formulary 2017 master negative changes from 2016 to 2017€¦ · affected drug description of...

Affected Drug Description of ChangeFormulary Alternative, if

ApplicableCategory Class

ACYCLOVIR OIN 5% On formulary, tier change tier 2 to tier 4 Antivirals Antiherpetic Agents

ACYCLOVIR NA INJ

500MG On formulary, tier change tier 2 to tier 4 Antivirals Antiherpetic Agents

ACYCLOVIR NA INJ

50MG/ML On formulary, tier change tier 2 to tier 4 Antivirals Antiherpetic Agents

ALBUTEROL TAB 2MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ALBUTEROL TAB 4MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ALBUTEROL TAB 4MG

ER On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents

Bronchodilators,

Sympathomimetic

ALBUTEROL TAB 8MG

ER On formulary, tier change tier 2 to tier 4

Respiratory Tract/

Pulmonary Agents

Bronchodilators,

Sympathomimetic

AMIKACIN INJ

1GM/4ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides

AMIKACIN INJ

500/2ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides

AMINOSYN-HF INJ 8% On formulary, tier change tier 2 to tier 4

Therapeutic Nutrients/

Minerals/ Electrolytes Nutrients

AMLOD/ATORVA TAB 10-

10MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents

Dyslipidemics, HMG CoA

Reductase Inhibitors













AMLOD/ATORVA TAB

2.5-10MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents



HCSC Formulary 2017 Master Negative Changes from 2016 to 2017

Pg. 1 of 63



AMLOD/ATORVA TAB




AMLOD/ATORVA TAB




AMLOD/ATORVA TAB 5-




AMLOD/ATORVA TAB 5-




AMLOD/ATORVA TAB 5-




AMLOD/ATORVA TAB 5-




AMLOD/VALSAR TAB

/HCTZ Not on 2017 formulary

amlodipine/valsartan used

in combination with

hydrochlorothiazide Cardiovascular Agents

Cardiovascular Agents,

Other

AMOX/K CLAV CHW

200MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

AMOX/K CLAV CHW

400MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

AMPHET/DEXTR CAP

10MG ER On formulary, tier change tier 2 to tier 4

Central Nervous System

Agents

Attention Deficit

Hyperactivity Disorder

Agents, Amphetamines

AMPHET/DEXTR CAP



Agents

Attention Deficit



AMPHET/DEXTR CAP



Agents

Attention Deficit



AMPHET/DEXTR CAP



Agents

Attention Deficit



Pg. 2 of 63



AMPHET/DEXTR CAP



Agents

Attention Deficit



AMPHET/DEXTR CAP



Agents

Attention Deficit



AMPHETAMINE CAP



Agents

Attention Deficit



AMPHETAMINE CAP



Agents

Attention Deficit



AMPHETAMINE CAP



Agents

Attention Deficit



AMPHETAMINE CAP



Agents

Attention Deficit



AMPHETAMINE CAP



Agents

Attention Deficit



AMPHETAMINE CAP



Agents

Attention Deficit



AMPICILLIN INJ 10GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins


AMPICILLIN INJ 250MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins


AMPICILLIN INJ 500MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

AMP-SULBACTA INJ 2-

1GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

Pg. 3 of 63



AMP-SULBACTA INJ

3GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

ANDROGEL GEL

1%(25MG) Not on 2017 formulary

testosterone 1% gel

(generic Androgel 1%

made by Actavis and Par

brand only)* *This drug

requires prior

authorization. To

download the specific

form, please visit

www.MyPrime.com or

contact the number on the

back of your insurance

card for more information.

Hormonal Agents,

Stimulant/ Replacement/

Modifying (Sex

Hormones/ Modifiers) Androgens

ANDROGEL GEL

1%(50MG) Not on 2017 formulary

testosterone 1% gel

(generic Androgel 1%

made by Actavis and Par

brand only)* *This drug

requires prior

authorization. To


form, please visit

www.MyPrime.com or




Hormonal Agents,


Modifying (Sex


Pg. 4 of 63



ANDROID CAP 10MG Not on 2017 formulary

methyltestosterone 10 mg

capsules* *This drug

requires prior

authorization. To


form, please visit

www.MyPrime.com or




Hormonal Agents,


Modifying (Sex


APAP/CODEINE SOL

120-12/5 On formulary, tier change tier 2 to tier 4 Analgesics

Opioid Analgesics, Short-

acting

APAP/CODEINE TAB 300-

15MG On formulary, tier change tier 2 to tier 4 Analgesics


acting




acting




acting

APTIOM TAB 200MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents




ASCOMP/COD CAP

30MG Not on 2017 formulary

diclofenac, etodolac,

ketoprofen IR, ibuprofen,

naproxen Antimigraine Agents Antimigraine Agents

AVIDOXY TAB 100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines

AZITHROMYCIN INJ

500MG On formulary, tier change tier 2 to tier 4 Antibacterials Macrolides

AZTREONAM INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Other

Pg. 5 of 63



AZTREONAM INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Other

BLEOMYCIN INJ

15UNIT On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

BLEOMYCIN INJ

30UNIT On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

BLINCYTO INJ 35MCG

On formulary, requires

prior authorization check with your doctor Antineoplastics Antineoplastics, Other

BUMETANIDE INJ

0.25/ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop

BUT/APAP/CAF CAP

CODEINE Not on 2017 formulary


ibuprofen, ketoprofen IR,


BUT/APAP/CAF CAP

CODEINE Not on 2017 formulary




BUT/ASA/CAF/ CAP COD





Pg. 6 of 63



BUTRANS DIS

10MCG/HR Not on 2017 formulary

fentanyl patch (12mcg,

25mcg, 50mcg, 75mcg,

100mcg), morphine

sulfate ER tablets,

methadone tablets,

Zohydro ER* *This drug

requires prior

authorization. To


form, please visit

www.MyPrime.com or




Anti-Addiction/ Substance

Abuse Treatment Agents

Opioid Dependence

Treatments

BUTRANS DIS




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or






Opioid Dependence

Treatments

Pg. 7 of 63



BUTRANS DIS




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or






Opioid Dependence

Treatments

BUTRANS DIS




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or






Opioid Dependence

Treatments

Pg. 8 of 63



BUTRANS DIS 7.5/HR Not on 2017 formulary



100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or






Opioid Dependence

Treatments

CALCITRIOL INJ

1MCG/ML On formulary, tier change tier 2 to tier 4

Metabolic Bone Disease

Agents


Agents

CARBOPLATIN INJ

150/15ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

CARBOPLATIN INJ


CARBOPLATIN INJ

50MG/5ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

CARBOPLATIN INJ


CEFAZOLIN INJ 10GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins


Beta-lactam,

Cephalosporins


Beta-lactam,

Cephalosporins

Pg. 9 of 63



CEFAZOLIN INJ

500MG On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFEPIME INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFEPIME INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFOTAXIME INJ

10GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFOTAXIME INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFOTAXIME INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFOTAXIME INJ


Beta-lactam,

Cephalosporins

CEFOXITIN INJ 10GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins


Beta-lactam,

Cephalosporins


Beta-lactam,

Cephalosporins

CEFTAZIDIME INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins


Beta-lactam,

Cephalosporins


Beta-lactam,

Cephalosporins

CEFTRIAXONE INJ

10GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFTRIAXONE INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

Pg. 10 of 63



CEFTRIAXONE INJ


Beta-lactam,

Cephalosporins

CEFTRIAXONE INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFTRIAXONE INJ


Beta-lactam,

Cephalosporins

CEFUROXIME INJ

1.5GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFUROXIME INJ

7.5GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins

CEFUROXIME INJ


Beta-lactam,

Cephalosporins

CHOR GONADOT INJ

10000UNT On formulary, tier change tier 2 to tier 4

Hormonal Agents,


Modifying (Pituitary)

Hormonal Agents,



CHOR GONADOT INJ

10000UNT


prior authorization check with your doctor

Hormonal Agents,



Hormonal Agents,



CIDOFOVIR INJ

75MG/ML On formulary, tier change tier 2 to tier 5 Antivirals

Anti-cytomegalovirus

(CMV) Agents

CIPROFLOXACN INJ

200MG On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones

CIPROFLOXACN INJ

400MG On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones

CISPLATIN INJ 100MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

CISPLATIN INJ 200MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

CISPLATIN INJ


CLINDAMYCIN INJ

150MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

Pg. 11 of 63



CLINDAMYCIN INJ

300/2ML On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

CLINDAMYCIN INJ

300MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

CLINDAMYCIN INJ


CLINDAMYCIN INJ


CLINDAMYCIN INJ


CLINDAMYCIN INJ

9000/60 On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

CLINDAMYCIN INJ


CLINDAMYCIN INJ

9GM/60ML On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

CLINISOL SF INJ 15% On formulary, tier change tier 2 to tier 3


Minerals/ Electrolytes



CODEINE SULF TAB



acting

CODEINE SULF TAB



acting

CODEINE SULF TAB



acting

COMVAX INJ Not on 2017 formulary check with your doctor Immunological Agents Vaccines

CUPRIMINE CAP


Depen Titra 250 mg

tablets Genitourinary Agents

Genitourinary Agents,

Other

CYCLOPHOSPH INJ

1GM On formulary, tier change tier 2 to tier 5 Antineoplastics Alkylating Agents

CYCLOPHOSPH INJ

2GM On formulary, tier change tier 2 to tier 5 Antineoplastics Alkylating Agents

Pg. 12 of 63



CYCLOPHOSPH INJ

500MG On formulary, tier change tier 2 to tier 5 Antineoplastics Alkylating Agents

CYCLOSERINE CAP

250MG On formulary, tier change tier 4 to tier 5 Antimycobacterials Antituberculars

CYCLOSPORINE INJ

50MG/ML On formulary, tier change tier 2 to tier 4 Immunological Agents Immune Suppressants

CYTARABINE INJ

100MG/ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

CYTARABINE INJ


CYTARABINE INJ


D2.5W/NACL INJ 0.45% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

D5W/LR INJ On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

D5W/NACL INJ 0.2% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement




Electrolyte/Mineral

Replacement




Electrolyte/Mineral

Replacement




Electrolyte/Mineral

Replacement

DACARBAZINE INJ

200MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

DARAPRIM TAB 25MG On formulary, tier change tier 4 to tier 5 Antiparasitics Antiprotozoals

DAUNORUBICIN INJ


Pg. 13 of 63



DAUNOXOME INJ

2MG/ML Not on 2017 formulary

daunorubicin injection 5

mg/ml Antineoplastics Antineoplastics, Other

DEMECLOCYCL TAB

150MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines

DEMECLOCYCL TAB


DENAVIR CRE 1% On formulary, tier change tier 4 to tier 5 Antivirals Antiherpetic Agents

DESMOPRESSIN INJ


Hormonal Agents,



Hormonal Agents,



DESMOPRESSIN SPR

0.01% Not on 2017 formulary desmopressin tablets

Hormonal Agents,



Hormonal Agents,



DEXAMETH PHO INJ

120MG/30 On formulary, tier change tier 2 to tier 4

Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

DEXAMETH PHO INJ

20MG/5ML On formulary, tier change tier 2 to tier 4

Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

DEXAMETH PHO INJ

4MG/ML On formulary, tier change tier 2 to tier 4

Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

DEXAMETH PHO SOL

0.1% OP On formulary, tier change tier 2 to tier 4 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

DEXEDRINE TAB

10MG On formulary, tier change tier 2 to tier 4


Agents

Attention Deficit



DEXEDRINE TAB 5MG On formulary, tier change tier 2 to tier 4


Agents

Attention Deficit



Pg. 14 of 63



DEXILANT CAP 30MG

DR Not on 2017 formulary

esomeprazole (20 mg, 40

mg), lansoprazole (15 mg,

30 mg), Nexium granules

(2.5mg, 5 mg, 10 mg, 20

mg, 40 mg), omeprazole

(10mg, 20 mg, 40 mg),

pantoprazole (20 mg, 40

mg) Gastrointestinal Agents Proton Pump Inhibitors

DEXILANT CAP 60MG

DR Not on 2017 formulary




(2.5mg, 5 mg, 10 mg, 20


(10mg, 20 mg, 40 mg),



DEXMETHYLPH TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

DEXMETHYLPH TAB

2.5MG On formulary, tier change tier 2 to tier 4


Agents

Attention Deficit


Agents, Non-

amphetamines

DEXMETHYLPH TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

DEXTROAMPHET CAP



Agents

Attention Deficit



Pg. 15 of 63



DEXTROAMPHET CAP



Agents

Attention Deficit



DEXTROAMPHET CAP



Agents

Attention Deficit



DEXTROAMPHET TAB



Agents

Attention Deficit



DEXTROAMPHET TAB



Agents

Attention Deficit



DEXTROSE INJ 10% On formulary, tier change tier 2 to tier 4





DEXTROSE INJ 5% On formulary, tier change tier 2 to tier 4





DEXTROSE INJ 5%

PGBK On formulary, tier change tier 2 to tier 4





DICLO/MISOPR TAB 50-

0.2MG

On formulary, quantity

limit may apply 120 tablets per 30 days Analgesics

Nonsteroidal Anti-

inflammatory Drugs

DICLO/MISOPR TAB 75-

0.2MG



Nonsteroidal Anti-

inflammatory Drugs

DICLOFEN POT TAB

50MG



Nonsteroidal Anti-

inflammatory Drugs

DICLOFENAC TAB

100MG ER



Nonsteroidal Anti-

inflammatory Drugs

DICLOFENAC TAB

25MG DR



Nonsteroidal Anti-

inflammatory Drugs

DICLOFENAC TAB

50MG DR



Nonsteroidal Anti-

inflammatory Drugs

Pg. 16 of 63



DICLOFENAC TAB

75MG DR



Nonsteroidal Anti-

inflammatory Drugs

DICYCLOMINE TAB

20MG On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents

Antispasmodics,

Gastrointestinal

DIPHENHYDRAM INJ


Respiratory Tract/

Pulmonary Agents Antihistamines

DIVIGEL GEL 0.25MG Not on 2017 formulary

Estrace vaginal cream,

Premarin vaginal cream,

Vagifem vaginal tablets,

citalopram, gabapentin,

venlafaxine

Hormonal Agents,


Modifying (Sex

Hormones/ Modifiers) Estrogens

DIVIGEL GEL 0.5MG Not on 2017 formulary





venlafaxine

Hormonal Agents,


Modifying (Sex


DIVIGEL GEL

1MG/GM Not on 2017 formulary





venlafaxine

Hormonal Agents,


Modifying (Sex


DOXORUBICIN INJ


DOXORUBICIN INJ


DOXORUBICIN INJ


DOXORUBICIN INJ


DOXORUBICIN INJ


Pg. 17 of 63



DOXORUBICIN INJ


DOXORUBICIN INJ

200/100 On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

DOXORUBICIN INJ


DOXORUBICIN INJ


DOXORUBICIN INJ


DOXORUBICIN INJ


DOXORUBICIN INJ


DOXORUBICIN INJ


DOXY 100 INJ 100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines

DOXYCYC CAP


DOXYCYC CAP 50MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines

DOXYCYC MONO CAP


DOXYCYC MONO CAP


DOXYCYC MONO TAB


DOXYCYC MONO TAB


DOXYCYC MONO TAB


Pg. 18 of 63



DOXYCYC MONO TAB


DOXYCYCL HYC INJ


DOXYCYCLINE CAP


DOXYCYCLINE CAP


ELIDEL CRE 1%


prior authorization check with your doctor Dermatological Agents Dermatological Agents

ENOXAPARIN INJ


Blood Products/Modifiers/

Volume Expanders Anticoagulants

ENOXAPARIN INJ

30/0.3ML On formulary, tier change tier 2 to tier 4



ENOXAPARIN INJ

300/3ML On formulary, tier change tier 2 to tier 4



ENOXAPARIN INJ




ENOXAPARIN INJ




ENOXAPARIN INJ




EPIRUBICIN INJ 200MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

EPIRUBICIN INJ


Pg. 19 of 63



EPROSART MES TAB


candesartan (4 mg, 8 mg,

16 mg, 32 mg), irbesartan

(75 mg, 150 mg, 300 mg),

losartan (25 mg, 50 mg,

100 mg) , telmisartan (20

mg, 40 mg, 80 mg),

valsartan (40 mg, 80 mg,

160 mg, 320 mg) Cardiovascular Agents

Angiotensin II Receptor

Antagonists

EQUETRO CAP


carbamazepine ER

capsules (generic

Carbatrol),

carbamazepine ER

tablets (generic Tegretol-

XR) Bipolar Agents Mood Stabilizers

EQUETRO CAP


carbamazepine ER

capsules (generic

Carbatrol),

carbamazepine ER



EQUETRO CAP


carbamazepine ER

capsules (generic

Carbatrol),

carbamazepine ER



ESOMEPRAZOLE INJ

40MG On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents Proton Pump Inhibitors

Pg. 20 of 63



ESTRADIOL DIS

0.025MG Not on 2017 formulary





venlafaxine

Hormonal Agents,


Modifying (Sex


ESTRADIOL DIS






venlafaxine

Hormonal Agents,


Modifying (Sex


ESTRADIOL DIS






venlafaxine

Hormonal Agents,


Modifying (Sex


ESTRADIOL DIS






venlafaxine

Hormonal Agents,


Modifying (Sex


ESTRADIOL DIS






venlafaxine

Hormonal Agents,


Modifying (Sex


ESTRADIOL DIS






venlafaxine

Hormonal Agents,


Modifying (Sex


Pg. 21 of 63



ETODOLAC CAP

200MG


limit may apply 150 capsules per 30 days Analgesics

Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC CAP

300MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC TAB

400MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC ER TAB

400MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC ER TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

ETODOLAC ER TAB

600MG



Nonsteroidal Anti-

inflammatory Drugs

ETOPOSIDE INJ

100/5ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors

ETOPOSIDE INJ

1GM/50ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors

ETOPOSIDE INJ

20MG/ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors

ETOPOSIDE INJ


EXELON DIS 13.3/24 Not on 2017 formulary

rivastigmine 13.3 mg/24

patches Antidementia Agents Cholinesterase Inhibitors

EXELON DIS

4.6MG/24 Not on 2017 formulary



EXELON DIS

9.5MG/24 Not on 2017 formulary



FAMOTIDINE INJ

10MG/ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents

Histamine2 (H2) Receptor

Antagonists

Pg. 22 of 63



FAMOTIDINE INJ

200/20ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents


Antagonists

FAMOTIDINE INJ

20MG/2ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents


Antagonists

FAMOTIDINE INJ



Antagonists

FAMOTIDINE SUS

40MG/5ML Not on 2017 formulary

cimetidine tablets and

solution 300mg/5mL,

ranitidine tablets and

syrup, famotidine tablets,

nizatidine capsules Gastrointestinal Agents


Antagonists

FAZACLO TAB 100

ODT Not on 2017 formulary

clozapine 100 mg ODT*

*This drug requires prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Antipsychotics Treatment-Resistant

Pg. 23 of 63



FAZACLO TAB 12.5


clozapine tablets (25 mg,

50 mg, 100 mg, 200 mg)*,

clozapine ODT tablets (25

mg, 100 mg)* *These

drugs require prior

authorization. To


form, please visit

www.MyPrime.com or




FAZACLO TAB 150



50 mg, 100 mg, 200 mg)*,


mg, 100 mg)* *These

drugs require prior

authorization. To


form, please visit

www.MyPrime.com or




Pg. 24 of 63



FAZACLO TAB 200



50 mg, 100 mg, 200 mg)*,


mg, 100 mg)* *These

drugs require prior

authorization. To


form, please visit

www.MyPrime.com or




FAZACLO TAB 25MG


clozapine 25 mg ODT*


authorization. To


form, please visit

www.MyPrime.com or




FLUCONAZOLE/ INJ

DEX 200 On formulary, tier change tier 2 to tier 4 Antifungals Antifungals

FLUCONAZOLE/ INJ

DEX 400 On formulary, tier change tier 2 to tier 4 Antifungals Antifungals

FLUCONAZOLE/ INJ

NACL 200 On formulary, tier change tier 2 to tier 4 Antifungals Antifungals

FLUCONAZOLE/ INJ

NACL 400 On formulary, tier change tier 2 to tier 4 Antifungals Antifungals

Pg. 25 of 63



FLUDARABINE INJ


FLUDARABINE INJ


FLUPHENAZ DE INJ

25MG/ML On formulary, tier change tier 2 to tier 4 Antipsychotics 1st Generation/Typical

FLURBIPROFEN TAB

100MG



Nonsteroidal Anti-

inflammatory Drugs

FLURBIPROFEN TAB

50MG



Nonsteroidal Anti-

inflammatory Drugs

FONDAPARINUX INJ

2.5/0.5 On formulary, tier change tier 2 to tier 4



FORTICAL SPR

200/ACT Not on 2017 formulary

calcitonin (salmon) nasal

spray 200units/act


Agents


Agents

FOSPHENYTOIN INJ

100/2ML On formulary, tier change tier 2 to tier 3 Anticonvulsants Sodium Channel Agents

FOSPHENYTOIN INJ

500/10ML On formulary, tier change tier 2 to tier 4 Anticonvulsants Sodium Channel Agents

FOSRENOL CHW

1000MG On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders

FOSRENOL CHW


FOSRENOL CHW


FOSRENOL POW


FOSRENOL POW


FUROSEMIDE INJ

100/10ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop

Pg. 26 of 63



FUROSEMIDE INJ

10MG/ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop

FUROSEMIDE INJ

20MG/2ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop

FUROSEMIDE INJ

40MG/4ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop

GABAPENTIN CAP

100MG


limit may apply

1080 capsules per 30

days Anticonvulsants

Gamma-aminobutyric

Acid (GABA) Augmenting

Agents

GABAPENTIN CAP

300MG


limit may apply 360 capsules per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GABAPENTIN CAP

400MG


limit may apply 270 capsules per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GABAPENTIN SOL

250/5ML


limit may apply 2160 mLs per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GABAPENTIN SOL

300/6ML


limit may apply 2160 mLs per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GABAPENTIN TAB

600MG


limit may apply 180 tablets per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GABAPENTIN TAB

800MG


limit may apply 120 tablets per 30 days Anticonvulsants

Gamma-aminobutyric


Agents

GAMUNEX-C INJ

10GM/100 On formulary, tier change tier 3 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GAMUNEX-C INJ

1GM/10ML On formulary, tier change tier 3 to tier 5 Immunological Agents

Immunizing Agents,

Passive

Pg. 27 of 63



GAMUNEX-C INJ

2.5GM/25 On formulary, tier change tier 3 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GAMUNEX-C INJ

20GM/200 On formulary, tier change tier 3 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GAMUNEX-C INJ

40/400ML On formulary, tier change tier 3 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GAMUNEX-C INJ

5GM/50ML On formulary, tier change tier 3 to tier 5 Immunological Agents

Immunizing Agents,

Passive

GANCICLOVIR INJ

500MG On formulary, tier change tier 2 to tier 3 Antivirals

Anti-cytomegalovirus

(CMV) Agents

GENTAM/NACL INJ

0.9MG/ML Not on 2017 formulary

gentamicin in saline

injection (0.8 mg/ml, 1

mg/ml, 1.2 mg/ml, 1.6

mg/ml) Antibacterials Aminoglycosides

GENTAM/NACL INJ

1.4MG/ML Not on 2017 formulary

gentamicin in saline

injection (0.8 mg/ml, 1

mg/ml, 1.2 mg/ml, 1.6

mg/ml) Antibacterials Aminoglycosides

GENTAM/NACL INJ

100MG On formulary, tier change tier 2 to tier 3 Antibacterials Aminoglycosides

GENTAM/NACL INJ


GENTAM/NACL INJ


GENTAM/NACL INJ

60MG PB On formulary, tier change tier 2 to tier 3 Antibacterials Aminoglycosides

GENTAM/NACL INJ


GENTAM/NACL INJ

80MG PB On formulary, tier change tier 2 to tier 3 Antibacterials Aminoglycosides

Pg. 28 of 63



GENTAMICIN INJ

10MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides

GENTAMICIN INJ


HALOPER DEC INJ


HALOPER DEC INJ


HALOPER LAC INJ


HEP SOD/D5W INJ




HEPARIN SOD INJ

1000/ML On formulary, tier change tier 2 to tier 3



HEPARIN SOD INJ




HEPARIN SOD INJ




HEPARIN SOD INJ




HEPARIN SOD INJ

5000/0.5 On formulary, tier change tier 2 to tier 4



HEPARIN SOD INJ




HEPATAMINE SOL 8% On formulary, tier change tier 2 to tier 4



HUMULIN R INJ U-500


prior authorization check with your doctor Blood Glucose Regulators Insulins

HYDROMORPHON LIQ

1MG/ML On formulary, tier change tier 2 to tier 4 Analgesics


acting

Pg. 29 of 63



IBANDRONATE INJ



Agents


Agents

IBUPROFEN SUS

100/5ML


limit may apply 4800 mLs per 30 days Analgesics

Nonsteroidal Anti-

inflammatory Drugs

IBUPROFEN TAB

400MG



Nonsteroidal Anti-

inflammatory Drugs

IBUPROFEN TAB

600MG



Nonsteroidal Anti-

inflammatory Drugs

IBUPROFEN TAB

800MG



Nonsteroidal Anti-

inflammatory Drugs

IFOSFAMIDE INJ 1GM On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

IFOSFAMIDE INJ

1GM/20ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

IFOSFAMIDE INJ

3GM/60ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

IMIPENEM/CIL INJ

250MG On formulary, tier change tier 2 to tier 3 Antibacterials Beta-lactam, Other

IMIPENEM/CIL INJ


INTRALIPID INJ 20% On formulary, tier change tier 2 to tier 4



ISOSORB DIN TAB

40MG ER Not on 2017 formulary

isosorbide dinitrate IR

tablet (5 mg, 10 mg, 20

mg, 30 mg), isosorbide

mononitrate ER tablet (30

mg, 60 mg, 120 mg) Cardiovascular Agents

Vasodilators, Direct-acting

Arterial/Venous

KCL IN NACL INJ On formulary, tier change tier 2 to tier 3



Electrolyte/Mineral

Replacement

KCL IN NACL INJ .15-

0.45 On formulary, tier change tier 2 to tier 3



Electrolyte/Mineral

Replacement

Pg. 30 of 63



KCL/D5W INJ 0.15% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

KCL/D5W INJ 0.3% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ

.075/.45 On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ .15-

.45% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ

.15/.33% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ

.15/.45% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ




Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ




Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ




Electrolyte/Mineral

Replacement

KCL/D5W/NACL INJ




Electrolyte/Mineral

Replacement

KETOPROFEN CAP

50MG



Nonsteroidal Anti-

inflammatory Drugs

KETOPROFEN CAP

75MG



Nonsteroidal Anti-

inflammatory Drugs

LACTATED RIN INJ On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

LAMOTRIGINE TAB


lamotrigine tablets,

lamotrigine chewable

tablets (5 mg, 25 mg) Anticonvulsants

Glutamate Reducing

Agents

Pg. 31 of 63



LAMOTRIGINE TAB





Glutamate Reducing

Agents

LAMOTRIGINE TAB

25MG ODT Not on 2017 formulary




Glutamate Reducing

Agents

LAMOTRIGINE TAB

50MG ODT Not on 2017 formulary




Glutamate Reducing

Agents

LEUCOVOR CA INJ


LEUCOVOR CA INJ


LEUCOVOR CA INJ


LEUPROLIDE INJ

1MG/0.2 On formulary, tier change tier 2 to tier 3

Hormonal Agents,

Suppressant (Pituitary)

Hormonal Agents,


LEVETIRACETM INJ

500/5ML On formulary, tier change tier 2 to tier 3 Anticonvulsants Anticonvulsants, Other

LEVOFLOX/D5W INJ

250/50ML On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones

LEVOFLOX/D5W INJ

500/100M On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones

LEVOFLOX/D5W INJ

750/150 On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones

LEVOFLOXACIN INJ

25MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones

LIDOCAINE INJ 1% Not on 2017 formulary check with your doctor Analgesics Local Anesthetics

LINDANE LOT 1% Not on 2017 formulary

Lindane 1% shampoo,

malathion 0.5% lotion Antiparasitics Pediculicides/Scabicides

Pg. 32 of 63



LIPODOX INJ


LIPODOX 50 INJ


LIVALO TAB 1MG Not on 2017 formulary

atorvastatin, lovastatin,

rosuvastatin, pravastatin,

simvastatin Cardiovascular Agents















LOTEMAX GEL 0.5% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents

Ophthalmic Anti-

inflammatories

MAGNESIUM SU INJ

50% On formulary, tier change tier 2 to tier 3



Electrolyte/Mineral

Replacement

MAGNESIUM SU INJ

50% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

MECLIZINE TAB 25MG Not on 2017 formulary check with your doctor Antiemetics Antiemetics, Other

MEDROXYPR AC INJ


Hormonal Agents,


Modifying (Sex

Hormones/ Modifiers) Progestins

MELOXICAM TAB

15MG



Nonsteroidal Anti-

inflammatory Drugs

MELOXICAM TAB

7.5MG



Nonsteroidal Anti-

inflammatory Drugs

Pg. 33 of 63



MENEST TAB 0.3MG Not on 2017 formulary





venlafaxine

Hormonal Agents,


Modifying (Sex


MENEST TAB






venlafaxine

Hormonal Agents,


Modifying (Sex


MENEST TAB






venlafaxine

Hormonal Agents,


Modifying (Sex


MENEST TAB 2.5MG Not on 2017 formulary





venlafaxine

Hormonal Agents,


Modifying (Sex


MEROPENEM INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Other

MEROPENEM INJ


MESNA INJ 1GM On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

MESTINON TAB

TIMESPAN Not on 2017 formulary

pyridostigmine CR 180

mg tablet Antimyasthenic Agents Parasympathomimetics

METADATE TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 34 of 63



METHADONE TAB


Opioid Analgesics, Long-

acting

METHADONE TAB



acting

METHERGINE TAB

0.2MG On formulary, tier change tier 2 to tier 5 Genitourinary Agents


Other

METHOCARBAM TAB

500MG



Skeletal Muscle

Relaxants

Skeletal Muscle

Relaxants

METHOCARBAM TAB

750MG



Skeletal Muscle

Relaxants

Skeletal Muscle

Relaxants

METHYLERGON TAB

0.2MG On formulary, tier change tier 2 to tier 5 Genitourinary Agents


Other

METHYLPHENID TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPHENID TAB

20MG SR On formulary, tier change tier 2 to tier 4


Agents

Attention Deficit


Agents, Non-

amphetamines

Pg. 35 of 63



METHYLPHENID TAB



Agents

Attention Deficit


Agents, Non-

amphetamines

METHYLPR SS INJ


Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

METHYLPR SS INJ


Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

METHYLPR SS INJ


Hormonal Agents,


Modifying (Adrenal)

Hormonal Agents,


Modifying (Adrenal)

METOCLOPRAM INJ


Gastrointestinal Agents,

Other

METOCLOPRAM INJ

5MG/ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents


Other

METOCLOPRAM SOL

10/10ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents


Other

METOCLOPRAM SOL



Other

METRON/NACL INJ


MINOCYCLINE CAP


MINOCYCLINE CAP


MINOCYCLINE CAP


MINOCYCLINE TAB


Pg. 36 of 63



MINOCYCLINE TAB


MINOCYCLINE TAB


MITOMYCIN INJ 20MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

MITOMYCIN INJ 40MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other

MITOXANTRON INJ

2MG/ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics

MONDOXYNE NL CAP


MONDOXYNE NL CAP


MONDOXYNE NL CAP


MORPHINE SUL CAP




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Analgesics


acting

Pg. 37 of 63



MORPHINE SUL CAP




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

MORPHINE SUL CAP




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 38 of 63



MORPHINE SUL CAP




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

MORPHINE SUL CAP




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 39 of 63



MORPHINE SUL CAP




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

MYOZYME INJ 50MG Not on 2017 formulary check with your doctor

Enzyme Replacement/

Modifiers

Enzyme Replacement/

Modifiers

MYRBETRIQ TAB


oxybutynin IR 5mg tablet,

oxybutynin ER tablet,

tolterodine IR and ER,

Toviaz, trospium IR and

ER Genitourinary Agents Antispasmodics, Urinary

MYRBETRIQ TAB







NABUMETONE TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

NABUMETONE TAB

750MG



Nonsteroidal Anti-

inflammatory Drugs

Pg. 40 of 63



NAFCILLIN INJ 10GM On formulary, tier change tier 2 to tier 5 Antibacterials Beta-lactam, Penicillins



NAMENDA SOL

10MG/5ML Not on 2017 formulary

memantine 2 mg/mL

solution* *This drug

requires prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Antidementia Agents

N-methyl-D-aspartate

(NMDA) Receptor

Antagonist

NAMENDA TAB 10MG Not on 2017 formulary

memantine 10 mg tablet*


authorization. To


form, please visit

www.MyPrime.com or





(NMDA) Receptor

Antagonist

Pg. 41 of 63



NAMENDA TAB 5-


memantine 5-10 mg

titration pack* *This drug

requires prior

authorization. To


form, please visit

www.MyPrime.com or





(NMDA) Receptor

Antagonist

NAMENDA TAB 5MG Not on 2017 formulary

memantine 5 mg tablet*


authorization. To


form, please visit

www.MyPrime.com or





(NMDA) Receptor

Antagonist

NAMENDA XR CAP


memantine IR tablets*


authorization. To


form, please visit

www.MyPrime.com or





(NMDA) Receptor

Antagonist

Pg. 42 of 63



NAMENDA XR CAP




authorization. To


form, please visit

www.MyPrime.com or





(NMDA) Receptor

Antagonist

NAMENDA XR CAP




authorization. To


form, please visit

www.MyPrime.com or





(NMDA) Receptor

Antagonist

NAMENDA XR CAP




authorization. To


form, please visit

www.MyPrime.com or





(NMDA) Receptor

Antagonist

Pg. 43 of 63



NAMENDA XR CAP

TITRATIO Not on 2017 formulary



authorization. To


form, please visit

www.MyPrime.com or





(NMDA) Receptor

Antagonist

NAPROXEN SUS

125/5ML


limit may apply 1800 mLs per 30 days Analgesics

Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN TAB

250MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN TAB

375MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN DR TAB

375MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN DR TAB

500MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN SOD TAB

275MG



Nonsteroidal Anti-

inflammatory Drugs

NAPROXEN SOD TAB

550MG



Nonsteroidal Anti-

inflammatory Drugs

NASONEX SPR

50MCG/AC Not on 2017 formulary mometasone nasal spray

Respiratory Tract/

Pulmonary Agents

Anti-inflammatories,

Inhaled Corticosteroids

Pg. 44 of 63



NEVANAC SUS 0.1% Not on 2017 formulary

Prolensa, bromfenac

0.09%, diclofenac drops,

flurbiprofen drops,

ketorolac drops, Ilevro Ophthalmic Agents

Ophthalmic Anti-

inflammatories

NEVIRAPINE TAB

100MG


limit may apply 90 tablets per 30 days Antivirals

Anti-HIV Agents, Non-

nucleoside Reverse

Transcriptase Inhibitors

(NNRTI)

NITROGLYCRN SPR

0.4MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents


Arterial/Venous

NITROGLYCRN SPR

LINGUAL On formulary, tier change tier 2 to tier 4 Cardiovascular Agents


Arterial/Venous

NORMOSOL -M INJ

/D5W On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

NUCYNTA ER TAB




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 45 of 63



NUCYNTA ER TAB




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

NUCYNTA ER TAB




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 46 of 63



NUCYNTA ER TAB




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

NUCYNTA ER TAB




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 47 of 63



NUTRILIPID EMU 20% On formulary, tier change tier 2 to tier 4



NUVIGIL TAB 150MG Not on 2017 formulary

armodafinil 150 mg* *This

drug requires prior

authorization. To


form, please visit

www.MyPrime.com or



card for more information. Sleep Disorder Agents Sleep Disorders, Other



drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




Pg. 48 of 63





drug requires prior

authorization. To


form, please visit

www.MyPrime.com or






drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




OCTREOTIDE INJ

100MCG On formulary, tier change tier 2 to tier 4

Hormonal Agents,


Hormonal Agents,


OCTREOTIDE INJ

200MCG On formulary, tier change tier 2 to tier 4

Hormonal Agents,


Hormonal Agents,


OCTREOTIDE INJ


Hormonal Agents,


Hormonal Agents,


OLANZAPINE INJ 10MG On formulary, tier change tier 2 to tier 4 Antipsychotics 2nd Generation/Atypical

Pg. 49 of 63



OLEPTRO TAB

24HR150 Not on 2017 formulary trazodone IR tablet Antidepressants

SSRIs/SNRIs (Selective

Serotonin Reuptake

Inhibitors/ Serotonin and

Norepinephrine Reuptake

Inhibitor

OLEPTRO TAB

24HR300 Not on 2017 formulary trazodone IR tablet Antidepressants


Serotonin Reuptake



Inhibitor

OMNITROPE INJ

5.8MG On formulary, tier change tier 3 to tier 4

Hormonal Agents,



Hormonal Agents,



ONDANSETRON INJ

40/20ML On formulary, tier change tier 2 to tier 4 Antiemetics

Emetogenic Therapy

Adjuncts

ONDANSETRON INJ

4MG/2ML On formulary, tier change tier 2 to tier 4 Antiemetics

Emetogenic Therapy

Adjuncts

ORAP TAB 1MG Not on 2017 formulary pimozide 1 mg Antipsychotics 1st Generation/Typical

ORAP TAB 2MG Not on 2017 formulary pimozide 2 mg Antipsychotics 1st Generation/Typical

OXALIPLATIN INJ


OXALIPLATIN INJ


OXALIPLATIN INJ 50MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other

OXAPROZIN TAB

600MG



Nonsteroidal Anti-

inflammatory Drugs

PARICALCITOL INJ



Agents


Agents

PARICALCITOL INJ



Agents


Agents

Pg. 50 of 63



PAROXETIN ER TAB


citalopram, escitalopram,

fluoxetine, fluvoxamine

IR, sertraline Antidepressants


Serotonin Reuptake



Inhibito

PAROXETIN ER TAB






Serotonin Reuptake



Inhibito

PAROXETINE TAB






Serotonin Reuptake



Inhibito

PATANOL SOL 0.1%

OP Not on 2017 formulary olopatadine 0.1% drops Ophthalmic Agents

Ophthalmic Anti-allergy

Agents

PENICILLN GK INJ 20MU On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

PENICILLN GK INJ 5MU On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

PHENOXYBENZA CAP


Alpha-adrenergic Blocking

Agents

PIPER/TAZOBA INJ 2-

0.25GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

PIPER/TAZOBA INJ 3-

0.375G On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

PIPER/TAZOBA INJ 4-

0.5GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins

PIROXICAM CAP

10MG



Nonsteroidal Anti-

inflammatory Drugs

Pg. 51 of 63



PIROXICAM CAP

20MG



Nonsteroidal Anti-

inflammatory Drugs

PLENAMINE INJ 15% On formulary, tier change tier 2 to tier 3





POT CHLORIDE INJ

2MEQ/ML On formulary, tier change tier 2 to tier 3



Electrolyte/Mineral

Replacement

PREGNYL INJ


Hormonal Agents,



Hormonal Agents,



PREGNYL INJ

10000UNT



Hormonal Agents,



Hormonal Agents,



PREMARIN TAB






venlafaxine

Hormonal Agents,


Modifying (Sex


PREMARIN TAB






venlafaxine

Hormonal Agents,


Modifying (Sex


PREMARIN TAB






venlafaxine

Hormonal Agents,


Modifying (Sex


Pg. 52 of 63



PREMARIN TAB






venlafaxine

Hormonal Agents,


Modifying (Sex


PREMARIN TAB






venlafaxine

Hormonal Agents,


Modifying (Sex


PREMASOL SOL 6% On formulary, tier change tier 2 to tier 3



PROCHLORPER INJ

10MG/2ML On formulary, tier change tier 2 to tier 4 Antiemetics Antiemetics, Other

PROCHLORPER INJ

5MG/ML On formulary, tier change tier 2 to tier 4 Antiemetics Antiemetics, Other

PROLASTIN-C INJ

1000MG



Respiratory Tract/

Pulmonary Agents

Respiratory Tract Agents,

Other

PROPRANOLOL INJ

1MG/ML On formulary, tier change tier 2 to tier 3 Cardiovascular Agents

Beta-adrenergic Blocking

Agents

QUINIDINE SU TAB

300MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Antiarrhythmics

RABEPRAZOLE TAB





(2.5mg, 5 mg, 10 mg, 20


(10mg, 20 mg, 40 mg),



Pg. 53 of 63



RESTASIS EMU 0.05% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents Ophthalmic Agents, Other

RESTASIS EMU 0.05%


limit may apply 60 vials per 30 days Ophthalmic Agents Ophthalmic Agents, Other

RIDAURA CAP 3MG On formulary, tier change tier 4 to tier 5 Immunological Agents Immunomodulators

RIFAMPIN INJ 600 MG On formulary, tier change tier 2 to tier 4 Antimycobacterials Antituberculars

SEROQUEL XR TAB


quetiapine IR tablets*


authorization. To


form, please visit

www.MyPrime.com or



card for more information. Antipsychotics 2nd Generation/Atypical

SEROQUEL XR TAB




authorization. To


form, please visit

www.MyPrime.com or




Pg. 54 of 63



SEROQUEL XR TAB




authorization. To


form, please visit

www.MyPrime.com or




SEROQUEL XR TAB




authorization. To


form, please visit

www.MyPrime.com or




SEROQUEL XR TAB




authorization. To


form, please visit

www.MyPrime.com or




Pg. 55 of 63



SOD CHLORIDE INJ

0.45% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

SOD CHLORIDE INJ

0.9% On formulary, tier change tier 2 to tier 4



Electrolyte/Mineral

Replacement

SOTALOL AF TAB

120MG Not on 2017 formulary sotalol hcl tablets Cardiovascular Agents Antiarrhythmics

SOTALOL AF TAB


SOTALOL AF TAB


STERIL WATER SOL

IRRIG On formulary, tier change tier 2 to tier 4





SULINDAC TAB

150MG



Nonsteroidal Anti-

inflammatory Drugs

SULINDAC TAB

200MG



Nonsteroidal Anti-

inflammatory Drugs

SUMATRIPTAN INJ

4MG/0.5 On formulary, tier change tier 2 to tier 4 Antimigraine Agents

Serotonin (5-HT) 1b/1d

Receptor Agonists

SUMATRIPTAN INJ

6MG/0.5 On formulary, tier change tier 2 to tier 4 Antimigraine Agents

Serotonin (5-HT) 1b/1d

Receptor Agonists

SURMONTIL CAP


citalopram, fluoxetine,

escitalopram, sertraline,

duloxetine capsules

(20mg, 30mg, 60mg),

venlafaxine IR tablets, ER

tablets (37.5mg, 75mg,

150mg ), and ER

capsules, mirtazapine,

bupropion Antidepressants Tricyclics

Pg. 56 of 63



SURMONTIL CAP




duloxetine capsules

(20mg, 30mg, 60mg),



150mg ), and ER



SURMONTIL CAP




duloxetine capsules

(20mg, 30mg, 60mg),



150mg ), and ER



TACROLIMUS OIN

0.03%



TACROLIMUS OIN

0.1%



TAZICEF INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials

Beta-lactam,

Cephalosporins


Beta-lactam,

Cephalosporins


Beta-lactam,

Cephalosporins

TEFLARO INJ 400MG On formulary, tier change tier 4 to tier 5 Antibacterials

Beta-lactam,

Cephalosporins

Pg. 57 of 63



TEFLARO INJ 600MG On formulary, tier change tier 4 to tier 5 Antibacterials

Beta-lactam,

Cephalosporins

TEGRETOL-XR TAB


carbamazepine ER 100

mg tablets Anticonvulsants Sodium Channel Agents

TESTOST CYP INJ


Hormonal Agents,


Modifying (Sex


TESTOST CYP INJ


Hormonal Agents,


Modifying (Sex


TESTOST ENAN INJ


Hormonal Agents,


Modifying (Sex


TIKOSYN CAP

125MCG Not on 2017 formulary dofetilide 125 mcg Cardiovascular Agents Antiarrhythmics

TIKOSYN CAP


TIKOSYN CAP


TOBRAMYCIN INJ

1.2/30ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides

TOBRAMYCIN INJ

1.2GM On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides

TOBRAMYCIN INJ


TOBRAMYCIN INJ


Pg. 58 of 63



TOBRAMYCIN INJ

80MG/2ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides

TOLMETIN SOD CAP

400MG



Nonsteroidal Anti-

inflammatory Drugs

TOPOSAR INJ


TOPOSAR INJ

1GM/50ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors

TOPOSAR INJ


TOPOSAR INJ


TOPOSAR INJ


TRAMADOL HCL TAB




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 59 of 63



TRAMADOL HCL TAB




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

TRAMADOL HCL TAB




100mcg), morphine

sulfate ER tablets,

methadone tablets,


requires prior

authorization. To


form, please visit

www.MyPrime.com or





acting

Pg. 60 of 63



TRANEX ACID INJ

1000M/10 On formulary, tier change tier 2 to tier 4


Volume Expanders Coagulants

TRANEX ACID INJ



Volume Expanders Coagulants

TYGACIL INJ 50MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other

TYZINE PED DRO

0.05% Not on 2017 formulary check with your doctor

Respiratory Tract/

Pulmonary Agents

Respiratory Tract Agents,

Other

VALPROATE INJ

100MG/ML On formulary, tier change tier 2 to tier 3 Anticonvulsants

Gamma-aminobutyric


Agents

VALPROATE INJ

500/5ML On formulary, tier change tier 2 to tier 3 Anticonvulsants

Gamma-aminobutyric


Agents

VANCOMYCIN INJ 1

GM On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

VANCOMYCIN INJ


VANCOMYCIN INJ

10GM On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

VANCOMYCIN INJ


VANCOMYCIN INJ 5GM On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other

VESICARE TAB 10MG Not on 2017 formulary






Pg. 61 of 63



VESICARE TAB 5MG Not on 2017 formulary






VINCASAR PFS INJ

1MG/ML



VINCRISTINE INJ

1MG/ML



VIRAMUNE XR TAB


nevirapine SR 100 mg

tablet Antivirals

Anti-HIV Agents, Non-

nucleoside Reverse

Transcriptase Inhibitors

(NNRTI)

VOLTAREN GEL 1% Not on 2017 formulary

diclofenac 1% gel* *This

drug requires prior

authorization. To


form, please visit

www.MyPrime.com or




Nonsteroidal Anti-

inflammatory Drugs

VORICONAZOLE INJ

200MG On formulary, tier change tier 2 to tier 4 Antifungals Antifungals

Pg. 62 of 63



VRAYLAR CAP 1.5-


Vraylar capsules (1.5 mg,

3 mg, 4.5 mg, 6 mg)*


authorization. To


form, please visit

www.MyPrime.com or




ZEMPLAR INJ

2MCG/ML Not on 2017 formulary paricalcitol 2 mcg/ml inj


Agents


Agents

ZEMPLAR INJ

5MCG/ML Not on 2017 formulary paricalcitol 5 mcg/ml inj


Agents


Agents

ZENZEDI TAB 10MG On formulary, tier change tier 2 to tier 4


Agents

Attention Deficit



ZENZEDI TAB 5MG On formulary, tier change tier 2 to tier 4


Agents

Attention Deficit



ZETIA TAB 10MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents Dyslipidemics, Other

ZOLEDRONIC INJ



Agents


Agents

ZOLEDRONIC INJ

5/100ML On formulary, tier change tier 2 to tier 4


Agents


Agents

Pg. 63 of 63

formulary 2017 master negative changes from 2016 to 2017€¦ · affected drug description of...

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