lithium carbonate er 1 TIVICAY 3 lithium carbonate oral 1 TIVICAY PD 3 Blood Products and Modifiers – TRIUMEQ 3 Drugs for Blood Disorders TYBOST 3 aminocaproic acid oral tablet 1 valacyclovir hcl oral 1 QL anagrelide hcl 1 valganciclovir hcl 1 ASTRINGYN 3 VEMLIDY 5 LEUKINE 5 PA VIRACEPT 3 MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 5 VIREAD ORAL POWDER 2 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML
Enhanced Formulary Comprehensive Medication List – 2021 | 15 Drug Name Drug Tier Notes Drug Name Drug Tier Notes MIRCERA INJECTION SOLUTION atenolol-chlorthalidone 1 PREFILLED SYRINGE 150 MCG/0.3ML, 5 QL atorvastatin calcium oral 1 30 MCG/0.3ML benazepril hcl oral 1 MOZOBIL 5 QL benazepril-hydrochlorothiazide 1 NEULASTA 2 betaxolol hcl oral 1 NEULASTA ONPRO 2 BIDIL 3 NIVESTYM INJECTION SOLUTION 5 bisoprolol fumarate oral 1 NIVESTYM INJECTION SOLUTION 2 PREFILLED SYRINGE bisoprolol-hydrochlorothiazide 1 NPLATE SUBCUTANEOUS SOLUTION bumetanide 1 5 RECONSTITUTED 250 MCG, 500 MCG BYSTOLIC 2 PROCRIT INJECTION SOLUTION candesartan cilexetil 1 10000 UNIT/ML, 2000 UNIT/ML, 5 PA 20000 UNIT/ML, 3000 UNIT/ML, candesartan cilexetil-hctz 1 4000 UNIT/ML captopril oral 1 PROCRIT INJECTION SOLUTION 5 captopril-hydrochlorothiazide 1 40000 UNIT/ML cartia xt 1 PROMACTA 5 PA carvedilol 1 RETACRIT 5 carvedilol phosphate er 1 TAVALISSE 5 PA chlorthalidone 1 tranexamic acid oral 1 cholestyramine light 1 UDENYCA 2 cholestyramine oral 1 ZARXIO 2 clonidine 1 ZIEXTENZO 5 clonidine hcl oral 1 Cardiovascular Agents – Drugs for Heart and Circulation Conditions colesevelam hcl 1 acebutolol hcl oral 1 colestipol hcl 1 acetazolamide sodium 1 CORLANOR ORAL TABLET 3 PA; QL ALDACTAZIDE ORAL TABLET 50-50 MG 3 DEMSER 3 aliskiren fumarate 1 digitek 1 alprostadil injection 1 digox 1 amiloride hcl oral 1 digoxin oral 1 amiloride-hydrochlorothiazide 1 DILATRATE-SR 3 amiodarone hcl oral 1 diltiazem hcl er 1 amlodipine besylate oral 1 diltiazem hcl er beads 1 amlodipine besylate-benazepril hcl 1 diltiazem hcl er coated beads 1 amlodipine besylate-valsartan 1 diltiazem hcl oral 1 amlodipine-atorvastatin 1 dilt-xr 1 amlodipine-olmesartan 1 disopyramide phosphate 1 amlodipine-valsartan-hctz 1 DIURIL 3 atenolol oral 1 dofetilide 1 doxazosin mesylate oral 1
Enhanced Formulary Comprehensive Medication List – 2021 | 16 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DUTOPROL 3 labetalol hcl oral 1 EDARBI 3 ST lisinopril oral 1 EDARBYCLOR 3 ST lisinopril-hydrochlorothiazide 1 enalapril maleate oral 1 losartan potassium oral 1 enalapril-hydrochlorothiazide 1 losartan potassium-hctz 1 ENTRESTO 2 QL lovastatin oral 1 ephedrine sulfate injection 1 matzim la 1 eplerenone 1 methyldopa 1 ethacrynic acid 1 methyldopa-hydrochlorothiazide 1 ezetimibe 1 metolazone 1 ezetimibe-simvastatin 1 PA metoprolol succinate er 1 felodipine er 1 metoprolol tartrate oral tablet 100 1 fenofibrate micronized oral capsule mg, 25 mg, 50 mg 1 134 mg, 200 mg, 67 mg metoprolol-hydrochlorothiazide 1 fenofibrate oral capsule 1 metyrosine 1 134 mg, 200 mg, 67 mg mexiletine hcl oral 1 fenofibrate oral tablet 1 145 mg, 160 mg, 48 mg, 54 mg midodrine hcl 1 fenofibric acid oral capsule delayed minitran 1 2 release minoxidil oral 1 fenofibric acid oral tablet 1 moexipril hcl 1 FIBRICOR ORAL TABLET 35 MG 3 MULTAQ 3 flecainide acetate 1 nadolol oral 1 fluvastatin sodium 1 niacin er (antihyperlipidemic) 1 fluvastatin sodium er 1 nicardipine hcl oral 1 fosinopril sodium 1 nifedipine er 1 fosinopril sodium-hctz 1 nifedipine er osmotic release 1 furosemide oral 1 nifedipine oral 1 gemfibrozil oral 1 nimodipine oral 1 guanfacine hcl 1 nisoldipine er 1 hydralazine hcl oral 1 NITRO-BID 3 hydrochlorothiazide oral 1 NITRO-DUR TRANSDERMAL PATCH 24 3 icosapent ethyl 1 PA HOUR 0.3 MG/HR, 0.8 MG/HR indapamide 1 nitroglycerin sublingual 1 irbesartan 1 nitroglycerin transdermal 1 irbesartan-hydrochlorothiazide 1 nitroglycerin translingual 1 isosorbide dinitrate 1 NITROMIST 3 isosorbide mononitrate 1 NORPACE CR 3 isosorbide mononitrate er 1 olmesartan medoxomil oral 1 isradipine 1 olmesartan medoxomil-hctz 1
Enhanced Formulary Comprehensive Medication List – 2021 | 17 Drug Name Drug Tier Notes Drug Name Drug Tier Notes olmesartan-amlodipine-hctz 1 telmisartan-hctz 1 omega-3-acid ethyl esters 1 tiadylt er 1 pentoxifylline er 1 timolol maleate oral 1 perindopril erbumine 1 torsemide 1 phenoxybenzamine hcl oral 1 trandolapril 1 pindolol 1 trandolapril-verapamil hcl er 1 PRALUENT 3 PA; QL triamterene oral 1 pravastatin sodium 1 triamterene-hctz 1 prazosin hcl oral 1 valsartan 1 prevalite 1 valsartan-hydrochlorothiazide 1 propafenone hcl 1 VASCEPA 3 PA propafenone hcl er 1 verapamil hcl er 1 propranolol hcl er 1 verapamil hcl oral 1 propranolol hcl oral 1 Central Nervous System Agents – propranolol-hctz 1 Drugs for Attention Deficit Disorder amphetamine-dextroamphetamine 1 QL quinapril hcl 1 amphetamine-dextroamphetamine er 2 QL quinapril-hydrochlorothiazide 1 atomoxetine hcl 1 QL quinidine gluconate er 1 DAYTRANA 3 QL quinidine sulfate 1 dexmethylphenidate hcl 1 ramipril 1 dexmethylphenidate hcl er oral ranolazine er 1 capsule extended release 24 hour 1 QL RECTIV 3 10 mg, 20 mg, 25 mg, 35 mg, 5 mg REPATHA 3 PA; QL dexmethylphenidate hcl er oral REPATHA PUSHTRONEX SYSTEM 3 PA; QL capsule extended release 24 hour 2 QL 15 mg, 30 mg, 40 mg REPATHA SURECLICK 3 PA; QL dextroamphetamine sulfate 1 QL rosuvastatin calcium 1 dextroamphetamine sulfate er 2 QL simvastatin oral tablet 10 mg, 20 mg, 1 40 mg, 5 mg guanfacine hcl er 1 simvastatin oral tablet 80 mg 1 PA methamphetamine hcl 1 QL sorine 1 methylphenidate hcl er (cd) 2 QL methylphenidate hcl er (la) oral sotalol hcl (af) 1 capsule extended release 24 hour 2 QL sotalol hcl oral 1 10 mg, 20 mg, 30 mg, 40 mg spironolactone oral 1 methylphenidate hcl er oral tablet spironolactone-hctz 1 extended release 10 mg, 18 mg, 2 QL 20 mg, 27 mg, 36 mg, 54 mg taztia xt 1 methylphenidate hcl er oral tablet 2 QL TEKTURNA HCT 3 extended release 24 hour telmisartan 1 methylphenidate hcl oral tablet 1 QL telmisartan-amlodipine 1 methylphenidate hcl oral tablet 1 QL chewable
Enhanced Formulary Comprehensive Medication List – 2021 | 18 Drug Name Drug Tier Notes Drug Name Drug Tier Notes QUILLIVANT XR 3 NEUTRASAL 3 VYVANSE 3 PA; QL oralone 1 Central Nervous System Agents – periogard 1 Drugs for Multiple Sclerosis pilocarpine hcl oral 1 AUBAGIO 5 QL SALIVAMAX 3 AVONEX PEN 5 QL sf 1 AVONEX PREFILLED 5 QL sf 5000 plus 1 BETASERON 5 sodium fluoride 5000 enamel 1 COPAXONE 5 QL sodium fluoride 5000 plus 1 dalfampridine er 5 PA; QL sodium fluoride 5000 ppm 1 dimethyl fumarate oral 5 QL sodium fluoride 5000 sensitive 1 dimethyl fumarate starter pack 5 QL sodium fluoride dental 1 GILENYA 5 QL triamcinolone acetonide glatiramer acetate 5 QL 1 mouth/throat glatopa 5 QL Dermatological Agents – Drugs for Skin Conditions KESIMPTA 5 accutane 1 MAVENCLAD 5 PA acitretin 1 Central Nervous System Agents – Miscellaneous ACZONE EXTERNAL GEL 7.5% 3 caffeine citrate oral 1 adapalene external cream 1 IMCIVREE 5 PA; QL adapalene external gel 1 NUEDEXTA 3 PA adapalene-benzoyl peroxide external pregabalin oral 1 QL 1 gel riluzole 5 QL ala-cort 1 SAVELLA 3 QL alclometasone dipropionate 1 SAVELLA TITRATION PACK 3 QL ALTRENO 3 tetrabenazine 5 PA amcinonide 1 TIGLUTIK 3 QL ammonium lactate external 1 Dental and Oral Agents – Drugs for Mouth and Throat Conditions amnesteem 1 BOCASAL 3 azelaic acid external 1 cavarest 1 AZELEX 3 cevimeline hcl 1 BENSAL HP 3 chlorhexidine gluconate mouth/ benzepro external foam 5.3% 1 1 throat BENZOYL PEROX-HYDROCORTISONE 3 DEBACTEROL 3 benzoyl peroxide external foam 1 easygel 1 benzoyl peroxide-erythromycin 1 fluoridex daily renewal 1 beser external lotion 1 lidocaine hcl mouth/throat 1 betamethasone dipropionate aug 1 lidocaine viscous hcl 1 betamethasone dipropionate external 1 MUCOSITISRX 3 betamethasone valerate external 1 NAFRINSE DAILY ACIDULATED 3 bp 10-1 1 Enhanced Formulary Comprehensive Medication List – 2021 | 19 Drug Name Drug Tier Notes Drug Name Drug Tier Notes bp wash external liquid 2.5%, 7% 1 ENSTILAR 3 QL calcipotriene external cream 1 EPIFOAM 3 calcipotriene external ointment 1 ery 1 calcipotriene external solution 1 erythromycin external 1 calcipotriene-betameth diprop 1 QL EUCRISA 3 PA calcitriol external 1 fluocinolone acetonide body 1 CAPEX 3 fluocinolone acetonide external 1 CARAC 3 QL fluocinolone acetonide scalp 1 claravis 1 fluocinonide emulsified base 1 clindacin etz external swab 1 fluocinonide external cream 0.05% 1 clindacin-p 1 fluocinonide external cream 0.1% 1 QL clindamycin phosphate-benzoyl fluocinonide external gel 1 1 peroxide fluocinonide external ointment 1 clindamycin phosphate external 1 fluocinonide external solution 1 clindamycin-tretinoin 1 FLUOROPLEX 2 clobetasol prop emollient base 1 FLUOROURACIL EXTERNAL CREAM 3 QL clobetasol propionate e 1 0.5% clobetasol propionate emulsion 1 fluorouracil external cream 5% 1 clobetasol propionate external 1 fluorouracil external solution 1 clocortolone pivalate 1 flurandrenolide external cream 1 clodan external shampoo 1 flurandrenolide external lotion 1 coal tar external 1 fluticasone propionate external 1 CONDYLOX 3 GENADUR EXTERNAL 3 CORDRAN EXTERNAL TAPE 3 glycolic acid solution 1 dapsone external gel 5% 1 GORDOFILM 3 halobetasol propionate external dapsone gel 7.5% external 1 1 cream DAPSONE GEL 7.5% EXTERNAL 3 halobetasol propionate external desonide external 1 1 ointment desoximetasone external cream 1 hydrocortisone butyr lipo base 1 desoximetasone external gel 1 hydrocortisone butyrate external 1 desoximetasone external ointment 1 cream desrx 1 hydrocortisone butyrate external 1 diclofenac sodium external gel 3% 3 PA; QL ointment hydrocortisone butyrate external diflorasone diacetate 1 1 solution doxepin hcl external 3 PA; QL hydrocortisone external cream 1%, 1 DRITHO-CREME HP 3 2.5% DUPIXENT SUBCUTANEOUS 5 PA hydrocortisone external lotion 2.5% 1 SOLUTION PEN-INJECTOR hydrocortisone external ointment DUPIXENT SUBCUTANEOUS 1 5 PA; QL 1%, 2.5% SOLUTION PREFILLED SYRINGE
Enhanced Formulary Comprehensive Medication List – 2021 | 20 Drug Name Drug Tier Notes Drug Name Drug Tier Notes hydrocortisone valerate 1 sulfacetamide sodium external liquid 1 imiquimod external 1 sulfacetamide sodium-sulfur external 1 isotretinoin oral 1 cream 10-2%, 10-5% sulfacetamide sodium-sulfur external KERALYT SCALP 3 1 emulsion lactic acid e 1 sulfacetamide sodium-sulfur external 1 lactic acid external 1 liquid 10-2%, 9-4% LEVULAN KERASTICK 3 sulfacetamide sodium-sulfur external 1 methoxsalen rapid 1 lotion 10-5% sulfacetamide sodium-sulfur external methyl salicylate external liquid 1 1 pad metronidazole external 1 sulfacetamide sodium-sulfur external 1 mometasone furoate external 1 suspension 10-5% myorisan 1 sulfacetamide sod-sulfur wash 1 NEO-SYNALAR EXTERNAL CREAM 3 external liquid 9-4% neuac external gel 1 sulfacetamide-sulfur in urea 1 nolix 1 sulfamez wash 1 NUCORT 3 SUMAXIN CP 3 OVACE PLUS EXTERNAL CREAM 3 tacrolimus external 1 pimecrolimus 1 tazarotene external cream 1 podocon 1 TAZORAC EXTERNAL CREAM 0.05% 3 podofilox external 1 TAZORAC EXTERNAL GEL 3 pramox 1 TEXACORT 3 prednicarbate 1 tovet external foam 1 PSORCON 1 tretinoin external 1 PYROGALLIC ACID 3 tretinoin microsphere 1 REGRANEX 3 PA tretinoin microsphere pump 1 triamcinolone acetonide external rosadan external cream 1 1 aerosol solution rosadan external gel 1 triamcinolone acetonide external 1 ROSADAN EXTERNAL KIT 0.75% (GEL) 3 cream salicylic acid external 1 triamcinolone acetonide external 1 salicylic acid-cleanser 1 lotion salimez 1 triamcinolone acetonide external 1 ointment 0.025%, 0.1%, 0.5% selenium sulfide external lotion 1 TRI-CHLOR 3 selenium sulfide external shampoo 1 2.25% triderm 1 sodium sulfacetamide 1 turpentine external 1 sodium sulfacetamide wash 1 VANOXIDE-HC 3 sss 10-5 external cream 1 ZACLIR CLEANSING 3 sulfacetamide sodium (acne) 1 zenatane 1
Enhanced Formulary Comprehensive Medication List – 2021 | 21 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Diabetes – Antidiabetic Agents TRIJARDY XR 2 acarbose oral 1 TRULICITY SUBCUTANEOUS BYDUREON BCISE AUTOINJECTOR 2 QL SOLUTION PEN-INJECTOR 0.75 2 QL MG/0.5ML, 1.5 MG/0.5ML BYETTA 10 MCG PEN 2 QL TRULICITY SUBCUTANEOUS BYETTA 5 MCG PEN 2 QL SOLUTION PEN-INJECTOR 3 2 FARXIGA 2 MG/0.5ML, 4.5 MG/0.5ML glimepiride 1 VICTOZA 2 glipizide er 1 XIGDUO XR 2 glipizide ir 1 Diabetes – Glucose Monitoring glipizide xl 1 ACCU-CHEK AVIVA DEVICE 2 glipizide-metformin hcl 1 ACCU-CHEK AVIVA PLUS TEST STRIPS 2 glyburide micronized 1 ACCU-CHEK COMPACT PLUS TEST 2 STRIPS glyburide oral 1 ACCU-CHEK FASTCLIX LANCET KIT 2 glyburide-metformin 1 ACCU-CHEK GUIDE TEST STRIPS 2 GLYXAMBI 2 ACCU-CHEK SMARTVIEW TEST STRIPS 2 JANUMET 2 ACCU-CHEK SOFTCLIX LANCET DEVICE JANUMET XR 2 2 KIT JANUVIA 2 AUTOLET II CLINISAFE 3 JARDIANCE 2 AUTOLET LANCING DEVICE 3 JENTADUETO 2 CARETOUCH LANCING/EJECTOR 3 JENTADUETO XR 2 CEQUR SIMPLICITY 2U 3 metformin hcl er 1 DEXCOM G4/G5/G6 RECEIVER, metformin hcl ir 1 TRANSMITTER, SENSOR (INCLUDING 2 PA; QL miglitol 1 PLATINUM, PLATINUM PEDIATRIC) nateglinide 1 DEXCOM G4/G5/G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING OZEMPIC SUBCUTANEOUS SOLUTION 2 PA; QL 2 QL PLATINUM, PLATINUM PEDIATRIC) PEN-INJECTOR 2 MG/1.5ML DEVICE OZEMPIC SUBCUTANEOUS SOLUTION 2 DIATHRIVE LANCING DEVICE 3 PEN-INJECTOR 4 MG/3ML DROPLET GENTEEL LANCING DEVICE 3 pioglitazone hcl 1 EMBRACE LANCING DEVICE/EJECTOR 3 pioglitazone hcl-glimepiride 1 FREESTYLE LIBRE 14 DAY READER 2 PA; QL pioglitazone hcl-metformin hcl 1 FREESTYLE LIBRE 14 DAY SENSOR 2 PA; QL repaglinide 1 FREESTYLE LIBRE 2 READER 2 PA; QL RYBELSUS 2 QL FREESTYLE LIBRE 2 SENSOR 2 PA; QL SYMLINPEN 120 3 FREESTYLE LIBRE READER 2 PA; QL SYMLINPEN 60 3 FREESTYLE LIBRE SENSOR SYSTEM 2 PA; QL SYNJARDY 2 GENTEEL LANCING KIT (BLUE) 3 SYNJARDY XR 2 GOJJI LANCING DEVICE/CLEAR CAP 3 tolbutamide 1 LANCETS 2 TRADJENTA 2 LANCETS 3 Enhanced Formulary Comprehensive Medication List – 2021 | 22 Drug Name Drug Tier Notes Drug Name Drug Tier Notes MICROLET NEXT LANCING DEVICE 3 INSULIN SYRINGES 27G X 1/2" 0.5 ML, NOVOPEN ECHO 3 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, OMNIPOD DASH SYSTEM 3 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, OMNIPOD STARTER 3 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 3 ONETOUCH DELICA LANCING DEV 2 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, ONETOUCH DELICA PLUS LANCING 3 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, ONETOUCH ULTRA 2 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML, 32G X 5/16" 0.5 ML, ONETOUCH VERIO TEST STRIPS 2 32G X 5/16" 1 ML VIVAGUARD LANCING DEVICE 3 LANTUS SOLOSTAR 2 Diabetes – Glycemic Agents LANTUS U-100 VIAL 2 BAQSIMI ONE PACK 2 LEVEMIR U-100 FLEXTOUCH 2 BAQSIMI TWO PACK 2 LEVEMIR U-100 VIAL 2 diazoxide oral 1 MAXICOMFORT SYR 27G X 1/2" 3 glucagon emergency kit 1 mg 1 NOVOFINE AUTOCOVER PEN NEEDLE 3 injection 1 mg NOVOFINE PEN NEEDLE 3 GLUCAGON EMERGENCY KIT 1 MG 3 INJECTION 1 MG NOVOFINE PLUS PEN NEEDLE 3 GLUCAGON EMERGENCY KIT 2 NOVOLIN 70/30 FLEXPEN 2 GVOKE HYPOPEN 1-PACK 2 NOVOLIN 70/30 FLEXPEN RELION 2 GVOKE HYPOPEN 2-PACK 2 NOVOLIN 70/30 RELION 2 GVOKE PFS 2 NOVOLIN 70/30 VIAL 2 Diabetes – Insulins NOVOLIN N FLEXPEN 2 BD AUTOSHIELD DUO PEN NEEDLES 3 NOVOLIN N FLEXPEN RELION 2 BD ULTRA-FINE INSULIN SYRINGES 3 NOVOLIN N RELION 2 BD ULTRA-FINE PEN NEEDLES 3 NOVOLIN N VIAL 2 BD VEO INSULIN SYR U/F 1/2UNIT 3 NOVOLIN R FLEXPEN 2 HUMALOG U-100 JUNIOR KWIKPEN 3 NOVOLIN R FLEXPEN RELION 2 HUMULIN R U-500 KWIKPEN 3 NOVOLIN R RELION 2 HUMULIN R U-500 VIAL 3 NOVOLIN R VIAL 2 INSULIN ASP PROT & ASP FLEXPEN 2 NOVOLOG FLEXPEN 2 INSULIN ASPART 2 NOVOLOG MIX 70/30 FLEXPEN 2 INSULIN ASPART FLEXPEN 2 NOVOLOG MIX 70/30 VIAL 2 INSULIN ASPART PENFILL 2 NOVOLOG PENFILL 2 INSULIN ASPART PROT & ASPART 2 NOVOLOG U-100 VIAL 2 INSULIN PEN NEEDLES 29G X NOVOTWIST PEN NEEDLE 3 12.7MM, 29G X 12MM, 29G X 5MM, TOUJEO MAX SOLOSTAR 2 29G X 8MM , 30G X 5 MM , 30G X 6 MM, 30G X 8 MM , 31G X 5 MM, 31G X 6 MM, 3 TOUJEO SOLOSTAR 2 31G X 8 MM , 32G X 4 MM, 32G X 5 MM, TRESIBA 2 32G X 6 MM , 32G X 8 MM , 33G X 4 MM, TRESIBA FLEXTOUCH 2 33G X 5 MM, 33G X 6 MM
Enhanced Formulary Comprehensive Medication List – 2021 | 23 Drug Name Drug Tier Notes Drug Name Drug Tier Notes TRUE COMFORT PRO INSULIN SYR iodine strong oral 1 3 32G X 5/16” 0.5 ML JYNARQUE ORAL TABLET 5 QL TRUE COMFORT PRO PEN NEEDLES JYNARQUE ORAL TABLET THERAPY 31G X 8 MM , 32G X 5 MM , 32G X 3 QL 3 PACK 15 MG 6 MM , 33G X 4 MM , 33G X 5 MM , JYNARQUE ORAL TABLET THERAPY 33G X 6 MM 3 PACK 30 & 15 MG ULTIGUARD SAFEPACK SYR/NEEDLE 3 kids first vitamin d3 gummies 1 PV UNIFINE PEN NEEDLES 3 klor-con 1 Electrolytes/Minerals/Metals/Vitamins klor-con 10 1 argyle sterile saline 1 klor-con m10 1 argyle sterile water 1 KLOR-CON M15 3 ATABEX OB 2 klor-con m20 1 CALCIFOL 3 klor-con/ef 1 CALCIUM-FOLIC ACID PLUS D 1 K-PHOS 3 CARBAGLU 5 PA K-PHOS NO 2 3 CHEMET 3 k-prime 1 clovique 1 lactated ringers irrigation 1 curity sterile saline 1 levocarnitine oral solution 1 cyanocobalamin injection solution 1 1000 mcg/ml levocarnitine oral tablet 1 cytra k crystals 1 levocarnitine sf 1 d3 high potency oral capsule 1 PV MAGNESIUM CARBONATE HEAVY 3 d3 super strength 1 PV MAGNESIUM CARBONATE POWDER 3 DECARA ORAL CAPSULE mifepristone 1 2 625 MCG (25000 UT) M-NATAL PLUS 2 PV deferasirox 5 PA n-acetyl-l-cysteine oral 1 deferasirox granules 5 PA nafrinse 1 PV deferiprone 5 PA nafrinse drops 1 PV d-vite pediatric 1 PV NASCOBAL 2 EFFER-K ORAL TABLET EFFERVESCENT 3 NEONATAL PLUS 2 PV 10 MEQ, 20 MEQ NESTABS 2 effer-k oral tablet effervescent 1 25 meq ONE VITE WOMENS 2 PV ergocalciferol oral capsule 1 ONE VITE WOMENS PLUS 2 PV FERRIPROX ORAL SOLUTION 5 PA ONEVITE 2 FERRIPROX ORAL TABLET 500 MG 5 PA ORACIT 3 ferrous sulfate oral solution pharmacist choice d-vitamin 1 PV 1 PV 75 (15 fe) mg/ml phosphorous 1 fluoritab 1 PV phospho-trin 250 neutral 1 folic acid oral tablet 1 mg 1 PHYSIOLYTE 3 GALZIN ORAL CAPSULE 50 MG 3 PHYSIOSOL IRRIGATION 3 hydroxocobalamin acetate 1
Enhanced Formulary Comprehensive Medication List – 2021 | 24 Drug Name Drug Tier Notes Drug Name Drug Tier Notes potassium chloride crys er 1 virt-phos 250 neutral 1 potassium chloride er 1 vitamin d (ergocalciferol) oral capsule 1 potassium chloride oral 1 1.25 mg (50000 ut) vp-pnv-dha 1 potassium citrate er 1 water for irrigation, sterile 1 potassium citrate-citric acid 1 weekly-d 1 PV PREMESISRX 2 WESTAB PLUS 2 PV PRENAISSANCE 2 Gastrointestinal Agents – Drugs for Acid Reflux and Ulcer prenatal multi +dha oral capsule 1 famotidine oral suspension 27-0.8-228 mg 1 reconstituted prenatal oral tablet 1 lansoprazole oral capsule delayed 27-0.8 mg, 27-1 mg 2 release prenatal plus iron 1 misoprostol oral 1 prenatal vitamin plus low iron 1 omeprazole oral capsule delayed 1 PRENATVITE RX 2 release preplus 1 pantoprazole sodium oral tablet 1 RELNATE DHA 2 delayed release rabeprazole sodium oral tablet ringers irrigation 1 2 delayed release saline bacteriostatic 1 sucralfate oral 1 SALINE-PHENOL 3 Gastrointestinal Agents – SELECT-OB ORAL TABLET CHEWABLE 2 Drugs for Bowel, Intestine and Stomach Conditions 29-1 MG alosetron hcl 1 sod citrate-citric acid 1 AMITIZA 3 PA; QL sodium chloride (pf) 1 amoxicill-clarithro-lansopraz 1 sodium chloride bacteriostatic 1 atropine sulfate injection solution sodium chloride irrigation 1 prefilled syringe 0.5 mg/5ml, 1 sodium fluoride oral solution 1 PV 1 mg/10ml sodium fluoride oral tablet 1 belladonna alkaloids-opium 1 sodium fluoride oral tablet chewable 1 PV cascara sagrada oral fluid extract 1 sodium polystyrene sulfonate 1 CHENODAL 3 sps 1 constulose 1 sterile water for irrigation 1 cromolyn sodium oral 1 tis-u-sol 1 CUVPOSA 3 TOLVAPTAN ORAL TABLET 15 MG 5 QL dicyclomine hcl intramuscular 1 tolvaptan oral tablet 30 mg 5 QL dicyclomine hcl oral 1 TRICARE PRENATAL DHA ONE 2 diphenoxylate-atropine 1 tricitrates 1 enulose 1 trientine hcl 1 gavilyte-c 1 PV TRINATE 2 gavilyte-g 1 PV UDAMIN SP 2 gavilyte-n with flavor pack 1 PV VELTASSA 3 QL generlac 1
Enhanced Formulary Comprehensive Medication List – 2021 | 25 Drug Name Drug Tier Notes Drug Name Drug Tier Notes GIALAX 3 CREON 2 glycopyrrolate injection solution CYSTADANE 3 1 0.2 mg/ml CYSTAGON 3 glycopyrrolate oral tablet 1 mg, 2 mg 1 EVRYSDI 5 PA GLYCOPYRROLATE ORAL TABLET 1 miglustat 5 1.5 MG nitisinone 5 PA HELIDAC THERAPY 3 PALYNZIQ 5 PA; QL hyoscyamine sulfate er 1 sapropterin dihydrochloride 5 PA hyoscyamine sulfate injection 1 sodium phenylbutyrate oral tablet 1 hyoscyamine sulfate oral 1 STRENSIQ 5 PA hyoscyamine sulfate sl 1 SUCRAID 3 hyoscyamine sulfate sublingual 1 ZENPEP 2 lactulose encephalopathy 1 Genitourinary Agents – lactulose oral solution 1 Drugs for Bladder, Genital and Kidney Conditions LEVSIN INJECTION 3 acetic acid irrigation 1 LINZESS 2 QL aminoacetic acid 1 loperamide hcl oral capsule 1 AURYXIA 3 LUBIPROSTONE 3 PA; QL bethanechol chloride oral 1 methscopolamine bromide oral 1 calcium acetate (phos binder) 1 MOVANTIK 2 PA; QL calcium acetate oral tablet 667 mg 1 oscimin 1 CAVERJECT 3 PA oscimin sr 1 darifenacin hydrobromide er 1 ST peg 3350-kcl-na bicarb-nacl 1 PV EDEX 3 PA peg-3350/electrolytes 1 PV ELMIRON 2 peg-3350/electrolytes/ascorbat 1 flavoxate hcl 1 peg-kcl-nacl-nasulf-na asc-c 1 glycine irrigation 1 peg-prep 1 glycine urologic 1 PYLERA 3 INTRAROSA 3 PA RELISTOR SUBCUTANEOUS 5 PA; QL lanthanum carbonate 1 SUPREP BOWEL PREP KIT 3 LITHOSTAT 3 SYMAX DUOTAB 3 me/naphos/mb/hyo1 1 SYMPROIC 2 PA; QL MUSE 3 PA TALICIA 3 MYRBETRIQ 3 ST ursodiol oral 1 oxybutynin chloride er 1 XERMELO 5 PA; QL oxybutynin chloride oral 1 ZELNORM 3 PA; QL penicillamine oral 1 Genetic or Enzyme Disorder – phenazo oral tablet 200 mg 1 Drugs for Replacement, Modification, Treatment phenazopyridine hcl oral tablet 1 CERDELGA 5 PA 100 mg, 200 mg CHOLBAM 5 PA PHOSLYRA 3
Enhanced Formulary Comprehensive Medication List – 2021 | 26 Drug Name Drug Tier Notes Drug Name Drug Tier Notes RENACIDIN 3 methylprednisolone acetate injection 1 sevelamer carbonate 1 suspension 40 mg/ml, 80 mg/ml methylprednisolone oral 1 sevelamer hcl 3 sildenafil citrate oral tablet prednisolone oral solution 1 1 PA 100 mg, 25 mg, 50 mg prednisolone sodium phosphate oral 1 solifenacin succinate 1 solution tadalafil oral tablet 10 mg, 20 mg 1 PA prednisone intensol 1 tadalafil oral tablet 2.5 mg, 5 mg 1 PA; QL prednisone oral 1 THIOLA 3 Hormonal Agents – Men’s Health tiopronin oral 1 danazol oral 1 tolterodine tartrate 1 methyltestosterone oral 1 tolterodine tartrate er 1 oxandrolone oral 1 QL TESTOSTERONE CYPIONATE trospium chloride 1 2 PA INJECTION trospium chloride er 1 testosterone cypionate intramuscular 2 PA urin ds 1 testosterone enanthate intramuscular 2 PA uro-mp 1 testosterone transdermal gel Genitourinary Agents – Drugs for Prostate Conditions 1.62%, 20.25 mg/1.25gm (1.62%), 1 PA alfuzosin hcl er 1 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%) dutasteride oral 1 Hormonal Agents – Osteoporosis dutasteride-tamsulosin hcl 1 OSPHENA 3 PA finasteride oral tablet 5 mg 1 raloxifene hcl 1 silodosin 1 Hormonal Agents – Pituitary tamsulosin hcl 1 cabergoline 1 terazosin hcl 1 CETROTIDE 5 PA Hormonal Agents – Adrenal chorionic gonadotropin intramuscular 5 PA ALKINDI SPRINKLE 5 PA desmopressin ace spray refrig 1 betamethasone sod phos & acet 1 desmopressin acetate injection 1 injection suspension 6 (3-3) mg/ml desmopressin acetate oral 1 dexamethasone intensol 1 desmopressin acetate pf 1 dexamethasone oral elixir 1 desmopressin acetate spray 1 dexamethasone oral solution 1 EGRIFTA SV 5 PA; QL dexamethasone oral tablet 1 ELIGARD 5 QL dexamethasone sod phosphate pf 1 injection solution FENSOLVI (6 MONTH) 5 dexamethasone sodium FOLLISTIM AQ 5 PA 1 phosphate injection ganirelix acetate 5 PA fludrocortisone acetate oral 1 GONAL-F 5 PA HEMADY 3 GONAL-F RFF 5 PA hydrocortisone oral 1 GONAL-F RFF REDIJECT 5 PA MEDROL ORAL TABLET 2 MG 3 INCRELEX 5 PA
Enhanced Formulary Comprehensive Medication List – 2021 | 27 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ISTURISA 5 PA aubra eq 1 PV leuprolide acetate injection 5 aurovela 1.5/30 1 PV LUPANETA PACK 5 QL aurovela 1/20 1 PV LUPRON DEPOT (1-MONTH) 5 aurovela 24 fe 1 PV LUPRON DEPOT (3-MONTH) 5 aurovela fe 1.5/30 1 PV LUPRON DEPOT (4-MONTH) aurovela fe 1/20 1 PV 5 INTRAMUSCULAR KIT 30MG aviane 1 PV LUPRON DEPOT (6-MONTH) 5 ayuna 1 PV INTRAMUSCULAR KIT 45MG azurette 1 PV LUPRON DEPOT-PED (1-MONTH) 5 balziva 1 PV LUPRON DEPOT-PED (3-MONTH) 5 bekyree 1 PV MENOPUR 5 PA BIJUVA 3 MYCAPSSA 5 PA blisovi 24 fe 1 PV NORDITROPIN FLEXPRO 5 PA blisovi fe 1.5/30 1 PV novarel intramuscular solution 5 PA blisovi fe 1/20 1 PV reconstituted 10000 unit briellyn 1 PV octreotide acetate 5 camila 1 PV ORILISSA 2 PA; QL camrese 1 PV; QL OVIDREL 5 PA camrese lo 1 PV; QL pregnyl 5 PA caziant 1 PV SANDOSTATIN LAR DEPOT 5 charlotte 24 fe 1 SIGNIFOR 5 QL chateal 1 PV SOMATULINE DEPOT 5 chateal eq 1 PV SOMAVERT 5 CLIMARA PRO 2 STIMATE 3 COMBIPATCH 3 SYNAREL 5 CRINONE 3 QL TRELSTAR MIXJECT 5 QL cryselle-28 1 PV Hormonal Agents – Prostaglandins cyclafem 1/35 1 PV KORLYM 5 PA cyclafem 7/7/7 1 PV Hormonal Agents – Sex Hormones and Birth Control cyred 1 PV afirmelle 1 PV cyred eq 1 PV altavera 1 PV dasetta 1/35 1 PV alyacen 1/35 1 PV dasetta 7/7/7 1 PV alyacen 7/7/7 1 PV daysee 1 PV; QL amabelz 1 deblitane 1 PV amethia 1 PV; QL delyla 1 PV amethyst 1 DEPO-ESTRADIOL 3 apri 1 PV DEPO-SUBQ PROVERA 104 3 QL aranelle 1 PV desogestrel-ethinyl estradiol 1 PV ashlyna 1 PV; QL aubra 1 PV Enhanced Formulary Comprehensive Medication List – 2021 | 28 Drug Name Drug Tier Notes Drug Name Drug Tier Notes DIVIGEL TRANSDERMAL GEL hydroxyprogesterone caproate 5 PA 0.25 MG/0.25GM, 0.5 MG/0.5GM, 3 intramuscular oil 0.75 MG/0.75GM, 1 MG/GM hydroxyprogesterone caproate 5 dolishale 1 intramuscular solution dotti 1 iclevia 1 PV; QL drospiren-eth estrad-levomefol 1 IMVEXXY MAINTENANCE PACK 3 drospirenone-ethinyl estradiol 1 PV IMVEXXY STARTER PACK 3 DUAVEE 3 PA incassia 1 PV ELESTRIN 3 introvale 1 PV; QL elinest 1 PV isibloom 1 PV ELLA 3 PV jaimiess 1 PV; QL eluryng 1 jasmiel 1 PV emoquette 1 PV jencycla 1 PV ENDOMETRIN 3 jinteli 1 enpresse-28 1 PV jolessa 1 PV; QL enskyce 1 PV juleber 1 PV errin 1 PV junel 1.5/30 1 PV estarylla 1 PV junel 1/20 1 PV estradiol oral 1 junel fe 1.5/30 1 PV estradiol transdermal 1 junel fe 1/20 1 PV estradiol vaginal 1 junel fe 24 1 PV estradiol valerate intramuscular 1 kaitlib fe 1 estradiol-norethindrone acet 1 kalliga 1 PV ESTRING 3 QL kariva 1 PV kelnor 1/35 1 PV ESTROGEL 3 kelnor 1/50 1 ethynodiol diac-eth estradiol oral 1 PV tablet 1-35 mg-mcg kurvelo 1 PV ethynodiol diac-eth estradiol oral larin 1.5/30 1 PV 1 tablet 1-50 mg-mcg larin 1/20 1 PV etonogestrel-ethinyl estradiol 1 larin 24 fe 1 PV EVAMIST 3 larin fe 1.5/30 1 PV falmina 1 PV larin fe 1/20 1 PV fayosim 1 QL larissia 1 PV FEMRING 3 QL layolis fe 1 femynor 1 PV leena 1 PV fyavolv 1 lessina 1 PV hailey 1.5/30 1 PV levonest 1 PV hailey 24 fe 1 PV levonorgest-eth est & eth est 1 QL hailey fe 1.5/30 1 PV levonorgest-eth estrad 91-day 1 PV; QL hailey fe 1/20 1 PV levonorgestrel 1 PV heather 1 PV
Enhanced Formulary Comprehensive Medication List – 2021 | 29 Drug Name Drug Tier Notes Drug Name Drug Tier Notes levonorgestrel-ethinyl estrad oral norethindrone oral 1 PV 1 PV tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg norethindrone-eth estradiol 1 levonorgestrel-ethinyl estrad oral norethin-eth estradiol-fe oral tablet 1 1 PV tablet 90-20 mcg chewable 0.4-35 mg-mcg levonorg-eth estrad triphasic 1 PV norethin-eth estradiol-fe oral tablet 1 levora 0.15/30 (28) 1 PV chewable 0.8-25 mg-mcg lillow 1 PV norgestimate-eth estradiol 1 PV LO LOESTRIN FE 3 norgestimate-ethinyl estradiol lojaimiess 1 PV; QL triphasic oral tablet 0.18/0.215/0.25 1 mg-25 mcg loryna 1 PV norgestimate-ethinyl estradiol low-ogestrel 1 PV triphasic oral tablet 1 PV lo-zumandimine 1 PV 0.18/0.215/0.25 mg-35 mcg lutera 1 PV norlyda 1 PV lyleq 1 PV norlyroc 1 PV lyllana 1 nortrel 0.5/35 (28) 1 PV lyza 1 PV nortrel 1/35 (21) 1 PV MAKENA SUBCUTANEOUS 5 PA nortrel 1/35 (28) 1 PV marlissa 1 PV nortrel 7/7/7 1 PV medroxyprogesterone acetate nylia 7/7/7 1 PV 1 QL intramuscular nymyo 1 PV medroxyprogesterone acetate oral 1 ocella 1 PV megestrol acetate oral 1 ORIAHNN 2 PA MENEST 3 orsythia 1 PV MENOSTAR 3 philith 1 PV microgestin 1.5/30 1 PV pimtrea 1 PV microgestin 1/20 1 PV pirmella 1/35 1 PV microgestin 24 fe 1 PV pirmella 7/7/7 1 PV microgestin fe 1.5/30 1 PV portia-28 1 PV microgestin fe 1/20 1 PV PREFEST 3 mili 1 PV PREMARIN 2 mimvey 1 PREMPHASE 2 mono-linyah 1 PV PREMPRO 2 NATAZIA 2 PV preventeza 1 PV necon 0.5/35 (28) 1 PV previfem 1 PV nikki 1 PV progesterone intramuscular 1 nora-be 1 PV progesterone oral 1 norethin ace-eth estrad-fe oral tablet 1 PV reclipsen 1 PV norethin ace-eth estrad-fe oral tablet 1 rivelsa 1 QL chewable setlakin 1 PV; QL norethindrone acetate oral 1 sharobel 1 PV norethindrone acet-ethinyl est 1 PV
Enhanced Formulary Comprehensive Medication List – 2021 | 30 Drug Name Drug Tier Notes Drug Name Drug Tier Notes simliya 1 PV zovia 1/35 (28) 1 PV simpesse 1 PV; QL zovia 1/35e (28) 1 PV sprintec 28 1 PV zumandimine 1 PV sronyx 1 PV Hormonal Agents – Thyroid syeda 1 PV ARMOUR THYROID 3 tarina 24 fe 1 PV euthyrox 1 tarina fe 1/20 1 PV levo-t 1 tarina fe 1/20 eq 1 PV levothyroxine sodium oral tablet 1 tilia fe 1 PV levoxyl 1 tri femynor 1 PV liothyronine sodium oral 1 tri-estarylla 1 PV methimazole oral 1 tri-legest fe 1 PV NATURE-THROID 2 tri-linyah 1 PV np thyroid 1 tri-lo-estarylla 1 propylthiouracil oral 1 tri-lo-marzia 1 SYNTHROID 3 tri-lo-mili 1 unithroid 1 tri-lo-sprintec 1 WESTHROID 2 tri-mili 1 PV WP THYROID 2 tri-nymyo 1 PV Immunological Agents – tri-previfem 1 PV Drugs for Immune System Stimulation or Suppression tri-sprintec 1 PV ACTEMRA ACTPEN 5 PA trivora (28) 1 PV ACTEMRA SUBCUTANEOUS 5 PA tri-vylibra 1 PV ACTIMMUNE 5 PA tri-vylibra lo 1 ALFERON N 5 PA tulana 1 PV ASTAGRAF XL 3 PA tyblume 1 PV AZASAN 3 tydemy 1 azathioprine oral 1 velivet 1 PV BENLYSTA SUBCUTANEOUS 5 PA vestura 1 PV CIMZIA 5 PA vienva 1 PV CIMZIA PREFILLED KIT 5 PA viorele 1 PV CIMZIA STARTER KIT 5 PA volnea 1 PV CINRYZE 5 PA vyfemla 1 PV CUVITRU 5 PA vylibra 1 PV cyclosporine modified 1 wera 1 PV cyclosporine oral 1 wymzya fe 1 PV ENVARSUS XR 3 PA xulane 2 PV everolimus oral tablet 1 yuvafem 1 0.25 mg, 0.5 mg, 0.75 mg zafemy 2 PV gengraf 1 zarah 1 PV HAEGARDA 5 PA
Enhanced Formulary Comprehensive Medication List – 2021 | 31 Drug Name Drug Tier Notes Drug Name Drug Tier Notes HEPAGAM B 5 PA tacrolimus oral 1 HIZENTRA 5 PA TAKHZYRO 5 PA HUMIRA 5 PA TALTZ 5 PA HUMIRA PEDIATRIC CROHNS START 5 PA TREMFYA 5 PA HUMIRA PEN 5 PA TREXALL 3 HUMIRA PEN-CD/UC/HS STARTER 5 PA XELJANZ 5 PA HUMIRA PEN-PEDIATRIC UC START 5 PA XELJANZ XR 5 PA HUMIRA PEN-PS/UV/ADOL HS START 5 PA XEMBIFY 5 PA HUMIRA PEN-PSOR/UVEIT STARTER 5 PA ZORTRESS 3 HYPERHEP B 5 PA Immunological Agents – Drugs for Vaccination HYQVIA 5 PA ACTHIB 3 PV ILUMYA 5 PA BEXSERO 3 PV KEVZARA 5 PA BOOSTRIX 3 PV leflunomide oral 1 ENGERIX-B 3 PV LUPKYNIS 5 PA; QL GARDASIL 9 3 PV methotrexate oral 1 HAVRIX 3 PV methotrexate sodium 1 HEPLISAV-B 3 methotrexate sodium (pf) 1 HIBERIX 3 PV mycophenolate mofetil oral 1 INFANRIX 3 PV mycophenolate sodium 1 IPOL 3 PV NABI-HB 5 PA KINRIX 3 PV OLUMIANT 5 PA MENACTRA 3 PV ORENCIA CLICKJECT 5 PA MENQUADFI 3 PV ORENCIA SUBCUTANEOUS 5 PA MENVEO 3 PV ORLADEYO 5 PA; QL M-M-R II 3 PV OTEZLA 5 PA PEDIARIX 3 PV PROGRAF ORAL PACKET 3 PEDVAX HIB 3 PV RIDAURA 3 PNEUMOVAX 23 3 PV RINVOQ 5 PA PREVNAR 13 3 PV SANDIMMUNE ORAL SOLUTION 3 PROQUAD 3 PV SIMPONI 5 PA QUADRACEL 3 PV sirolimus oral 1 RECOMBIVAX HB 3 PV SKYRIZI 5 PA ROTARIX 3 PV SKYRIZI (150 MG DOSE) 5 PA ROTATEQ 3 PV SKYRIZI PEN 5 PA SHINGRIX 2 PV STELARA SUBCUTANEOUS SOLUTION 5 TRUMENBA 3 PV STELARA SUBCUTANEOUS SOLUTION TWINRIX 3 PV 5 PA PREFILLED SYRINGE VAQTA 3 PV SYNAGIS 5 PA VARIVAX 3 PV
Enhanced Formulary Comprehensive Medication List – 2021 | 32 Drug Name Drug Tier Notes Drug Name Drug Tier Notes Inflammatory Bowel Disease Agents risedronate sodium oral tablet 1 ana-lex 1 30 mg, 5 mg risedronate sodium oral tablet balsalazide disodium 1 1 QL delayed release budesonide er 1 TERIPARATIDE (RECOMBINANT) 5 PA budesonide oral 1 TYMLOS 5 PA CORTIFOAM 2 Metabolic Bone Disease Agents – Other DIPENTUM 3 calcitriol oral 1 hydrocortisone (perianal) 1 cinacalcet hcl 5 hydrocortisone ace-pramoxine 1 doxercalciferol oral 1 external cream 1-1% NATPARA 5 PA; QL hydrocortisone rectal 1 paricalcitol oral 1 lidocaine-hydrocort (perianal) 1 Miscellaneous Therapeutic Agents LIDOCAINE-HYDROCORTISONE ACE 1 RECTAL GEL ALCOHOL PREP PADS SHEET 70% 3 lidocaine-hydrocortisone ace BACTERIOSTATIC WATER(BENZ ALC) 3 1 rectal kit BOTOX 5 PA mesalamine er oral capsule 0.375 gm 1 BREATHE EASE LARGE 3 mesalamine oral tablet delayed 1 BREATHE EASE MEDIUM 3 release BREATHE EASE SMALL 3 mesalamine rectal 1 BROMELAIN 3 mesalamine-cleanser 1 CAYA 3 PENTASA 3 CHARCOAL ACTIVATED 3 PROCTOFOAM HC 2 CHLORHEXIDINE GLUCONATE 3 procto-med hc 1 SOLUTION 20% procto-pak 1 COMPACT SPACE CHAMBER/LG MASK 3 proctozone-hc 1 COMPACT SPACE CHAMBER/MED 3 SFROWASA 2 MASK COMPACT SPACE CHAMBER/SM sulfasalazine oral 1 3 MASK UCERIS RECTAL 3 DYSPORT 5 PA Metabolic Bone Disease Agents – Drugs for Osteoporosis EASIVENT 3 alendronate sodium oral solution 1 ENCARE 2 PV alendronate sodium oral tablet 1 10 mg, 5 mg ENDARI 3 PA alendronate sodium oral tablet 35 ergoloid mesylates oral 1 1 QL mg, 70 mg FC FEMALE CONDOM 3 PV calcitonin (salmon) nasal 1 QL FC2 FEMALE CONDOM 3 PV EVENITY 5 PA; QL FEMCAP 3 PV ibandronate sodium oral 3 ST; QL FLEXICHAMBER ADULT MASK/SMALL 3 PROLIA 5 PA; QL FLEXICHAMBER CHILD MASK/LARGE 3 risedronate sodium oral tablet 1 QL FLEXICHAMBER CHILD MASK/SMALL 3 150 mg, 35 mg formaldehyde external solution 37% 1
Enhanced Formulary Comprehensive Medication List – 2021 | 33 Drug Name Drug Tier Notes Drug Name Drug Tier Notes GELCLAIR 3 Ophthalmic Agents – GELX 3 Drugs for Eye Allergy, Infection and Inflammation ALOCRIL 3 GLUCAGON HCL (DIAGNOSTIC) 2 ALOMIDE 3 glutaraldehyde external 1 AZASITE 3 HYLENEX 3 azelastine hcl ophthalmic 1 INSPIREASE RESERVOIR BAGS 3 bacitracin ophthalmic 1 methergine 1 bepotastine besilate 1 methylene blue injection 1 BESIVANCE 3 methylergonovine maleate 1 BETADINE OPHTHALMIC PREP 3 MICROCHAMBER 3 bromfenac sodium (once-daily) 1 QL MUCOTROL 3 CILOXAN OPHTHALMIC OINTMENT 3 MYOBLOC 5 PA ciprofloxacin hcl ophthalmic 1 NEXAVIR 3 cromolyn sodium ophthalmic 1 OMNIPOD 5 PACK 3 dexamethasone sodium phosphate OMNIPOD DASH 5 PACK PODS 3 1 ophthalmic ORAPEUTIC 3 diclofenac sodium ophthalmic 1 POCKET SPACER 3 epinastine hcl 1 SORBITOL IRRIGATION SOLUTION 3% 3 erythromycin ophthalmic 1 sorbitol irrigation solution 3.3% 1 EYSUVIS 3 QL sorbitol-mannitol 1 FLAREX 3 sterile water for injection 1 fluorometholone 1 THYROGEN 5 flurbiprofen sodium 1 TODAY SPONGE 2 PV FML 2 VCF VAGINAL CONTRACEPTIVE 2 PV FML FORTE 2 VAGINAL FILM gatifloxacin ophthalmic 1 vcf vaginal contraceptive vaginal gel 1 gentak 1 VITRASE 3 WIDE-SEAL DIAPHRAGM 60 3 PV gentamicin sulfate ophthalmic 1 WIDE-SEAL DIAPHRAGM 65 3 PV INVELTYS 3 WIDE-SEAL DIAPHRAGM 70 3 PV ketorolac tromethamine ophthalmic 1 WIDE-SEAL DIAPHRAGM 75 3 PV KLARITY-A 3 WIDE-SEAL DIAPHRAGM 80 3 PV levofloxacin ophthalmic 1 loteprednol etabonate ophthalmic WIDE-SEAL DIAPHRAGM 85 3 PV 1 suspension WIDE-SEAL DIAPHRAGM 90 3 PV WIDE-SEAL DIAPHRAGM 95 3 PV MAXIDEX 3 XEOMIN INTRAMUSCULAR SOLUTION moxifloxacin hcl (2x day) 1 3 RECONSTITUTED 100 UNIT, 50 UNIT moxifloxacin hcl ophthalmic solution 1 XEOMIN INTRAMUSCULAR SOLUTION NATACYN 3 3 PA RECONSTITUTED 200 UNIT ofloxacin ophthalmic 1
Enhanced Formulary Comprehensive Medication List – 2021 | 34 Drug Name Drug Tier Notes Drug Name Drug Tier Notes olopatadine hcl ophthalmic 1 timolol maleate pf 1 POVIDONE-IODINE OPHTHALMIC 3 TIMOPTIC OCUDOSE OPHTHALMIC 2 PRED MILD 2 SOLUTION 0.25% travoprost (bak free) 1 QL prednisolone acetate ophthalmic 1 Ophthalmic Agents – prednisolone acetate p-f 1 Drugs for Miscellaneous Eye Conditions prednisolone sodium phosphate 1 ak-poly-bac 1 ophthalmic AKTEN 3 sulfacetamide sodium ophthalmic 1 altafrin 1 tobramycin ophthalmic 1 atropine sulfate ophthalmic ointment 1 TOBREX OPHTHALMIC OINTMENT 3 atropine sulfate ophthalmic solution trifluridine 1 1 1% UPNEEQ 3 PA bacitracin-polymyxin b ophthalmic 1 ZIRGAN 3 bacitra-neomycin-polymyxin-hc 1 Ophthalmic Agents – Drugs for Glaucoma BLEPHAMIDE 3 acetazolamide er 1 BLEPHAMIDE S.O.P. 3 acetazolamide oral 1 CEQUA 3 PA ALPHAGAN P OPHTHALMIC 2 CYCLOMYDRIL 3 SOLUTION 0.1% cyclopentolate hcl ophthalmic 1 apraclonidine hcl 1 homatropaire 1 betaxolol hcl ophthalmic 1 LACRISERT 3 BETIMOL 3 LASTACAFT 3 BETOPTIC-S 2 bimatoprost ophthalmic 1 QL neomycin-bacitracin zn-polymyx 1 neomycin-polymyxin-dexameth brimonidine tartrate ophthalmic 1 1 ophthalmic ointment brinzolamide 1 neomycin-polymyxin-dexameth 1 carteolol hcl 1 ophthalmic suspension 3.5-10000-0.1 COMBIGAN 2 neomycin-polymyxin-gramicidin 1 dorzolamide hcl ophthalmic 1 neomycin-polymyxin-hc ophthalmic 1 dorzolamide hcl-timolol mal 1 neo-polycin 1 dorzolamide hcl-timolol mal pf 1 neo-polycin hc 1 IOPIDINE 3 OMIDRIA 3 latanoprost ophthalmic 1 OXERVATE 5 PA; QL levobunolol hcl 1 phenylephrine hcl ophthalmic 1 LUMIGAN 2 QL polycin 1 methazolamide oral 1 polymyxin b-trimethoprim 1 pilocarpine hcl ophthalmic 1 PRED-G 3 SIMBRINZA 2 PRED-G S.O.P. 3 timolol maleate ocudose 1 proparacaine hcl ophthalmic 1 timolol maleate ophthalmic 1 RESTASIS 2
Enhanced Formulary Comprehensive Medication List – 2021 | 35 Drug Name Drug Tier Notes Drug Name Drug Tier Notes RESTASIS MULTIDOSE 2 hydromet 1 QL sulfacetamide-prednisolone HYPERSAL INHALATION 1 3 ophthalmic solution NEBULIZATION SOLUTION 3.5% tetracaine hcl ophthalmic 1 ipratropium bromide nasal 1 TOBRADEX OPHTHALMIC OINTMENT 3 mometasone furoate nasal 1 PA; QL tobramycin-dexamethasone 1 NUCALA 5 PA; QL tropicamide ophthalmic 1 promethazine hcl oral 1 promethazine hcl rectal suppository XIIDRA 2 1 QL 12.5 mg ZYLET 3 promethazine hcl rectal suppository 1 Otic Agents – Drugs for Ear Conditions 25 mg acetic acid otic 1 promethazine vc 1 CIPRO HC 3 promethazine vc/codeine 1 QL ciprofloxacin hcl otic 1 promethazine-codeine 1 QL ciprofloxacin-dexamethasone 1 promethazine-dm 1 CORTISPORIN-TC 3 promethazine-phenyleph-codeine 1 QL flac 1 promethazine-phenylephrine 1 fluocinolone acetonide otic 1 promethegan rectal suppository 1 QL hydrocortisone-acetic acid 1 12.5 mg promethegan rectal suppository neomycin-polymyxin-hc otic 1 1 25 mg, 50 mg ofloxacin otic 1 pseudoephedrine-bromphen-dm 1 Respiratory Tract/Pulmonary Agents – Drugs for Allergies, Cough, Cold sodium chloride inhalation 1 azelastine hcl nasal solution SSKI 3 1 QL 0.1%, 137 mcg/spray SURVANTA 3 benzonatate 1 XOLAIR 5 PA carbinoxamine maleate oral tablet 1 Respiratory Tract/Pulmonary Agents – clemastine fumarate oral syrup 1 Drugs for Asthma and Other Lung Conditions clemastine fumarate oral tablet acetylcysteine inhalation 1 1 2.68 mg ADVAIR DISKUS 2 QL CUROSURF 3 ADVAIR HFA 2 QL cyproheptadine hcl oral 1 albuterol sulfate er 1 dexchlorpheniramine maleate oral 1 albuterol sulfate hfa aerosol solution 1 QL di-phen 1 108 (90 base) mcg/act inhalation diphen oral elixir 1 ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT 3 QL diphenhydramine hcl oral elixir 1 INHALATION flunisolide nasal 1 QL albuterol sulfate inhalation 1 QL fluticasone propionate nasal 1 albuterol sulfate oral 1 hydrocodone polst-chlorphen polst 1 QL ANORO ELLIPTA 2 QL er susp ARFORMOTEROL TARTRATE 3 QL hydrocodone-homatropine 1 QL ARNUITY ELLIPTA 2 QL
Enhanced Formulary Comprehensive Medication List – 2021 | 36 Drug Name Drug Tier Notes Drug Name Drug Tier Notes ATROVENT HFA 3 QL TRELEGY ELLIPTA 2 PA; QL BREO ELLIPTA 2 QL VENTOLIN HFA 2 QL BREZTRI AEROSPHERE 3 PA wixela inhub 1 QL BROVANA 3 QL zafirlukast 1 budesonide inhalation 1 QL Respiratory Tract/Pulmonary Agents – COMBIVENT RESPIMAT 3 QL Drugs for Cystic Fibrosis cromolyn sodium inhalation 1 BRONCHITOL 5 PA; QL DALIRESP 3 PA BRONCHITOL TOLERANCE TEST 5 PA; QL ELIXOPHYLLIN 1 CAYSTON 5 KALYDECO ORAL PACKET 50 MG, 75 epinephrine (anaphylaxis) 1 5 PA MG epinephrine injection solution auto- 1 QL injector 0.15 mg/0.3ml, 0.3 mg/0.3ml KALYDECO ORAL TABLET 5 PA ESBRIET 5 PA ORKAMBI 5 PA; QL FLOVENT DISKUS 2 QL PULMOZYME 5 SYMDEKO ORAL TABLET THERAPY FLOVENT HFA 2 QL 5 QL PACK 100-150 & 150 MG fluticasone-salmeterol inhalation aerosol powder breath activated tobramycin nebulization solution 300 1 QL 5 100-50 mcg/dose, 250-50 mcg/dose, mg/5ml inhalation 500-50 mcg/dose TOBRAMYCIN NEBULIZATION 5 FLUTICASONE-SALMETEROL SOLUTION 300 MG/5ML INHALATION INHALATION AEROSOL POWDER TRIKAFTA 5 PA; QL 1 QL BREATH ACTIVATED 113-14 MCG/ACT, Respiratory Tract/Pulmonary Agents – 232-14 MCG/ACT, 55-14 MCG/ACT Drugs for Pulmonary Hypertension ipratropium bromide inhalation 1 QL ADEMPAS 5 PA; QL ipratropium-albuterol 1 QL alyq 5 PA; QL montelukast sodium oral 1 ambrisentan 5 PA; QL OFEV 5 PA bosentan 5 PA; QL PERFOROMIST 3 QL OPSUMIT 5 PA; QL PROAIR HFA 2 QL sildenafil citrate oral suspension 5 PA; QL PROAIR RESPICLICK 2 QL reconstituted PULMICORT FLEXHALER 2 QL sildenafil citrate oral tablet 20 mg 5 PA; QL SEREVENT DISKUS 2 QL tadalafil (pah) 5 PA; QL SPIRIVA HANDIHALER 2 QL TRACLEER 32 MG 5 PA; QL SPIRIVA RESPIMAT 2 QL TYVASO 5 PA; QL STIOLTO RESPIMAT 2 QL TYVASO REFILL 5 PA; QL STRIVERDI RESPIMAT 3 QL TYVASO STARTER 5 PA; QL SYMBICORT 2 QL UPTRAVI 5 PA; QL terbutaline sulfate injection 1 VENTAVIS 5 PA; QL terbutaline sulfate oral 1 Skeletal Muscle Relaxants – Drugs for Muscle Pain and Spasm THEO-24 3 baclofen oral tablet 10 mg, 20 mg 1 theophylline er 1 carisoprodol oral tablet 350 mg 1
Enhanced Formulary Comprehensive Medication List – 2021 | 37 Drug Name Drug Tier Notes chlorzoxazone oral tablet 500 mg 1 cyclobenzaprine hcl oral 1 dantrolene sodium oral 1 metaxalone oral tablet 800 mg 2 PA methocarbamol oral 1 orphenadrine citrate er 1 tizanidine hcl oral tablet 1 Sleep Disorder Agents AMYTAL SODIUM 3 armodafinil 1 PA; QL doxepin hcl oral tablet 1 PA; QL eszopiclone 2 QL flurazepam hcl 1 QL modafinil 1 PA; QL ramelteon 1 QL SUNOSI 3 PA; QL temazepam 1 QL WAKIX 5 PA; QL XYREM 5 PA; QL XYWAV 5 PA; QL zaleplon 1 QL zolpidem tartrate er 2 QL zolpidem tartrate oral 1 QL
Enhanced Formulary Comprehensive Medication List – 2021 | 38 Index of Drugs ALFERON N 31 APTIVUS 14 alfuzosin hcl er 27 ARAKODA 13 A ALINIA 13 aranelle 28 aliskiren fumarate 16 ARFORMOTEROL TARTRATE 36 abacavir-lamivudine-zidovudine 14 ALKINDI SPRINKLE 27 argyle sterile saline 24 abacavir sulfate 14 allopurinol 10 argyle sterile water 24 abacavir sulfate-lamivudine 14 almotriptan malate 10 ARIKAYCE 7 ABILIFY MAINTENA 13 ALOCRIL 34 aripiprazole 13 abiraterone acetate 11 ALOMIDE 34 ARISTADA 13 acamprosate calcium 6 alosetron hcl 25 ARISTADA INITIO 14 acarbose 22 ALPHAGAN P 35 armodafinil 38 ACCU-CHEK AVIVA DEVICE 22 alprazolam 15 ARMOUR THYROID 31 ACCU-CHEK AVIVA PLUS KIT W/DEVICE 22 alprazolam intensol 15 ARNUITY ELLIPTA 36 ACCU-CHEK COMPACT PLUS TEST STRIPS 22 alprostadil 16 ascomp-codeine 5 ACCU-CHEK FASTCLIX LANCET KIT 22 ALTABAX 7 asenapine maleate 14 ACCU-CHEK GUIDE TEST STRIPS 22 altafrin 35 ashlyna 28 ACCU-CHEK SMARTVIEW TEST STRIPS 22 altavera 28 aspirin 5 ACCU-CHEK SOFTCLIX LANCET DEVICE KIT 22 ALTRENO 19 aspirin adult low strength 5 accutane 19 ALUNBRIG 11 aspirin childrens 5 acebutolol hcl 16 alyacen 1/35 28 aspirin-dipyridamole er 13 acetaminophen-codeine 5 alyacen 7/7/7 28 aspirin ec 5 acetaminophen-codeine #2 5 alyq 37 aspirin ec low dose 5 acetaminophen-codeine #3 5 amabelz 28 aspirin ec low strength 5 acetaminophen-codeine #4 5 amantadine hcl 13 aspirin low dose 5 acetazolamide 35 ambrisentan 37 ASTAGRAF XL 31 acetazolamide er 35 amcinonide 19 ASTRINGYN 15 acetazolamide sodium 16 amethia 28 ATABEX OB 24 acetic acid 26, 36 amethyst 28 atazanavir sulfate 14 acetylcysteine 36 amikacin sulfate 7 atenolol 16 acitretin 19 amiloride hcl 16 atenolol-chlorthalidone 16 ACTEMRA 31 amiloride-hydrochlorothiazide 16 atomoxetine hcl 18 ACTEMRA ACTPEN 31 aminoacetic acid 26 atorvastatin calcium 16 ACTHIB 32 aminocaproic acid 15 atovaquone 13 ACTIMMUNE 31 amiodarone hcl 16 atovaquone-proguanil hcl 13 acyclovir 14 AMITIZA 25 atropine sulfate 25, 35 ACZONE 19 amitriptyline hcl 9 ATROVENT HFA 37 adapalene 19 amlodipine-atorvastatin 16 AUBAGIO 19 adapalene-benzoyl peroxide 19 amlodipine besylate 16 aubra 28 adefovir dipivoxil 14 amlodipine besylate-benazepril hcl 16 aubra eq 28 ADEMPAS 37 amlodipine besylate-valsartan 16 AUGMENTIN 7 adult aspirin regimen 5 amlodipine-olmesartan 16 aurovela 1.5/30 28 ADVAIR DISKUS 36 amlodipine-valsartan-hctz 16 aurovela 1/20 28 ADVAIR HFA 36 ammonium lactate 19 aurovela 24 fe 28 AEMCOLO 7 amnesteem 19 aurovela fe 1.5/30 28 AFINITOR 11 amoxapine 9 aurovela fe 1/20 28 afirmelle 28 amoxicill-clarithro-lansopraz 25 AURYXIA 26 AIMOVIG 10 amoxicillin 7 AUTOLET II CLINISAFE 22 ak-poly-bac 35 amoxicillin-potassium clavulanate 7 AUTOLET LANCING DEVICE 22 AKTEN 35 amoxicillin-potassium clavulanate er 7 aviane 28 ala-cort 19 amphetamine-dextroamphetamine 18 avidoxy 7 albendazole 13 amphetamine-dextroamphetamine er 18 AVONEX PEN 19 albuterol sulfate 36 ampicillin 7 AVONEX PREFILLED 19 albuterol sulfate er 36 AMYTAL SODIUM 38 ayuna 28 albuterol sulfate hfa 36 anagrelide hcl 15 AYVAKIT 11 ALBUTEROL SULFATE HFA 36 ana-lex 33 AZASAN 31 alclometasone dipropionate 19 anastrozole 11 AZASITE 34 ALCOHOL PREP PADS 33 ANORO ELLIPTA 36 azathioprine 31 ALDACTAZIDE 16 apraclonidine hcl 35 azelaic acid 19 ALECENSA 11 aprepitant 9 azelastine hcl 34, 36 alendronate sodium 33 apri 28 AZELEX 19
Enhanced Formulary Comprehensive Medication List – 2021 | 39 azithromycin 7 BOCASAL 19 calcium acetate 26 azurette 28 BOOSTRIX 32 calcium acetate (phos binder) 26 bosentan 37 CALCIUM-FOLIC ACID PLUS D 24 B BOSULIF 11 CALQUENCE 11 BOTOX 33 camila 28 bac 5 bp 10-1 19 camrese 28 bacitracin 7, 34 bp wash 20 camrese lo 28 bacitracin-polymyxin b 35 BRAFTOVI 11 candesartan cilexetil 16 bacitra-neomycin-polymyxin-hc 35 BREATHE EASE LARGE 33 candesartan cilexetil-hctz 16 baclofen 37 BREATHE EASE MEDIUM 33 capecitabine 11 BACTERIOSTATIC WATER(BENZ ALC) 33 BREATHE EASE SMALL 33 CAPEX 20 balsalazide disodium 33 BREO ELLIPTA 37 CAPRELSA 11 BALVERSA 11 BREZTRI AEROSPHERE 37 captopril 16 balziva 28 briellyn 28 captopril-hydrochlorothiazide 16 BAQSIMI ONE PACK 23 BRILINTA 13 CARAC 20 BAQSIMI TWO PACK 23 brimonidine tartrate 35 CARBAGLU 24 BARACLUDE 14 brinzolamide 35 carbamazepine 8 BAXDELA 7 BRIVIACT 8 carbamazepine er 8 BD AUTOSHIELD DUO PEN NEEDLES 23 BROMELAIN 33 carbidopa 13 BD ULTRA-FINE INSULIN SYRINGES 23 bromfenac sodium (once-daily) 34 carbidopa-levodopa 13 BD ULTRA-FINE PEN NEEDLES 23 bromocriptine mesylate 13 carbidopa-levodopa-entacapone 13 BD VEO INSULIN SYR U/F 1/2UNIT 23 BRONCHITOL 37 carbidopa-levodopa er 13 bekyree 28 BRONCHITOL TOLERANCE TEST 37 carbinoxamine maleate 36 belladonna alkaloids-opium 25 BROVANA 37 CARETOUCH LANCING/EJECTOR 22 benazepril hcl 16 BRUKINSA 11 carisoprodol 37 benazepril-hydrochlorothiazide 16 budesonide 33, 37 carisoprodol-aspirin-codeine 5 BENLYSTA 31 budesonide er 33 carteolol hcl 35 BENSAL HP 19 bumetanide 16 cartia xt 16 benzalkonium chloride 7 bupivacaine-epinephrine 6 carvedilol 16 benzepro 19 bupivacaine-epinephrine (pf) 6 carvedilol phosphate er 16 BENZNIDAZOLE 13 bupivacaine fisiopharma 6 cascara sagrada 25 benzonatate 36 bupivacaine hcl 6 cavarest 19 BENZOYL PEROX-HYDROCORTISONE 19 bupivacaine hcl (pf) 6 CAVERJECT 26 benzoyl peroxide 19 buprenorphine 5 CAYA 33 benzoyl peroxide-erythromycin 19 buprenorphine hcl 6 CAYSTON 37 benztropine mesylate 13 buprenorphine hcl-naloxone hcl 6 caziant 28 bepotastine besilate 34 bupropion hcl 9 cefaclor 7 beser 19 bupropion hcl er (smoking det) 6 cefaclor er 7 BESIVANCE 34 bupropion hcl er (sr) 9 cefadroxil 7 BETADINE OPHTHALMIC PREP 34 bupropion hcl er (xl) 9 cefdinir 7 betamethasone dipropionate 19 buspirone hcl 15 cefixime 7 betamethasone dipropionate aug 19 butalbital-acetaminophen 5 cefpodoxime proxetil 7 betamethasone sod phos & acet 27 butalbital-apap-caff-cod 5 cefprozil 7 betamethasone valerate 19 butalbital-apap-caffeine 5 ceftriaxone sodium 7 BETASERON 19 butalbital-asa-caff-codeine 5 cefuroxime axetil 7 betaxolol hcl 16, 35 butalbital-aspirin-caffeine 5 celecoxib 5 bethanechol chloride 26 butorphanol tartrate 5 CELONTIN 8 BETIMOL 35 BYDUREON BCISE AUTOINJECTOR 22 cephalexin 7 BETOPTIC-S 35 BYETTA 5 MCG PEN 22 CEQUA 35 bexarotene 11 BYETTA 10 MCG PEN 22 CEQUR SIMPLICITY 2U 22 BEXSERO 32 BYSTOLIC 16 CERDELGA 26 bicalutamide 11 CETROTIDE 27 BIDIL 16 C cevimeline hcl 19 BIJUVA 28 CHANTIX 6 BIKTARVY 14 CABENUVA 14 CHANTIX CONTINUING MONTH PAK 6 bimatoprost 35 cabergoline 27 CHANTIX STARTING MONTH PAK 6 bisoprolol fumarate 16 CABOMETYX 11 CHARCOAL ACTIVATED 33 bisoprolol-hydrochlorothiazide 16 caffeine citrate 19 charlotte 24 fe 28 BLEPHAMIDE 35 CALCIFOL 24 chateal 28 BLEPHAMIDE S.O.P. 35 calcipotriene 20 chateal eq 28 blisovi 24 fe 28 calcipotriene-betameth diprop 20 CHEMET 24 blisovi fe 1.5/30 28 calcitonin (salmon) 33 CHENODAL 25 blisovi fe 1/20 28 calcitriol 20, 33 chlordiazepoxide-amitriptyline 9 Enhanced Formulary Comprehensive Medication List – 2021 | 40 chlordiazepoxide hcl 15 COLCHICINE 10 dasetta 1/35 28 chlorhexidine gluconate 19 colchicine-probenecid 10 dasetta 7/7/7 28 CHLORHEXIDINE GLUCONATE 33 colesevelam hcl 16 DAURISMO 11 chloroprocaine hcl (pf) 6 colestipol hcl 16 daysee 28 chloroquine phosphate 13 colistimethate sodium (cba) 7 DAYTRANA 18 chlorpromazine hcl 14 COMBIGAN 35 DEBACTEROL 19 chlorthalidone 16 COMBIPATCH 28 deblitane 28 chlorzoxazone 38 COMBIVENT RESPIMAT 37 DECARA 24 CHOLBAM 26 COMETRIQ 11 deferasirox 24 cholestyramine 16 COMPACT SPACE CHAMBER/LG MASK 33 deferasirox granules 24 cholestyramine light 16 COMPACT SPACE CHAMBER/MED MASK 33 deferiprone 24 chorionic gonadotropin 27 COMPACT SPACE CHAMBER/SM MASK 33 DELSTRIGO 14 ciclodan 10 COMPLERA 14 delyla 28 ciclopirox 10 compro 9 demeclocycline hcl 7 ciclopirox olamine 10 CONDYLOX 20 DEMSER 16 ciclopirox treatment 10 constulose 25 DEPO-ESTRADIOL 28 cilostazol 13 COPAXONE 19 DEPO-SUBQ PROVERA 104 28 CILOXAN 34 COPIKTRA 11 DESCOVY 14 CIMDUO 14 CORDRAN 20 desipramine hcl 9 CIMZIA 31 CORLANOR 16 desmopressin ace spray refrig 27 CIMZIA PREFILLED KIT 31 CORTIFOAM 33 desmopressin acetate 27 CIMZIA STARTER KIT 31 CORTISPORIN-TC 36 desmopressin acetate pf 27 cinacalcet hcl 33 COTELLIC 11 desmopressin acetate spray 27 CINRYZE 31 CREON 26 desogestrel-ethinyl estradiol 28 CIPRO 7 CRESEMBA 10 desonide 20 ciprofloxacin-dexamethasone 36 CRINONE 28 desoximetasone 20 ciprofloxacin hcl 7, 34, 36 CRIXIVAN 14 desrx 20 CIPRO HC 36 cromolyn sodium 25, 34, 37 DESVENLAFAXINE ER 9 citalopram hydrobromide 9 crotan 13 desvenlafaxine succinate er 9 claravis 20 cryselle-28 28 dexamethasone 27 clarithromycin 7 curity sterile saline 24 dexamethasone intensol 27 clarithromycin er 7 CUROSURF 36 dexamethasone sodium phosphate 27, 34 clemastine fumarate 36 CUVITRU 31 dexamethasone sod phosphate pf 27 CLEOCIN 7 CUVPOSA 25 dexchlorpheniramine maleate 36 CLIMARA PRO 28 cyanocobalamin 24 DEXCOM G4 / G5 / G6 RECEIVER, TRANSMIT- clindacin etz 20 cyclafem 1/35 28 TER, SENSOR (INCLUDING PLATINUM, PLATI- clindacin-p 20 cyclafem 7/7/7 28 NUM PEDIATRIC) 22 clindamycin hcl 7 cyclobenzaprine hcl 38 dexmethylphenidate hcl 18 clindamycin palmitate hcl 7 CYCLOMYDRIL 35 dexmethylphenidate hcl er 18 clindamycin phosphate 7, 20 cyclopentolate hcl 35 dextroamphetamine sulfate 18 clindamycin phosphate-benzoyl peroxide 20 cyclophosphamide 11 dextroamphetamine sulfate er 18 clindamycin-tretinoin 20 CYCLOPHOSPHAMIDE 11 DIATHRIVE LANCING DEVICE 22 clobazam 8 cycloserine 11 diazepam 8, 15 clobetasol prop emollient base 20 cyclosporine 31 diazepam intensol 15 clobetasol propionate 20 cyclosporine modified 31 diazoxide 23 clobetasol propionate e 20 cyproheptadine hcl 36 diclofenac-misoprostol 6 clobetasol propionate emulsion 20 cyred 28 DICLOFENAC PATCH 1.3% 5 clocortolone pivalate 20 cyred eq 28 diclofenac potassium 6 clodan 20 CYSTADANE 26 diclofenac sodium 6, 20, 34 clomipramine hcl 9 CYSTAGON 26 diclofenac sodium er 6 clonazepam 15 cytra k crystals 24 dicloxacillin sodium 7 clonidine 16 dicyclomine hcl 25 clonidine hcl 16 D DIFICID 7 clopidogrel bisulfate 13 diflorasone diacetate 20 d3 high potency 24 clorazepate dipotassium 15 diflunisal 6 d3 super strength 24 clotrimazole 10 digitek 16 dalfampridine er 19 clotrimazole-betamethasone 10 digox 16 DALIRESP 37 clovique 24 digoxin 16 danazol 27 clozapine 14 dihydroergotamine mesylate 10 dantrolene sodium 38 coal tar 20 DILANTIN 8 dapsone 11, 20 COARTEM 13 DILANTIN INFATABS 8 DAPSONE 20 codeine sulfate 5 DILATRATE-SR 16 darifenacin hydrobromide er 26 colchicine 10 diltiazem hcl 16 Enhanced Formulary Comprehensive Medication List – 2021 | 41 diltiazem hcl er 16 eletriptan hydrobromide 10 estradiol-norethindrone acet 29 diltiazem hcl er beads 16 ELIGARD 27 estradiol valerate 29 diltiazem hcl er coated beads 16 elinest 29 ESTRING 29 dilt-xr 16 ELIQUIS 8 ESTROGEL 29 dimethyl fumarate 19 ELIQUIS DVT/PE STARTER PACK 8 eszopiclone 38 dimethyl fumarate starter pack 19 ELIXOPHYLLIN 37 ethacrynic acid 17 DIPENTUM 33 ELLA 29 ethambutol hcl 11 di-phen 36 ELMIRON 26 ethosuximide 8 diphen 36 eluryng 29 ethyl chloride 6 diphenhydramine hcl 36 EMBRACE LANCING DEVICE/EJECTOR 22 ethynodiol diac-eth estradiol 29 diphenoxylate-atropine 25 EMCYT 11 etodolac 6 dipyridamole 13 EMEND 10 etonogestrel-ethinyl estradiol 29 disopyramide phosphate 16 EMGALITY 10 etoposide 11 disulfiram 6 EMGALITY (300 MG DOSE) 10 EUCRISA 20 DIURIL 16 emoquette 29 euthyrox 31 divalproex sodium 8 EMSAM 9 EVAMIST 29 divalproex sodium er 8 emtricitabine 14 EVENITY 33 DIVIGEL 29 emtricitabine-tenofovir df 14 everolimus 11, 31 dofetilide 16 EMTRIVA 14 EVOTAZ 14 dolishale 29 enalapril-hydrochlorothiazide 17 EVRYSDI 26 donepezil hcl 9 enalapril maleate 17 EXELDERM 10 dorzolamide hcl 35 ENCARE 33 exemestane 11 dorzolamide hcl-timolol mal 35 ENDARI 33 EYSUVIS 34 dorzolamide hcl-timolol mal pf 35 endocet 5 ezetimibe 17 dotti 29 ENDOMETRIN 29 ezetimibe-simvastatin 17 DOVATO 14 ENGERIX-B 32 doxazosin mesylate 16 enoxaparin sodium 8 F doxepin hcl 9, 20, 38 enpresse-28 29 falmina 29 doxercalciferol 33 enskyce 29 famciclovir 14 doxycycline hyclate 7 ENSTILAR 20 famotidine 25 doxycycline monohydrate 7 entacapone 13 FANAPT 14 DRITHO-CREME HP 20 entecavir 14 FANAPT TITRATION PACK 14 dronabinol 9 ENTRESTO 17 FARXIGA 22 droperidol 9 enulose 25 FARYDAK 11 DROPLET GENTEEL LANCING DEVICE 22 ENVARSUS XR 31 fayosim 29 drospiren-eth estrad-levomefol 29 ephedrine sulfate 17 FC2 FEMALE CONDOM 33 drospirenone-ethinyl estradiol 29 EPIDIOLEX 8 FC FEMALE CONDOM 33 DROXIA 11 EPIFOAM 20 febuxostat 10 DUAVEE 29 epinastine hcl 34 felbamate 8 duloxetine hcl 9 epinephrine 37 felodipine er 17 DUPIXENT 20 epinephrine (anaphylaxis) 37 FEMCAP 33 dutasteride 27 epitol 8 FEMRING 29 dutasteride-tamsulosin hcl 27 EPIVIR HBV 14 femynor 29 DUTOPROL 17 eplerenone 17 fenofibrate 17 d-vite pediatric 24 EQUETRO 15 fenofibrate micronized 17 DYSPORT 33 ergocalciferol 24 fenofibric acid 17 ergoloid mesylates 33 FENSOLVI (6 MONTH) 27 E ERGOMAR 10 fentanyl 5 ergotamine-caffeine 11 EASIVENT 33 fentanyl citrate 5 ERIVEDGE 11 easygel 19 FERRIPROX 24 ERLEADA 11 econazole nitrate 10 ferrous sulfate 24 erlotinib hcl 11 EDARBI 17 FIBRICOR 17 errin 29 EDARBYCLOR 17 finasteride 27 ERTACZO 10 EDEX 26 FINTEPLA 8 ery 20 EDURANT 14 flac 36 erythromycin 7, 20, 34 efavirenz 14 FLAREX 34 erythromycin base 7 efavirenz-emtricitab-tenofovir 14 flavoxate hcl 26 erythromycin ethylsuccinate 7 efavirenz-lamivudine-tenofovir 14 flecainide acetate 17 ESBRIET 37 effer-k 24 FLECTOR 6 escitalopram oxalate 9 EFFER-K 24 FLEXICHAMBER ADULT MASK/SMALL 33 estarylla 29 EGRIFTA SV 27 FLEXICHAMBER CHILD MASK/LARGE 33 estazolam 15 ELESTRIN 29 FLEXICHAMBER CHILD MASK/SMALL 33 estradiol 29 Enhanced Formulary Comprehensive Medication List – 2021 | 42 FLOVENT DISKUS 37 GARDASIL 9 32 hailey fe 1.5/30 29 FLOVENT HFA 37 gatifloxacin 34 hailey fe 1/20 29 fluconazole 10 gavilyte-c 25 halobetasol propionate 20 flucytosine 10 gavilyte-g 25 haloperidol 14 fludrocortisone acetate 27 gavilyte-n with flavor pack 25 haloperidol decanoate 14 flunisolide 36 GAVRETO 11 haloperidol lactate 14 fluocinolone acetonide 20, 36 GELCLAIR 34 HAVRIX 32 fluocinolone acetonide body 20 GELX 34 heather 29 fluocinolone acetonide scalp 20 gemfibrozil 17 HELIDAC THERAPY 26 fluocinonide 20 GENADUR 20 HEMADY 27 fluocinonide emulsified base 20 generlac 25 HEPAGAM B 32 fluoridex daily renewal 19 gengraf 31 HEPLISAV-B 32 fluoritab 24 gentak 34 HIBERIX 32 fluorometholone 34 gentamicin sulfate 7, 34 HIZENTRA 32 FLUOROPLEX 20 GENTEEL LANCING KIT (BLUE) 22 homatropaire 35 fluorouracil 20 GENVOYA 14 HUMALOG U-100 JUNIOR KWIKPEN 23 FLUOROURACIL 20 GIALAX 26 HUMIRA 32 fluoxetine hcl 9 GILENYA 19 HUMIRA PEDIATRIC CROHNS START 32 fluphenazine decanoate 14 GILOTRIF 11 HUMIRA PEN 32 fluphenazine hcl 14 glatiramer acetate 19 HUMIRA PEN-CD/UC/HS STARTER 32 flurandrenolide 20 glatopa 19 HUMIRA PEN-PEDIATRIC UC START 32 flurazepam hcl 38 GLEOSTINE 11 HUMIRA PEN-PSOR/UVEIT STARTER 32 flurbiprofen 6 glimepiride 22 HUMIRA PEN-PS/UV/ADOL HS START 32 flurbiprofen sodium 34 glipizide er 22 HUMULIN R U-500 KWIKPEN 23 flutamide 11 glipizide ir 22 HUMULIN R U-500 VIAL 23 fluticasone propionate 20, 36 glipizide-metformin hcl 22 HYCAMTIN 11 fluticasone-salmeterol 37 glipizide xl 22 hydralazine hcl 17 FLUTICASONE-SALMETEROL 37 glucagon emergency kit 23 hydrochlorothiazide 17 fluvastatin sodium 17 GLUCAGON EMERGENCY KIT 23 hydrocodone-acetaminophen 5 fluvastatin sodium er 17 GLUCAGON HCL (DIAGNOSTIC) 34 hydrocodone-homatropine 36 fluvoxamine maleate 9 glutaraldehyde 34 hydrocodone-ibuprofen 5 fluvoxamine maleate er 9 glyburide 22 hydrocodone polst-chlorphen polst er susp 36 FML 34 glyburide-metformin 22 hydrocortisone 20, 27, 33 FML FORTE 34 glyburide micronized 22 hydrocortisone ace-pramoxine 33 folic acid 24 glycine 26 hydrocortisone-acetic acid 36 FOLLISTIM AQ 27 glycine urologic 26 hydrocortisone butyrate 20 fondaparinux sodium 8 glycolic acid 20 hydrocortisone butyr lipo base 20 formaldehyde 33 glycopyrrolate 26 hydrocortisone (perianal) 33 fosamprenavir calcium 14 GLYCOPYRROLATE 26 hydrocortisone valerate 21 fosfomycin tromethamine 7 glydo 6 hydrogen peroxide 7 fosinopril sodium 17 GLYXAMBI 22 hydromet 36 fosinopril sodium-hctz 17 GOJJI LANCING DEVICE/CLEAR CAP 22 hydromorphone hcl 5 FRAGMIN 8 GONAL-F 27 hydromorphone hcl er 5 FREESTYLE LIBRE 2 READER 22 GONAL-F RFF 27 hydroxocobalamin acetate 24 FREESTYLE LIBRE 2 SENSOR 22 GONAL-F RFF REDIJECT 27 hydroxychloroquine sulfate 13 FREESTYLE LIBRE 14 DAY READER 22 goodsense aspirin low dose 6 hydroxyprogesterone caproate 29 FREESTYLE LIBRE 14 DAY SENSOR 22 GORDOFILM 20 hydroxyurea 11 FREESTYLE LIBRE READER 22 granisetron hcl 10 hydroxyzine hcl 15 FREESTYLE LIBRE SENSOR SYSTEM 22 griseofulvin microsize 10 hydroxyzine pamoate 15 frovatriptan succinate 11 griseofulvin ultramicrosize 10 HYLENEX 34 fulvestrant 11 guanfacine hcl 17 hyoscyamine sulfate 26 furosemide 17 guanfacine hcl er 18 hyoscyamine sulfate er 26 FUZEON 14 GUANIDINE HCL 11 hyoscyamine sulfate sl 26 fyavolv 29 GVOKE HYPOPEN 1-PACK 23 HYPERHEP B 32 FYCOMPA 8 GVOKE HYPOPEN 2-PACK 23 HYPERSAL 36 GVOKE PFS 23 HYQVIA 32 G GYNAZOLE-1 10 I gabapentin 8 H galantamine hydrobromide 9 ibandronate sodium 33 galantamine hydrobromide er 9 HAEGARDA 31 IBRANCE 11 GALZIN 24 hailey 1.5/30 29 ibuprofen 6 ganirelix acetate 27 hailey 24 fe 29 iclevia 29
Enhanced Formulary Comprehensive Medication List – 2021 | 43 ICLUSIG 11, 12 J L icosapent ethyl 17 IDHIFA 12 jaimiess 29 labetalol hcl 17 ILUMYA 32 JAKAFI 12 LACRISERT 35 imatinib mesylate 12 jantoven 8 lactated ringers 24 IMBRUVICA 12 JANUMET 22 lactic acid 21 IMCIVREE 19 JANUMET XR 22 lactic acid e 21 imipramine hcl 9 JANUVIA 22 lactulose 26 imipramine pamoate 9 JARDIANCE 22 lactulose encephalopathy 26 imiquimod 21 jasmiel 29 lamivudine 14 IMVEXXY MAINTENANCE PACK 29 jencycla 29 lamivudine-zidovudine 15 IMVEXXY STARTER PACK 29 JENTADUETO 22 lamotrigine 8 INBRIJA 13 JENTADUETO XR 22 lamotrigine er 8 incassia 29 jinteli 29 LAMPIT 13 INCRELEX 27 jolessa 29 LANCETS 22 indapamide 17 juleber 29 lansoprazole 25 INDOCIN 6 junel 1.5/30 29 lanthanum carbonate 26 indomethacin 6 junel 1/20 29 LANTUS SOLOSTAR 23 indomethacin er 6 junel fe 1.5/30 29 LANTUS U-100 VIAL 23 INFANRIX 32 junel fe 1/20 29 lapatinib ditosylate 12 INLYTA 12 junel fe 24 29 larin 1.5/30 29 INREBIC 12 JYNARQUE 24 larin 1/20 29 INSPIREASE RESERVOIR BAGS 34 larin 24 fe 29 INSULIN ASPART 23 K larin fe 1.5/30 29 larin fe 1/20 29 INSULIN ASPART FLEXPEN 23 kaitlib fe 29 larissia 29 INSULIN ASPART PENFILL 23 KALETRA 14 LASTACAFT 35 INSULIN ASPART PROT & ASPART 23 kalliga 29 latanoprost 35 INSULIN ASP PROT & ASP FLEXPEN 23 KALYDECO 37 LATUDA 14 INSULIN PEN NEEDLES 23 kariva 29 layolis fe 29 INSULIN SYRINGES 23 kelnor 1/35 29 leena 29 INTELENCE 14 kelnor 1/50 29 leflunomide 32 INTRAROSA 26 KERALYT SCALP 21 LENVIMA 12 INTRON A 14 KESIMPTA 19 lessina 29 introvale 29 ketoconazole 10 letrozole 12 INVEGA SUSTENNA 14 ketodan 10 leucovorin calcium 12 INVEGA TRINZA 14 ketoprofen 6 LEUKERAN 12 INVELTYS 34 ketoprofen er 6 LEUKINE 15 INVIRASE 14 ketorolac tromethamine 6, 34 leuprolide acetate 28 iodine strong 24 KEVZARA 32 LEVEMIR U-100 FLEXTOUCH 23 iodine tincture 7 kids first vitamin d3 gummies 24 LEVEMIR U-100 VIAL 23 IOPIDINE 35 KINRIX 32 levetiracetam 8 IPOL 32 KISQALI 12 levetiracetam er 8 ipratropium-albuterol 37 KISQALI FEMARA 12 levobunolol hcl 35 ipratropium bromide 36, 37 KLARITY-A 34 levocarnitine 24 irbesartan 17 klor-con 24 levocarnitine sf 24 irbesartan-hydrochlorothiazide 17 klor-con 10 24 levofloxacin 7, 34 IRESSA 12 klor-con/ef 24 levonest 29 ISENTRESS 14 klor-con m10 24 levonorgest-eth est & eth est 29 ISENTRESS HD 14 KLOR-CON M15 24 levonorgest-eth estrad 91-day 29 isibloom 29 klor-con m20 24 levonorgestrel 29 isoniazid 11 KORLYM 28 levonorgestrel-ethinyl estrad 30 isosorbide dinitrate 17 KOSELUGO 12 levonorg-eth estrad triphasic 30 isosorbide mononitrate 17 K-PHOS 24 levora 0.15/30 (28) 30 isosorbide mononitrate er 17 K-PHOS NO 2 24 levo-t 31 isotretinoin 21 k-prime 24 levothyroxine sodium 31 isradipine 17 KRINTAFEL 13 levoxyl 31 ISTURISA 28 kurvelo 29 LEVSIN 26 itraconazole 10 KYNMOBI 13 LEVULAN KERASTICK 21 ivermectin 13 KYNMOBI TITRATION KIT 13 LEXIVA 15
Enhanced Formulary Comprehensive Medication List – 2021 | 44 lidocaine 6 MAKENA 30 methylphenidate hcl er (la) 18 lidocaine-epinephrine 6 malathion 13 methylprednisolone 27 lidocaine hcl 6, 19 maprotiline hcl 9 methylprednisolone acetate 27 lidocaine hcl (pf) 6 marlissa 30 methyl salicylate 21 lidocaine hcl urethral/mucosal 6 MARPLAN 9 methyltestosterone 27 lidocaine-hydrocortisone ace 33 MATULANE 12 metoclopramide hcl 10 LIDOCAINE-HYDROCORTISONE ACE 33 matzim la 17 metolazone 17 lidocaine-hydrocort (perianal) 33 MAVENCLAD 19 metoprolol-hydrochlorothiazide 17 lidocaine-prilocaine 6 MAVYRET 15 metoprolol succinate er 17 lidocaine viscous hcl 19 MAXIDEX 34 metoprolol tartrate 17 lidopin 6 meclizine hcl 10 metronidazole 7, 21 lillow 30 meclofenamate sodium 6 metyrosine 17 lindane 13 MEDROL 27 mexiletine hcl 17 linezolid 7 medroxyprogesterone acetate 30 miconazole 3 10 LINZESS 26 mefenamic acid 6 MICROCHAMBER 34 liothyronine sodium 31 mefloquine hcl 13 microgestin 1.5/30 30 lisinopril 17 megestrol acetate 30 microgestin 1/20 30 lisinopril-hydrochlorothiazide 17 MEKINIST 12 microgestin 24 fe 30 lithium 15 MEKTOVI 12 microgestin fe 1.5/30 30 lithium carbonate 15 meloxicam 6 microgestin fe 1/20 30 lithium carbonate er 15 melphalan 12 MICROLET NEXT LANCING DEVICE 23 LITHOSTAT 26 memantine hcl 9 midodrine hcl 17 lojaimiess 30 memantine hcl er 9 mifepristone 24 LO LOESTRIN FE 30 MENACTRA 32 MIGERGOT 11 LONSURF 12 me/naphos/mb/hyo1 26 miglitol 22 loperamide hcl 26 MENEST 30 miglustat 26 lopinavir-ritonavir 15 MENOPUR 28 mili 30 lorazepam 15 MENOSTAR 30 mimvey 30 lorazepam intensol 15 MENQUADFI 32 minitran 17 LORBRENA 12 MENTAX 10 minocycline hcl 7 LORTAB 5 MENVEO 32 minoxidil 17 loryna 30 meperidine hcl 5 MIRCERA 15, 16 losartan potassium 17 meprobamate 15 mirtazapine 9 losartan potassium-hctz 17 mercaptopurine 12 misoprostol 25 loteprednol etabonate 34 mesalamine 33 MITIGARE 10 lovastatin 17 mesalamine-cleanser 33 M-M-R II 32 low-ogestrel 30 mesalamine er oral capsule 0.375 gm 33 M-NATAL PLUS 24 loxapine succinate 14 MESNEX 12 modafinil 38 lo-zumandimine 30 metaxalone 38 moexipril hcl 17 LUBIPROSTONE 26 metformin hcl er 22 mometasone furoate 21, 36 LUMIGAN 35 metformin hcl ir 22 mondoxyne nl 7 LUPANETA PACK 28 methadone hcl 5 mono-linyah 30 LUPKYNIS 32 methadone hcl intensol 5 montelukast sodium 37 LUPRON DEPOT (1-MONTH) 28 methadose 5 morgidox 7 LUPRON DEPOT (3-MONTH) 28 methamphetamine hcl 18 morphine sulfate 5 LUPRON DEPOT (4-MONTH) INTRAMUSCULAR methazolamide 35 morphine sulfate (concentrate) 5 KIT 30MG 28 methenamine hippurate 7 morphine sulfate er 5 LUPRON DEPOT (6-MONTH) INTRAMUSCULAR methenamine mandelate 7 morphine sulfate er beads 5 KIT 45MG 28 methergine 34 MOVANTIK 26 LUPRON DEPOT-PED (1-MONTH) 28 methimazole 31 moxifloxacin hcl 7, 34 LUPRON DEPOT-PED (3-MONTH) 28 methocarbamol 38 moxifloxacin hcl (2x day) 34 lutera 30 methotrexate 32 MOZOBIL 16 lyleq 30 methotrexate sodium 32 MUCOSITISRX 19 lyllana 30 methotrexate sodium (pf) 32 MUCOTROL 34 LYNPARZA 12 methoxsalen rapid 21 MULTAQ 17 LYSODREN 12 methscopolamine bromide 26 mupirocin 8 lyza 30 methyldopa 17 mupirocin calcium 8 methyldopa-hydrochlorothiazide 17 MUSE 26 M methylene blue 34 MYCAPSSA 28 methylergonovine maleate 34 mycophenolate mofetil 32 mafenide acetate 7 methylphenidate hcl 18 mycophenolate sodium 32 MAGNESIUM CARBONATE 24 methylphenidate hcl er 18 MYLERAN 12 MAGNESIUM CARBONATE HEAVY 24 methylphenidate hcl er (cd) 18 MYOBLOC 34 Enhanced Formulary Comprehensive Medication List – 2021 | 45 myorisan 21 nitrofurantoin monohydrate macrocrystals 8 O MYRBETRIQ 26 nitroglycerin 17 NITROMIST 17 ocella 30 N NIVESTYM 16 octreotide acetate 28 nolix 21 ODEFSEY 15 NABI-HB 32 nora-be 30 ODOMZO 12 nabumetone 6 NORDITROPIN FLEXPRO 28 OFEV 37 n-acetyl-l-cysteine 24 norethin ace-eth estrad-fe 30 ofloxacin 8, 34, 36 nadolol 17 norethindrone 30 olanzapine 14 nafrinse 24 norethindrone acetate 30 olanzapine-fluoxetine hcl 9 NAFRINSE DAILY ACIDULATED 19 norethindrone acet-ethinyl est 30 olmesartan-amlodipine-hctz 18 nafrinse drops 24 norethindrone-eth estradiol 30 olmesartan medoxomil 17 naftifine hcl 10 norethin-eth estradiol-fe 30 olmesartan medoxomil-hctz 17 naloxone hcl 6 norgestimate-eth estradiol 30 olopatadine hcl 35 naltrexone hcl 7 norgestimate-ethinyl estradiol triphasic 30 OLUMIANT 32 naproxen 6 norlyda 30 omega-3-acid ethyl esters 18 naproxen sodium 6 norlyroc 30 omeprazole 25 naratriptan hcl 11 NORPACE CR 17 OMIDRIA 35 NASCOBAL 24 nortrel 0.5/35 (28) 30 OMNIPOD 5 PACK 34 NATACYN 34 nortrel 1/35 (21) 30 OMNIPOD DASH 5 PACK PODS 34 NATAZIA 30 nortrel 1/35 (28) 30 OMNIPOD DASH SYSTEM 23 nateglinide 22 nortrel 7/7/7 30 OMNIPOD STARTER 23 NATPARA 33 nortriptyline hcl 9 ondansetron hcl 10 NATURE-THROID 31 NORVIR 15 ondansetron odt 10 necon 0.5/35 (28) 30 novarel 28 ONETOUCH DELICA LANCING DEV 23 nefazodone hcl 9 NOVOFINE AUTOCOVER PEN NEEDLE 23 ONETOUCH DELICA PLUS LANCING 23 neomycin-bacitracin zn-polymyx 35 NOVOFINE PEN NEEDLE 23 ONETOUCH ULTRA 23 neomycin-polymyxin b gu 8 NOVOFINE PLUS PEN NEEDLE 23 ONETOUCH VERIO KIT W/DEVICE 23 neomycin-polymyxin-dexameth 35 NOVOLIN 70/30 FLEXPEN 23 ONEVITE 24 neomycin-polymyxin-gramicidin 35 NOVOLIN 70/30 FLEXPEN RELION 23 ONE VITE WOMENS 24 neomycin-polymyxin-hc 35, 36 NOVOLIN 70/30 RELION 23 ONE VITE WOMENS PLUS 24 neomycin sulfate 8 NOVOLIN 70/30 VIAL 23 ONUREG 12 NEONATAL PLUS 24 NOVOLIN N FLEXPEN 23 OPSUMIT 37 neo-polycin 35 NOVOLIN N FLEXPEN RELION 23 ORACIT 24 neo-polycin hc 35 NOVOLIN N RELION 23 oralone 19 NEO-SYNALAR 21 NOVOLIN N VIAL 23 ORAPEUTIC 34 NERLYNX 12 NOVOLIN R FLEXPEN 23 ORAVIG 10 NESTABS 24 NOVOLIN R FLEXPEN RELION 23 ORENCIA 32 neuac 21 NOVOLIN R RELION 23 ORENCIA CLICKJECT 32 NEULASTA 16 NOVOLIN R VIAL 23 ORIAHNN 30 NEULASTA ONPRO 16 NOVOLOG FLEXPEN 23 ORILISSA 28 NEUPRO 13 NOVOLOG MIX 70/30 FLEXPEN 23 ORKAMBI 37 NEUTRASAL 19 NOVOLOG MIX 70/30 VIAL 23 ORLADEYO 32 nevirapine 15 NOVOLOG PENFILL 23 orphenadrine citrate er 38 nevirapine er 15 NOVOLOG U-100 VIAL 23 orsythia 30 NEXAVAR 12 NOVOPEN ECHO 23 oscimin 26 NEXAVIR 34 NOVOTWIST PEN NEEDLE 23 oscimin sr 26 niacin er (antihyperlipidemic) 17 NOXAFIL 10 oseltamivir phosphate 15 nicardipine hcl 17 NPLATE 16 OSPHENA 27 nifedipine 17 np thyroid 31 OTEZLA 32 nifedipine er 17 NUBEQA 12 OVACE PLUS 21 nifedipine er osmotic release 17 NUCALA 36 OVIDREL 28 nikki 30 NUCORT 21 oxandrolone 27 nilutamide 12 NUEDEXTA 19 oxaprozin 6 nimodipine 17 NUPLAZID 14 oxazepam 15 NINLARO 12 NURTEC 11 oxcarbazepine 8 nisoldipine er 17 nyamyc 10 OXERVATE 35 nitazoxanide 13 nylia 7/7/7 30 oxiconazole nitrate 10 nitisinone 26 nymyo 30 OXISTAT 10 NITRO-BID 17 nystatin 10 oxybutynin chloride 26 NITRO-DUR 17 nystatin-triamcinolone 10 oxybutynin chloride er 26 nitrofurantoin 8 nystop 10 oxycodone-acetaminophen 5 nitrofurantoin macrocrystal 8 oxycodone-aspirin 5 Enhanced Formulary Comprehensive Medication List – 2021 | 46 oxycodone hcl 5 pioglitazone hcl 22 previfem 30 oxymorphone hcl 5 pioglitazone hcl-glimepiride 22 PREVNAR 13 32 oxymorphone hcl er 5 pioglitazone hcl-metformin hcl 22 PREVYMIS 15 OZEMPIC 22 PIQRAY 12 PREZCOBIX 15 pirmella 1/35 30 PREZISTA 15 P pirmella 7/7/7 30 PRIFTIN 11 piroxicam 6 primaquine phosphate 13 paliperidone er 14 PNEUMOVAX 23 32 primidone 8 PALYNZIQ 26 POCKET SPACER 34 PRIMSOL 8 PANRETIN 12 podocon 21 PROAIR HFA 37 pantoprazole sodium 25 podofilox 21 PROAIR RESPICLICK 37 paricalcitol 33 polocaine 6 probenecid 10 paromomycin sulfate 8 polocaine-mpf 6 prochlorperazine 10 paroxetine hcl 9 polycin 35 prochlorperazine maleate 10 paroxetine hcl er 9 polymyxin b sulfate 8 PROCRIT 16 PASER 11 polymyxin b-trimethoprim 35 PROCTOFOAM HC 33 PEDIARIX 32 POMALYST 12 procto-med hc 33 PEDVAX HIB 32 portia-28 30 procto-pak 33 peg-3350/electrolytes 26 posaconazole 10 proctozone-hc 33 peg-3350/electrolytes/ascorbat 26 potassium chloride 25 progesterone 30 peg 3350-kcl-na bicarb-nacl 26 potassium chloride crys er 25 PROGRAF 32 PEGASYS 15 potassium chloride er 25 PROLIA 33 PEGINTRON 15 potassium citrate-citric acid 25 PROMACTA 16 peg-kcl-nacl-nasulf-na asc-c 26 potassium citrate er 25 promethazine-codeine 36 peg-prep 26 POVIDONE-IODINE 35 promethazine-dm 36 PEMAZYRE 12 PRADAXA 8 promethazine hcl 36 penicillamine 26 PRALUENT 18 promethazine-phenyleph-codeine 36 penicillin g procaine 8 pramipexole dihydrochloride 13 promethazine-phenylephrine 36 penicillin v potassium 8 pramipexole dihydrochloride er 13 promethazine vc 36 pentamidine isethionate 13 pramox 21 promethazine vc/codeine 36 PENTASA 33 prasugrel hcl 13 promethegan 36 pentazocine-naloxone hcl 5 pravastatin sodium 18 propafenone hcl 18 pentoxifylline er 18 praziquantel 13 propafenone hcl er 18 PERFOROMIST 37 prazosin hcl 18 proparacaine hcl 35 perindopril erbumine 18 PRED-G 35 propranolol hcl 18 periogard 19 PRED-G S.O.P. 35 propranolol hcl er 18 permethrin 13 PRED MILD 35 propranolol-hctz 18 perphenazine 10 prednicarbate 21 propylthiouracil 31 perphenazine-amitriptyline 9 prednisolone 27 PROQUAD 32 PERSERIS 14 prednisolone acetate 35 protriptyline hcl 9 pharmacist choice d-vitamin 24 prednisolone acetate p-f 35 pseudoephedrine-bromphen-dm 36 phenazo 26 prednisolone sodium phosphate 27, 35 PSORCON 21 phenazopyridine hcl 26 prednisone 27 PULMICORT FLEXHALER 37 phenelzine sulfate 9 prednisone intensol 27 PULMOZYME 37 phenobarbital 8 PREFEST 30 PYLERA 26 phenoxybenzamine hcl 18 pregabalin 19 pyrazinamide 11 phenylephrine hcl 35 pregnyl 28 pyridostigmine bromide 11 phenytoin 8 PREMARIN 30 pyridostigmine bromide er 11 phenytoin infatabs 8 PREMESISRX 25 pyrimethamine 13 phenytoin sodium extended 8 premium lidocaine 6 PYROGALLIC ACID 21 philith 30 PREMPHASE 30 PHOSLYRA 26 PREMPRO 30 Q phosphorous 24 PRENAISSANCE 25 phospho-trin 250 neutral 24 QINLOCK 12 prenatal 25 PHYSIOLYTE 24 QUADRACEL 32 prenatal multi +dha 25 PHYSIOSOL IRRIGATION 24 quazepam 15 prenatal plus iron 25 PIFELTRO 15 quetiapine fumarate 14 prenatal vitamin plus low iron 25 pilocarpine hcl 19, 35 quetiapine fumarate er 14 PRENATVITE RX 25 pimecrolimus 21 QUILLIVANT XR 19 preplus 25 pimozide 14 quinapril hcl 18 prevalite 18 pimtrea 30 quinapril-hydrochlorothiazide 18 preventeza 30 pindolol 18 quinidine gluconate er 18
Enhanced Formulary Comprehensive Medication List – 2021 | 47 quinidine sulfate 18 S SOFOSBUVIR-VELPATASVIR 15 quinine sulfate 13 solifenacin succinate 27 salicylic acid 21 SOLTAMOX 12 R salicylic acid-cleanser 21 SOMATULINE DEPOT 28 salimez 21 SOMAVERT 28 rabeprazole sodium 25 saline bacteriostatic 25 sorbitol 34 raloxifene hcl 27 SALINE-PHENOL 25 SORBITOL 34 ramelteon 38 SALIVAMAX 19 sorbitol-mannitol 34 ramipril 18 salsalate 6 sorine 18 ranolazine er 18 SANDIMMUNE 32 sotalol hcl 18 rasagiline mesylate 13 SANDOSTATIN LAR DEPOT 28 sotalol hcl (af) 18 reclipsen 30 sapropterin dihydrochloride 26 spinosad 13 RECOMBIVAX HB 32 SAVELLA 19 SPIRIVA HANDIHALER 37 RECTIV 18 SAVELLA TITRATION PACK 19 SPIRIVA RESPIMAT 37 REGRANEX 21 scopolamine 10 spironolactone 18 RELENZA DISKHALER 15 SECUADO 14 spironolactone-hctz 18 RELISTOR 26 SELECT-OB 25 sprintec 28 31 RELNATE DHA 25 selegiline hcl 13 SPRYCEL 12 RENACIDIN 27 selenium sulfide 21 sps 25 repaglinide 22 SELZENTRY 15 sronyx 31 REPATHA 18 sensorcaine-mpf 6 ssd 8 REPATHA PUSHTRONEX SYSTEM 18 SENSORCAINE-MPF/EPINEPHRINE 6 SSKI 36 REPATHA SURECLICK 18 SEREVENT DISKUS 37 sss 10-5 21 RESTASIS 35 sertraline hcl 9 stavudine 15 RESTASIS MULTIDOSE 36 setlakin 30 STELARA 32 RETACRIT 16 sevelamer carbonate 27 sterile water for injection 34 RETEVMO 12 sevelamer hcl 27 sterile water for irrigation 25 REVLIMID 12 sf 19 STIMATE 28 REXULTI 14 sf 5000 plus 19 STIOLTO RESPIMAT 37 REYATAZ 15 SFROWASA 33 STIVARGA 12 ribavirin 15 sharobel 30 STRENSIQ 26 RIDAURA 32 SHINGRIX 32 streptomycin sulfate 8 rifabutin 11 SIGNIFOR 28 STRIBILD 15 rifampin 11 SIKLOS 12 STRIVERDI RESPIMAT 37 riluzole 19 sildenafil citrate 27, 37 subvenite 9 rimantadine hcl 15 silodosin 27 SUCRAID 26 ringers irrigation 25 silver nitrate 8 sucralfate 25 RINVOQ 32 silver sulfadiazine 8 SULCONAZOLE NITRATE 10 risedronate sodium 33 SIMBRINZA 35 sulfacetamide-prednisolone 36 RISPERDAL CONSTA 14 simliya 31 sulfacetamide sodium 21, 35 risperidone 14 simpesse 31 sulfacetamide sodium (acne) 21 ritonavir 15 SIMPONI 32 sulfacetamide sodium-sulfur 21 rivastigmine 9 simvastatin 18 sulfacetamide sod-sulfur wash 21 rivastigmine tartrate 9 sirolimus 32 sulfacetamide-sulfur in urea 21 rivelsa 30 SIVEXTRO 8 sulfadiazine 8 rizatriptan benzoate 11 SKYRIZI 32 sulfamethoxazole-trimethoprim 8 ropinirole hcl 13 SKYRIZI (150 MG DOSE) 32 sulfamez wash 21 ropinirole hcl er 13 SKYRIZI PEN 32 SULFAMYLON 8 ropivacaine hcl 6 sod citrate-citric acid 25 sulfasalazine 33 rosadan 21 sodium chloride 25, 36 sulfatrim pediatric 8 ROSADAN 21 sodium chloride bacteriostatic 25 sulfurated lime 13 rosuvastatin calcium 18 sodium chloride (pf) 25 sulindac 6 ROTARIX 32 sodium fluoride 19, 25 sumatriptan 11 ROTATEQ 32 sodium fluoride 5000 enamel 19 sumatriptan succinate 11 roweepra 9 sodium fluoride 5000 plus 19 sumatriptan succinate refill 11 ROZLYTREK 12 sodium fluoride 5000 ppm 19 SUMAXIN CP 21 RUBRACA 12 sodium fluoride 5000 sensitive 19 SUNOSI 38 rufinamide 9 sodium phenylbutyrate 26 SUPRAX 8 RUKOBIA 15 sodium polystyrene sulfonate 25 SUPREP BOWEL PREP KIT 26 RYBELSUS 22 sodium sulfacetamide 21 SURVANTA 36 RYDAPT 12 sodium sulfacetamide wash 21 SUTENT 12
Enhanced Formulary Comprehensive Medication List – 2021 | 48 syeda 31 THEO-24 37 tretinoin microsphere pump 21 SYMAX DUOTAB 26 theophylline er 37 TREXALL 32 SYMBICORT 37 THIOLA 27 triamcinolone acetonide 19, 21 SYMDEKO 37 thioridazine hcl 14 triamterene 18 SYMLINPEN 60 22 thiothixene 14 triamterene-hctz 18 SYMLINPEN 120 22 THYROGEN 34 triazolam 15 SYMPROIC 26 tiadylt er 18 TRICARE PRENATAL DHA ONE 25 SYMTUZA 15 tiagabine hcl 9 TRI-CHLOR 21 SYNAGIS 32 TIBSOVO 12 tricitrates 25 SYNAREL 28 TIGLUTIK 19 triderm 21 SYNDROS 10 tilia fe 31 trientine hcl 25 SYNJARDY 22 timolol maleate 18, 35 tri-estarylla 31 SYNJARDY XR 22 timolol maleate ocudose 35 tri femynor 31 SYNTHROID 31 timolol maleate pf 35 trifluoperazine hcl 14 TIMOPTIC OCUDOSE 35 trifluridine 35 T tinidazole 8 trihexyphenidyl hcl 13 tiopronin 27 TRIJARDY XR 22 TABLOID 12 tis-u-sol 25 TRIKAFTA 37 TABRECTA 12 TIVICAY 15 tri-legest fe 31 tacrolimus 21, 32 TIVICAY PD 15 tri-linyah 31 tadalafil 27 tizanidine hcl 38 tri-lo-estarylla 31 tadalafil (pah) 37 TOBRADEX 36 tri-lo-marzia 31 TAFINLAR 12 tobramycin 35, 37 tri-lo-mili 31 TAGRISSO 12 TOBRAMYCIN 37 tri-lo-sprintec 31 TAKHZYRO 32 tobramycin-dexamethasone 36 trimethobenzamide hcl 10 TALICIA 26 tobramycin sulfate 8 trimethoprim 8 TALTZ 32 TOBREX 35 tri-mili 31 TALZENNA 12 TODAY SPONGE 34 trimipramine maleate 9 tamoxifen citrate 12 tolbutamide 22 TRINATE 25 tamsulosin hcl 27 tolcapone 13 tri-nymyo 31 TARGRETIN 12 tolmetin sodium 6 tri-previfem 31 tarina 24 fe 31 tolterodine tartrate 27 tri-sprintec 31 tarina fe 1/20 31 tolterodine tartrate er 27 TRIUMEQ 15 tarina fe 1/20 eq 31 tolvaptan 25 trivora (28) 31 TASIGNA 12 TOLVAPTAN 25 tri-vylibra 31 TAVALISSE 16 topiramate 9 tri-vylibra lo 31 tazarotene 21 topiramate er 9 tropicamide 36 TAZORAC 21 toremifene citrate 12 trospium chloride 27 taztia xt 18 torsemide 18 trospium chloride er 27 TAZVERIK 12 TOUJEO MAX SOLOSTAR 23 TRUE COMFORT PRO INSULIN SYR 24 TEKTURNA HCT 18 TOUJEO SOLOSTAR 23 TRUE COMFORT PRO PEN NEEDLES 24 telmisartan 18 tovet 21 TRULICITY 22 telmisartan-amlodipine 18 TRACLEER 37 TRUMENBA 32 telmisartan-hctz 18 TRADJENTA 22 TUKYSA 12 temazepam 38 tramadol-acetaminophen 5 tulana 31 TEMIXYS 15 tramadol hcl er 5 TURALIO 12 temozolomide 12 tramadol hcl er (biphasic) 5 turpentine 21 tenofovir disoproxil fumarate 15 tramadol hcl ir 5 TWINRIX 32 TEPMETKO 12 trandolapril 18 tyblume 31 terazosin hcl 27 trandolapril-verapamil hcl er 18 TYBOST 15 terbinafine hcl 10 tranexamic acid 16 tydemy 31 terbutaline sulfate 37 tranylcypromine sulfate 9 TYMLOS 33 terconazole 10 travoprost (bak free) 35 TYVASO 37 TERIPARATIDE (RECOMBINANT) 33 trazodone hcl 9 TYVASO REFILL 37 testosterone 27 TRECATOR 11 TYVASO STARTER 37 testosterone cypionate 27 TRELEGY ELLIPTA 37 TESTOSTERONE CYPIONATE 27 TRELSTAR MIXJECT 28 U testosterone enanthate 27 TREMFYA 32 tetrabenazine 19 UBRELVY 11 TRESIBA 23 tetracaine hcl 36 UCERIS 33 TRESIBA FLEXTOUCH 23 TEXACORT 21 UDAMIN SP 25 tretinoin 12, 21 THALOMID 12 UDENYCA 16 tretinoin microsphere 21
Enhanced Formulary Comprehensive Medication List – 2021 | 49 UKONIQ 12 VIVITROL 7 XPOVIO (100 MG ONCE WEEKLY) 13 ULTIGUARD SAFEPACK SYR/NEEDLE 24 VIZIMPRO 13 XTAMPZA ER 5 UNIFINE PEN NEEDLES 24 volnea 31 XTANDI 13 unithroid 31 voriconazole 10 xulane 31 UPNEEQ 35 VOSEVI 15 XYREM 38 UPTRAVI 37 VOTRIENT 13 XYWAV 38 urin ds 27 vp-pnv-dha 25 uro-mp 27 VRAYLAR 14 Y ursodiol 26 vyfemla 31 YONSA 13 vylibra 31 yuvafem 31 V VYVANSE 19 valacyclovir hcl 15 W Z valganciclovir hcl 15 ZACLIR CLEANSING 21 valproic acid 9 WAKIX 38 zafemy 31 valsartan 18 warfarin sodium 8 zafirlukast 37 valsartan-hydrochlorothiazide 18 water for irrigation, sterile 25 zaleplon 38 VALTOCO 9 weekly-d 25 zarah 31 vancomycin hcl 8 wera 31 ZARXIO 16 vandazole 8 WESTAB PLUS 25 ZEJULA 13 VANOXIDE-HC 21 WESTHROID 31 ZELAPAR 13 VAQTA 32 WIDE-SEAL DIAPHRAGM 60 34 ZELBORAF 13 VARIVAX 32 WIDE-SEAL DIAPHRAGM 65 34 ZELNORM 26 VARUBI (180 MG DOSE) 10 WIDE-SEAL DIAPHRAGM 70 34 zenatane 21 VASCEPA 18 WIDE-SEAL DIAPHRAGM 75 34 ZENPEP 26 vcf vaginal contraceptive 34 WIDE-SEAL DIAPHRAGM 80 34 zidovudine 15 VCF VAGINAL CONTRACEPTIVE 34 WIDE-SEAL DIAPHRAGM 85 34 ZIEXTENZO 16 velivet 31 WIDE-SEAL DIAPHRAGM 90 34 ziprasidone hcl 14 VELTASSA 25 WIDE-SEAL DIAPHRAGM 95 34 ZIRGAN 35 VEMLIDY 15 wixela inhub 37 ZOLINZA 13 VENCLEXTA 12 WP THYROID 31 zolmitriptan 11 VENCLEXTA STARTING PACK 12 wymzya fe 31 ZOLMITRIPTAN 11 venlafaxine hcl 9 zolpidem tartrate 38 venlafaxine hcl er 9 X zolpidem tartrate er 38 VENTAVIS 37 XALKORI 13 ZOMIG 11 VENTOLIN HFA 37 XARELTO 8 zonisamide 9 verapamil hcl 18 XARELTO STARTER PACK 8 ZONTIVITY 13 verapamil hcl er 18 XCOPRI 9 ZORTRESS 32 VERZENIO 12 XELJANZ 32 zovia 1/35 (28) 31 vestura 31 XELJANZ XR 32 zovia 1/35e (28) 31 VIBRAMYCIN 8 XEMBIFY 32 zumandimine 31 VICTOZA 22 XENLETA 8 ZYDELIG 13 vienva 31 XEOMIN 34 ZYLET 36 vigabatrin 9 XERMELO 26 ZYPREXA RELPREVV 14 vigadrone 9 XIFAXAN 8 VIIBRYD 9 XIGDUO XR 22 VIIBRYD STARTER PACK 9 XIIDRA 36 VIMPAT 9 XOLAIR 36 viorele 31 XOLEGEL 10 VIRACEPT 15 XOSPATA 13 VIREAD 15 XPOVIO (40 MG ONCE WEEKLY) 13 virt-phos 250 neutral 25 XPOVIO (40 MG TWICE WEEKLY) 13 vitamin d (ergocalciferol) 25 XPOVIO (60 MG ONCE WEEKLY) 13 VITRAKVI 13 XPOVIO (60 MG TWICE WEEKLY) 13 VITRASE 34 XPOVIO (80 MG ONCE WEEKLY) 13 VIVAGUARD LANCING DEVICE 23 XPOVIO (80 MG TWICE WEEKLY) 13
Enhanced Formulary Comprehensive Medication List – 2021 | 50 HEALTH INSURANCE
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