ESI HIGH PERFORMANCE FORMULARY - VCHCP - … DQM= 1 tab/30 days; 30mg DQM=30 tabs/Rx; 35mg DQm=4 tabs/28 days; 5mg DQM=30 tabs/Rx; ... ESI HIGH PERFORMANCE FORMULARY TIER SUGGESTED

Updated 10.28.2014

PA = Prior Authorization Required: a clinical review is to be done to determine appropriateness of use.

ST = Step Therapy: a clinical look back to determine if a first line drug has been utilized first.

DQM = Drug Quantity Management: a clinically approved standardized limitation applied to the product, approved by the plan

* Zero Dollar Copay

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

ABILIFY DISCMELT DQM=60 tabs/RxABILIFY injABILIFY tab, sol DQM=30 tabs/Rxabsorica PAABSTRAL QL = 120 units/30 days fentanyl citrate OTFC lozengeACANYA clindamycin/benzoyl peroxideacarboseACCOLATE zafirlukastACCU-CHEKACCU-CHEK ACTIVE FREESTYLEACCU-CHEK AVIVA FREESTYLEACCU-CHEK AVIVA PLUS FREESTYLEACCU-CHEK COMFORT CURVE FREESTYLEACCU-CHEK COMPACT FREESTYLEACCU-CHEK COMPACT BLUE CONTROL FREESTYLEACCU-CHEK FASTCLIXACCU-CHEK NANO SMARTVIEW FREESTYLEACCU-CHEK SMARTVIEW FREESTYLEACCU-CHEK SOFTCLIXacebutolol hclacetaminophen-codeine QL = 120 units/30 daysacetazolamideACIPHEX ST genericsACTIVELLA estradiol/noreth acetate

ACTONEL

150mg DQM= 1 tab/30 days; 30mg DQM=30 tabs/Rx; 35mg DQm=4 tabs/28 days; 5mg DQM=30 tabs/Rx; 75mg DQM=2 tab/30 days alendronate sodium

ACTOPLUS MET DQM=90 tabs/Rx pioglitazone/metformin

ACTOPLUS MET XR15 DQM=60 tabs/Rx; 30 DQM=30 tabs/Rx

ACTOS DQM=30 tabs/Rx pioglitazoneACUVAIL diclofenac, ketorolacacycloviradapaleneADCIRCA DQM=60 tabs/RxADDERALL XR dextroamphetamne-amphetamne erADVAIR DISKUS DQM=1 device/Rx DULERA, SYMBICORTADVAIR HFA DQM=1 inhaler/Rx DULERA, SYMBICORT

ADVICOR

750mg, 1000mg DQM=60 tabs/Rx; 500mg DQM=30 tabs/Rx lovastatin + NIASPAN

AGGRENOXalbuterol sulfatealclometasone dipropionatealendronate sodiumalfuzosin hclALLEGRA-D 24 HOUR DQM=30 tabs/RxallopurinolALOCRIL azelastine hclALOMIDE azelastine hclALPHAGAN P brimonidine tartratealprazolam/er/xrALREX azelastine

ESI HIGH PERFORMANCE FORMULARY

TIER

SUGGESTED PREFFERED ALTERNATIVES

DRUG NAME

Commercial & Custom Platinum PlanBronze Plan

Data Class: Confidential Page 1 of 24

Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


ALTABAX mupirocinaltavera*ALTOPREV ST; DQM=30 tabs/Rx atorvastatin, simvastatin

ALVESCO160 mcg DQM=2 inhalers/Rx; 80 mcg DQM=1 inhaler/Rx PULMICORT FLEX, QVAR

amantadineAMBIEN ST; DQM=30 tabs/Rx zolpidem tartrateAMBIEN CR ST; DQM=30 tabs/Rx zolpidem eramiloride hclamiodarone hclAMITIZA LINZESSamitriptyline hclamlodipine besylateamlodipine besylate-benazeprilamlodipine-atorvastatinamnesteem PAamox tr-potassium clavulanateamoxicillinamoxicillin-clavulanate eramphetamine salt comboAMPYRAAMRIX immed-release cyclobenzaprineAMTURNIDE gen ace/arb+hctz+amlodipineanagrelide hclANALPRAM ADVANCED hydrocortisone/pramoxine creamANALPRAM E hydrocortisone/pramoxine creamANALPRAM HC hydrocortisone/pramoxine creamanastrozoleANDRODERM TESTIMANDROGEL TESTIMANGELIQ ee/noreth ac,PREMPHASE/PREMPROANTARA fenofibrateantipyrine-benzocaineanucort-hcAPIDRA/SOLOSTAR HUMALOGapri*APRISOaranelle*ARANESP PROCRITarbinoxa

ARCAPTA NEOHALER DQM=1 package (30 caps)/Rx FORADILARICEPT donepezilARICEPT ODT donepezil odtARIMIDEX anastrozoleARIXTRA fondaparinux sodiumARMOUR THYROIDASACOL HD balsalazide, APRISOASCENSIA AUTODISC FREESTYLEASMANEX DQM=1 inhaler/Rx PULMICORT FLEX, QVARaspirinaspirin ecASTELIN DQM=2 bottles/Rx azelastineASTEPRO azelastineATACAND ST losartan, DIOVANATACAND HCT ST candesartan/hydrochlorothiazdeATELVIA DQM=4 tabs/28 days alendronate sodiumatenololatenolol-chlorthalidoneatorvastatin calcium


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


atovaquone-proguanil hclATRALIN PA Required - Age > 34 tretinoinATRIPLA PAatropine sulfateATROVENT HFA DQM=2 inhalers/RxAUTODISC NORMAL FREESTYLEAVALIDE ST irbesartan/hydrochlorothiazideAVANDAMET DQM=60 tabs/Rx pioglit/metfor,ACTOPLUS MET XRAVANDARYL DQM=30 tabs/Rx pioglitazone/glimepiride

AVANDIA8mg DQM=30 tabs/Rx; 2mg, 4mg DQM=60 tabs/Rx pioglitazone

AVAPRO ST irbesartanAVELOX/ABC PACK ciproflox, levoflox, ofloxacinaviane*AVINZA QL = 120 units/30 days morph sul er,OPANA ER,OXYCONTNAVODART finasterideAVONEX DQM=4 syringes/28 daysAVONEX ADMINISTRATION PACK DQM=4 vials/28 daysAVONEX PEN DQM=1 box/28 daysAXERT 6.25mg DQM=6 tabs/Rx;

12.5mg DQM=12 tabs/Rxnaratriptan,sumatrip,zolmitrip

AXIRONAZASITE tobramycin, ciprofloxacinazathioprineazelastine hclAZILECT selegilineazithromycin inj PAazithromycin pwd, susp, tabAZOPT generics, ALPHAGAN P 0.1%AZOR ST amlod+losar or DIOVAN,EXFORGEazurette*bacitracinbacitracin-polymyxinbaclofenBACTROBAN mupirocinbalsalazide disodiumbalziva*BARACLUDEBECONASE AQ ST; DQM=2 inhalers/Rx flunisolide, fluticasonebenazepril hclbenazepril-hydrochlorothiazideBENICAR ST losartan, DIOVANBENICAR HCT ST losartan/hctz, valsartan/hctzBENZACLIN clindamycin/benzoyl peroxidebenzonatatebenzoyl peroxidebenztropine mesylateBEPREVE azelastine hclBESIVANCE ciprofl,levoflox,oflox, MOXEZAbetamethasone dipropionatebetamethasone valerateBETASERON DQM=14 vials/30 days AVONEX, EXTAVIA, REBIFbethanechol chlorideBETIMOL generics, ALPHAGAN P 0.1%BETOPTIC S BETAXOLOLBEYAZ* generic oral contraceptivesbicalutamideBIDIL isosorbide dn + hydralazineBIFERA RX hemetab iron supplement tabsBINOSTO DQM=4 tabs/28 days alendronate, ibandronatebisoprolol fumarate


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


bisoprolol-hydrochlorothiazideBONIVA inj alendronate sodiumBONIVA tab DQM=1 tab/30 days alendronate sodiumBOTOXBRAVELLE PA GONAL F/RFFBREEZE 2 FREESTYLEBRILINTAbrimonidine tartratebromocriptine mesylateBROVANA DQM=2 cartons/Rx PERFOROMISTbudeprion sr DQM=60 tabs/Rx budeprion xl DQM=30 tabs/Rxbudesonidebudesonide ecbumetanidebuprenorphine hcl inj PAbuprenorphine hcl pwd, tabbupropion hclbupropion hcl srbupropion xlbuspirone hclbutalbital compound-codeinebutalbital-aspirin-caffeinebutorphanol tartrate inj PA butorphanol tartrate spray, pwd DQM (spray) =2 bottles/RxBUTRANS QL = 120 units/30 daysBYDUREON DQM=1 carton/RxBYETTA DQM=1 syringe/RxBYSTOLIC atenolol,carvedil,metoprol erCADUET ST; DQM=30 tabs/Rx amlodipine/atorvastatincalcipotrienecalcitonin nasal spraycalcitrenecalcitriolcalcium acetateCAMBIA ST; DQM=9 packets/Rx diclofenac potassiumcamila*camrese*CANASAcaptoprilcaptopril-hydrochlorothiazideCARAC fluorouracil 5% cream, solnCARAFATE sucralfatecarbamazepinecarbamazepine xrCARBATROL carbamazepine ercarbidopa-levodopacarbidopa-levodopa-entacaponeCARDENE SR immediate-release nicardipineCARDIZEM LA diltiazem 24 hr erCARDURA XL DQM=30 tabs/Rx alfuzosin er, tamsulosincartia xtcarvedilolCEDAX cefpodoxime,cefuroxime,cefdinrcefaclor ercefadroxilcefdinircefpodoxime proxetilcefprozilcefuroxime injcefuroxime tab


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


CELEBREX STCELLCEPT mycophenolate mofetilCENESTIN estradiol, MENESTcephalexinCEREFOLIN folic acidCEREFOLIN NACcesiacetirizineCETRAXAL ciprofloxacin 0.2% oticCETROTIDE PA GANIRELIX ACETATECHANTIX* Age < 18 Not Covered; SCchlordiazepoxide hclchlordiazepoxide-clidiniumchlorpromazine hclchlorthalidonechlorzoxazonecholestyraminecholine mag trisalicylate

CIALIS

PA; 2.5mg DQM=30 tabs/Rx; 5mg, 10mg, 20mg DQM=8 tabs/Rx VIAGRA

ciclopiroxcilostazolcimetidineCIMZIA ENBREL, HUMIRACIPRO HC CIPRODEXCIPRODEXciprofloxacin erciprofloxacin hclcitalopramcitalopram hbrclaravis PACLARINEX DQM=30 tabs/Rx desloratadineCLARINEX-D 12 HOUR DQM=60 tabs/Rx desloratadineCLARINEX-D 24 HOUR DQM=30 tabs/Rx desloratadineclarithromycin/erCLIMARA PRO DQM=4 patches/28 days estradiol patch + progesteroneclindamycin hclclindamycin phosphateclindamycin phosphate injclindamycin phosphate other dose formsclindamycin-benzoyl peroxideCLINDESSE CLEOCIN, CLINDAMAXclobetasol emollientclobetasol propionateCLOBEX clobetasol solutionclomiphene citrateclomipramine hclclonazepamclonidineclonidine hcl clorazepate dipotassiumclotrimazoleclotrimazole-betamethasoneclozapineCOLCRYScolestipol hclCOMBIGAN generics, ALPHAGAN P 0.1%COMBIPATCH estradiol patch + progesteroneCOMBIVENT DQM=2 inhalers/Rx


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


COMBIVENT RESPIMAT DQM=2 inhalers/RxCOMBIVIR PA lamivudine/zidovudineCOMPLERA PA ATRIPLACOMTAN entacaponeCONCEPTIONCONCERTA methylphenidate erCONDYLOX podofiloxCONTOUR FREESTYLECONTOUR NEXT FREESTYLECONTOUR NEXT EZ FREESTYLECONTOUR NEXT USB FREESTYLECONTOUR USB FREESTYLECONTROL SOLUTION FREESTYLECOPAXONE 20MG DQM=1 kit/30 daysCOREG CR carvedilolCOSOPT PF generics, ALPHAGAN P 0.1%COUMADIN warfarin sodiumCOZAAR ST losartanCREONCRESTOR ST; DQM=30 tabs/Rx atorvastatin, simvastatinCRINONE PA estradi/noreth ace,medroxyprogcromolyn sodiumcryselle*cyclafem*cyclobenzaprine hclcyclosporine modifiedCYMBALTA ST; DQM 20mg & 60mg=60

caps/Rx; DQM 30mg=30 caps/Rx

venlafax er(NOT UCB NDCS-65580

cyproheptadine hclCYTOMEL liothyronineDALIRESP FORADIL, SPIRIVADAPSONE

DAYTRANA methylphenidate cd, er,VYVANSEDELZICOL balsalazide, APRISODENAVIRDEPAKOTE ER divalproex sodium erDEPLIN folic aciddesipramine hcldesmopressin acetate PAdesonide

desoximetasoneDETROL tolterodineDETROL LA oxybutynin er, trospium erdexamethasonedexamethasone sodium phosphateDEXCOM G4 FREESTYLE

DEXCOM G4 FREESTYLEDEXILANT ST; DQM=30 caps/Rx genericsdexmethylphenidate hcldextroamphetamine sulfatedextroamphetamine-amphetaminediazepamdiclofenac potassiumdiclofenac sodium


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


dicloxacillin sodiumdicyclomine hclDIFFERIN adapalene 0.1% crmDIFICID metronidazolediflunisaldigoxinDILANTIN phenytoin sodium extendeddiltiazem erdiltiazem inj PAdiltiazem tab, pwdDIOVAN STDIOVAN HCT ST valsartan/hydrochlorothiazideDIPENTUM balsalazide, APRISOdiphenhydramine hcldiphenoxylate-atropinedipyridamoledivalproex sodium/erDIVIGEL DQM=30 packets/Rx generic estradiol patchesdonepezil hclDORYX ST doxycyclne hyclate delayed-reldorzolamide hcldorzolamide-timololDOVONEX calcipotriene ointment, solndoxazosin mesylatedoxepin hcldoxycycline hyclatedoxycycline monohydratedronabinolDUAC clindamycin/benzoyl peroxideDUETACT DQM=30 tabs/Rx pioglitazone/glimepirideDUEXIS ST ibuprofen plus famotidineDULERA DQM=1 inhaler/RxDUREZOL generic ophth. steroidDYMISTA ST; DQM=1 bottle/Rx azelastine + fluticasoneeconazole nitrate

EDARBI STcandesartan/-hctz, irbesartan/-hctz, losartan/-hctz, telmisartan/-hctz, DIOVAN

EDARBYCLOR ST losartan/hctz, valsartan/hctzEDLUAR ST; DQM=30 tabs/Rx zolpidem immediate release

EFFEXOR XRST; DQM=30 tabs/Rx (XR 75, DQM=90 tabs/Rx) venlafax er(NOT UCB NDCS-65580

EFFIENT PAELESTRIN DQM=52 gm (2 pumps)/Rx generic estradiol patchesELIDEL PROTOPICELIGARDeliphos

ELIQUISELMIRONEMADINE azelastine hcl

EMEND cap

PA; 40mg, 125mg DQM=1 cap/Rx; 80mg DQM=2 caps/Rx

EMEND inj PA; DQM=1 vial/RxENABLEX oxybutynin er, trospium erenalapril maleateenalapril-hydrochlorothiazide


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


ENBREL

25mg DQM=8 vials/syringes/28 days; 50mg DQM=4 vials/syringes/28 days

endocet QL = 120 units/30 daysENDOMETRIN PAENJUVIA estradiol, MENESTenoxaparin sodiumenpresse*enuloseEPICERAM emulsion sb, tl-cermideEPIDUO adapalene gel+benzoyl peroxideepinastine hclepinephrine inj DQM=2 units (1 carton)/Rxepinephrine pwd

EPIPEN/JRDQM=3 units (pkg size 1), 2 units (pkg size 2)/Rx

EPIVIR PAEPIVIR HBVeplerenoneeprosartan mesylateEPZICOM PAerrin*ERTACZO ciclopirox, ketoconazoleerythromycinerythromycin-benzoyl peroxideescitalopram oxalateestazolamESTRACE VAGIFEMestradiolESTRASORB DQM=56 packets/Rx generic estradiol patchesESTRING VAGIFEMESTROGEL DQM=1 pump bottle/Rx generic estradiol patchesestrogen & methyltestosteroneestrogen-methyltestosteroneestropipateetidronate disodiumetodolacEURAXEVAMIST DQM=2 pumps/Rx generic estradiol patchesEVISTAEXALGO QL = 120 units/30 days generics, OPANA ER, OXYCONTINEXELDERM econazole, ketoconazoleEXELON donepezil, galantamine, rivastigmine, NAMENDA

exemestaneEXFORGE STEXFORGE HCT ST

EXTAVIA

Kit DQM=15 blister units/vials/30 days; Vials DQM=14 or 15 vials/30 days

FACTIVE ciproflox, levoflox, ofloxacinfamciclovirfamotidine

FANAPTDQM=60 tabs/Rx; Pack DQM 1 pack/Rx generc, ABILIFY/DISC,SEROQL XR

felodipine erFEMARA letrozoleFEMCON FE zenchent fe chewable, zeosaFEMHRT ee/noreth ac,PREMPHASE/PREMPRO


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


fenofibratefenofibric acidFENOGLIDE fenofibratefentanyl inj PA; QL = 120 units/30 daysfentanyl patchFENTORA QL = 120 units/30 days fentanyl citrate OTFC lozengefexofenadine hclFINACEA metronidazole topicalfinasterideflecainide acetateFLECTOR ST; DQM=60 patches/Rx ORAL NSAIDSFLOMAX tamsulosin hcl

FLOVENT DISKUS100mcg DQM=1 inhaler/Rx; 250mcg DQM=4 inhalers/Rx PULMICORT FLEX, QVAR

FLOVENT HFA

110mcg, 44 mcg DQM=1 inhaler/Rx; 220 mcg DQM=2 inhalers/Rx PULMICORT FLEX, QVAR

fluconazole PAfludrocortisone acetateflunisolide DQM=2 inhalers/bottles/Rxfluocinolone acetonidefluocinonidefluorometholoneFLUOROPLEX fluorouracil, imiquimodfluorouracil

fluoxetine hclST; 10mg DQM=30 caps/Rx; 40mg DQM=60 caps/Rx

fluphenazine hcl inj PAfluphenazine hcl tab, elixar, concflurazepam hclflurbiprofenfluticasone propionatefluticasone propionatefluvastatin sodiumfluvoxamine maleateFML FORTE generic ophth. steroidFOCALIN XR methylphenidate cd, er,VYVANSE

folic acid*FOLLISTIM AQ PA GONAL F/RFFFOLTXfondaparinux sodiumFORA LANCING DEVICEFORA TEST STRIP FREESTYLEFORA V30A FREESTYLEFORACARE LANCETS

FORADIL

DQM=1 package (12 caps)/Rx; 1 package (60 caps)/Rx

FORTAMET metformin erFORTEO DQM=1 pen/28 daysFORTESTA TESTIMFOSAMAX PLUS D DQM=4 tabs/28 days alendronate sodiumfosinopril sodiumfosinopril-hydrochlorothiazideFOSRENOL RENVELAFRAGMIN enoxaparin, fondaparinux


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


FREESTYLE FREEDOM LITEFREESTYLE INSULINXFREESTYLE INSULINX TEST STRIPSFREESTYLE LITE METERFREESTYLE LITE STRIPSFREESTYLE TEST STRIPSFROVA DQM=9 tabs/Rx naratriptan,sumatrip,zolmitripfurosemidegabapentingalantamine hbrGANIRELIX ACETATE

GELNIQUESachets DQM=1 carton/Rx; Gel DQM=1 pump/Rx oxybutynin er, trospium er

gemfibrozilGENERESS FE* generic oral contraceptivesGENOTROPIN PA OMNITROPE, TEV-TROPINgentamicin sulfategentamicin sulfate inj PAgentamicin sulfate other dose formsGEODON cap DQM=60 caps/Rx ziprasidoneGEODON inj ziprasidonegildess fe*GLEEVECglimepirideglipizide/erglipizide-metforminGLUCAGENGLUCAGON EMERGENCY KITGLUCOSE TEST STRIP FREESTYLEglyburideglyburide micronizedglyburide-metformin hclGOLYTELY* peg 3350-electrolyteGONAL-F/RFF PAGRALISE gabapentingranisetron hclGRIFULVIN V griseofulvin microsizegriseofulvinguaifenesin/codieneguanfacine hclGUARDIAN RT STARTER KIT FREESTYLEHALFLYTELY-BISACODYL* peg 3350-electrolytehalobetasol propionateHALOG betmet dp crm/oint,desoxi .25%haloperidolHECTOROL calcitriolHELIDAC bismuth+metronidaz+tetracyclinheparin sodium inj PAheparin sodium pwdHORIZANT gabapentinHUMALOG productsHUMATROPE PA OMNITROPE, TEV-TROPIN

HUMIRA

40mg DQM=2 pen/28 days; all others DQM=2 syringes/28 days

HUMULIN productshydrochlorothiazidehydrocodone bit-ibuprofen QL = 120 units/30 dayshydrocodone-acetaminophen QL = 120 units/30 dayshydrocortisonehydrocortisone acetate


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


hydrocortisone butyratehydrocortisone valeratehydromorphone hcl inj PA; QL = 120 units/30 dayshydromorphone hcl other dose forms QL = 120 units/30 dayshydroxychloroquine sulfatehydroxyureahydroxyzinehyoscyamine sulfateHYZAAR ST losartan/hctzibandronate sodium injibandronate sodium tabsibuprofenILEVRO diclofenac, ketorolacimipramine hclimiquimodIMITREX inj PA inj and Age < 13;

DQM=see DQM documentsumatriptan

IMITREX nasal spray, tabs PA - Age < 13; DQM=see DQM document

sumatriptan

INCIVEK PAindapamideindomethacinINTELENCE PAINTERMEZZO ST; DQM=30 tabs/Rx zolpidem immediate releaseINTUNIV methylphenidate er

INVEGADQM=30 tabs/Rx; 6mg DQM=60 tabs/Rx generc, ABILIFY/DISC,SEROQL XR

ipratropium bromideipratropium bromideipratropium-albuterolirbesartanirbesartan-hydrochlorothiazideISENTRESS PAisoniazidisosorbide/dinitrateisotretinoin PAISTALOL generics, ALPHAGAN P 0.1%itraconazole PA; DQM=15 tabs/RxJALYN finasteride + tamsulosin

JANUMET/XRST; DQM=100mg 30 tabs/Rx; 50mg DQM=60 tabx/Rx

JANUVIA ST; DQM=30 tabs/RxJENTADUETO ST; DQM=60 tabs/Rxjintelijolessa*jolivette*junel fe*junel*KADIAN QL = 120 units/30 days morph sul er,OPANA ER,OXYCONTNKALETRA PAKAPVAY generic clonidine(imm release)kariva*KAZANO ST; DQM=60 tabs/Rx JANUMET/XR, JENTADUETOkelnor 1-35*KENALOG triamcinolone (non aerosol)KEPPRA levetiracetamKEPPRA XR levetiracetam erketoconazoleketoprofenketorolac tromethamine


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


ketotifen fumarateKINERET ORENCIA

KOMBIGLYZE XRST; 2.5mg DQM=60 tabs/Rx; 5mg DQM=30 tabs/Rx metformin, JANUVIA, TRADJENTA, JENTADUETO

KRISTALOSE lactuloselabetalol hcl inj PAlabetalol hcl tab, pwdlactuloseLAMICTAL/ODT/XR lamotriginelamivudine PAlamivudine-zidovudine PAlamotrigineLANOXIN digoxinLANTUS/SOLOSTARLASTACAFT azelastine hcllatanoprost

LATUDADQM=30 tabs/Rx; 80mg DQM=60 tabs/Rx generc, ABILIFY/DISC,SEROQL XR

LAZANDA QL = 120 units/30 days fentanyl citrate OTFC lozengeleena*leflunomide

LESCOLST; 20mg DQM=30 caps/Rx; 40mg DQM=60 caps/Rx fluvastatin

LESCOL XL ST; DQM=30 tabs/Rx atorvastat,fluvastat,simvastatlessina*LETAIRISletrozoleleucovorin calciumleuprolide acetate inj PAleuprolide acetate pwdLEVAQUIN levofloxacinLEVEMIR/FLEXPENlevetiracetamLEVITRA PA; DQM=8 tabs/Rx VIAGRAlevobunolol hcllevocarnitinelevocetirizine dihydrochloridelevofloxacinlevora-28*levothyroxine sodiumLEXAPRO ST; DQM=30 tabs/Rx escitalopramLEXIVA PALIALDA balsalazide, APRISOlidocaine hcl injlidocaine hcl other dose formslidocaine-prilocaineLIDODERMLINZESSLIPITOR ST; DQM=30 tabs/Rx atorvastatinLIPOFEN fenofibrateLIPTRUZET ST; DQM=30 tabs/Rx atorvastatin + ZETIAlisinoprillisinopril-hydrochlorothiazidelithium carbonateLIVALO ST; DQM=30 tabs/Rx atorvastatin, simvastatinLO LOESTRIN FE* generic oral contraceptivesLOCOID hydrocortisone butyLOCOID LIPOCREAM hydrocortisone butyloperamideloratadinelorazepam


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


loryna*losartan potassiumlosartan-hydrochlorothiazideLOSEASONIQUE amethia lo, camrese loLOTEMAX generic ophth. steroidLOTREL amlodipine/benazeprillovastatinLOVAZA VASCEPALOVENOX enoxaparinlow-ogestrel*LUMIGAN latanoprostLUNESTA ST; DQM=30 tabs/Rx zolpidem immediate releaseLUPRON DEPOT PA ELIGARDlutera*LUVOX CR ST; DQM=60 tabs/Rx generic SSRILYRICALYSTEDA tranexamic acidMAKENA PAMALARONE atovaquone/proguanil hclMAXAIR AUTOHALER DQM=1 inhaler/Rx PROAIR HFAMAXALT DQM=18 tabs/Rx rizatriptanMAXALT MLT DQM=18 tabs/Rx rizatriptan odtmeclizine hclmedroxyprogesterone acetate*mefloquine hclMEGACE ES megestrol acetatemegestrol acetatemeloxicamMENESTMENOSTAR DQM=4 patches/28 days generic estradiol patchesmercaptopurineMETADATE CD methylphenidate cd

metaproterenol sulfatemetaxalonemetformin hclmetformin hcl ermethadone hcl inj PA; QL = 120 units/30 daysmethadone hcl other dose forms QL = 120 units/30 daysmethimazolemethocarbamolmethotrexatemethyldopamethylphenidate ermethylphenidate hclmethylphenidate srmethylprednisolonemetoclopramide hclmetolazonemetoprolol succinatemetoprolol tartrate inj PAmetoprolol tartrate tab, pwdmetoprolol-hydrochlorothiazideMETROGEL metronidazole 0.75% creammetronidazoleMICARDIS ST losartan, DIOVANMICARDIS HCT ST losartan/hctz, valsartan/hctzmicrogestin fe*microgestin*

MIGRANALDQM=8 spray devices = 1 kit/Rx ZOMIG NASAL


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


MINASTRIN 24 FE* generic oral contraceptivesMINILINK REAL-TIME TRANSMITTERMINIMEDMINIMED RESERVOIRMINIVELLE DQM=8 patches/28 days generic estradiol patchesminocycline hclminoxidilMIRAPEX pramipexoleMIRAPEX ER pramipexole immediate releasemirtazapinemisoprostolmodafinil PAmoexipril hclmoexipril-hydrochlorothiazidemometasone furoatemononessa*montelukast sodiummorphine sulfate er QL = 120 units/30 daysmorphine sulfate inj PA; QL = 120 units/30 daysmorphine sulfate other dose forms QL = 120 units/30 daysMOVIPREP* peg 3350-electrolyteMOXEZAmoxifloxacinMULTAQ amiodarone,OTHER ANTIARRHYTHmupirocinMUSE PA; DQM=12 supp/Rxmycophenolate mofetilMYFORTICmyorisan PAMYRBETRIQ oxybutynin er, trospium ernabumetonenadololNAFTIN ciclopirox, ketoconazolenaltrexone hclNAMENDANAMENDA XR NAMENDA IMMEDIATE-RELEASE TABSNAPRELAN ST naproxen sodiumnaproxennaproxen sodiumnaratriptan hclNASACORT AQ ST; DQM=1 bottle/Rx triamcinolone acetonideNASCOBAL cyanocobalamin injNASONEX ST; DQM=1 bottle/Rx flunisolide, fluticasoneNATAZIA* generic oral contraceptivesnateglinidenecon*neomycin-bacitracin-polymyxinneomycin-polymyxin-dexamethneomycin-polymyxin-hcneomycin-polymyxin-hydrocortNESINA ST; DQM=30 tabs/Rx JANUVIA, TRADJENTANEULASTA DQM=2 syringes/30 daysNEUPOGENNEUPRO pramipexole, ropinirole/erNEVANAC diclofenac, ketorolacnevirapine PA

NEXIUMST; DQM=30 caps or packets/Rx generics

NIASPANNICOTROL INHALER SCnifediac cc


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


nifedical xlnifedipine ernisoldipinenitrofurantoinnitrofurantoin mono-macronitroglycerinnitroglycerin patchNITROSTATnizatidinenora-be*NORDITROPIN FLEXPRO PA OMNITROPE, TEV-TROPINNORDITROPIN NORDIFLEX PA OMNITROPE, TEV-TROPINnorethindronenorethindrone acetate*NOROXIN ciproflox, levoflox, ofloxacinnortrel*nortriptyline hclNORVIR PAnovarel PA; DQM=3 vials/RxNOVOFINENOVOFINE 32NOVOFINE AUTOCOVERNOVOLIN products HUMULINNOVOLOG products HUMALOGNUCYNTA QL = 120 units/30 days oxycodone, tramadolNUCYNTA ER QL = 120 units/30 days OPANA ER, OXYCONTINNUEDEXTANULYTELY WITH FLAVOR PACKS peg-3350 w/flavor packs solnNUTROPIN/AQ/AQ NUSPIN PA OMNITROPE, TEV-TROPINNUVARING* generic oral contraceptivesNUVIGIL modafinilnystatinnystatin-triamcinoloneocella*ofloxacinogestrel*olanzapine inj PAolanzapine odtolanzapine tabolanzapine-fluoxetine hclOLUX clobetasol propion 0.05% foamOLUX-E clobetasol propionate crm,ointOLYSIO PA

OMECLAMOX-PAKDQM=80 caps/tabs (10 cards) = 1 pack/Rx omeprazole+clarithromycin+amox

omeprazoleomeprazole-sodium bicarbonateOMNARIS ST; DQM=1 bottle/Rx flunisolide, fluticasoneOMNITROPE PAondansetron hcl bag PAondansetron hcl other dose formsondansetron odtONE TOUCH LANCETSONE TOUCH TEST STRIPS FREESTYLEONE TOUCH ULTRA 2 FREESTYLEONE TOUCH ULTRA SMART FREESTYLEONE TOUCH ULTRA SYSTEM FREESTYLEONE TOUCH ULTRA TEST STRIPS FREESTYLEONE TOUCH ULTRAMINI FREESTYLEONE TOUCH VERIO FREESTYLEONE TOUCH VERIO IQ FREESTYLE


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


ONGLYZA ST; DQM=30 tabs/Rx JANUVIA,TRADJENTAONMEL DQM=15 tabs/Rx itraconazole capsulesONSOLIS QL = 120 units/30 days fentanyl citrate OTFC lozengeOPANA QL = 120 units/30 days oxymorphoneOPANA ER QL = 120 units/30 daysOPTICHAMBERORACEA ST doxycycline hyclateORAVIG nystatin, clotrimazol trocheORENCIAorphenadrine citrateORTHO EVRA* aviane, lessinaORTHO TRI-CYCLEN trinesa, tri-previ, tri-sprintORTHO TRI-CYCLEN LO* generic oral contraceptivesOSENI ST; DQM=30 tabs/Rx pioglitazne+JANUVIAorTRADJENTAOSMOPREP* peg 3350-electrolyteOVIDREL PA chorionic gonadotropin,novareloxaprozinoxazepamoxcarbazepineOXISTAT ciclopirox, ketoconazoleoxybutynin chlorideoxybutynin chloride eroxycodone hcl QL = 120 units/30 daysoxycodone-acetaminophen QL = 120 units/30 daysOXYCONTIN QL = 120 units/30 daysoxymorphone hcl QL = 120 units/30 daysOXYTROL DQM=8 patches/28 days oxybutynin er, trospium erPANCREAZE CREONpancrelipase 5,000pantoprazole sodiumPARADIGMPARADIGM INFUSIONPARADIGM REAL-TIMEPARADIGM SILHOUETTEparoxetine hclPATADAY azelastine hclPATANASE DQM= 1 bottle/Rx azelastine, ASTEPROPATANOL azelastine hclpeg 3350-electrolyte*

PEGASYSDQM=1 box/28 days or 4 vials/28 days

PEGASYS PROCLICK DQM=1 box/28 daysPEGINTRON/REDIPEN DQM=4 vials or pens/28 days PEGASYS

penicillin v potassiumPENNSAID ST ORAL NSAIDSPENTASApentoxifyllinePERFOROMIST DQM=1 carton/RxpermethrinperphenazinePERTZYE CREONphenazopyridine hclphenobarbitalphentermine hclPHENYTEK phenytoin sodium extendedphenytoin sodium extendedPHOSLYRA calcium acetate caps, eliphosPICATO fluorouracil, imiquimodpilocarpine hclpindolol


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


piroxicamPLAVIX clopidogrelPOLYFINPOLYFIN QRpolymyxin b sul-trimethoprimportia*potassium chloride other dose formspotassium chloride sol PApotassium citratePOTIGAPRADAXA PApramipexole dihydrochloridePRAMOSONE hydrocort 2.5/pramoxine 1% crmPRAMOSONE E hydrocort 2.5/pramoxine 1% crmPRANDIMET DQM=150 tabs/Rx nateglinide plus metforminPRANDIN repaglinidepravastatin sodiumprazosin hclPRECISIONPRECISION XTRAprednisoloneprednisolone acetateprednisolone sodium phosphateprednisonePREFERA OB hemenatal ob tabsPREFERA-OB ONE prenatal mv & min capsulePREFERA-OB PLUS DHA hemenatal ob+dha combo pkPREFEST ee/noreth ac,PREMPHASE/PREMPROPREMARIN inj PA VAGIFEMPREMARIN tab, vag cream VAGIFEMPREMPHASEPREMPROPRENATE DHA generic Rx prenatal vitamansPRENATE ELITE generic Rx prenatal vitamansPRENATE ESSENTIAL generic Rx prenatal vitamansPREPOPIK* peg 3350-electrolytePREVACID ST; DQM=30 solutabs/Rx lansoprazoleprevifem*

PREVPACDQM=112 caps (14 cards) = 1 pack/Rx amox+clarithromyc+lansoprazole

PREZISTA PAPRIMABELLAprimidonePRISTIQ ER ST; DQM=30 tabs/Rx venlafax er(NOT UCB NDCS-65580PROAIR HFA DQM=2 inhalers/Rxprobenecidprochlorperazine maleatePROCRITproctosol-hcproctozone-hcPRODIGY FREESTYLEPRODIGY INSULIN SYRINGEPRODIGY NO CODING FREESTYLEPRODIGY PEN NEEDLEPRODIGY POCKET FREESTYLEPRODIGY VOICE FREESTYLEprogesterone in oil inj PAprogesterone in oil other dose formsPROGRAF tacrolimusPROLENSA bromfenacpromethazine hcl inj


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


promethazine hcl tab, pwd, syrup, suppromethazine vcpromethazine vc-codeinepromethazine-codeinepromethazine-dmprometheganPROMETRIUM progesteronePROMISEB selenium sulfide, sod sulfacetpropafenone hclpropranolol hcl inj PApropranolol hcl tab, sol, cap, pwdpropylthiouracilPROTONIX ST; DQM=30 tabs/Rx pantoprazole sodiumPROTOPICPROVENTIL HFA DQM=2 inhalers/Rx PROAIR HFAPROVIGIL PA modafinil

PULMICORT

0.25mg & 0.5mg DQM=60 respules/Rx; 1mg DQM=30 respules/Rx budesonide

PULMICORT FLEXHALER90 mcg DQM=1 inhaler/Rx; 180 mcg DQM=2 inhalers/Rx

PULMOZYMEPYLERA metronidazole + tetracyclinepyridostigmine bromideQNASL ST; DQM=1 bottle/Rx flunisolide, fluticasoneQSYMIA benzphet,diethylprop,phentermQUALAQUIN quinine sulfateQUARTETTE* generic oral contraceptivesquasense*quetiapine fumarateQUICK RELEASE SOFT TEFLONQUILLIVANT XR methylphenidate cd, VYVANSEquinapril hclquinapril-hydrochlorothiazide

QVAR40 mcg DQM=2 inhalers/Rx; 80 mcg DQM=3 inhalers/Rx

ramiprilRANEXA gen beta blocker, ccb, nitrateranitidine hclRAPAFLO alfuzosin er, tamsulosinRAPAMUNERAYOS immediate-release prednisone

REBIFDQM=12 syringes/28 days; Pack DQM=1 pack/28 days

REBIF REBIDOSEreclipsen*RECTIV

RELENZADQM=20 blisters (1 carton)/Rx

RELISTORRELPAX DQM=6 tabs/Rx naratriptan,sumatrip,zolmitripRENAGEL calcium acetate, RENVELARENVELAreprexain QL = 120 units/30 daysREQUIP XL ropinirole erRESCULA latanoprostRESTASIS DQM=60 vials/RxRETIN-A MICRO/PUMP PA Required - Age > 34 tretinoinREVATIO inj sildenafilREVATIO tab DQM=90 tabs/Rx sildenafil


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


REVLIMIDREYATAZ PAREZIRA promethazine vc with codeineRHINOCORT AQUA ST; DQM=2 bottles/Rx flunisolide, fluticasoneribapak PAribavirin PArifampinRIOMET

RISPERDAL CONSTAall forms Risperdal DQM=60 tabs/Rx

risperidoneRITALIN LA methylphenidate cd,er,VYVANSErivastigminerizatriptan/odtropinirole hclroxicet QL = 120 units/30 daysROZEREM ST; DQM=30 tabs/RxRYTHMOL SR propafenone erSAFYRAL* generic oral contraceptivesSAIZEN PA OMNITROPE, TEV-TROPINsalsalateSANCTURA XR trospium erSANCUSO DQM=1 patch/Rx oral granisetron or ondansetrnSANDOSTATIN LARSANTYLSAPHRIS DQM=60 tabs/Rx generc, ABILIFY/DISC,SEROQL XRSEASONIQUE amethia, camreseselenium sulfideSENSIPARSEREVENT DISKUS DQM=1 package/Rx FORADIL

SEROQUEL

25mg, 50mg, 100mg, 200mg DQM=90 tabs/Rx; 300mg, 400mg DQM=60 tabs/Rx quetiapine fumarate

SEROQUEL XR

150mg, 200mg DQM=30 tabs/Rx; 50mg, 300mg, 400mg DQM=60 tabs/Rx

sertraline hclSFROWASA mesalamine 4 gm/60 ml enemaSILENOR ST; DQM=30 tabs/Rx zolpidem immediate releaseSILHOUETTEsilver sulfadiazineSIMBRINZA generics, ALPHAGAN P 0.1%SIMCOR 500mg DQM=30 tabs/Rx;

750mg DQM=60 tabs/Rx; 1000mg-20mg=60 tabs/Rx; 1000mg-40mg=30 tabs/Rx

simvastatin + NIASPAN

SIMPONI ENBREL, HUMIRAsimvastatinSINGULAIR montelukastSKELAXIN metaxalonesodium fluoride*sodium sulfacetamide-sulfurSOF-SENSOR FREESTYLESOF-SETSOF-SET MICROSOFT TOUCHSOFTCLIXSOLARAZE fluorouracil 5% cream, solnsolia*


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


SOLODYN ST minocycline hclSOMA metaxalone, tizanidineSOMATULINE DEPOT SANDOSTATIN LARSORILUX calcipotrienesotalol inj PAsotalol tabsotret PA

SPIRIVADQM=1 package (30 doses)/Rx

spironolactone/-hctzsprintec*SPRIX ST; DQM=5 bottles/Rx ketorolac tabletssronyx*STALEVO carbidopa/levodopa/entacaponeSTAXYN PA; DQM=8 tabs/Rx VIAGRASTELARA ENBREL, HUMIRASTRATTERASTRIANT TESTIMSUBOXONE QL = 120 units/30 days buprenorphine/naloxone sl tabsSUBSYS QL = 120 units/30 days fentanyl citrate OTFC lozengeSUCLEAR* peg 3350-electrolytesucralfateSULAR nisoldipine ersulfacetamide sodiumsulfamethoxazole-trimethoprimsulfasalazinesulindacsumatriptan PASUMAVEL DOSEPRO PA; DQM=6 units/Rx SUMATRIPTAN VIALSUPRAX cefpodoxime,cefuroxime,cefdinrSUPREP* peg 3350-electrolyteSURESTEP FREESTYLESURE-TSUSTIVA PAsyeda*SYMBICORT DQM=1 package/RxSYMBYAX olanzapine/fluoxetine hclSYMLINPEN DQM=7 pens/RxSYNAGISSYNTHROID levothyroxine sodiumTACLONEX calcipotriene + betamethasonetacrolimus PATAMIFLU DQM=see DQM documenttamoxifen citratetamsulosin hclTARKA verapamil er + trandolaprilTAZORACTEGRETOL XR carbamazepine xrTEKAMLO generc ACE INH/ARB+ amlodipineTEKTURNA ACE INH, losartan, DIOVANTEKTURNA HCT ace/hct,losart/hct,valsart/hcttelmisartantelmisartan-hctztemazepamterazosin hclterbinafine hclterconazoleTESTIM ANDROGEL, AXIRONtestosterone cypionatetetracycline hcl


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


TEVETEN STcandesartan, irbesartan, losartan, telmisartan, DIOVAN

TEVETEN HCT STcandesartan/-hctz, irbesartan/-hctz, losartan/-hctz, telmisartan/-hctz, DIOVAN

TEV-TROPIN PATHALOMIDtheophyllinetheophylline anhydrousthioridazine hclthiothixeneTIKOSYNtilia fe*timolol maleateTIMOPTIC OCUDOSE timolol maleate multidosetinidazoletizanidine hcl

TOBISol DQM=56 amps/Rx; Podhaler DQM=224 caps/Rx

TOBRADEX tobramycin/dexamethasone suspTOBRADEX ST tobramycin/dexamethasone susptobramycin sulfate inj PAtobramycin sulfate pwd, dropstobramycin-dexamethasonetolterodine ext-release

tolterodine tartrateTOPAMAX topiramate sprinkle capstopiramateTOPROL XL metoprolol succinate ertorsemideTOVIAZ oxybutynin er, trospium erTRACLEERTRADJENTA ST; DQM=30 tabs/Rx

tramadol hcl/er50mg DQM=240 tabs/Rx; ER 150mg DQM=60 caps/Rx

tramadol hcl-acetaminophentrandolaprilTRANSDERM-SCOP meclizinetranylcypromine sulfateTRAVATAN Z latanoprosttravoprosttrazodone hcltretinointretinoin PA Required - Age > 34tretinoinTREXIMET DQM=9 tabs/Rx sumatriptan tab + naproxentriamcinolone acetonidetriamterene-hctztriamterene-hydrochlorothiazidtriazolamTRIBENZOR ST amlodi+losartn-hct,EXFORGETRICOR fenofibratetrifluoperazine hcltrifluridineTRIGLIDE fenofibratetrihexyphenidyl hcltri-legest fe*


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


TRILIPIX fenofibratetrilyte with flavor packetstrimethoprimtrinessa*tri-previfem*tri-sprintec*trivora-28*TRUE2GO BLOOD GLUCOSE SYSTEM FREESTYLETRUERESULT BLOOD GLUCOSE SYSTM FREESTYLETRUETEST TEST STRIPS FREESTYLETRUETRACK SMART SYSTEM FREESTYLETRUETRACK TEST STRIP FREESTYLE

TRUVADA PATUDORZA PRESSAIR DQM=1 inhaler/RxTUSSICAPS hydrocodone/chlorpheniram suspTUSSIONEX hydrocodone/chlorpheniram suspTWYNSTA ST amlodipine+losartn,EXFORGETYKERBULESFIA permethrinULORICULTRAVATE PAC halobetasol propionate crmULTRESA pancrelipase dr 5000u CREONUROXATRAL alfuzosin hclursodiolVAGIFEMvalacyclovirvalproic acidVALTREX DQM=30 caplets/Rx valacyclovirVANCOCIN HCL vancomycinvancomycin hcl cap, pwdvancomycin hcl inj PAvandazoleVASCEPAVECTICAL calcipotriene ointvelivet*VELTIN PA Required - Age > 34 clindamycin-bp gelvenlafaxine hclVENLAFAXINE HCL ER ST venlafax er(NOT UCB NDCS-65580venlafaxine hcl er ST; DQM=30 tabs/RxVENTOLIN HFA DQM=1 inhaler/Rx PROAIR HFAVERAMYST ST; DQM=1 bottle/Rx flunisolide, fluticasoneverapamil er pmverapamil inj PAverapamil tab, cap, pwdVEREGEN imiquimod, podofiloxveripred 20VESICARE oxybutynin er, trospium erVEXOL generic ophth. steroidVGO 20VGO 30VGO 40VIAGRA PA; DQM=8 tabs/Rx

VICTOZAPak DQM=1 package/Rx; Tab DQM=30 tabs/Rx BYDUREON, BYETTA

VICTRELIS PAVIGAMOX ciprofl,levoflox,oflox, MOXEZA

VIIBRYDST; DQM=30 tabs/Rx; Pack DQM=1 pack/Rx generic SSRI

VIMOVO ST naproxen + omeprazoleVIMPAT


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


VIRAMUNE PA nevirapineVIRAMUNE XR PAVIREAD PAvitamin dVIVELLE-DOT DQM=8 patches/28 days generic estradiol patchesVOLTAREN ST ORAL NSAIDSvoriconazole PAVYTORIN ST; DQM=30 tabs/Rx simvastatin + ZETIAVYVANSEwarfarin sodiumWELCHOL cholestyramineWELLBUTRIN XL ST; DQM=30 tabs/Rx bupropion xlXALATAN latanoprostXARELTOXELJANZ ENBREL, HUMIRA, ORENCIA SCXELODAXERESE acyclovir + hydrocortisoneXIFAXANXOLAIR DQM=6 vials/28 daysXOPENEX levalbuterolXOPENEX CONCENTRATE levalbuterolXOPENEX HFA PROAIR HFAXYZAL DQM=30 tabs/Rx levocetirizineYASMIN 28 ocella,syeda,zarahYAZ gianvi, loryna, vesturazafirlukastzaleplonzamicet QL = 120 units/30 dayszarah*

ZEGERIDST; DQM=30 caps/packets/Rx generics

ZEMPLAR calcitriolzenatane PAzenchent*ZENPEP pancrelipase drZETIA

ZETONNAST; DQM=1 canister (60 actuations per canister)/Rx flunisolide, fluticasone

ZIAGEN PA abacavirZIANA PA Required - Age > 34 tretinoin + clindamycinZIOPTAN latanoprostziprasidone hclzolpidem tartratezolpidem tartrate erZOLPIMIST ST; DQM=1 bottle/Rx zolpidem tartrateZOMIG DQM=6 tabs/spray

devices/RxZOMIG ZMT DQM=6 tabs/Rx zolmitripan odtzonisamideZOSTAVAX*zovia 1-35e*zovia 1-50e*ZOVIRAX acyclovir ointmentZUBSOLV QL = 120 units/30 daysZUPLENZ ondansetron odtZUTRIPRO promethazine vc with codeineZYBAN SCZYCLARA imiquimodZYLET tobra/dexame susp,TOBRADEX STZYMAXID ciproflox, levoflox, ofloxacinZYPREXA inj PA olanzapine


Updated 10.28.2014

1($9)

($19)

2($30)($50)

3($45)($75)

4 (25%)(30%)

TIER


DRUG NAME


ZYPREXA tab DQM=30 tabs/Rx olanzapineZYPREXA ZYDIS DQM=30 tabs/Rx olanzapine odtZYRTEC DQM=30 tabs/RxZYRTEC-D DQM=60 tabs/RxZYTIGAZYVOX


Documents

ESI HIGH PERFORMANCE FORMULARY - VCHCP - … DQM= 1 tab/30 days; 30mg DQM=30 tabs/Rx; 35mg DQm=4 tabs/28 days; 5mg DQM=30 tabs/Rx; ... ESI HIGH PERFORMANCE FORMULARY TIER SUGGESTED