PrimeChoice™ Accord Formulary, April 2020 Your prescription drug benefit plan may not cover certain products or drug categories, regardless of their appearance in this document. Questions may be directed to Prime Therapeutics LLC, P.O. Box 64812, St. Paul, MN 55164-0812, Phone 800.858.0723. Thank you for your cooperation. GENERIC BRAND GENERIC BRAND DR ........................................................................ Delayed-release tobramycin inhal soln VIDEX ER ...................................................................... Extended-release SULFADIAZINE VIREAD, NF = 300 mg IR ...................................................................... Immediate-release VOSEVI ANTIMYCOBACTERIAL AGENTS NF ............................................................................ Non-formulary ANTIMALARIALS ODT .................................................... Orally disintegrating tablets ethambutol ISONIAZID syrup OSM ..................................................................... Osmotic-release isoniazid tabs PRIFTIN atovaquone/proguanil CHLOROQUINE 250 mg SL .................................................................................. Sublingual pyrazinamide chloroquine 500 mg COARTEM rifabutin hydroxychloroquine DARAPRIM This formulary list was current at time of printing and is subject to rifampin primaquine MEFLOQUINE change. To access a searchable version of this formulary visit our ANTHELMINTICS website at MyPrime.com. ANTIFUNGALS fluconazole NOXAFIL susp albendazole BENZNIDAZOLE GENERIC BRAND flucytosine ivermectin tabs praziquantel ANTI-INFECTIVE AGENTS griseofulvin microsize itraconazole ANTI-INFECTIVE AGENTS - MISC. PENICILLINS nystatin oral clindamycin ALINIA amoxicillin caps, susp, tabs AMOXICILLIN chew tabs posaconazole DR dapsone tabs IMPAVIDO amoxicillin/potassium clavulanate AMOXICILLIN/CLAVULANATE terbinafine linezolid NEBUPENT for susp; IR tabs chew tabs; ER, 1000-62.5 mg voriconazole metronidazole tabs SIVEXTRO dicloxacillin AMPICILLIN ANTIVIRALS pentamidine XIFAXAN 550 mg penicillin v potassium tabs AUGMENTIN susp, 125 mg/5 mL sulfamethoxazole/trimethoprim PENICILLIN V POTASSIUM soln abacavir ATRIPLA abacavir/lamivudine BARACLUDE soln trimethoprim CEPHALOSPORINS abacavir/lamivudine/zidovudine BIKTARVY vancomycin cefaclor caps SUPRAX chew tabs; susp acyclovir CIMDUO BIOLOGICALS cefadroxil adefovir DELSTRIGO SYNAGIS cefdinir atazanavir caps DESCOVY cefixime didanosine DR caps, 200 mg, DIDANOSINE caps, 400 mg ANTINEOPLASTIC AGENTS cefpodoxime 250 mg EPCLUSA abiraterone ACTIMMUNE cefprozil efavirenz EPIVIR HBV soln anastrozole AFINITOR ceftriaxone entecavir EVOTAZ bexarotene AFINITOR DISPERZ cefuroxime famciclovir GENVOYA bicalutamide ALECENSA cephalexin, NF = tabs lamivudine HARVONI capecitabine ALUNBRIG MACROLIDES lamivudine/zidovudine INTELENCE cyclophosphamide BOSULIF lopinavir/ritonavir soln ISENTRESS erlotinib CAPRELSA azithromycin susp, tabs AZITHROMYCIN packets nevirapine IR susp; tabs, 200 mg; ISENTRESS HD everolimus COMETRIQ clarithromycin tabs; ER CLARITHROMYCIN susp ER 400 mg KALETRA tabs exemestane COTELLIC TETRACYCLINES oseltamivir LEDIPASVIR/SOFOSBUVIR flutamide EMCYT demeclocycline ribavirin 200 mg MAVYRET hydroxyurea ERIVEDGE doxycycline hyclate caps, 50 mg, ritonavir tabs NEVIRAPINE ER tabs, 100 mg imatinib ERLEADA 100 mg; tabs, 20 mg, 100 mg stavudine NORVIR, NF = tabs letrozole ETOPOSIDE caps doxycycline monohydrate, NF = tenofovir disoproxil fumarate tabs, ODEFSEY leucovorin calcium tabs, 5 mg, FARYDAK susp 300 mg PEGASYS 25 mg GILOTRIF minocycline IR valacyclovir PREZCOBIX megestrol GLEOSTINE tetracycline valganciclovir PREZISTA melphalan HYCAMTIN caps zidovudine SOFOSBUVIR/VELPATASVIR mercaptopurine IBRANCE FLUOROQUINOLONES SOVALDI methotrexate tabs ICLUSIG ciprofloxacin tabs, 250 mg, CIPROFLOXACIN tabs, 100 mg SYMFI nilutamide IMBRUVICA 500 mg, 750 mg SYMFI LO tamoxifen INLYTA levofloxacin TEMIXYS temozolomide IRESSA ofloxacin tabs, 400 mg TIVICAY toremifene JAKAFI AMINOGLYCOSIDES TRIUMEQ tretinoin caps KISQALI KISQALI FEMARA dose pack neomycin sulfate PAROMOMYCIN TRUVADA (continued) 2060 © Prime Therapeutics LLC 04/20 PrimeChoice™ Accord Page 1 of 6 GENERIC BRAND GENERIC BRAND GENERIC BRAND LENVIMA testosterone gel, 1%, 1.62%; Intermediate-Acting Insulins LEUCOVORIN CALCIUM tabs, soln, 30 mg/act INSULIN ASPART PROTAMINE 10 mg, 15 mg ESTROGENS LEUKERAN NOVOLIN N LONSURF estradiol CLIMARA PRO NOVOLIN 70/30 LYNPARZA estradiol/norethindrone acetate DIVIGEL NOVOLOG MIX 70/30 LYSODREN norethindrone acetate/ethinyl ESTROGEL Basal Insulins estradiol PREMARIN tabs MATULANE LANTUS MEKINIST PREMPHASE PREMPRO LEVEMIR MESNEX tabs TOUJEO MAX SOLOSTAR MYLERAN CONTRACEPTIVES TOUJEO SOLOSTAR NEXAVAR medroxyprogesterone acetate inj, ELLA TRESIBA NINLARO 150 mg/mL MIRENA TRESIBA FLEXTOUCH NUBEQA oral contraceptive generics, NF = NUVARING THYROID AGENTS ODOMZO drospirenone/ethinyl estradiol/ OGESTREL PIQRAY DAILY DOSE levomefolate; levonorgestrel/ SKYLA levothyroxine POMALYST ethinyl estradiol 90-20 mcg XULANE liothyronine PURIXAN oral contraceptive generics, NF = methimazole ROZLYTREK levonorgestrel/ethinyl estradiol propylthiouracil RUBRACA 0.15-0.02/0.025/0.03 mg/ OXYTOCICS RYDAPT ethinyl estradiol 0.01 mg; methylergonovine SOLTAMOX norethindrone/ethinyl ENDOCRINE and METABOLIC AGENTS - MISC. SPRYCEL estradiol/fe 0.8 mg-25 mcg, STIVARGA 1 mg-20 mcg alendronate tabs, 10 mg, 35 mg, ALENDRONATE 5 mg SUTENT 70 mg CHORIONIC GONADOTROPIN PROGESTINS SYLATRON cabergoline CLOMIPHENE CITRATE TABLOID medroxyprogesterone acetate calcitonin-salmon CYSTADANE TAFINLAR tabs calcitriol FOLLISTIM AQ TAGRISSO norethindrone acetate cinacalcet INCRELEX TASIGNA progesterone micronized desmopressin MENOPUR TYKERB ANTIDIABETICS ganirelix acetate NITYR VENCLEXTA acarbose GLUCAGON EMERGENCY KIT ibandronate NORDITROPIN FLEXPRO VERZENIO glimepiride GLYXAMBI levocarnitine NOVAREL VITRAKVI glipizide IR, ER GVOKE PFS nitisinone caps, 2 mg, 5 mg, OCTREOTIDE 200, 1000 mcg/mL VOTRIENT glipizide/metformin INVOKAMET 10 mg ORFADIN XALKORI glyburide micronized INVOKAMET XR octreotide ORILISSA XTANDI glyburide/metformin INVOKANA paricalcitol PREGNYL YONSA glyburide, distributor of Diabeta JANUMET raloxifene PROLIA ZELBORAF glyburide, generics of Micronase JANUMET XR risedronate IR REVCOVI ZOLINZA metformin IR, ER; NF = modified JANUVIA SANDOSTATIN LAR DEPOT ZYDELIG release, OSM, soln JARDIANCE STIMATE ZYKADIA nateglinide KOMBIGLYZE XR STRENSIQ ZYTIGA 500 mg pioglitazone ONGLYZA TYMLOS ENDOCRINE AND METABOLIC DRUGS pioglitazone/metformin OZEMPIC CARDIOVASCULAR AGENTS CORTICOSTEROIDS repaglinide PROGLYCEM CARDIOTONICS RYBELSUS budesonide DR caps, 3 mg CORTISONE digoxin DIGOXIN soln SYNJARDY dexamethasone, NF = therapy DEXAMETHASONE soln; tabs, SYNJARDY XR ANTIANGINAL AGENTS pack 1 mg, 2 mg TRULICITY fludrocortisone DEXAMETHASONE INTENSOL isosorbide dinitrate 5 mg, 10 mg, NITRO-BID VICTOZA hydrocortisone PREDNISOLONE syrup 20 mg, 30 mg methylprednisolone PREDNISONE soln, 5 mg/5 mL Rapid-Acting Insulins isosorbide mononitrate IR, ER nitroglycerin patches, SL tabs prednisolone sodium phosphate FIASP soln, 5 mg/5 mL, 15 mg/5 mL INSULIN ASPART BETA BLOCKERS prednisone tabs NOVOLOG acebutolol PROPRANOLOL soln ANDROGEN-ANABOLIC Short-Acting Insulins atenolol TIMOLOL 10 mg, 20 mg bisoprolol danazol TESTOSTERONE ENANTHATE HUMULIN R U-500 carvedilol testosterone cypionate NOVOLIN R (continued) 2060 © Prime Therapeutics LLC 04/20 PrimeChoice™ Accord Page 2 of 6 GENERIC BRAND GENERIC BRAND GENERIC BRAND labetalol moexipril bosentan OPSUMIT metoprolol succinate ER olmesartan sildenafil 20 mg TRACLEER tabs for oral susp metoprolol tartrate 25 mg, 50 mg, olmesartan/hydrochlorothiazide tadalafil UPTRAVI 100 mg perindopril tadalafil (pah) VYNDAMAX nadolol phenoxybenzamine VYNDAQEL pindolol prazosin RESPIRATORY AGENTS propranolol IR, ER quinapril sotalol quinapril/hydrochlorothiazide ANTIHISTAMINES sotalol AF ramipril cetirizine syrup DESLORATADINE ODT timolol 5 mg telmisartan cyproheptadine PROMETHEGAN 50 mg CALCIUM CHANNEL BLOCKERS telmisartan/hydrochlorothiazide desloratadine terazosin levocetirizine tabs, soln amlodipine DILT-XR trandolapril promethazine supp 12.5 mg, diltiazem IR; ER caps – 24 hr VERAPAMIL SR caps, 360 mg valsartan 25 mg; syrup, tabs dosing valsartan/hydrochlorothiazide felodipine ER NASAL AGENTS - SYSTEMIC and TOPICAL nifedipine ER DIURETICS azelastine FLUNISOLIDE nimodipine acetazolamide IR, ER CHLOROTHIAZIDE fluticasone propionate verapamil IR, ER, NF = caps, amiloride ipratropium 100 mg, 200 mg, 300 mg amiloride/hydrochlorothiazide mometasone ANTIARRHYTHMICS bumetanide COUGH/COLD/ALLERGY chlorthalidone 25 mg, 50 mg acetylcysteine inhal soln amiodarone MEXILETINE furosemide, NF = soln, 8 mg/mL disopyramide MULTAQ hydrochlorothiazide ANTIASTHMATIC and BRONCHODILATOR AGENTS flecainide QUINIDINE SULFATE IR indapamide albuterol, NF = ER ADVAIR HFA propafenone IR, ER methazolamide budesonide inhal susp ANORO ELLIPTA quinidine gluconate ER metolazone cromolyn sodium inhal soln ARNUITY ELLIPTA ANTIHYPERTENSIVES spironolactone ipratropium inhal soln ASMANEX HFA amlodipine/benazepril CAPTOPRIL/ spironolactone/ ipratropium/albuterol sulfate inhal ASMANEX TWISTHALER amlodipine/valsartan HYDROCHLOROTHIAZIDE hydrochlorothiazide soln ATROVENT HFA amlodipine/valsartan/ METOPROLOL/ torsemide levalbuterol inhal soln BREO ELLIPTA hydrochlorothiazide HYDROCHLOROTHIAZIDE triamterene/hydrochlorothiazide, montelukast COMBIVENT RESPIMAT atenolol/chlorthalidone 100/50 mg NF = 50-25 mg terbutaline DULERA benazepril PROPRANOLOL/