Martin’s Point Generations Advantage
Select (PPO)
2015 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT
CONTAINS INFORMATION ABOUT THE
DRUGS WE COVER IN THIS PLAN
H1365_2015_340 ACCEPTED: 10/7/2014
FORMULARY ID 00015292, VERSION #10
EFFECTIVE 01/01/2015
This formulary was updated on 12/18/2014. For
more recent information or other questions, please
contact Martin’s Point Generations Advantage
Select Member Engagement at 1-866-544-7504 or,
for TTY users, 711. We’re available 8 am to 8 pm,
seven days a week, from October 1 to February
14. From February 14 to September 30, we are
available Monday through Friday from 8 am to 8
pm. Or visit www.MartinsPoint.org/medicare.
Note to existing members: This formulary
has changed since last year. Please review this
document to make sure that it still contains the
drugs you take.
When this drug list (formulary) refers to “we,” “us”,
or “our,” it means Martin’s Point Generations, LLC.
When it refers to “plan” or “our plan,” it means
Generations Advantage Select.
This document includes the list of the drugs
(formulary) for our plan which is current as of
December 18, 2014. For an updated formulary,
please contact us. Our contact information, along
with the date we last updated the formulary,
appears on the front and back cover pages.
You must generally use network pharmacies
to use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/
2015 SELECT (PPO) PLAN FORMULARY
coinsurance may change on January 1, 2016, and
from time to time during the year.
WHAT IS THE GENERATIONS
ADVANTAGE SELECT FORMULARY?
A formulary is a list of covered drugs selected
by Generations Advantage Select in consultation
with a team of health care providers, which
represents the prescription therapies believed to
be a necessary part of a quality treatment program.
Generations Advantage Select will generally cover
the drugs listed in our formulary as long as the
drug is medically necessary, the prescription is
filled at a Generations Advantage Select network
pharmacy, and other plan rules are followed. For
more information on how to fill your prescriptions,
please review your Evidence of Coverage.
CAN THE FORMULARY
(DRUG LIST) CHANGE?
Generally, if you are taking a drug on our 2015
formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage
of the drug during the 2015 coverage year except
when a new, less expensive generic drug becomes
available or when new adverse information about
the safety or effectiveness of a drug is released.
Other types of formulary changes, such as
removing a drug from our formulary, will not affect
members who are currently taking the drug. It
will remain available at the same cost-sharing for
those members taking it for the remainder of the
coverage year. We feel it is important that you have
continued access for the remainder of the coverage
year to the formulary drugs that were available
when you chose our plan, except for cases in which
1
you can save additional money or we can ensure
your safety.
If we remove drugs from our formulary, or add
prior authorization, quantity limits and/or step
therapy restrictions on a drug, or move a drug to
a higher cost-sharing tier, we must notify affected
members of the change at least 60 days before
the change becomes effective, or at the time the
member requests a refill of the drug, at which time
the member will receive a 60-day supply of the
drug. If the Food and Drug Administration (FDA)
deems a drug on our formulary to be unsafe or
the drug’s manufacturer removes the drug from
the market, we will immediately remove the drug
from our formulary and provide notice to members
who take the drug. The enclosed formulary is
current as of December 18, 2014. To get updated
information about the drugs covered by the
plan, please contact us. Our contact information
appears on the front and back cover pages. On a
monthly basis, members affected by any mid-year,
non-maintenance changes to this formulary that
would have a negative impact, such as increases in
copayments, will receive a hard copy notification of
such changes.
HOW DO I USE THE FORMULARY?
drugs are listed in the Index. Look in the Index
and find your drug. Next to your drug, you will
see the page number where you can find coverage
information. Turn to the page listed in the Index
and find the name of your drug in the first column
of the list.
WHAT ARE GENERIC DRUGS?
Generations Advantage Select covers both brand
name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active
ingredient as the brand name drug. Generally,
generic drugs cost less than brand name drugs.
ARE THERE ANY RESTRICTIONS
ON MY COVERAGE?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
ϐϐ
Prior Authorization: Generations Advantage
Select requires you or your physician to get prior
authorization for certain drugs. This means
that you will need to get approval from the plan
before you fill your prescriptions. If you don’t
get approval, the plan may not cover the drug.
ϐϐ
Quantity Limits: For certain drugs,
Generations Advantage Select limits the amount
of the drug that Generations Advantage Select
will cover. For example, Generations Advantage
Select provides 12 tabs per prescription for
Relpax. This may be in addition to a standard
one-month or three-month supply.
ϐϐ
Step Therapy: In some cases, Generations
Advantage Select requires you to first try certain
drugs to treat your medical condition before we
will cover another drug for that condition. For
example, if Drug A and Drug B both treat your
medical condition, the plan may not cover Drug
B unless you try Drug A first. If Drug A does not
work for you, the plan will then cover Drug B.
There are two ways to find your drug within the
formulary:
Medical Condition
The formulary begins on page 7. The drugs in this
formulary are grouped into categories depending
on the type of medical conditions that they are
used to treat. For example, drugs used to treat
a heart condition are listed under the category,
“Cardiovascular”. If you know what your drug is
used for, look for the category name in the list that
begins on page number 7. Then look under the
category name for your drug.
Alphabetical Listing
If you are not sure what category to look under,
you should look for your drug in the Index
that begins on page 63. The Index provides an
alphabetical list of all of the drugs included in this
document. Both brand name drugs and generic
2
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 7. You can also get more
information about the restrictions applied to
specific covered drugs by visiting our Web site. We
2015 SELECT (PPO) PLAN FORMULARY
have posted on line documents that explain our
prior authorization and step therapy restrictions.
You may also ask us to send you a copy. Our
contact information, along with the date we last
updated the formulary, appears on the front and
back cover pages.
You can ask Generations Advantage Select to
make an exception to these restrictions or limits
or for a list of other, similar drugs that may treat
your health condition. See the section, “How do I
request an exception to the Generations Advantage
Select formulary?” on page 3 for information about
how to request an exception.
WHAT IF MY DRUG IS NOT
ON THE FORMULARY?
If your drug is not included in this formulary (list
of covered drugs), you should first contact Member
Engagement and ask if your drug is covered.
If you learn that Generations Advantage Select
does not cover your drug, you have two options:
ϐϐ
You can ask Member Engagement for a list of
similar drugs that are covered by Generations
Advantage Select. When you receive the
list, show it to your doctor and ask him
or her to prescribe a similar drug that is
covered by Generations Advantage Select.
ϐϐ
You can ask Generations Advantage
Select to make an exception and cover
your drug. See below for information
about how to request an exception.
HOW DO I REQUEST AN EXCEPTION
TO THE GENERATIONS ADVANTAGE
SELECT’S PLAN FORMULARY?
You can ask Generations Advantage Select to make
an exception to our coverage rules. There are
several types of exceptions that you can ask us to
make.
ϐϐ
You can ask us to cover a drug even if it is not
on our formulary. If approved, this drug will
be covered at a pre-determined cost-sharing
level, and you would not be able to ask us to
provide the drug at a lower cost-sharing level.
2015 SELECT (PPO) PLAN FORMULARY
ϐϐ
You can ask us to cover a formulary drug at a
lower cost-sharing level if this drug is not on
the specialty tier. If approved this would lower
the amount you must pay for your drug.
ϐϐ
You can ask us to waive coverage restrictions
or limits on your drug. For example, for certain
drugs, Generations Advantage Select limits the
amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to
waive the limit and cover a greater amount.
Generally, Generations Advantage Select will
only approve your request for an exception if
the alternative drugs included on the plan’s
formulary, the lower cost-sharing drug or
additional utilization restrictions would not be as
effective in treating your condition and/or would
cause you to have adverse medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering or
utilization restriction exception. When you
request a formulary, tiering or utilization
restriction exception you should submit a
statement from your prescriber or physician
supporting your request. Generally, we must
make our decision within 72 hours of getting
your prescriber’s supporting statement. You
can request an expedited (fast) exception if
you or your doctor believe that your health
could be seriously harmed by waiting up to 72
hours for a decision. If your request to expedite
is granted, we must give you a decision no
later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
WHAT DO I DO BEFORE I CAN
TALK TO MY DOCTOR ABOUT
CHANGING MY DRUGS OR
REQUESTING AN EXCEPTION?
As a new or continuing member in our plan you
may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our
formulary but your ability to get it is limited. For
example, you may need a prior authorization from
us before you can fill your prescription. You should
talk to your doctor to decide if you should switch
to an appropriate drug that we cover or request
3
a formulary exception so that we will cover the
drug you take. While you talk to your doctor to
determine the right course of action for you, we
may cover your drug in certain cases during the
first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary
or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a
prescription written for fewer days) when you go to
a network pharmacy. After your first 30-day supply,
we will not pay for these drugs, even if you have
been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we
will allow you to refill your prescription until we
have provided you with up to a 98-day transition
supply, consistent with dispensing increment,
(unless you have a prescription written for fewer
days). We will cover more than one refill of these
drugs for the first 90 days you are a member of
our plan. If you need a drug that is not on our
formulary or if your ability to get your drugs
is limited, but you are past the first 90 days of
membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have
a prescription for fewer days) while you pursue a
formulary exception.
FOR MORE INFORMATION
For more detailed information about your
Generations Advantage Select prescription drug
coverage, please review your Evidence of Coverage
and other plan materials.
If you have questions about Generations Advantage
Select, please contact us. Our contact information,
along with the date we last updated the formulary,
appears on the front and back cover pages.
If you have general questions about Medicare
prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227) 24 hours a
day/7 days a week. TTY users should call
1-877-486-2048. Or, visit www.medicare.gov.
If you change your level of care, such as a move
from a hospital to a home setting, and you need a
drug that is not on our formulary or if your ability
to get your drugs is limited, but you are past the
first 90 days of membership in our plan, we will
cover up to a temporary 30-day supply (or 31-day
supply if you are a long term care resident) when
you go to a network pharmacy. After your first
30-day supply, you are required to use the plan’s
exception process. Our transition supply will not
cover drugs that Medicare does not allow Part D
plans to cover, such as drugs that might be covered
under Medicare Part B.
4
2015 SELECT (PPO) PLAN FORMULARY
Generations Advantage
Select Formulary
The formulary that begins on page 7 provides
coverage information about the drugs covered by
Generations Advantage Select. If you have trouble
finding your drug in the list, turn to the Index that
begins on page 63.
The first column of the chart lists the drug name.
Brand name drugs are capitalized (e.g., AVELOX)
and generic drugs are listed in lower-case italics
(e.g., azithromycin).
The information in the Requirements/Limits
column tells you if Generations Advantage Select
has any special requirements for coverage of
your drug.
2015 SELECT (PPO) PLAN FORMULARY
Prescription drugs can be ordered through
the network mail-order program. Typically
prescriptions will arrive 25 days after the pharmacy
receives a valid and complete order. If your
prescription does not arrive within this time frame,
call 1-888-296-6961. Automated mail-order delivery
is an option.
Most prescription drugs are available through
the mail order pharmacy. Those that cannot be
delivered by mail are noted with ‘NM’ in the table
that begins on page 7.
5
6
2015 SELECT (PPO) PLAN FORMULARY
$95
33% coinsurance
Cost-Sharing Tier 4
$90
(Non-preferred Brands
and Select Nonpreferred Generics)
Cost-Sharing Tier 5
33% coin(Specialty Medications) surance
$45
$10
$6
Cost-Sharing Tier 2
(Non-preferred
Generics and Select
Preferred Brands)
Cost-Sharing Tier 3
$40
(Preferred Brands and
Select Non-preferred
Generics)
$4
$0
Non-Preferred
Pharmacies
Cost-Sharing Tier 1
(Preferred Generics
and Select Preferred
Brands)
Preferred
Pharmacies
Network Pharmacy
33% coinsurance
$95
$45
$10
$4
The plan’s
mail-order
service
33% coinsurance
$95
$45
$10
$4
Network
long-term care
pharmacy
33% plus the cost
difference between
the Network and NonNetwork Pharmacy
$90 plus the cost
difference between
the Network and NonNetwork Pharmacy
$45 plus the cost
difference between
the Network and NonNetwork Pharmacy
$10 plus the cost
difference between
the Network and NonNetwork Pharmacy
$4 plus the cost
difference between
the Network and NonNetwork Pharmacy
Out-of-network pharmacy
Your share of the cost when you get a one-month (30-day) supply
(or less) of a covered Part D prescription drug from:
33% coinsurance
$270
$120
$18
$0
Preferred
Pharmacies
33% coinsurance
$285
$135
$30
$12
Non-Preferred
Pharmacies
Network Pharmacy
33% coinsurance
$237.50
$112.50
$25
$10
The plan’s
mail-order
service
Your share of the cost when you get a
long-term (90-day) supply of a covered
Part D prescription drug from:
2015 Generations Advantage Pharmacy Cost-Sharing Tiers for Initial Coverage Stage
PART D FORMULARY
2015 Formulary
Notes key
B/D = C
overed under Medicare B
or D
GEL = Gel
gm = gram
INJ = Injection
LA = Limited Access
lpop = lollipop
mL = milliliter
NM=Not available by mail order
OINT = Ointment
PA = Prior Authorization
ptch = patch
Drug Name
ANALGESICS
GOUT
allopurinol tab
colchicine w/ probenecid
COLCRYS
probenecid
ULORIC
NSAIDS
CELEBREX CAP 50MG
CELEBREX CAP 100MG
CELEBREX CAP 200MG
CELEBREX CAP 400MG
diclofenac potassium
diclofenac sodium TB24; TBEC
diflunisal
etodolac
etodolac er
flurbiprofen TABS
ibuprofen SUSP
ibuprofen TABS 400mg, 600mg
ibuprofen tab 800 mg
ketoprofen CAPS
MELOXICAM SUSP
meloxicam TABS
nabumetone TABS
NAPRELAN
naproxen SUSP
QL = Quantity Limits
SOLN = Solution
ST = Step Therapy
supp = suppository
SUSP = Suspension
Drug
Tier
1
2
3
2
3
4
4
4
4
2
2
2
2
2
2
2
1
1
2
2
1
2
4
2
Requirements/Limits*
QL (120 tabs / 30 days)
ST
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
7
PART D FORMULARY
Drug Name
naproxen TABS; TBEC
naproxen sodium TABS 275mg, 550mg
piroxicam CAPS
sulindac TABS
OPIOID ANALGESICS
acetaminophen w/ codeine SOLN
acetaminophen w/ codeine TABS
butorphanol tartrate SOLN 1mg/ml, 2mg/ml
hydroco/apap tab 5-325mg
hydroco/apap tab 7.5-325
hydroco/apap tab 10-325mg
hydrocodone-acetaminophen 7.5-325 mg/15ml
hydrocodone-ibuprofen tab 7.5-200 mg
lorcet hd tab 10-325mg
lorcet plus tab 7.5-325
lorcet tab 5-325mg
lortab tab 5-325mg
lortab tab 7.5-325
lortab tab 10-325mg
tramadol hcl TABS
tramadol-acetaminophen
OPIOID ANALGESICS, CII
DURAMORPH
endocet
fentanyl 12mcg/hr, 25mcg/hr
fentanyl 50mcg/hr, 75mcg/hr, 100mcg/hr
fentanyl citrate LPOP
hydromorphon inj 10mg/ml
hydromorphone hcl LIQD
hydromorphone hcl TABS
LAZANDA SPR 100MCG
LAZANDA SPR 400MCG
methadone hcl CONC
methadone hcl SOLN 5mg/5ml, 10mg/5ml
methadone hcl TABS
morphine ext-rel tab 15mg, 30mg, 60mg, 100mg
morphine ext-rel tab 200mg
MORPHINE SUL INJ 1MG/ML, 4MG/ML, 10MG/ML,
15MG/ML
morphine sul inj .5mg/ml, 1mg/ml
morphine sulfate CP24 10mg, 20mg, 30mg, 50mg, 60mg
Drug
Tier
1
1
2
1
Requirements/Limits*
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL (5000 mL / 30 days)
QL (400 tabs / 30 days)
2
2
2
2
5
2
2
2
5
5
2
2
2
2
2
B/D
QL (360 tabs / 30 days)
QL (10 patches / 30 days)
QL (10 patches / 30 days), PA
QL (120 lozenges / 30 days), PA
B/D
2
B/D
2
2
B/D
QL (60 caps / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (5400 mL / 30 days)
QL (150 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (240 tabs / 30 days)
QL (240 tabs / 30 days)
QL (270 tabs / 30 days)
QL (30 bottles / 30 days), PA
QL (30 bottles / 30 days), PA
QL (120 mL / 30 days)
QL (600 mL / 30 days)
QL (240 tabs / 30 days)
QL (90 tabs / 30 days)
QL (60 tabs / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
8
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
morphine sulfate CP24 80mg
MORPHINE SULFATE SOLN 2MG/ML, 8MG/ML
MORPHINE SULFATE TABS
morphine sulfate beads
morphine sulfate cap 100mg er
MORPHINE SULFATE ORAL SOL
oxycodone hcl CAPS
OXYCODONE HCL CONC
oxycodone hcl SOLN
oxycodone hcl TABS
oxycodone hcl tab 5 mg
oxycodone w/ acetaminophen 2.5-325mg
oxycodone w/ acetaminophen 5-325mg
oxycodone w/ acetaminophen 7.5-325mg
oxycodone w/ acetaminophen 10-325mg
roxicet soln
roxicet tab 5-325mg
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl (local anesth.)
lidocaine inj 0.5%
lidocaine inj 1%
lidocaine inj 1.5%
lidocaine inj 2%
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate SOLN
gentamicin in saline
gentamicin sulfate SOLN
neomycin sulfate TABS
paromomycin sulfate CAPS
streptomycin sulfate SOLR
sulfadiazine TABS
tobramycin NEBU
tobramycin sulfate SOLN; SOLR
tobramycin sulfate in saline
Drug
Tier
5
2
2
2
5
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
4
5
2
3
Requirements/Limits*
QL (60 caps / 30 days)
B/D
QL (180 tabs / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (180 caps / 30 days)
QL (180 tabs / 30 days)
QL (180 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (1800 mL / 30 days soln)
QL (360 tabs / 30 days)
B/D
B/D
B/D
B/D
B/D
B/D, NM
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
9
PART D FORMULARY
Drug Name
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA
ALINIA
atovaquone SUSP
AZACTAM
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
aztreonam
BILTRICIDE
CAYSTON
clindamycin cap 75mg
clindamycin cap 300mg
clindamycin hcl cap 150 mg
clindamycin phosphate inj
clindamycin sol 75mg/5ml
colistimethate sodium SOLR
CUBICIN
dapsone TABS
DARAPRIM
e.s.p.
ees/sulfisox sus 200-600
imipenem-cilastatin
INVANZ
meropenem
methenamine hippurate
metronidazole TABS
metronidazole in nacl
NEBUPENT
nitrofurantoin macrocrystal
nitrofurantoin monohyd macro
PENTAM 300
SIVEXTRO
sulfamethoxazole-trimethoprim
sulfamethoxazole-trimethoprim inj
SYNERCID
trimethoprim TABS
TYGACIL
vancomycin hcl CAPS
vancomycin hcl SOLR
ZYVOX
Drug
Tier
4
4
5
4
4
5
2
3
5
1
1
1
2
2
2
5
2
4
2
2
2
4
2
2
1
2
4
4
4
4
5
1
2
5
1
5
5
2
5
Requirements/Limits*
NM, LA, PA
B/D
B/D
PA; 90 day limit if >64 yr
PA; 90 day limit if >64 yr
B/D
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
10
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
ANTIFUNGALS
ABELCET
AMBISOME
amphotericin b SOLR
CANCIDAS
ERAXIS
fluconazole SUSR; TABS
fluconazole in dextrose
fluconazole in nacl
flucytosine CAPS
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole CAPS
ketoconazole TABS
MYCAMINE
NOXAFIL SUSP; TBEC
nystatin TABS
terbinafine hcl TABS
voriconazole SOLR
voriconazole SUSR; TABS
ANTIMALARIALS
atovaquone-proguanil hcl
chloroquine phosphate TABS
COARTEM
mefloquine hcl
PRIMAQUINE PHOSPHATE
quinine sulfate CAPS
ANTIRETROVIRAL AGENTS
abacavir sulfate
APTIVUS
CRIXIVAN
didanosine
EDURANT
EMTRIVA
EPIVIR SOLN
FUZEON
INTELENCE 25MG
INTELENCE 100MG, 200MG
INVIRASE CAPS
Drug
Tier
5
5
2
5
5
2
2
2
5
2
2
2
2
5
5
2
1
2
5
2
2
3
2
3
2
2
5
4
2
5
3
3
5
4
5
4
Requirements/Limits*
B/D
B/D
B/D
PA
PA
QL (90 tabs / 365 days)
PA
NM
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
11
PART D FORMULARY
Drug Name
INVIRASE TABS
ISENTRESS CHEW 25MG
ISENTRESS CHEW 100MG
ISENTRESS PACK
ISENTRESS TABS
lamivudine 150mg, 300mg
LEXIVA SUSP
LEXIVA TABS
NEVIRAPINE SUSP
nevirapine TABS; TB24
NORVIR
PREZISTA SUSP
PREZISTA TABS 75MG, 150MG
PREZISTA TABS 600MG, 800MG
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ
SELZENTRY
stavudine
SUSTIVA CAPS
SUSTIVA TABS
TIVICAY
TYBOST
VIDEX PEDIATRIC
VIRACEPT
VIRAMUNE XR 100MG
VIREAD
ZIAGEN SOLN
zidovudine
ANTIRETROVIRAL COMBINATION AGENTS
abacavir sulfate-lamivudine-zidovudine
ATRIPLA
COMPLERA
EPZICOM
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine
STRIBILD
TRIUMEQ
TRUVADA
Drug
Tier
5
3
5
3
5
2
4
5
2
2
3
5
3
5
4
3
5
5
2
3
5
5
4
4
5
4
5
4
2
5
5
5
5
5
3
5
5
5
5
5
Requirements/Limits*
QL (30 tabs / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
12
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
ANTITUBERCULAR AGENTS
CAPASTAT SULFATE
cycloserine CAPS
ethambutol hcl TABS
isoniazid TABS
isoniazid inj 100 mg/ml
isoniazid syp 50mg/5ml
paser d/r
PRIFTIN
pyrazinamide
rifabutin
rifampin CAPS; SOLR
RIFATER
SIRTURO
TRECATOR
ANTIVIRALS
acyclovir CAPS; TABS
acyclovir SUSP
acyclovir sodium
adefovir dipivoxil
BARACLUDE SOLN
BARACLUDE TABS
entecavir
EPIVIR HBV SOLN
famciclovir TABS
foscarnet sodium
ganciclovir inj 500mg
lamivudine 100mg
moderiba 800 dose pack
moderiba pak 600/day
moderiba pak 1000/day
moderiba pak 1200/day
moderiba tab 200mg
OLYSIO
REBETOL SOLN
RELENZA DISKHALER
ribapak mis 600/day
ribasphere CAPS
ribasphere TABS 200mg, 400mg
ribasphere TABS 600mg
Drug
Tier
5
2
2
1
2
2
3
4
2
2
2
4
5
4
1
2
2
5
3
5
5
4
2
2
2
2
5
5
5
5
2
5
5
3
5
2
2
5
Requirements/Limits*
LA, PA
B/D
B/D
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
13
PART D FORMULARY
Drug Name
ribasphere ribapak 800
ribasphere ribapak 1000
ribasphere ribapak 1200
ribavirin 200mg
rimantadine hydrochloride
SOVALDI
TAMIFLU
TYZEKA
valacyclovir hcl TABS
VALCYTE
VICTRELIS
CEPHALOSPORINS
cefaclor
cefaclor monohydrate er
cefadroxil
cefazolin in d5w
cefazolin inj
cefazolin sodium 1gm, 20gm
cefdinir
cefepime hcl
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime 1gm, 2gm, 6gm
CEFTAZIDIME/DEXTROSE
ceftriaxone sodium SOLR
cefuroxime axetil TABS
cefuroxime sodium 1.5gm, 7.5gm, 750mg
cephalexin CAPS 250mg, 500mg
cephalexin SUSR
SUPRAX CAPS
suprax CHEW
suprax SUSR 100mg/5ml, 200mg/5ml
SUPRAX SUSR 500MG/5ML
suprax TABS
tazicef SOLR
tazicef vial
TEFLARO
Drug
Tier
5
5
5
2
2
5
3
5
2
5
5
Requirements/Limits*
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
2
3
2
3
2
2
2
2
2
2
2
2
2
4
2
1
2
1
2
3
4
3
3
3
2
2
4
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
14
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
ERYTHROMYCINS/MACROLIDES
AZITHROMYCIN PACK
azithromycin SOLR 500mg
azithromycin SUSR
azithromycin TABS 250mg
azithromycin TABS 500mg, 600mg
clarithromycin TABS
clarithromycin er
clarithromycin for susp
DIFICID
e.e.s.
e.e.s. 400
E.E.S. GRANULES
ery-tab
ERYPED 200
ERYPED 400
erythrocin lactobionate 500mg
erythrocin stearate
erythromycin base
erythromycin cap 250mg ec
ZMAX
FLUOROQUINOLONES
AVELOX
AVELOX ABC PACK
ciprofloxacin SUSR
ciprofloxacin er
ciprofloxacin hcl tab
ciprofloxacin in d5w
ciprofloxacin inj
levofloxacin TABS
levofloxacin in d5w
levofloxacin inj 25mg/ml
levofloxacin oral soln 25 mg/ml
PENICILLINS
amoxicillin
amoxicillin & pot clavulanate
ampicillin & sulbactam sodium
ampicillin cap 250 mg
ampicillin cap 500 mg
Drug
Tier
Requirements/Limits*
2
2
2
1
2
2
2
2
5
2
2
4
4
4
4
4
2
2
2
3
4
4
2
2
1
2
2
2
2
2
2
1
2
2
1
1
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
15
PART D FORMULARY
Drug Name
ampicillin for susp 125 mg/5ml
ampicillin for susp 250 mg/5ml
ampicillin inj
ampicillin sodium
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium 1gm
nafcillin sodium 2gm, 10gm
oxacillin sodium 1gm, 2gm
oxacillin sodium 10gm
PENICILLIN G POT IN DEXTROSE
penicillin g potassium
penicillin g procaine
penicillin g sodium
penicillin v potassium
penicilln gk inj 5mu
piperacillin sodium-tazobactam sodium
TIMENTIN SOLR
TIMENTIN INJ 3.1GM
TETRACYCLINES
doxycycline (monohydrate) CAPS 50mg, 100mg
doxycycline (monohydrate) TABS
doxycycline hyclate CAPS; SOLR; TABS
minocycline hcl CAPS
VIBRAMYCIN SYRP
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BICNU
BUSULFEX
CYCLOPHOSPHAMIDE CAPS
cyclophosphamide SOLR; TABS
dacarbazine 200mg
EMCYT
HEXALEN
IFEX 3GM
ifosfamide inj 1gm
ifosfamide inj 1gm/20ml
IFOSFAMIDE INJ 3GM
ifosfamide inj 3gm/60ml
LEUKERAN
Drug
Tier
1
1
2
2
4
2
2
5
2
5
4
2
3
2
1
2
2
4
4
Requirements/Limits*
2
2
2
2
4
4
4
4
2
2
4
5
4
2
2
4
2
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
16
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
LOMUSTINE
melphalan hcl
MUSTARGEN
TREANDA
ANTHRACYCLINES
adriamycin 50mg
daunorubicin hcl
doxorubicin hcl for inj 50 mg
doxorubicin hcl liposomal inj 2mg/ml
doxorubicin inj 50mg
epirubicin hcl SOLN
idarubicin hcl
ANTIBIOTICS
bleomycin sulfate
mitomycin SOLR
ANTIMETABOLITES
adrucil
ALIMTA
azacitidine
cladribine
cytarabine SOLN 20mg/ml
fludarabine phosphate
fluorouracil SOLN
GEMCITABINE HCL SOLN
gemcitabine hcl SOLR
mercaptopurine TABS
methotrexate sodium inj
NIPENT
TABLOID
ANTIMITOTIC, TAXOIDS
DOCETAXEL CONC 20MG/ML, 80MG/4ML
docetaxel CONC 140mg/7ml
DOCETAXEL SOLN 80MG/8ML
paclitaxel
Drug
Requirements/Limits*
Tier
2
5 B/D
4 B/D
5 B/D, NM
2
2
2
5
2
2
5
B/D
B/D
B/D
B/D
B/D
B/D
B/D
2
2
B/D
B/D
2
5
5
5
2
2
2
5
5
2
2
5
4
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D
B/D
B/D
5
5
5
2
B/D
B/D
B/D
B/D
B/D
B/D
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
17
PART D FORMULARY
Drug Name
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate SOLN
vincasar
vincristine sulfate
vinorelbine tartrate
BIOLOGIC RESPONSE MODIFIERS
AVASTIN
ERIVEDGE
HERCEPTIN
ISTODAX
KADCYLA
PROLEUKIN
RITUXAN
VELCADE
ZOLINZA
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole TABS
bicalutamide
DEPO-PROVERA INJ 400/ML
exemestane
FARESTON
FASLODEX
flutamide
letrozole TABS
leuprolide acetate KIT
LUPR DEP-PED INJ 30MG (3-MONTH)
LUPRON DEPOT 3.75MG
LUPRON DEPOT INJ 11.25 MG
LUPRON DEPOT-PED
LYSODREN
MEGACE ES
megestrol acetate SUSP; TABS
NILANDRON
SOLTAMOX
tamoxifen citrate TABS
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
XTANDI
ZYTIGA
Drug
Tier
Requirements/Limits*
3
2
2
2
B/D
B/D
B/D
B/D
5
5
5
5
5
5
5
5
5
B/D, NM
NM, LA, PA
B/D, NM
B/D, NM
B/D, NM
B/D, NM
NM, PA
B/D, NM
NM, PA
2
2
4
2
5
5
2
2
2
5
5
5
5
3
5
4
5
4
1
5
5
5
5
B/D
B/D
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
PA
PA
NM, PA
NM, PA
NM, LA, PA
NM, PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
18
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
KINASE INHIBITORS
AFINITOR
AFINITOR DISPERZ
BOSULIF
CAPRELSA
COMETRIQ
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GLEEVEC
ICLUSIG
IMBRUVICA CAP 140MG
INLYTA
JAKAFI
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT 12.5MG, 25MG, 50MG
SUTENT 37.5MG
TAFINLAR
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYDELIG
ZYKADIA
MISCELLANEOUS
DROXIA
hydroxyurea CAPS
MATULANE
mitoxantrone hcl
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
Drug
Tier
Requirements/Limits*
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
NM, PA
NM, PA
NM, PA
NM, LA, PA
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM, LA, PA
NM, PA
NM, LA, PA
NM, PA
PA
NM, PA
NM, PA
NM, PA
NM, LA, PA
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
3
2
5
2
5
5
5
5
B/D, NM
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
19
PART D FORMULARY
Drug Name
SYLATRON KIT 296MCG
SYLATRON KIT 444MCG
SYLATRON KIT 888MCG
TARGRETIN CAPS
tretinoin (chemotherapy)
TRISENOX
PLATINUM-BASED AGENTS
carboplatin SOLN
cisplatin
oxaliplatin
PROTECTIVE AGENTS
amifostine crystalline
dexrazoxane 250mg
ELITEK
leucovorin calcium SOLR
leucovorin calcium TABS
leucovorin calcium for inj 500 mg
mesna
MESNEX TABS
TOPOISOMERASE INHIBITORS
etoposide SOLN 500mg/25ml
irinotecan hcl
toposar 1gm/50ml
topotecan hcl SOLR
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine-benazepril hcl cap 10-20 mg
amlodipine-benazepril hcl cap 2.5-10 mg
amlodipine-benazepril hcl cap 5-10 mg
amlodipine-benazepril hcl cap 5-20 mg
amlodipine-benazepril hcl cap 5-40 mg
amlodipine-benazepril hcl cap 10-40mg
benazepril & hydrochlorothiazide
captopril & hydrochlorothiazide
enalapril maleate & hydrochlorothiazide
fosinopril sodium & hydrochlorothiazide
lisinopril & hydrochlorothiazide
Drug
Tier
5
5
5
5
5
5
Requirements/Limits*
NM, PA
NM, PA
NM, PA
NM, PA
B/D
2
2
5
B/D
B/D
B/D
5
5
5
2
2
2
2
5
B/D
B/D
B/D
B/D
2
5
2
5
B/D
B/D
B/D
B/D
1
1
1
1
1
1
1
1
1
1
1
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
B/D
B/D
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
20
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
Drug
Tier
1
1
Requirements/Limits*
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
ACE INHIBITORS
benazepril hcl TABS
1
captopril TABS
1
enalapril maleate TABS
1
fosinopril sodium
1
lisinopril TABS
1
moexipril hcl
1
perindopril erbumine
1
quinapril hcl
1
ramipril
1
trandolapril
1
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone
2
spironolactone TABS
1
ALPHA BLOCKERS
doxazosin mesylate 1mg, 2mg, 4mg
2 QL (30 tabs / 30 days)
doxazosin mesylate 8mg
2
prazosin hcl
1
terazosin hcl
1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
AZOR 10-40MG
3
AZOR TAB 5-20MG
3 QL (30 tabs / 30 days)
AZOR TAB 5-40MG
3 QL (30 tabs / 30 days)
AZOR TAB 10-20MG
3 QL (30 tabs / 30 days)
BENICAR HCT 40-25MG
3
BENICAR HCT TAB 20-12.5MG
3 QL (30 tabs / 30 days)
BENICAR HCT TAB 40-12.5MG
3 QL (30 tabs / 30 days)
EXFORGE HCT/5- TAB 160-12.5
3 QL (30 tabs / 30 days)
EXFORGE HCT/5- TAB 160-25
3 QL (60 tabs / 30 days)
EXFORGE HCT/10- TAB 160-12.5
3 QL (30 tabs / 30 days)
EXFORGE HCT/10- TAB 160-25
3 QL (30 tabs / 30 days)
EXFORGE HCT/10- TAB 320-25
3
EXFORGE TAB 5-160MG
1 QL (30 tabs / 30 days)
EXFORGE TAB 5-320MG
1 QL (30 tabs / 30 days)
EXFORGE TAB 10-160MG
1 QL (30 tabs / 30 days)
EXFORGE TAB 10-320MG
1
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
21
PART D FORMULARY
Drug Name
losartan-hctz 50-12.5mg
losartan-hctz 100-12.5mg
losartan-hctz 100-25mg
TRIBENZOR40- TAB 10-25MG
TRIBENZOR TAB 20-5-12.5MG
TRIBENZOR TAB 40-5-12.5MG
TRIBENZOR TAB 40-5-25MG
TRIBENZOR TAB 40-10-12.5
valsartan & hctz tab 80-12.5mg
valsartan & hctz tab 160-12.5mg
valsartan & hctz tab 160-25mg
valsartan & hctz tab 320-12.5mg
valsartan & hctz tab 320-25mg
ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR 5MG
BENICAR 20MG
BENICAR 40MG
DIOVAN 40MG, 80MG, 160MG
DIOVAN 320MG
losartan potassium 25mg, 50mg
losartan potassium 100mg
valsartan 40mg, 80mg, 160mg
valsartan 320mg
ANTIARRHYTHMICS
amiodarone hcl SOLN
amiodarone hcl TABS 100mg, 400mg
amiodarone hcl TABS 200mg
disopyramide phosphate
flecainide acetate
mexiletine hcl
MULTAQ
NORPACE CR
pacerone 100mg, 400mg
pacerone 200mg
propafenone hcl
quinidine gluconate TBCR
quinidine sulfate TABS
sorine
Drug
Tier
1
1
1
3
3
3
3
3
1
1
1
1
1
3
3
3
4
4
1
1
1
1
2
2
1
4
2
2
4
4
2
1
2
2
1
2
Requirements/Limits*
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
PA
PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
22
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug
Tier
sotalol hcl
2
sotalol hcl (afib/afl)
2
TIKOSYN
4
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
atorvastatin calcium
1
CRESTOR
3
LESCOL
4
LESCOL XL
4
lovastatin 10mg
1
lovastatin 20mg
1
lovastatin 40mg
1
pravastatin sodium
1
simvastatin TABS
1
ANTILIPEMICS, MISCELLANEOUS
cholestyramine
2
cholestyramine light
2
choline fenofibrate
2
colestipol hcl
2
fenofibrate TABS
2
fenofibrate micronized
2
fenofibrate micronized cap
2
gemfibrozil TABS
2
niacin (antihyperlipidemic) 500mg
2
niacin (antihyperlipidemic) 750mg, 1000mg
2
niacor
2
NIASPAN
4
omega-3-acid ethyl esters
2
prevalite
2
VASCEPA
4
WELCHOL
3
ZETIA TAB 10MG
3
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone
1
bisoprolol & hydrochlorothiazide
1
metoprolol & hctz tab 50-25mg
2
metoprolol & hctz tab 100-25mg
2
metoprolol & hctz tab 100-50mg
2
propranolol & hydrochlorothiazide
2
Drug Name
Requirements/Limits*
NM
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (90 tabs / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
23
PART D FORMULARY
Drug Name
Drug
Tier
Requirements/Limits*
BETA-BLOCKERS
acebutolol hcl CAPS
1
atenolol TABS
1
bisoprolol fumarate
2
BYSTOLIC
4
carvedilol
1
labetalol hcl TABS
2
metoprolol succinate 25mg, 50mg
2 QL (60 tabs / 30 days)
metoprolol succinate 100mg
2 QL (45 tabs / 30 days)
metoprolol succinate 200mg
2
metoprolol tartrate SOLN
2
metoprolol tartrate TABS
1
nadolol TABS
2
pindolol
2
propranolol cap er
2
propranolol hcl SOLN
2
propranolol hcl TABS
1
timolol maleate TABS
2
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
CADUET
4
CALCIUM CHANNEL BLOCKERS
afeditab cr 30mg
2 QL (60 tabs / 30 days)
afeditab cr 60mg
2
amlodipine besylate TABS 2.5mg, 5mg
1 QL (45 tabs / 30 days)
amlodipine besylate TABS 10mg
1
cartia xt cap 120/24hr
2
cartia xt cap 180/24hr
2
cartia xt cap 240/24hr
2
cartia xt cap 300/24hr
2
dilt-cd cap
2
dilt-xr cap
2
diltiazem cap
2
diltiazem cap 120mg/24hr
2
diltiazem cap er/12hr
2
diltiazem hcl SOLN
2
diltiazem hcl TABS
1
diltiazem hcl coated beads CP24
2
diltzac
2
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
24
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
felodipine 2.5mg
felodipine 5mg
felodipine 10mg
isradipine
nicardipine hcl CAPS
nifedical 30mg
nifedical 60mg
nifedipine TB24 30mg
nifedipine TB24 60mg, 90mg
nifedipine er 30mg
nifedipine er 60mg, 90mg
nimodipine CAPS
NYMALIZE
taztia
verapamil cap er 100mg, 120mg, 180mg, 200mg,
240mg, 300mg
VERAPAMIL CAP ER 360MG
verapamil hcl SOLN
verapamil hcl TABS
verapamil tab er
DIGITALIS GLYCOSIDES
digoxin SOLN
digoxin TABS 125mcg
digoxin TABS 250mcg
DIGOXIN SOL 50MCG/ML
LANOXIN TABS 125MCG
LANOXIN TABS 250MCG
DIRECT RENIN INHIBITORS/COMBINATIONS
AMTURNIDE TAB 150-5-12.5
AMTURNIDE TAB 300-5-12.5
AMTURNIDE TAB 300-5-25MG
AMTURNIDE TAB 300-10-12.5
AMTURNIDE TAB 300-10-25 MG
TEKAMLO 300-10MG
TEKAMLO TAB 150-5MG
TEKAMLO TAB 150-10MG
TEKAMLO TAB 300-5MG
TEKTURNA 150MG
Drug
Tier
2
2
2
2
2
2
2
2
2
2
2
2
5
2
Requirements/Limits*
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
2
2
2
1
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
QL (30 tabs / 30 days)
PA
PA
QL (30 tabs / 30 days)
PA
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
25
PART D FORMULARY
Drug Name
TEKTURNA 300MG
TEKTURNA HCT TAB 150-12.5MG
TEKTURNA HCT TAB 150-25MG
TEKTURNA HCT TAB 300-12.5MG
TEKTURNA HCT TAB 300-25MG
DIURETICS
acetazolamide CP12; TABS
amiloride & hydrochlorothiazide
amiloride hcl
bumetanide SOLN
bumetanide TABS
chlorothiazide
chlorthalidone 25mg, 50mg
DIURIL SUS 250/5ML
DYRENIUM
EDECRIN
furosemide SOLN 8mg/ml
furosemide SOLN 10mg/ml
furosemide TABS
furosemide inj
hydrochlorothiazide CAPS; TABS
indapamide
methazolamide TABS
methyclothiazide
metolazone
spironolactone & hydrochlorothiazide
torsemide inj
torsemide tabs
triamterene & hydrochlorothiazide TABS
triamterene & hydrochlorothiazide cap 37.5-25 mg
MISCELLANEOUS
clonidine hcl PTWK
clonidine hcl TABS
DEMSER
hydralazine hcl
midodrine hcl
minoxidil TABS
RANEXA
Drug
Requirements/Limits*
Tier
3
3 QL (30 tabs / 30 days)
3 QL (60 tabs / 30 days)
3 QL (30 tabs / 30 days)
3
2
1
2
2
1
1
1
3
4
4
2
1
1
2
1
1
2
2
2
1
2
1
1
1
2
1
5
2
2
2
3
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
26
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
NITRATES
isosorb mononitrate tab
isosorbide dinitrate
isosorbide mononitrate er tab
minitran
nitro-bid
NITRO-DUR DIS 0.3MG/HR
NITRO-DUR DIS 0.8MG/HR
nitroglycerin PT24
NITROLINGUAL PUMPSPRAY
NITROSTAT
PULMONARY ARTERIAL HYPERTENSION
ADCIRCA
ADEMPAS
LETAIRIS
REMODULIN
REVATIO SUSR
sildenafil citrate (pulmonary hypertension)
TRACLEER 62.5MG
TRACLEER 125MG
VENTAVIS
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam CONC
alprazolam tab 0.5mg
alprazolam tab 0.25mg
alprazolam tab 1mg
alprazolam tab 2mg
buspirone hcl TABS
fluvoxamine maleate TABS 25mg, 50mg
fluvoxamine maleate TABS 100mg
lorazepam CONC
lorazepam SOLN
lorazepam TABS
ANTICONVULSANTS
APTIOM 200MG
APTIOM 400MG
APTIOM 600MG
APTIOM 800MG
Drug
Tier
Requirements/Limits*
1
2
1
2
3
4
4
2
3
3
5
5
5
5
5
5
5
5
5
QL (60 tabs / 30 days), NM, PA
QL (90 tabs / 30 days), NM, PA
QL (30 tabs / 30 days), NM, LA, PA
B/D, NM, LA
QL (2 bottles / 30 days), NM, PA
QL (90 tabs / 30 days), NM, PA
QL (120 tabs / 30 days), NM, LA, PA
QL (60 tabs / 30 days), NM, LA, PA
B/D
2
1
1
1
1
2
2
2
2
2
1
QL (300 mL / 30 days)
QL (240 tabs / 30 days)
QL (480 tabs / 30 days)
QL (120 tabs / 30 days)
QL (150 tabs / 30 days)
4
4
4
4
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (45 tabs / 30 days)
QL (150 mL / 30 days)
QL (150 tabs / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
27
PART D FORMULARY
Drug Name
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
carbamazepine CHEW; TABS
carbamazepine CP12; SUSP; TB12
CELONTIN
clonazepam TABS 1mg
clonazepam TABS 2mg
clonazepam TABS .5mg
clonazepam TBDP 1mg
clonazepam TBDP 2mg
clonazepam TBDP .5mg
clonazepam TBDP .25mg
clonazepam TBDP .125mg
clorazepate dipotassium 3.75mg, 7.5mg
clorazepate dipotassium 15mg
diazepam CONC
diazepam SOLN
diazepam TABS
DIAZEPAM GEL
diazepam inj
dilantin
DILANTIN-125 SUS 125/5ML
divalproex sodium
epitol
ethosuximide CAPS; SOLN
felbamate SUSP
felbamate TABS 400mg
felbamate TABS 600mg
FYCOMPA 2MG
FYCOMPA 4MG
FYCOMPA 6MG
FYCOMPA 8MG, 10MG, 12MG
gabapentin CAPS 100mg
gabapentin CAPS 300mg
gabapentin CAPS 400mg
gabapentin SOLN
gabapentin TABS 600mg
Drug
Tier
5
4
5
1
2
4
1
1
1
2
2
2
2
2
2
2
2
2
1
2
2
3
3
2
1
2
5
2
5
4
4
4
4
1
1
1
2
2
Requirements/Limits*
PA
PA
PA
QL (600 tabs / 30 days)
QL (300 tabs / 30 days)
QL (1200 tabs / 30 days)
QL (600 tabs / 30 days)
QL (300 tabs / 30 days)
QL (1200 tabs / 30 days)
QL (2400 tabs / 30 days)
QL (4800 tabs / 30 days)
QL (120 tabs / 30 days), PA
QL (180 tabs / 30 days), PA
QL (240 mL / 30 days), PA
QL (1200 mL / 30 days), PA
QL (120 tabs / 30 days), PA
QL (180 tabs / 30 days), PA
QL (90 tabs / 30 days), PA
QL (60 tabs / 30 days), PA
QL (30 tabs / 30 days), PA
QL (1080 caps / 30 days)
QL (360 caps / 30 days)
QL (270 caps / 30 days)
QL (2160 mL / 30 days)
QL (180 tabs / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
28
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
gabapentin TABS 800mg
GABITRIL 12MG, 16MG
lamotrigine CHEW; TB24
lamotrigine TABS
levetiracetam SOLN; TABS; TB24
LYRICA CAPS 25MG, 50MG, 75MG, 100MG, 150MG
LYRICA CAPS 200MG
LYRICA CAPS 225MG, 300MG
LYRICA SOLN
ONFI
oxcarbazepine
PEGANONE
phenobarbital ELIX; TABS
PHENOBARBITAL SODIUM 65MG/ML
phenobarbital sodium 130mg/ml
phenytek
phenytoin CHEW; SUSP
phenytoin sodium SOLN
phenytoin sodium extended
POTIGA 50MG
POTIGA 200MG
POTIGA 300MG, 400MG
primidone TABS
Drug
Tier
2
4
2
1
2
3
3
3
3
4
2
4
4
4
4
3
2
2
2
4
4
4
2
SABRIL PACK
5
SABRIL TABS
TEGRETOL
TEGRETOL-XR
tiagabine hcl
topiramate CPSP; TABS
valproate sodium SOLN; SYRP
valproic acid CAPS
VIMPAT SOLN 10MG/ML
VIMPAT SOLN 200MG/20ML
VIMPAT TABS 50MG
VIMPAT TABS 100MG, 150MG, 200MG
zonisamide
5
4
4
2
2
2
2
4
4
4
4
2
Requirements/Limits*
QL (120 tabs / 30 days)
QL (120 caps / 30 days)
QL (90 caps / 30 days)
QL (60 caps / 30 days)
QL (946 mL / 30 days)
PA
PA
PA
PA
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
QL (180 packets / 30 days), NM, LA,
PA
QL (180 tabs / 30 days), NM, LA, PA
QL (1200 mL / 30 days)
QL (180 tabs / 30 days)
QL (60 tabs / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
29
PART D FORMULARY
Drug Name
ANTIDEMENTIA
donepezil hydrochloride TABS 5mg
donepezil hydrochloride TABS 10mg, 23mg
donepezil hydrochloride TBDP 5mg
donepezil hydrochloride TBDP 10mg
EXELON PATCHES
galantamine hydrobromide CP24 8mg, 16mg
galantamine hydrobromide CP24 24mg
galantamine hydrobromide SOLN
galantamine hydrobromide TABS 4mg
galantamine hydrobromide TABS 8mg
galantamine hydrobromide TABS 12mg
NAMENDA SOL 10MG/5ML
NAMENDA TAB
NAMENDA XR
NAMENDA XR TITRATION PACK
rivastigmine tartrate
ANTIDEPRESSANTS
amitriptyline hcl TABS
amoxapine tab 25mg
amoxapine tab 50mg
amoxapine tab 100mg
amoxapine tab 150mg
BRINTELLIX 5MG
BRINTELLIX 10MG
BRINTELLIX 20MG
bupropion hcl TABS
bupropion hcl TB12
bupropion hcl TB24 150mg
bupropion hcl TB24 300mg
citalopram hydrobromide SOLN
citalopram hydrobromide TABS 10mg, 20mg
citalopram hydrobromide TABS 40mg
clomipramine hcl CAPS
desipramine hcl TABS
doxepin hcl CAPS; CONC
duloxetine hcl CPEP
EMSAM
Drug
Tier
Requirements/Limits*
2
2
2
2
4
2
2
2
2
2
2
3
4
4
4
2
QL (30 tabs / 30 days)
4
2
2
2
2
4
4
4
2
2
2
2
2
1
1
4
2
4
2
5
PA
QL (30 tabs / 30 days)
QL (30 patches / 30 days)
QL (30 caps / 30 days)
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
PA; PA if <30 yr
PA; PA if <30 yr
PA; PA if <30 yr
PA; PA if <30 yr
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (90 tabs / 30 days)
QL (30 tabs / 30 days)
QL (45 tabs / 30 days)
QL (30 tabs / 30 days)
PA
PA
QL (60 caps / 30 days)
QL (30 patches / 30 days), PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
30
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
escitalopram oxalate SOLN
escitalopram oxalate TABS 5mg, 10mg
escitalopram oxalate TABS 20mg
FETZIMA 20MG
FETZIMA 40MG
FETZIMA 80MG, 120MG
FETZIMA TITRATION PACK
fluoxetine hcl CAPS 10mg
fluoxetine hcl CAPS 20mg
fluoxetine hcl CAPS 40mg
fluoxetine hcl SOLN
fluoxetine hcl TABS 10mg
fluoxetine hcl TABS 20mg
imipramine hcl TABS
maprotiline hcl
MARPLAN TAB 10MG
mirtazapine TABS 7.5mg
mirtazapine TABS 15mg
mirtazapine TABS 30mg, 45mg
mirtazapine TBDP 15mg
mirtazapine TBDP 30mg, 45mg
nefazodone hcl
nortriptyline hcl CAPS
nortriptyline hcl SOLN
paroxetine hcl TABS 10mg, 20mg, 40mg
paroxetine hcl TABS 30mg
PAXIL SUSP
phenelzine sulfate TABS
PRISTIQ
protriptyline hcl
sertraline hcl CONC
sertraline hcl TABS 25mg, 50mg
sertraline hcl TABS 100mg
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
SURMONTIL CAP 100MG
tranylcypromine sulfate
trazodone hcl TABS 50mg, 100mg, 150mg
venlafaxine hcl CP24 37.5mg, 75mg
Drug
Tier
2
2
2
4
4
4
4
1
1
1
2
1
1
4
2
4
2
1
1
2
2
2
1
2
1
1
4
2
3
2
2
1
1
4
4
4
2
1
2
Requirements/Limits*
QL (600 mL / 30 days)
QL (45 tabs / 30 days)
QL (60 tabs / 30 days)
QL (180 caps / 30 days)
QL (90 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (120 caps / 30 days)
QL (45 tabs / 30 days)
PA
QL (180 tabs / 30 days)
QL (45 tabs / 30 days)
QL (45 tabs / 30 days)
QL (30 tabs / 30 days)
QL (45 tabs / 30 days)
QL (60 tabs / 30 days)
QL (900 mL / 30 days)
QL (30 tabs / 30 days)
QL (45 tabs / 30 days)
QL (240 caps / 30 days), PA
QL (120 caps / 30 days), PA
QL (60 caps / 30 days), PA
QL (30 caps / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
31
PART D FORMULARY
Drug Name
venlafaxine hcl CP24 150mg
venlafaxine hcl TABS
VIIBRYD KIT
VIIBRYD TABS
ANTIPARKINSONIAN AGENTS
amantadine hcl CAPS; SYRP; TABS
APOKYN
AZILECT
benztropine mesylate SOLN
benztropine mesylate TABS
bromocriptine mesylate CAPS; TABS
carbidopa-levodopa
CARBIDOPA/LEVODOPA/ENTACAPONE
entacapone
NEUPRO
pramipexole dihydrochloride
ropinirole hydrochloride TABS
selegiline hcl CAPS; TABS
STALEVO 50
STALEVO 75
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
ANTIPSYCHOTICS
ABILIFY SOLN 1MG/ML
ABILIFY SOLN 9.75MG/1.3ML
ABILIFY TABS
ABILIFY DISCMELT
ABILIFY MAIN INJ 300MG
ABILIFY MAIN INJ 400MG
chlorpromazine hcl SOLN
chlorpromazine hcl TABS
clozapine TABS 25mg, 50mg
clozapine TABS 100mg
clozapine TABS 200mg
CLOZAPINE TBDP 12.5MG, 25MG
CLOZAPINE TBDP 100MG
Drug
Requirements/Limits*
Tier
2 QL (60 caps / 30 days)
2
4
4 QL (30 tabs / 30 days)
2
5
3
2
4
2
2
2
2
4
2
2
2
4
4
4
4
4
4
5
4
5
5
5
5
4
2
2
2
2
2
2
NM, LA, PA
PA
QL (900 mL / 30 days)
QL (4 mL / 1 day)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (1 vial / 28 days)
QL (1 vial / 28 days)
QL (270 tabs / 30 days)
QL (135 tabs / 30 days)
PA
QL (270 tabs / 30 days), PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
32
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
FANAPT
FANAPT TITRATION PACK
FAZACLO TAB 12.5/ODT
FAZACLO TAB 25MG ODT
FAZACLO TAB 100/ODT
FAZACLO TAB 150MG
FAZACLO TAB 200MG
fluphenazine decanoate SOLN
fluphenazine hcl
GEODON SOLR
haloperidol TABS
haloperidol decanoate SOLN
haloperidol lactate
haloperidol lactate oral conc 2 mg/ml
INVEGA 1.5MG, 3MG, 9MG
INVEGA 6MG
INVEGA SUST INJ 39 MG/0.25 ML
INVEGA SUST INJ 78 MG/0.5 ML
INVEGA SUST INJ 117 MG/0.75 ML
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234 MG/1.5 ML
LATUDA 20MG
LATUDA 40MG, 120MG
LATUDA 60MG, 80MG
loxapine succinate
olanzapine SOLR
olanzapine TABS 2.5mg, 5mg, 7.5mg
olanzapine TABS 10mg, 15mg, 20mg
olanzapine TBDP 5mg
olanzapine TBDP 10mg, 15mg
olanzapine TBDP 20mg
ORAP
perphenazine TABS
quetiapine fumarate
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
Drug
Tier
4
4
4
4
4
4
4
2
2
4
2
2
2
2
5
5
4
5
5
5
5
5
5
5
2
2
2
2
2
2
5
4
2
2
4
4
5
5
Requirements/Limits*
QL (60 tabs / 30 days), ST
ST
PA
PA
QL (270 tabs / 30 days), PA
QL (180 tabs / 30 days), PA
QL (135 tabs / 30 days), PA
QL (6 mL / 3 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (1 injection / 28 days)
QL (1 injection / 28 days)
QL (1 injection / 28 days)
QL (1 injection / 28 days)
QL (1 injection / 28 days)
QL (240 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (3 vials / 1 day)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (90 tabs / 30 days)
QL (2 injections / 28 days)
QL (2 injections / 28 days)
QL (2 injections / 28 days)
QL (2 injections / 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
33
PART D FORMULARY
Drug
Tier
risperidone SOLN
2
risperidone TABS 1mg, 2mg, 3mg
2
risperidone TABS 4mg
2
risperidone TABS .25mg, .5mg
2
risperidone TBDP 1mg, 2mg, 3mg
2
risperidone TBDP 4mg
2
risperidone TBDP .25mg, .5mg
2
SAPHRIS 5MG
4
SAPHRIS 10MG
4
SEROQUEL XR 50MG
4
SEROQUEL XR 150MG, 200MG
4
SEROQUEL XR 300MG, 400MG
4
thioridazine hcl TABS
4
thiothixene
2
trifluoperazine hcl
2
VERSACLOZ
5
ziprasidone hcl 20mg, 40mg
2
ziprasidone hcl 60mg, 80mg
2
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine-dextroamphetamine cap sr 24hr 5 mg
2
amphetamine-dextroamphetamine cap sr 24hr 10 mg
2
amphetamine-dextroamphetamine cap sr 24hr 15 mg
2
amphetamine-dextroamphetamine cap sr 24hr 20 mg
2
amphetamine-dextroamphetamine cap sr 24hr 25 mg
2
amphetamine-dextroamphetamine cap sr 24hr 30 mg
2
amphetamine-dextroamphetamine tab 5 mg
2
amphetamine-dextroamphetamine tab 7.5 mg
2
amphetamine-dextroamphetamine tab 10 mg
2
amphetamine-dextroamphetamine tab 12.5 mg
2
amphetamine-dextroamphetamine tab 15 mg
2
amphetamine-dextroamphetamine tab 20 mg
2
amphetamine-dextroamphetamine tab 30 mg
2
INTUNIV
4
metadate tab 20mg er
2
methylphenidate hcl TABS 5mg, 10mg
2
methylphenidate hcl TABS 20mg
2
methylphenidate hcl TBCR 10mg, 20mg
2
methylphenidate hcl oral soln 5mg/5ml
2
methylphenidate hcl oral soln 10mg/5ml
2
Drug Name
Requirements/Limits*
QL (240 mL / 30 days)
QL (60 tabs / 30 days)
QL (120 tabs / 30 days)
QL (90 tabs / 30 days)
QL (60 tabs / 30 days)
QL (120 tabs / 30 days)
QL (90 tabs / 30 days)
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (120 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
PA
QL (600 mL / 30 days), PA
QL (60 caps / 30 days)
QL (90 caps / 30 days)
QL (90 caps / 30 days)
QL (90 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (360 tabs / 30 days)
QL (240 tabs / 30 days)
QL (180 tabs / 30 days)
QL (144 tabs / 30 days)
QL (120 tabs / 30 days)
QL (90 tabs / 30 days)
QL (60 tabs / 30 days)
QL (90 tabs / 30 days)
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
QL (90 tabs / 30 days)
QL (1800 mL / 30 days)
QL (900 mL / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
34
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
STRATTERA 10MG, 18MG, 25MG
STRATTERA 40MG
STRATTERA 60MG, 80MG, 100MG
HYPNOTICS
ROZEREM
SILENOR 3MG
SILENOR 6MG
Drug
Requirements/Limits*
Tier
4 QL (120 caps / 30 days)
4 QL (60 caps / 30 days)
4 QL (30 caps / 30 days)
4
3
3
temazepam 7.5mg
2
temazepam 15mg
2
zolpidem tartrate TABS
2
MIGRAINE
cafergot
dihydroergotamine mesylate
naratriptan hcl
RELPAX
rizatriptan benzoate
SUMATRIPTAN SOLN 5MG/ACT
SUMATRIPTAN SOLN 20MG/ACT
SUMATRIPTAN SUCCINATE SOCT
sumatriptan succinate SOSY
sumatriptan succinate TABS
SUMATRIPTAN SUCCINATE INJ SOAJ 4MG/0.5ML
sumatriptan succinate inj SOAJ 6mg/0.5ml
SUMATRIPTAN SUCCINATE INJ SOCT
sumatriptan succinate inj SOLN
zolmitriptan TABS
zolmitriptan odt
MISCELLANEOUS
lithium carbonate CAPS; TABS
lithium carbonate er
LITHIUM CITRATE
NUEDEXTA
pyridostigmine bromide TABS
riluzole
XENAZINE 12.5MG
XENAZINE 25MG
4
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
1
2
3
3
2
2
5
5
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 caps / 30 days), PA; 90 day
limit if >64 yr
QL (60 caps / 30 days), PA; 90 day
limit if >64 yr
QL (30 tabs / 30 days), PA; 90 day
limit if >64 yr
QL (9 tabs / 30 days)
QL (12 tabs / 30 days)
QL (18 tabs / 30 days)
QL (24 inhalers / 30 days)
QL (12 inhalers / 30 days)
QL (6 mL / 30 days)
QL (6 mL / 30 days)
QL (9 tabs / 30 days)
QL (6 mL / 30 days)
QL (6 mL / 30 days)
QL (6 mL / 30 days)
QL (6 mL / 30 days)
QL (12 tabs / 30 days)
QL (12 tabs / 30 days)
PA
QL (240 tabs / 30 days), NM, LA, PA
QL (120 tabs / 30 days), NM, LA, PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
35
PART D FORMULARY
Drug Name
MULTIPLE SCLEROSIS AGENTS
BETASERON
COPAXONE INJ 40MG/ML
COPAXONE KIT 20MG/ML
GILENYA CAP 0.5MG
TYSABRI
MUSCULOSKELETAL THERAPY AGENTS
baclofen TABS
cyclobenzaprine hcl TABS 5mg, 10mg
dantrolene sodium CAPS
tizanidine hcl TABS
NARCOLEPSY/CATAPLEXY
modafinil
NUVIGIL 50MG
NUVIGIL 150MG
NUVIGIL 200MG, 250MG
XYREM
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium
buprenorphine hcl SUBL
buprenorphine hcl-naloxone hcl sl
buproban
CHANTIX
CHANTIX STARTER PACK
disulfiram TABS
naloxone hcl SOLN
naltrexone hcl TABS
NICOTROL INHALER
NICOTROL NS
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
SUBOXONE MIS 8-2MG
SUBOXONE MIS 12-3MG
ENDOCRINE AND METABOLIC
ANDROGENS
ANDRODERM
androxy
oxandrolone TABS
Drug
Tier
5
5
5
5
5
1
4
2
2
4
4
4
4
5
2
2
2
2
4
4
2
2
2
4
4
4
4
4
4
4
4
2
Requirements/Limits*
QL (14 syringes / 28 days), NM, PA
QL (12 syringes / 28 days), NM, PA
QL (1 kit / 30 days), NM, PA
QL (28 caps / 28 days), NM, PA
NM, LA, PA
PA
PA
QL (150 tabs / 30 days), PA
QL (60 tabs / 30 days), PA
QL (30 tabs / 30 days), PA
QL (540 mL / 30 days), LA, PA
PA
QL (120 tabs / 30 days), PA
PA
PA
QL (4 boxes / 30 days), PA
QL (4 boxes / 30 days), PA
QL (4 boxes / 30 days), PA
QL (2 boxes / 30 days), PA
QL (30 patches / 30 days), PA
PA
PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
36
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
TESTIM
testosterone cypionate OIL
testosterone enanthate OIL
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
GAUZE PADS 2” X 2”
HUMULIN R INJ U-500
INSULIN PEN NEEDLE
INSULIN SAFETY NEEDLES
INSULIN SYRINGE
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30 PREFILL
NOVOLOG PENFILL
SYMLINPEN 60
SYMLINPEN 120
VICTOZA
ANTIDIABETICS, ORAL
acarbose
glimepiride 1mg
glimepiride 2mg
glimepiride 4mg
glip/metform tab 5-500mg
glipizide TABS 5mg
glipizide TABS 10mg
glipizide TB24 2.5mg
glipizide TB24 5mg
glipizide TB24 10mg
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 2.5-500 mg
Drug
Requirements/Limits*
Tier
3 QL (300 grams / 30 days), PA
2
2
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
3
2
1
1
1
1
1
1
1
1
1
1
1
B/D
RELION not covered
RELION not covered
RELION not covered
QL (8 pens / 30 days), PA
QL (4 pens / 30 days), PA
QL (3 pens / 30 days)
QL (240 tabs / 30 days)
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (120 tabs / 30 days)
QL (240 tabs / 30 days)
QL (120 tabs / 30 days)
QL (240 tabs / 30 days)
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (240 tabs / 30 days)
QL (120 tabs / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
37
PART D FORMULARY
Drug Name
INVOKAMET TAB 50-500MG
INVOKAMET TAB 50-1000
INVOKAMET TAB 150-500
INVOKAMET TAB 150-1000
INVOKANA 100MG
INVOKANA 300MG
JANUMET
JANUMET XR TAB 50-500MG
JANUMET XR TAB 50-1000
JANUMET XR TAB 100-1000
JANUVIA
JENTADUETO
metformin hcl TABS 500mg
metformin hcl TABS 850mg
metformin hcl TABS 1000mg
metformin hcl TB24 500mg
metformin hcl TB24 750mg
nateglinide
pioglitazone hcl
repaglinide 2mg
repaglinide .5mg, 1mg
RIOMET
TRADJENTA
BISPHOSPHONATES
alendronate sodium TABS 5mg, 10mg
alendronate sodium TABS 35mg, 70mg
alendronate sodium TABS 40mg
FOSAMAX PLUS D
ibandronate sodium TABS
pamidronate disodium SOLN
zoledronic inj 4mg/5ml
ZOMETA SOLN
CALCIUM RECEPTOR AGONISTS
SENSIPAR 30MG
SENSIPAR 60MG
SENSIPAR 90MG
CHELATING AGENTS
CHEMET
DEPEN TITRATABS
EXJADE
kionex
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
4
3
1
1
2
4
2
2
5
5
3
5
5
4
5
5
2
Requirements/Limits*
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (90 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (150 tabs / 30 days)
QL (90 tabs / 30 days)
QL (75 tabs / 30 days)
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (90 tabs / 30 days)
QL (30 tabs / 30 days)
QL (240 tabs / 30 days)
QL (120 tabs / 30 days)
QL (946 mL / 30 days)
QL (30 tabs / 30 days)
QL (4 tabs / 28 days)
B/D, QL (1 tab / 30 days)
B/D
B/D, NM
B/D, NM
QL (120 tabs / 30 days), NM
QL (60 tabs / 30 days), NM
QL (120 tabs / 30 days), NM
NM, LA, PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
38
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
sodium polystyrene sulfonate
sps susp 15gm/60ml
SYPRINE
CONTRACEPTIVES
altavera
apri 28 day
aranelle 28
aubra 0.1-0.02mg
aviane 28
balziva 28 day
briellyn 28 day
camila 28 day
cryselle 28
cyclafem 1/35 28 day
cyclafem 7/7/7 28 day
delyla 0.1-0.02mg
drospirenone-ethinyl estradiol
ELLA
emoquette
enpresse 28 day
errin 28 day
falmina
GIANVI
gildagia
gildess 1.5/30
heather
introvale 91 day
JOLIVETTE
junel 1.5/30 21 day
junel 1/20 21 day
junel fe 1.5/30 28 day
junel fe 1/20 28 day
kariva 28 day
larin 1.5/30
larin 1/20
larin fe 1.5/30
larin fe 1/20
LEENA
lessina 28 day
levonest 28 day
levonorgestrel (emergency oc)
Drug
Tier
2
2
5
Requirements/Limits*
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
39
PART D FORMULARY
Drug Name
levonorgestrel-ethinyl estradiol (91-day)
levora 0.15/30 28 day
loryna 28 day
low-ogestrel 28 day
lutera 28 day
lyza
marlissa 28 day
medroxyprogesterone acetate 150 mg/ml
microgestin 1.5/30 21 day
microgestin 1/20 21 day
microgestin fe 1.5/30 28 day
microgestin fe 1/20 28 day
MONONESSA
my way
myzilra
necon 0.5/35 28 day
necon 1/35 28 day
NECON 7/7/7
necon 10/11 28 day
NECON TAB 1/50-28
next choice one dose
nikki 3-0.02mg
NORA-BE TAB
norethindrone (contraceptive)
norgestimate-ethinyl estradiol (triphasic)
norlyroc 0.35mg
nortrel 0.5/35 28 day
nortrel 1/35 21 day
nortrel 1/35 28 day
nortrel 7/7/7 28 day
NUVARING
OCELLA TAB 3-0.03MG
orsythia 28 day
philith
pimtrea pack
pirmella 1/35 28 day
portia 28 day
previfem 28 day
quasense 91 day
reclipsen 28 day
sharobel 0.35mg
Drug
Tier
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
2
2
4
2
2
2
2
2
2
2
2
2
2
Requirements/Limits*
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
40
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
SOLIA
sprintec 28 day
sronyx
tri-legest 28 day
tri-previfem 28 day
tri-sprintec 28 day
TRINESSA
trivora 28 day
velivet 28 day
vestura
viorele
vyfemia 28 day
xulane
zarah
zenchent 28 day
ENDOMETRIOSIS
danazol CAPS
SYNAREL
ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
CARBAGLU
CEREZYME
CYSTADANE
CYSTAGON
FABRAZYME
KUVAN
levocarnitine (metabolic modifiers)
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
sodium phenylbutyrate
ZAVESCA
ESTROGENS
COMBIPATCH
estradiol PTWK; TABS
ESTRADIOL VALERATE OIL 10MG/ML, 40MG/ML
estradiol valerate OIL 20mg/ml
PREMARIN CREAM
VAGIFEM
Drug
Tier
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits*
2
5
5
5
5
5
5
4
5
5
2
5
5
5
5
5
5
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM
NM, PA
NM, PA
NM, PA
B/D
NM, PA
NM, PA
NM, LA, PA
NM, PA
NM
NM, LA, PA
4
4
2
2
4
4
PA
PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
41
PART D FORMULARY
Drug Name
GLUCOCORTICOIDS
a-hydrocort
cortisone acetate TABS
dexamethasone CONC; ELIX; SOLN
dexamethasone TABS
dexamethasone sodium phosphate
fludrocortisone acetate TABS
hydrocortisone TABS
methylpr ace inj 40mg/ml
methylpr ace inj 80mg/ml
methylpr ss inj 1gm
methylpr ss inj 40mg
methylpr ss inj 125mg
methylpred pak 4mg
methylpred tab 4mg
methylpred tab 8mg
methylpred tab 16mg
methylpred tab 32mg
pred sod pho sol 5mg/5ml
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisolone syp 15mg/5ml
prednisone con 5mg/ml
prednisone pak 5mg
prednisone pak 10mg
prednisone sol 5mg/5ml
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 5mg
prednisone tab 10mg
prednisone tab 20mg
prednisone tab 50mg
SOLU-CORTEF 250MG
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
PROGLYCEM SUS 50MG/ML
Drug
Tier
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
3
1
1
2
1
1
1
1
1
1
3
Requirements/Limits*
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
3
3
4
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
42
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
Drug
Tier
HUMAN GROWTH HORMONES
GENOTROPIN
5
GENOTROPIN MINIQUICK .2MG
4
GENOTROPIN MINIQUICK .4MG, .6MG, .8MG, 1MG,
5
1.2MG, 1.4MG, 1.6MG, 1.8MG, 2MG
NORDITROPIN FLEXPRO
5
NORDITROPIN NORDIFLEX PEN
5
TEV-TROPIN
5
MISCELLANEOUS
cabergoline
2
calcitonin (salmon)
2
FORTICAL
3
INCRELEX
5
methylergonovine maleate TABS
2
MIACALCIN 200UNIT/ML
4
octreotide acetate 50mcg/ml, 100mcg/ml, 200mcg/ml
2
octreotide acetate 500mcg/ml, 1000mcg/ml
5
PROLIA
4
raloxifene hcl
2
SANDOSTATIN LAR DEPOT
5
SOMATULINE DEPOT
5
SOMAVERT
5
XGEVA
5
PARATHYROID HORMONES
FORTEO
5
PHOSPHATE BINDER AGENTS
calcium acetate (phosphate binder)
2
FOSRENOL
5
PHOSLYRA
3
RENVELA PAK 0.8GM
5
RENVELA PAK 2.4GM
5
RENVELA TAB 800MG
3
PROGESTINS
medroxyprogesterone acetate tab
1
norethindrone acetate TABS
2
SELECTIVE ESTROGEN RECEPTOR MODULATORS
EVISTA
4
Requirements/Limits*
PA
PA
PA
NM, PA
NM, PA
NM, PA
NM, LA, PA
B/D
NM, PA
NM, PA
QL (1 syringe / 180 days), NM
NM, PA
NM, PA
NM, LA, PA
NM, PA
QL (1 pen / 28 days), NM, PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
43
PART D FORMULARY
Drug Name
THYROID AGENTS
levothyroxine sodium TABS
LEVOXYL
liothyronine sodium TABS
methimazole TABS
propylthiouracil TABS
SYNTHROID
UNITHROID
VASOPRESSINS
desmopressin acetate spray
desmopressin acetate spray refrigerated
desmopressin acetate tabs
desmopressin inj 4mcg/ml
DESMOPRESSIN SOL 0.01%
GASTROINTESTINAL
ANTIEMETICS
compro
dronabinol 2.5mg, 5mg
dronabinol 10mg
EMEND CAP 40MG
EMEND CAP 80MG
EMEND CAP 125MG
EMEND PAK 80 & 125
granisetron hcl SOLN
granisetron hcl TABS
meclizine hcl TABS
metoclopramide hcl SOLN; TABS
metoclopramide inj
ondansetron hcl SOLN
ondansetron hcl TABS
ondansetron hcl inj
ondansetron hcl oral soln
ondansetron odt
prochlorperazine inj
prochlorperazine maleate TABS
prochlorperazine supp
promethazine hcl SOLN 25mg/ml, 50mg/ml
TRANSDERM-SCOP
Drug
Tier
Requirements/Limits*
1
1
2
1
2
4
1
2
2
2
2
2
2
2
5
4
4
4
4
2
2
2
1
2
2
2
2
2
2
2
1
2
4
4
B/D, QL (60 caps / 30 days)
B/D, QL (60 caps / 30 days)
PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
PA
QL (10 patches / 30 days), PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
44
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
ANTISPASMODICS
CUVPOSA
dicyclomine hcl CAPS; TABS
dicyclomine hcl SOLN
glycopyrrolate TABS
glycopyrrolate inj
H2-RECEPTOR ANTAGONISTS
famotidine SOLN 40mg/4ml, 200mg/20ml
famotidine SUSR
famotidine TABS 20mg, 40mg
famotidine inj
ranitidine hcl SOLN 50mg/2ml
ranitidine hcl TABS 150mg, 300mg
ranitidine hcl inj
ranitidine syrup
INFLAMMATORY BOWEL DISEASE
APRISO
ASACOL HD
balsalazide disodium
budesonide ec
CANASA
colocort enema 100mg
DELZICOL
DIPENTUM
HYDROCORTISONE (INTRARECTAL)
LIALDA
mesalamine enema
mesalamine w/ cleanser
PENTASA
sulfasalazine TABS
sulfasalazine ec
UCERIS
LAXATIVES
constulose
enulose
gaviltye-g
gavilyte-c
Drug
Tier
Requirements/Limits*
4
1
2
2
2
2
2
1
2
2
1
2
2
3
4
2
5
4
2
4
5
2
4
2
2
4
2
2
5
2
2
1
1
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
45
PART D FORMULARY
Drug Name
gavilyte-n
generlac
GOLYTELY
lactulose
lactulose (encephalopathy)
MOVIPREP
NULYTELY/FLAVOR PACKS
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
peg 3350-potassium chloride-sod bicarbonate-sod
chloride
PEG 3350/ELECTROLYTES
polyethylene glycol 3350 PACK; POWD
RELISTOR
SUPREP BOWEL PREP
trilyte
MISCELLANEOUS
AMITIZA CAP 8MCG
AMITIZA CAP 24MCG
cromolyn sodium (mastocytosis)
diphenoxylate w/ atropine LIQD
diphenoxylate w/ atropine TABS
LINZESS CAP 145MCG
LINZESS CAP 290MCG
loperamide hcl CAPS
LOTRONEX
misoprostol TABS
SUCRAID
sucralfate TABS
ursodiol CAPS; TABS
XIFAXAN 550MG
PANCREATIC ENZYMES
CREON
ZENPEP
PROTON PUMP INHIBITORS
DEXILANT
esomeprazole sodium
NEXIUM CAP
NEXIUM GRA 2.5MG DR
Drug
Tier
2
2
3
2
2
4
3
1
Requirements/Limits*
2
1
2
4
4
2
3
3
5
2
1
3
3
1
5
2
5
2
2
5
PA
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (30 caps / 30 days)
PA
PA
3
4
3
2
3
3
QL (30 caps / 30 days)
QL (30 caps / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
46
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
NEXIUM GRA 20MG DR
NEXIUM GRA 40MG DR
omeprazole CPDR 10mg, 40mg
omeprazole CPDR 20mg
pantoprazole sodium TBEC
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl
AVODART
finasteride TABS 5mg
JALYN
tamsulosin hcl
MISCELLANEOUS
bethanechol chloride TABS
ELMIRON
POTASSIUM CITRATE (ALKALINIZER)
URINARY ANTISPASMODICS
MYRBETRIQ 25MG
MYRBETRIQ 50MG
oxybutynin chloride SYRP
oxybutynin chloride TABS
oxybutynin chloride TB24 5mg
oxybutynin chloride TB24 10mg, 15mg
TOLTERODINE TARTRATE CAP ER
tolterodine tartrate tabs
TOVIAZ
trospium chloride TABS
VESICARE
VAGINAL ANTI-INFECTIVES
clindamycin phosphate vaginal
metronidazole vaginal
terconazole vaginal
VANDAZOLE
zazole .4%
ZAZOLE .8%
Drug
Tier
3
3
3
3
1
1
2
2
3
2
3
2
Requirements/Limits*
QL (30 packets / 30 days)
QL (30 packets / 30 days)
QL (30 packets / 30 days)
QL (30 caps / 30 days)
QL (60 caps / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (60 caps / 30 days)
2
4
2
4
4
1
2
2
2
2
2
3
2
4
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 caps / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
2
2
2
2
2
2
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
47
PART D FORMULARY
Drug Name
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN
ELIQUIS
enoxaparin sodium 30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml, 300mg/3ml
enoxaparin sodium 100mg/ml, 120mg/0.8ml, 150mg/
ml
fondaparinux sodium 2.5mg/0.5ml
fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml,
10mg/0.8ml
heparin sod inj 1000/ml
HEPARIN SOD INJ 2000/ML
HEPARIN SOD INJ 2500/ML
heparin sod inj 5000/ml
heparin sod inj 10000/ml
heparin sod inj 20000/ml
HEPARIN SODIUM/D5W
HEPARIN SODIUM/NACL 0.45%
HEPARIN SODIUM/SODIUM CHL
jantoven
PRADAXA
warfarin sodium
XARELTO
XARELTO STARTER PACK
HEMATOPOIETIC GROWTH FACTORS
GRANIX
LEUKINE
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/
ML, 10000UNIT/ML
PROCRIT 20000UNIT/ML, 40000UNIT/ML
MISCELLANEOUS
anagrelide hcl
cilostazol
CINRYZE
FIRAZYR
Drug
Tier
Requirements/Limits*
4
3
2
5
2
5
2
3
3
2
2
2
3
3
3
1
3
1
3
3
B/D
B/D
B/D
B/D
B/D
B/D
5
5
5
5
5
5
NM, PA
NM, PA
NM, PA
PA
NM
NM, PA
3
NM, PA
5
NM, PA
2
2
5
5
NM, LA, PA
NM, PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
48
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
Drug
Tier
2
5
5
5
5
2
Requirements/Limits*
pentoxifylline TBCR
PROMACTA 12.5MG
QL (240 tabs / 30 days), NM, LA, PA
PROMACTA 25MG
QL (120 tabs / 30 days), NM, LA, PA
PROMACTA 50MG
QL (60 tabs / 30 days), NM, LA, PA
PROMACTA 75MG
QL (30 tabs / 30 days), NM, LA, PA
tranexamic acid SOLN; TABS
PLATELET AGGREGATION INHIBITORS
AGGRENOX
4
BRILINTA
4
clopidogrel bisulfate 75mg
2 QL (30 tabs / 30 days)
EFFIENT
4
ZONTIVITY
4
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
CIMZIA
5 NM, PA
CIMZIA STARTER KIT
5 NM, PA
HUMIRA
5 NM, PA
HUMIRA KIT 40MG/0.8
5 NM, PA
HUMIRA PEN
5 NM, PA
HUMIRA PEN-CROHNS DISEASE
5 NM, PA
HUMIRA PEN-PSORIASIS STAR
5 NM, PA
hydroxychloroquine sulfate
1
leflunomide TABS
2
methotrexate sodium tabs
2
REMICADE
5 NM, PA
IMMUNOGLOBULINS
BIVIGAM
5 NM, PA
CARIMUNE NANOFILTERED
5 NM, PA
FLEBOGAMMA
5 NM, PA
FLEBOGAMMA DIF
5 NM, PA
GAMASTAN S/D
3 B/D, NM
GAMMAGARD LIQUID
5 NM, PA
GAMMAGARD S/D
5 NM, PA
GAMMAKED
5 NM, PA
GAMMAPLEX 2.5GM/50ML, 5GM/100ML,
5 NM, PA
10GM/200ML
GAMUNEX-C
5 NM, PA
GAMUNEX-C 1GM/10ML
5 NM, PA
OCTAGAM
5 NM, PA
PRIVIGEN
5 NM, PA
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
49
PART D FORMULARY
Drug Name
IMMUNOMODULATORS
ACTIMMUNE
ARCALYST
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 50MU
PEG-INTRON
PEG-INTRON REDIPEN
PEGASYS SOLN
PEGASYS PROCLICK
REVLIMID
THALOMID
IMMUNOSUPPRESSANTS
azathioprine TABS
CELLCEPT SUSR
cyclosporine CAPS; SOLN
cyclosporine modified (for microemulsion)
gengraf
mycophenolate mofetil
mycophenolate sodium 180mg
mycophenolate sodium 360mg
NEORAL
NULOJIX
PROGRAF CAPS 5MG
PROGRAF CAPS .5MG, 1MG
RAPAMUNE SOLN
RAPAMUNE TABS 1MG, 2MG
SANDIMMUNE CAPS
SANDIMMUNE SOLN 100MG/ML
sirolimus TABS
tacrolimus CAPS 5mg
tacrolimus CAPS .5mg, 1mg
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
Drug
Tier
Requirements/Limits*
5
5
5
5
5
5
5
5
5
5
5
5
NM, LA, PA
NM, PA
B/D, NM
B/D, NM
B/D, NM
B/D, NM
NM, PA
NM, PA
PA
PA
NM, LA, PA
NM, PA
2
5
2
2
2
2
2
5
3
5
5
4
5
5
3
3
2
5
2
5
4
5
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
50
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
VACCINES
ACTHIB
ADACEL
BCG VACCINE
BOOSTRIX
CERVARIX
COMVAX
DAPTACEL
DIPHTHERIA/TETANUS TOXOID
ENGERIX-B SUSP
GARDASIL
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
M-M-R II W/DILUENT 10 DOS
MENACTRA
MENOMUNE-A/C/Y/W-135
MENVEO
PEDVAX HIB
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
SYNAGIS
TENIVAC
TETANUS TOXOID ADSORBED
TETANUS/DIPHTHERIA TOXOID
TWINRIX INJ
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
Drug
Tier
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
Requirements/Limits*
B/D
B/D
B/D
B/D
B/D
B/D
QL (1 vial per lifetime)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
51
PART D FORMULARY
Drug Name
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON 8
KLOR-CON 10
klor-con m15
klor-con m20
klor-con pow 20meq
MAGNESIUM SULFATE SOLN 40MG/ML, 80MG/ML
MAGNESIUM SULFATE SOLN 50%
MAGNESIUM SULFATE IN D5W
magnesium sulfate inj 50%
potassium chloride CPCR
potassium chloride LIQD
POTASSIUM CHLORIDE TBCR
POTASSIUM CHLORIDE ER
potassium chloride microencapsulated crystals cr
SODIUM CHLORIDE SOLN 2.5MEQ/ML
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML
SOLN
TPN ELECTROLYTES
IV NUTRITION
AMINOSYN
AMINOSYN 7%/ELECTROLYTES
AMINOSYN 8.5%/ELECTROLYTE
AMINOSYN II
AMINOSYN II 8.5%/ELECTROL
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF 7%
AMINOSYN-RF
CLINIMIX 2.75%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 5%
CLINIMIX 4.25%/DEXTROSE 25%
CLINIMIX 5%/DEXTROSE 15%
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX INJ 4.25/D10
Drug
Tier
Requirements/Limits*
2
2
2
2
2
3
2
3
2
2
1
2
2
2
2
2
4
B/D
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
52
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
CLINIMIX INJ 4.25/D20
FREAMINE HBC 6.9%
FREAMINE III
HEPATAMINE
INTRALIPID INJ 20%
INTRALIPID INJ 30%
NEPHRAMINE
premasol sol 6%
premasol sol 10%
PROCALAMINE
PROSOL
travasol 10
TROPHAMINE INJ 10%
IV REPLACEMENT SOLUTIONS
DEXTROSE 2.5%/NACL 0.45%
DEXTROSE 5%
DEXTROSE 5% /ELECTROLYTE
DEXTROSE 5%/LACTATED RING
DEXTROSE 5%/NACL 0.2%
DEXTROSE 5%/NACL 0.3%
DEXTROSE 5%/NACL 0.9%
DEXTROSE 5%/NACL 0.33%
DEXTROSE 5%/NACL 0.45%
DEXTROSE 5%/NACL 0.225%
DEXTROSE 5%/POTASSIUM CHL
DEXTROSE 10% FLEX CONTAIN
DEXTROSE 10%/NACL 0.2%
DEXTROSE 10%/NACL 0.45%
DEXTROSE 50%
dextrose inj 70%
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
ISOLYTE P
isolyte s
KCL0.15%/D5W/NACL0.2%
KCL0.15%/D5W/NACL0.225%
KCL 0.3%/D5W/NACL 0.9%
Drug
Tier
4
4
4
4
3
3
4
2
4
4
4
4
4
Requirements/Limits*
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
2
2
3
2
2
2
2
2
2
2
2
2
3
2
2
2
4
4
4
4
2
3
2
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
53
PART D FORMULARY
Drug Name
KCL 0.3%/D5W/NACL 0.45%
KCL 0.15%/D5W/NACL 0.9%
KCL 0.075%/D5W/NACL 0.45%
KCL/D5W INJ 0.3%
KCL/NACL INJ 0.3-0.9
LACTATED RINGER’S INJ
normosol-m
NORMOSOL-R
NORMOSOL-R IN D5W
PLASMA-LYTE A
PLASMA-LYTE-56/D5W
PLASMA-LYTE-148
POTASSIUM CHLORIDE SOLN 10MEQ/100ML,
20MEQ/100ML
potassium chloride SOLN .4meq/ml, 2meq/ml,
10meq/50ml, 40meq/100ml
POTASSIUM CHLORIDE 0.15%
POTASSIUM CHLORIDE 0.22%
potassium chloride in nacl
RINGER’S
SODIUM CHLORIDE SOLN 3%, 5%
SODIUM CHLORIDE 0.45% VIA
SODIUM CHLORIDE INJ 0.9%
VITAMINS
calcitriol CAPS
calcitriol inj
calcitriol oral soln 1 mcg/ml
paricalcitol
PRENATAL VITAMIN/FOLIC ACID > 0.8 MG
(GENERIC)
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-poly-neomycin-hc
blephamide OINT
neomycin-polymy-dexameth
neomycin-polymyxin-hc (ophth)
sulfacetamide sod-prednisolone
TOBRADEX OINT
Drug
Tier
2
2
2
2
2
1
2
4
4
4
4
4
Requirements/Limits*
2
2
2
2
2
2
2
2
2
2
2
2
2
B/D
B/D
B/D
B/D
2
2
4
2
2
2
3
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
54
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
TOBRADEX ST
tobramycin-dexamethasone
ZYLET
ANTI-INFECTIVES
bacitracin (ophthalmic)
bacitracin-polymyxin b (ophth)
BESIVANCE
CILOXAN OINT
ciprofloxacin hcl (ophth)
erythromycin (ophth)
gatifloxacin (ophth)
gentak
gentamicin sulfate (ophth) OINT
gentamicin sulfate (ophth) SOLN
MOXEZA
NATACYN
neomycin-bacitracin zn-polymyxin
neomycin-polymy-gramicid
ofloxacin (ophth)
polymyxin b-trimethoprim
sulfacetamide sodium (ophth) OINT
sulfacetamide sodium (ophth) SOLN
tobramycin sulfate (ophth)
TOBREX OINT
trifluridine SOLN
VIGAMOX
ANTI-INFLAMMATORIES
ALREX
BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)
dexamethasone sodium phosphate (ophth)
diclofenac sodium (ophth)
DUREZOL
FLUOROMETHOLONE
flurbiprofen sodium
ILEVRO
ketorolac tromethamine (ophth)
LOTEMAX
MAXIDEX
Drug
Tier
3
2
3
Requirements/Limits*
2
2
3
3
2
1
2
2
2
1
3
4
2
2
1
1
2
1
1
4
2
3
3
2
2
2
3
2
1
3
2
3
3
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
55
PART D FORMULARY
Drug Name
NEVANAC
PREDNISOLONE ACETATE (OPHTH)
prednisolone sodium phosphate (ophth)
ANTIALLERGICS
azelastine hcl (ophth)
BEPREVE
cromolyn sodium (ophth)
LASTACAFT
PATADAY
PATANOL
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
AZOPT
betaxolol hcl (ophth)
BETOPTIC-S
brimonidine sol 0.2%
BRIMONIDINE SOL 0.15%
carteolol hcl (ophth)
COMBIGAN
dorzolamide hcl
dorzolamide hcl-timolol maleate
ISTALOL
latanoprost
levobunolol hcl .5%
LEVOBUNOLOL HCL .25%
LUMIGAN
metipranolol
PHOSPHOLINE IODIDE
PILOCARPINE HCL SOLN
SIMBRINZA
timolol maleate (ophth)
TIMOLOL MALEATE GEL
TRAVATAN Z
MISCELLANEOUS
naphazoline 0.1%
PROLENSA
proparacaine hcl SOLN
RESTASIS
Drug
Tier
3
2
3
Requirements/Limits*
2
3
1
4
3
3
3
3
2
3
1
2
1
3
2
2
3
2
2
2
3
2
3
2
3
1
2
3
1
3
1
3
QL (64 vials / 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
56
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
Drug
Tier
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ANORO ELLIPTA
3
COMBIVENT RESPIMAT
4
ipratropium-albuterol nebu
2
ANTICHOLINERGICS
ATROVENT HFA
4
ipratropium bromide SOLN
2
ipratropium bromide (nasal)
2
SPIRIVA HANDIHALER
3
TUDORZA PRESSAIR
3
ANTIHISTAMINES
ASTEPRO
3
azelastine hcl SOLN
2
azelastine spr 0.1%
2
cetirizine syrup
2
diphenhydramine inj
2
hydroxyzine hcl SOLN 25mg/ml, 50mg/ml
4
levocetirizine dihydrochloride
2
PATANASE
3
BETA AGONISTS
albuterol sulfate NEBU
2
albuterol sulfate SYRP
1
albuterol sulfate TABS; TB12
2
FORADIL AEROLIZER
3
levalbuterol conc 1.25mg/0.5ml
2
PERFOROMIST
4
PROAIR HFA
3
PROVENTIL HFA
4
SEREVENT DISKUS
3
terbutaline sulfate SOLN; TABS
2
XOPENEX HFA
3
LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast sodium CHEW; PACK; TABS
2
SINGULAIR
4
zafirlukast
2
MAST CELL STABILIZERS
cromolyn sodium nebu
2
Requirements/Limits*
QL (1 inhaler / 30 days)
QL (2 inhalers / 30 days)
B/D
QL (2 inhalers / 30 days)
B/D
QL (30 caps / 30 days)
QL (1 inhaler / 30 days)
PA
B/D
QL (60 caps / 30 days)
B/D
B/D
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
QL (1 inhaler / 30 days)
QL (2 inhalers / 30 days)
B/D
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
57
PART D FORMULARY
Drug Name
MISCELLANEOUS
acetylcysteine SOLN 10%, 20%
ARALAST NP
AUVI-Q
DALIRESP
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
PROLASTIN-C
PULMOZYME
XOLAIR
ZEMAIRA
NASAL STEROIDS
flunisolide (nasal)
fluticasone propionate (nasal)
NASONEX
STEROID INHALANTS
ASMANEX 14 METERED DOSES
ASMANEX 30 METERED DOSES
ASMANEX 60 METERED DOSES
ASMANEX 120 METERED DOSES
budesonide (inhalation)
FLOVENT DISKUS 50MCG/BLIST, 100MCG/BLIST
FLOVENT DISKUS 250MCG/BLIST
FLOVENT HFA
PULMICORT FLEXHALER
QVAR 40MCG/ACT
QVAR 80MCG/ACT
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA
DULERA
SYMBICORT
XANTHINES
aminophylline inj
elixophyllin
theo-24
theophylline SOLN; TB24
theophylline TB12
Drug
Tier
Requirements/Limits*
2
5
3
4
3
3
5
5
5
5
B/D
NM, LA, PA
2
2
4
QL (2 bottles / 30 days)
QL (1 bottle / 30 days)
QL (2 bottles / 30 days)
3
3
3
3
2
3
3
3
4
3
3
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
B/D
QL (2 inhalers / 30 days)
QL (4 inhalers / 30 days)
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
QL (1 inhaler / 30 days)
QL (2 inhalers / 30 days)
3
3
3
4
3
QL (1 inhaler / 30 days)
QL (1 inhaler / 30 days)
QL (1 inhaler / 30 days)
QL (1 inhaler / 30 days)
QL (1 inhaler / 30 days)
NM, LA, PA
B/D, NM
NM, LA, PA
NM, LA, PA
2
4
4
2
1
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
58
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
TOPICAL
DERMATOLOGY, ACNE
adapalene CREA
adapalene GEL .1%
amnesteem
AVITA
benzoyl peroxide-erythromycin
claravis
clindamycin phosphate (topical) GEL; LOTN; SOLN;
SWAB
ery pad 2%
erythromycin (acne aid)
myorisan
sulfacetamide sodium (acne)
tretinoin CREA; GEL
zenatane
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate (topical)
mafenide acetate PACK
mupirocin OINT
SILVER SULFADIAZINE CREA
SSD
SULFAMYLON CREA
DERMATOLOGY, ANTIFUNGALS
ciclopirox CREA; GEL; SUSP
ciclopirox shampoo 1%
clotrimazole (topical) CREA
clotrimazole (topical) SOLN
econazole nitrate CREA
ketoconazole cream
NAFTIN GEL
nyamyc
nystatin (topical)
nystop
pedi-dri
DERMATOLOGY, ANTIPRURITIC
procto-pak
proctosol hc
proctozone hc
PRUDOXIN CRE 5%
Drug
Tier
Requirements/Limits*
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
2
2
4
2
2
2
1
2
2
4
2
2
2
2
2
1
1
2
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
59
PART D FORMULARY
Drug Name
DERMATOLOGY, ANTIPSORIATICS
acitretin
calcipotriene CREA; OINT; SOLN
calcitrene oin 0.005%
8-MOP
TAZORAC CREA
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo
selenium sulfide LOTN
DERMATOLOGY, ANTIVIRALS
acyclovir topical
DENAVIR
DERMATOLOGY, CORTICOSTEROIDS
ala-cort
alclometasone dipropionate
amcinonide CREA; LOTN
amcinonide OINT
betamethasone dipropionate (topical)
betamethasone dipropionate augmented
betamethasone valerate CREA; LOTN; OINT
clobetasol propionate CREA
clobetasol propionate GEL
clobetasol propionate OINT
clobetasol propionate SOLN
DESONIDE CREA
desonide LOTN; OINT
desoximetasone CREA
desoximetasone GEL
DESOXIMETASONE OINT .05%
desoximetasone OINT .25%
diflorasone diacetate
fluocinolone acetonide CREA; OIL; OINT; SOLN
fluocinonide CREA .05%
fluocinonide GEL
fluocinonide OINT
fluocinonide SOLN
fluocinonide emulsified base
fluticasone propionate CREA
Drug
Tier
5
2
2
4
4
Requirements/Limits*
PA
PA
1
1
2
4
1
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
60
2015 SELECT (PPO) PLAN FORMULARY
PART D FORMULARY
Drug Name
Drug
Tier
2
2
1
2
2
2
2
2
4
4
1
2
1
Requirements/Limits*
fluticasone propionate OINT
halobetasol propionate
hydrocortisone (topical) CREA; OINT
hydrocortisone (topical) LOTN
hydrocortisone butyrate
hydrocortisone valerate
LOKARA LOTN 0.05%
mometasone furoate CREA; OINT; SOLN
TACLONEX
texacort soln 2.5%
triamcinolone acetonide (topical) CREA; OINT
triamcinolone acetonide (topical) LOTN
triderm
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine PTCH
2 QL (3 patches / 1 day), PA
lidocaine hcl GEL
2
lidocaine hcl SOLN 4%
1
lidocaine oint 5%
2
lidocaine-prilocaine
2 B/D
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
ammonium lactate CREA; LOTN
2
ELIDEL
4 PA
fluorouracil (topical)
2
imiquimod CREA
2
laclotion lotn 12%
2
metronidazole (topical) CREA; LOTN
2
metronidazole gel 0.75%
2
PANRETIN
5
podofilox SOLN
2
rosadan cre 0.75%
2
TARGRETIN GEL
5 NM, PA
VALCHLOR
5 NM, LA, PA
VOLTAREN
3
DERMATOLOGY, SCABICIDES AND PEDICULIDES
EURAX
4
malathion
2
permethrin CREA
2
You can find information on what the symbols and abbreviations on this table mean by going to page 7.
*
2015 SELECT (PPO) PLAN FORMULARY
61
INDEX OF DRUGS LISTED IN FORMULARY
Drug Name
DERMATOLOGY, WOUND CARE AGENTS
acetic acid .25%
REGRANEX
SANTYL
SODIUM CHLORIDE 0.9%
STERILE WATER IRRIGATION
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl
chlorhexidine gluconate (mouth-throat)
clotrimazole TROC
lidocaine hcl (mouth-throat)
nystatin (mouth-throat)
periogard
pilocarpine hcl (oral)
triamcinolone acetonide (mouth)
OTIC
acetic acid (otic)
acetic acid-aluminum acetate
CIPRODEX
fluocinolone acetonide (otic)
neomycin-polymyxin-hc (otic)
ofloxacin (otic)
62
Drug
Tier
1
5
4
1
2
Requirements/Limits*
PA
2
1
2
1
2
1
2
2
2
2
3
2
2
2
2015 SELECT (PPO) PLAN FORMULARY
INDEX OF DRUGS LISTED IN FORMULARY
Index
Brand-name drogs are capitalized (e.g., LIDODERM) and generic drugs are lised in lower-case italics
(e.g., acetaminophen/codine). Look up a drug alphabetically, and the index will indicate on which page
that drug can be found in the formulary chart.
8
8-MOP . . . . . . . . . . . . . . . . . . 60
A
a-hydrocort. . . . . . . . . . . . . . 42
abacavir sulfate. . . . . . . . . . . 11
abacavir sulfatelamivudine-zidovudine. . 12
ABELCET. . . . . . . . . . . . . . . . 11
ABILIFY. . . . . . . . . . . . . . . . . 32
ABILIFY DISCMELT. . . . . . . . 32
ABILIFY MAIN INJ 300MG. . . 32
ABILIFY MAIN INJ 400MG. . . 32
acamprosate calcium . . . . . . 36
acarbose . . . . . . . . . . . . . . . . 37
acebutolol hcl . . . . . . . . . . . . 24
acetaminophen w/ codeine. . . 8
acetazolamide. . . . . . . . . . . . 26
acetic acid. . . . . . . . . . . . . . . 62
acetic acid (otic) . . . . . . . . . . 62
acetic acid-aluminum
acetate. . . . . . . . . . . . . . . 62
acetylcysteine. . . . . . . . . . . . . 58
acitretin. . . . . . . . . . . . . . . . . 60
ACTHIB. . . . . . . . . . . . . . . . . 51
ACTIMMUNE. . . . . . . . . . . . . 50
acyclovir . . . . . . . . . . . . . 13, 60
acyclovir sodium. . . . . . . . . . 13
acyclovir topical . . . . . . . . . . 60
ADACEL. . . . . . . . . . . . . . . . . 51
ADAGEN . . . . . . . . . . . . . . . . 41
adapalene. . . . . . . . . . . . . . . 59
ADCIRCA. . . . . . . . . . . . . . . . 27
adefovir dipivoxil. . . . . . . . . . 13
ADEMPAS. . . . . . . . . . . . . . . . 27
adriamycin. . . . . . . . . . . . . . 17
adrucil. . . . . . . . . . . . . . . . . . 17
ADVAIR DISKUS. . . . . . . . . . . 58
ADVAIR HFA. . . . . . . . . . . . . . 58
afeditab cr. . . . . . . . . . . . . . . 24
AFINITOR . . . . . . . . . . . . . . . 19
AFINITOR DISPERZ. . . . . . . . 19
AGGRENOX. . . . . . . . . . . . . . 49
ala-cort. . . . . . . . . . . . . . . . . 60
ALBENZA. . . . . . . . . . . . . . . . 10
albuterol sulfate. . . . . . . . . . . 57
alclometasone dipropionate. 60
ALCOHOL SWABS . . . . . . . . . 37
ALDURAZYME. . . . . . . . . . . . 41
alendronate sodium . . . . . . . 38
alfuzosin hcl . . . . . . . . . . . . . 47
ALIMTA . . . . . . . . . . . . . . . . . 17
ALINIA. . . . . . . . . . . . . . . . . . 10
allopurinol tab . . . . . . . . . . . . 7
ALPHAGAN P SOL 0.1% . . . . . 56
alprazolam. . . . . . . . . . . . . . 27
alprazolam tab 0.25mg. . . . . 27
alprazolam tab 0.5mg. . . . . . 27
alprazolam tab 1mg . . . . . . . 27
alprazolam tab 2mg . . . . . . . 27
ALREX. . . . . . . . . . . . . . . . . . 55
altavera. . . . . . . . . . . . . . . . . 39
amantadine hcl. . . . . . . . . . . 32
AMBISOME . . . . . . . . . . . . . . 11
amcinonide. . . . . . . . . . . . . . 60
amifostine crystalline. . . . . . . 20
amikacin sulfate . . . . . . . . . . . 9
amiloride &
hydrochlorothiazide. . . . . 26
amiloride hcl. . . . . . . . . . . . . 26
aminophylline inj . . . . . . . . . 58
AMINOSYN . . . . . . . . . . . . . . 52
AMINOSYN 7%/
ELECTROLYTES. . . . . . . . 52
AMINOSYN 8.5%/
ELECTROLYTE. . . . . . . . . 52
AMINOSYN II. . . . . . . . . . . . . 52
AMINOSYN II 8.5%/
ELECTROL. . . . . . . . . . . . 52
AMINOSYN M . . . . . . . . . . . . 52
2015 SELECT (PPO) PLAN FORMULARY
AMINOSYN-HBC. . . . . . . . . . 52
AMINOSYN-PF. . . . . . . . . . . . 52
AMINOSYN-PF 7%. . . . . . . . . 52
AMINOSYN-RF. . . . . . . . . . . . 52
amiodarone hcl. . . . . . . . . . . 22
AMITIZA CAP 24MCG . . . . . . 46
AMITIZA CAP 8MCG . . . . . . . 46
amitriptyline hcl . . . . . . . . . . 30
amlodipine besylate. . . . . . . . 24
amlodipine-benazepril hcl
cap 10-20 mg . . . . . . . . . . 20
amlodipine-benazepril hcl
cap 10-40mg. . . . . . . . . . . 20
amlodipine-benazepril hcl
cap 2.5-10 mg. . . . . . . . . . 20
amlodipine-benazepril hcl
cap 5-10 mg . . . . . . . . . . . 20
amlodipine-benazepril hcl
cap 5-20 mg. . . . . . . . . . . 20
amlodipine-benazepril hcl
cap 5-40 mg. . . . . . . . . . . 20
ammonium lactate. . . . . . . . 61
amnesteem . . . . . . . . . . . . . . 59
amoxapine tab 100mg. . . . . . 30
amoxapine tab 150mg. . . . . . 30
amoxapine tab 25mg. . . . . . . 30
amoxapine tab 50mg. . . . . . . 30
amoxicillin . . . . . . . . . . . . . . 15
amoxicillin &
pot clavulanate. . . . . . . . 15
amphetaminedextroamphetamine cap
sr 24hr 10 mg. . . . . . . . . . 34
amphetaminedextroamphetamine cap
sr 24hr 15 mg. . . . . . . . . . 34
amphetaminedextroamphetamine cap
sr 24hr 20 mg. . . . . . . . . . 34
63
INDEX OF DRUGS LISTED IN FORMULARY
amphetaminedextroamphetamine cap
sr 24hr 25 mg. . . . . . . . . . 34
amphetaminedextroamphetamine cap
sr 24hr 30 mg. . . . . . . . . . 34
amphetaminedextroamphetamine cap
sr 24hr 5 mg. . . . . . . . . . . 34
amphetaminedextroamphetamine tab
10 mg. . . . . . . . . . . . . . . . 34
amphetaminedextroamphetamine tab
12.5 mg. . . . . . . . . . . . . . . 34
amphetaminedextroamphetamine tab
15 mg. . . . . . . . . . . . . . . . 34
amphetaminedextroamphetamine tab
20 mg. . . . . . . . . . . . . . . . 34
amphetaminedextroamphetamine tab
30 mg. . . . . . . . . . . . . . . . 34
amphetaminedextroamphetamine tab
5 mg. . . . . . . . . . . . . . . . . 34
amphetaminedextroamphetamine tab
7.5 mg. . . . . . . . . . . . . . . . 34
amphotericin b . . . . . . . . . . . 11
ampicillin & sulbactam
sodium. . . . . . . . . . . . . . . 15
ampicillin cap 250 mg. . . . . . 15
ampicillin cap 500 mg. . . . . . 15
ampicillin for susp 125
mg/5ml. . . . . . . . . . . . . . . 16
ampicillin for susp 250
mg/5ml. . . . . . . . . . . . . . . 16
ampicillin inj. . . . . . . . . . . . . 16
ampicillin sodium. . . . . . . . . 16
AMTURNIDE TAB 150-5-12.5 . 25
AMTURNIDE TAB 300-10-12.5.25
AMTURNIDE TAB 300-10-25
MG. . . . . . . . . . . . . . . . . . 25
AMTURNIDE TAB 300-5-12.5 . 25
64
AMTURNIDE TAB
300-5-25MG . . . . . . . . . . . 25
anagrelide hcl. . . . . . . . . . . . 48
anastrozole. . . . . . . . . . . . . . 18
ANDRODERM . . . . . . . . . . . . 36
androxy. . . . . . . . . . . . . . . . . 36
ANORO ELLIPTA . . . . . . . . . . 57
APOKYN . . . . . . . . . . . . . . . . 32
apri 28 day . . . . . . . . . . . . . . 39
APRISO . . . . . . . . . . . . . . . . . 45
APTIOM. . . . . . . . . . . . . . . . . 27
APTIVUS . . . . . . . . . . . . . . . . 11
ARALAST NP . . . . . . . . . . . . . 58
aranelle 28. . . . . . . . . . . . . . . 39
ARCALYST. . . . . . . . . . . . . . . 50
ASACOL HD. . . . . . . . . . . . . . 45
ASMANEX 120 METERED
DOSES. . . . . . . . . . . . . . . 58
ASMANEX 14 METERED
DOSES. . . . . . . . . . . . . . . 58
ASMANEX 30 METERED
DOSES. . . . . . . . . . . . . . . 58
ASMANEX 60 METERED
DOSES. . . . . . . . . . . . . . . 58
ASTEPRO. . . . . . . . . . . . . . . . 57
atenolol. . . . . . . . . . . . . . . . . 24
atenolol & chlorthalidone. . . 23
atorvastatin calcium. . . . . . . 23
atovaquone. . . . . . . . . . . . . . 10
atovaquone-proguanil hcl. . . 11
ATRIPLA. . . . . . . . . . . . . . . . . 12
ATROVENT HFA. . . . . . . . . . . 57
aubra 0.1-0.02mg. . . . . . . . . . . 39
AUVI-Q . . . . . . . . . . . . . . . . . 58
AVASTIN. . . . . . . . . . . . . . . . . 18
AVELOX. . . . . . . . . . . . . . . . . 15
AVELOX ABC PACK. . . . . . . . . 15
aviane 28. . . . . . . . . . . . . . . . 39
AVITA. . . . . . . . . . . . . . . . . . . 59
AVODART. . . . . . . . . . . . . . . . 47
azacitidine . . . . . . . . . . . . . . 17
AZACTAM . . . . . . . . . . . . . . . 10
AZACTAM/DEX INJ 1GM . . . . 10
AZACTAM/DEX INJ 2GM. . . . 10
azathioprine. . . . . . . . . . . . . 50
azelastine hcl. . . . . . . . . . . . . 57
azelastine hcl (ophth). . . . . . . 56
azelastine spr 0.1%. . . . . . . . . 57
AZILECT . . . . . . . . . . . . . . . . 32
azithromycin. . . . . . . . . . . . . 15
AZITHROMYCIN . . . . . . . . . . 15
AZOPT. . . . . . . . . . . . . . . . . . 56
AZOR 10-40MG . . . . . . . . . . . 21
AZOR TAB 10-20MG. . . . . . . . 21
AZOR TAB 5-20MG. . . . . . . . . 21
AZOR TAB 5-40MG. . . . . . . . . 21
aztreonam. . . . . . . . . . . . . . . 10
B
bacitracin (ophthalmic). . . . . 55
bacitracin-poly-neomycin-hc. 54
bacitracin-polymyxin b
(ophth). . . . . . . . . . . . . . . 55
baclofen. . . . . . . . . . . . . . . . . 36
balsalazide disodium . . . . . . 45
balziva 28 day. . . . . . . . . . . . 39
BANZEL SUS 40MG/ML . . . . . 28
BANZEL TAB 200MG. . . . . . . 28
BANZEL TAB 400MG. . . . . . . 28
BARACLUDE . . . . . . . . . . . . . 13
BCG VACCINE . . . . . . . . . . . . 51
benazepril &
hydrochlorothiazide. . . . . 20
benazepril hcl. . . . . . . . . . . . 21
BENICAR. . . . . . . . . . . . . . . . 22
BENICAR HCT 40-25MG. . . . . 21
BENICAR HCT TAB
20-12.5MG. . . . . . . . . . . . . 21
BENICAR HCT TAB
40-12.5MG. . . . . . . . . . . . . 21
benzoyl peroxideerythromycin. . . . . . . . . . 59
benztropine mesylate. . . . . . . 32
BEPREVE. . . . . . . . . . . . . . . . 56
BESIVANCE . . . . . . . . . . . . . . 55
betamethasone dipropionate
(topical). . . . . . . . . . . . . . 60
betamethasone dipropionate
augmented. . . . . . . . . . . . 60
betamethasone valerate. . . . . 60
BETASERON. . . . . . . . . . . . . . 36
betaxolol hcl (ophth) . . . . . . . 56
bethanechol chloride. . . . . . . 47
BETOPTIC-S. . . . . . . . . . . . . . 56
2015 SELECT (PPO) PLAN FORMULARY
INDEX OF DRUGS LISTED IN FORMULARY
bicalutamide. . . . . . . . . . . . . 18
BICILLIN L-A . . . . . . . . . . . . . 16
BICNU. . . . . . . . . . . . . . . . . . 16
BILTRICIDE. . . . . . . . . . . . . . 10
bisoprolol &
hydrochlorothiazide. . . . . 23
bisoprolol fumarate. . . . . . . . 24
BIVIGAM. . . . . . . . . . . . . . . . 49
bleomycin sulfate. . . . . . . . . . 17
blephamide . . . . . . . . . . . . . . 54
BOOSTRIX. . . . . . . . . . . . . . . 51
BOSULIF . . . . . . . . . . . . . . . . 19
BREO ELLIPTA. . . . . . . . . . . . 58
briellyn 28 day. . . . . . . . . . . . 39
BRILINTA. . . . . . . . . . . . . . . . 49
BRIMONIDINE SOL 0.15% . . . 56
brimonidine sol 0.2%. . . . . . . 56
BRINTELLIX. . . . . . . . . . . . . . 30
BROMFENAC SODIUM
(OPHTH)(ONCE-DAILY). . 55
bromocriptine mesylate. . . . . 32
budesonide (inhalation) . . . . 58
budesonide ec. . . . . . . . . . . . 45
bumetanide. . . . . . . . . . . . . . 26
buprenorphine hcl. . . . . . . . . 36
buprenorphine hclnaloxone hcl sl. . . . . . . . . 36
buproban. . . . . . . . . . . . . . . . 36
bupropion hcl . . . . . . . . . . . . 30
buspirone hcl. . . . . . . . . . . . . 27
BUSULFEX. . . . . . . . . . . . . . . 16
butorphanol tartrate. . . . . . . . 8
BYSTOLIC . . . . . . . . . . . . . . . 24
C
cabergoline. . . . . . . . . . . . . . 43
CADUET . . . . . . . . . . . . . . . . 24
cafergot. . . . . . . . . . . . . . . . . 35
calcipotriene. . . . . . . . . . . . . 60
calcitonin (salmon). . . . . . . . 43
calcitrene oin 0.005%. . . . . . . 60
calcitriol . . . . . . . . . . . . . . . . 54
calcitriol inj. . . . . . . . . . . . . . 54
calcitriol oral soln 1 mcg/ml . 54
calcium acetate (phosphate
binder). . . . . . . . . . . . . . . 43
camila 28 day. . . . . . . . . . . . 39
CANASA. . . . . . . . . . . . . . . . . 45
CANCIDAS. . . . . . . . . . . . . . . 11
CAPASTAT SULFATE. . . . . . . . 13
CAPRELSA. . . . . . . . . . . . . . . 19
captopril . . . . . . . . . . . . . . . . 21
captopril &
hydrochlorothiazide. . . . . 20
CARBAGLU . . . . . . . . . . . . . . 41
carbamazepine. . . . . . . . . . . 28
carbidopa-levodopa . . . . . . . 32
CARBIDOPA/LEVODOPA/
ENTACAPONE . . . . . . . . . 32
carboplatin. . . . . . . . . . . . . . 20
CARIMUNE NANOFILTERED. 49
carteolol hcl (ophth). . . . . . . . 56
cartia xt cap 120/24hr. . . . . . 24
cartia xt cap 180/24hr . . . . . . 24
cartia xt cap 240/24hr. . . . . . 24
cartia xt cap 300/24hr. . . . . . 24
carvedilol. . . . . . . . . . . . . . . . 24
CAYSTON. . . . . . . . . . . . . . . . 10
cefaclor . . . . . . . . . . . . . . . . . 14
cefaclor monohydrate er. . . . 14
cefadroxil. . . . . . . . . . . . . . . . 14
cefazolin in d5w . . . . . . . . . . 14
cefazolin inj. . . . . . . . . . . . . . 14
cefazolin sodium. . . . . . . . . . 14
cefdinir . . . . . . . . . . . . . . . . . 14
cefepime hcl. . . . . . . . . . . . . . 14
cefotaxime sodium. . . . . . . . . 14
cefoxitin sodium . . . . . . . . . . 14
cefpodoxime proxetil. . . . . . . 14
cefprozil. . . . . . . . . . . . . . . . . 14
ceftazidime . . . . . . . . . . . . . . 14
CEFTAZIDIME/DEXTROSE . . 14
ceftriaxone sodium. . . . . . . . 14
cefuroxime axetil. . . . . . . . . . 14
cefuroxime sodium. . . . . . . . 14
CELEBREX CAP 100MG. . . . . . 7
CELEBREX CAP 200MG. . . . . . 7
CELEBREX CAP 400MG. . . . . . 7
CELEBREX CAP 50MG. . . . . . . 7
CELLCEPT . . . . . . . . . . . . . . . 50
CELONTIN. . . . . . . . . . . . . . . 28
cephalexin. . . . . . . . . . . . . . . 14
CEREZYME . . . . . . . . . . . . . . 41
CERVARIX . . . . . . . . . . . . . . . 51
cetirizine syrup. . . . . . . . . . . 57
2015 SELECT (PPO) PLAN FORMULARY
cevimeline hcl . . . . . . . . . . . . 62
CHANTIX. . . . . . . . . . . . . . . . 36
CHANTIX STARTER PACK. . . 36
CHEMET . . . . . . . . . . . . . . . . 38
chlorhexidine gluconate
(mouth-throat). . . . . . . . . 62
chloroquine phosphate. . . . . . 11
chlorothiazide. . . . . . . . . . . . 26
chlorpromazine hcl. . . . . . . . 32
chlorthalidone. . . . . . . . . . . . 26
cholestyramine . . . . . . . . . . . 23
cholestyramine light. . . . . . . . 23
choline fenofibrate. . . . . . . . . 23
ciclopirox. . . . . . . . . . . . . . . . 59
ciclopirox shampoo 1% . . . . . 59
cilostazol. . . . . . . . . . . . . . . . 48
CILOXAN. . . . . . . . . . . . . . . . 55
CIMZIA . . . . . . . . . . . . . . . . . 49
CIMZIA STARTER KIT . . . . . . 49
CINRYZE . . . . . . . . . . . . . . . . 48
CIPRODEX. . . . . . . . . . . . . . . 62
ciprofloxacin. . . . . . . . . . . . . 15
ciprofloxacin er. . . . . . . . . . . 15
ciprofloxacin hcl (ophth). . . . 55
ciprofloxacin hcl tab. . . . . . . 15
ciprofloxacin in d5w. . . . . . . 15
ciprofloxacin inj . . . . . . . . . . 15
cisplatin. . . . . . . . . . . . . . . . . 20
citalopram hydrobromide. . . 30
cladribine . . . . . . . . . . . . . . . 17
claravis. . . . . . . . . . . . . . . . . 59
clarithromycin. . . . . . . . . . . . 15
clarithromycin er. . . . . . . . . . 15
clarithromycin for susp. . . . . 15
clindamycin cap 300mg . . . . 10
clindamycin cap 75mg. . . . . . 10
clindamycin hcl cap 150 mg . 10
clindamycin phosphate
(topical). . . . . . . . . . . . . . 59
clindamycin phosphate inj. . . 10
clindamycin phosphate
vaginal. . . . . . . . . . . . . . . 47
clindamycin sol 75mg/5ml. . . 10
CLINIMIX 2.75%/
DEXTROSE 5%. . . . . . . . . 52
CLINIMIX 4.25%/
DEXTROSE 25%. . . . . . . . 52
65
INDEX OF DRUGS LISTED IN FORMULARY
CLINIMIX 4.25%/
DEXTROSE 5%. . . . . . . . . 52
CLINIMIX 5%/
DEXTROSE 15%. . . . . . . . 52
CLINIMIX 5%/
DEXTROSE 20%. . . . . . . . 52
CLINIMIX 5%/
DEXTROSE 25%. . . . . . . . 52
CLINIMIX INJ 4.25/D10. . . . . . 52
CLINIMIX INJ 4.25/D20 . . . . . 53
clobetasol propionate . . . . . . 60
clomipramine hcl . . . . . . . . . 30
clonazepam. . . . . . . . . . . . . . 28
clonidine hcl . . . . . . . . . . . . . 26
clopidogrel bisulfate. . . . . . . . 49
clorazepate dipotassium. . . . 28
clotrimazole . . . . . . . . . . . . . 62
clotrimazole (topical) . . . . . . 59
clozapine. . . . . . . . . . . . . . . . 32
CLOZAPINE. . . . . . . . . . . . . . 32
COARTEM. . . . . . . . . . . . . . . 11
colchicine w/ probenecid. . . . . 7
COLCRYS. . . . . . . . . . . . . . . . . 7
colestipol hcl . . . . . . . . . . . . . 23
colistimethate sodium . . . . . . 10
colocort enema 100mg . . . . . 45
COMBIGAN. . . . . . . . . . . . . . 56
COMBIPATCH . . . . . . . . . . . . 41
COMBIVENT RESPIMAT . . . . 57
COMETRIQ . . . . . . . . . . . . . . 19
COMPLERA . . . . . . . . . . . . . . 12
compro . . . . . . . . . . . . . . . . . 44
COMVAX. . . . . . . . . . . . . . . . 51
constulose . . . . . . . . . . . . . . . 45
COPAXONE INJ 40MG/ML . . . 36
COPAXONE KIT 20MG/ML. . . 36
cortisone acetate. . . . . . . . . . 42
COUMADIN. . . . . . . . . . . . . . 48
CREON. . . . . . . . . . . . . . . . . . 46
CRESTOR. . . . . . . . . . . . . . . . 23
CRIXIVAN . . . . . . . . . . . . . . . 11
cromolyn sodium
(mastocytosis). . . . . . . . . . 46
cromolyn sodium (ophth). . . . 56
cromolyn sodium nebu. . . . . 57
cryselle 28 . . . . . . . . . . . . . . . 39
CUBICIN . . . . . . . . . . . . . . . . 10
66
CUVPOSA. . . . . . . . . . . . . . . . 45
cyclafem 1/35 28 day . . . . . . . 39
cyclafem 7/7/7 28 day. . . . . . . 39
cyclobenzaprine hcl. . . . . . . . 36
CYCLOPHOSPHAMIDE . . . . . 16
cyclophosphamide. . . . . . . . . 16
cycloserine CAPS. . . . . . . . . . 13
cyclosporine. . . . . . . . . . . . . . 50
cyclosporine modified (for
microemulsion). . . . . . . . 50
CYSTADANE . . . . . . . . . . . . . 41
CYSTAGON . . . . . . . . . . . . . . 41
cytarabine. . . . . . . . . . . . . . . 17
D
dacarbazine . . . . . . . . . . . . . 16
DALIRESP. . . . . . . . . . . . . . . .58
danazol. . . . . . . . . . . . . . . . . 41
dantrolene sodium . . . . . . . . 36
dapsone. . . . . . . . . . . . . . . . . 10
DAPTACEL. . . . . . . . . . . . . . . 51
DARAPRIM. . . . . . . . . . . . . . . 10
daunorubicin hcl . . . . . . . . . 17
delyla 0.1-0.02mg. . . . . . . . . . 39
DELZICOL . . . . . . . . . . . . . . . 45
DEMSER. . . . . . . . . . . . . . . . . 26
DENAVIR. . . . . . . . . . . . . . . . 60
DEPEN TITRATABS . . . . . . . . 38
DEPO-PROVERA INJ 400/ML . 18
desipramine hcl. . . . . . . . . . . 30
desmopressin acetate spray. . 44
desmopressin acetate spray
refrigerated . . . . . . . . . . . 44
desmopressin acetate tabs. . . 44
desmopressin inj 4mcg/ml. . . 44
DESMOPRESSIN SOL 0.01%. . 44
desonide . . . . . . . . . . . . . . . . 60
DESONIDE. . . . . . . . . . . . . . . 60
desoximetasone. . . . . . . . . . . 60
DESOXIMETASONE. . . . . . . . 60
dexamethasone. . . . . . . . . . . 42
dexamethasone sodium
phosphate. . . . . . . . . . . . . 42
dexamethasone sodium
phosphate (ophth). . . . . . . 55
DEXILANT. . . . . . . . . . . . . . . 46
dexrazoxane. . . . . . . . . . . . . 20
DEXTROSE 10% FLEX
CONTAIN. . . . . . . . . . . . . 53
DEXTROSE 10%/NACL 0.2%. . 53
DEXTROSE 10%/NACL 0.45%. 53
DEXTROSE 2.5%/NACL 0.45%. 53
DEXTROSE 5%. . . . . . . . . . . . 53
DEXTROSE 5% /
ELECTROLYTE. . . . . . . . . 53
DEXTROSE 5%/LACTATED
RING . . . . . . . . . . . . . . . . 53
DEXTROSE 5%/NACL 0.2%. . . 53
DEXTROSE 5%/NACL 0.225%. 53
DEXTROSE 5%/NACL 0.3%. . . 53
DEXTROSE 5%/NACL 0.33%. . 53
DEXTROSE 5%/NACL 0.45%. . 53
DEXTROSE 5%/NACL 0.9%. . . 53
DEXTROSE 5%/POTASSIUM
CHL . . . . . . . . . . . . . . . . . 53
DEXTROSE 50%. . . . . . . . . . . 53
dextrose inj 70%. . . . . . . . . . . 53
diazepam. . . . . . . . . . . . . . . . 28
DIAZEPAM GEL. . . . . . . . . . . 28
diazepam inj. . . . . . . . . . . . . 28
diclofenac potassium. . . . . . . . 7
diclofenac sodium. . . . . . . . . . 7
diclofenac sodium (ophth). . . 55
dicloxacillin sodium . . . . . . . 16
dicyclomine hcl. . . . . . . . . . . 45
didanosine. . . . . . . . . . . . . . . 11
DIFICID. . . . . . . . . . . . . . . . . 15
diflorasone diacetate. . . . . . . 60
diflunisal. . . . . . . . . . . . . . . . . 7
digoxin . . . . . . . . . . . . . . . . . 25
DIGOXIN SOL 50MCG/ML. . . 25
dihydroergotamine mesylate. 35
dilantin. . . . . . . . . . . . . . . . . 28
DILANTIN-125 SUS 125/5ML. . 28
dilt-cd cap. . . . . . . . . . . . . . . 24
dilt-xr cap . . . . . . . . . . . . . . . 24
diltiazem cap. . . . . . . . . . . . . 24
diltiazem cap 120mg/24hr. . . 24
diltiazem cap er/12hr. . . . . . . 24
diltiazem hcl . . . . . . . . . . . . . 24
diltiazem hcl coated beads . . 24
diltzac. . . . . . . . . . . . . . . . . . 24
DIOVAN. . . . . . . . . . . . . . . . . 22
DIPENTUM . . . . . . . . . . . . . . 45
2015 SELECT (PPO) PLAN FORMULARY
INDEX OF DRUGS LISTED IN FORMULARY
diphenhydramine inj. . . . . . . 57
diphenoxylate w/ atropine. . . 46
DIPHTHERIA/TETANUS
TOXOID. . . . . . . . . . . . . . 51
disopyramide phosphate . . . . 22
disulfiram . . . . . . . . . . . . . . . 36
DIURIL SUS 250/5ML . . . . . . . 26
divalproex sodium. . . . . . . . . 28
docetaxel. . . . . . . . . . . . . . . . 17
DOCETAXEL. . . . . . . . . . . . . 17
donepezil hydrochloride. . . . 30
dorzolamide hcl . . . . . . . . . . 56
dorzolamide hcl-timolol
maleate . . . . . . . . . . . . . . 56
doxazosin mesylate. . . . . . . . 21
doxepin hcl . . . . . . . . . . . . . . 30
doxorubicin hcl for inj 50 mg.17
doxorubicin hcl liposomal
inj 2mg/ml. . . . . . . . . . . . 17
doxorubicin inj 50mg . . . . . . 17
doxycycline (monohydrate). . 16
doxycycline hyclate. . . . . . . . 16
dronabinol . . . . . . . . . . . . . . 44
drospirenone-ethinyl
estradiol. . . . . . . . . . . . . . 39
DROXIA. . . . . . . . . . . . . . . . . 19
DULERA. . . . . . . . . . . . . . . . . 58
duloxetine hcl . . . . . . . . . . . . 30
DURAMORPH . . . . . . . . . . . . . 8
DUREZOL . . . . . . . . . . . . . . . 55
DYRENIUM . . . . . . . . . . . . . . 26
E
e.e.s.. . . . . . . . . . . . . . . . . . . . 15
e.e.s. 400. . . . . . . . . . . . . . . . . 15
E.E.S. GRANULES. . . . . . . . . . 15
e.s.p.. . . . . . . . . . . . . . . . . . . . 10
econazole nitrate. . . . . . . . . . 59
EDECRIN. . . . . . . . . . . . . . . . 26
EDURANT. . . . . . . . . . . . . . . 11
ees/sulfisox sus 200-600 . . . . . 10
EFFIENT . . . . . . . . . . . . . . . . 49
ELIDEL. . . . . . . . . . . . . . . . . . 61
ELIQUIS. . . . . . . . . . . . . . . . . 48
ELITEK. . . . . . . . . . . . . . . . . . 20
elixophyllin . . . . . . . . . . . . . . 58
ELLA. . . . . . . . . . . . . . . . . . . . 39
ELMIRON. . . . . . . . . . . . . . . . 47
EMCYT. . . . . . . . . . . . . . . . . . 16
EMEND CAP 125MG. . . . . . . . 44
EMEND CAP 40MG . . . . . . . . 44
EMEND CAP 80MG . . . . . . . . 44
EMEND PAK 80 & 125 . . . . . . 44
emoquette . . . . . . . . . . . . . . . 39
EMSAM . . . . . . . . . . . . . . . . . 30
EMTRIVA. . . . . . . . . . . . . . . . 11
enalapril maleate. . . . . . . . . 21
enalapril maleate &
hydrochlorothiazide. . . . . 20
endocet . . . . . . . . . . . . . . . . . . 8
ENGERIX-B . . . . . . . . . . . . . . 51
enoxaparin sodium. . . . . . . . 48
enpresse 28 day. . . . . . . . . . . 39
entacapone. . . . . . . . . . . . . . 32
entecavir. . . . . . . . . . . . . . . . 13
enulose . . . . . . . . . . . . . . . . . 45
EPIPEN 2-PAK. . . . . . . . . . . . . 58
EPIPEN-JR 2-PAK. . . . . . . . . . . 58
epirubicin hcl . . . . . . . . . . . . 17
epitol. . . . . . . . . . . . . . . . . . . 28
EPIVIR. . . . . . . . . . . . . . . . . . 11
EPIVIR HBV. . . . . . . . . . . . . . 13
eplerenone. . . . . . . . . . . . . . . 21
EPZICOM. . . . . . . . . . . . . . . . 12
ERAXIS . . . . . . . . . . . . . . . . . 11
ERIVEDGE. . . . . . . . . . . . . . . 18
errin 28 day. . . . . . . . . . . . . . 39
ery pad 2%. . . . . . . . . . . . . . . 59
ery-tab. . . . . . . . . . . . . . . . . . 15
ERYPED 200. . . . . . . . . . . . . . 15
ERYPED 400. . . . . . . . . . . . . . 15
erythrocin lactobionate. . . . . 15
erythrocin stearate. . . . . . . . . 15
erythromycin (acne aid). . . . 59
erythromycin (ophth). . . . . . . 55
erythromycin base. . . . . . . . . 15
erythromycin cap 250mg ec. . 15
escitalopram oxalate. . . . . . . 31
esomeprazole sodium . . . . . . 46
estradiol. . . . . . . . . . . . . . . . . 41
estradiol valerate. . . . . . . . . . 41
ESTRADIOL VALERATE. . . . . 41
ethambutol hcl. . . . . . . . . . . . 13
ethosuximide. . . . . . . . . . . . . 28
etodolac. . . . . . . . . . . . . . . . . . 7
2015 SELECT (PPO) PLAN FORMULARY
etodolac er. . . . . . . . . . . . . . . . 7
etoposide. . . . . . . . . . . . . . . . 20
EURAX. . . . . . . . . . . . . . . . . . 61
EVISTA. . . . . . . . . . . . . . . . . . 43
EXELON PATCHES. . . . . . . . . 30
exemestane. . . . . . . . . . . . . . 18
EXFORGE HCT/10- TAB
160-12.5. . . . . . . . . . . . . . . 21
EXFORGE HCT/10- TAB
160-25. . . . . . . . . . . . . . . . 21
EXFORGE HCT/10- TAB
320-25. . . . . . . . . . . . . . . . 21
EXFORGE HCT/5- TAB
160-12.5. . . . . . . . . . . . . . . 21
EXFORGE HCT/5- TAB 160-25.21
EXFORGE TAB 10-160MG. . . . 21
EXFORGE TAB 10-320MG. . . . 21
EXFORGE TAB 5-160MG. . . . . 21
EXFORGE TAB 5-320MG . . . . 21
EXJADE. . . . . . . . . . . . . . . . . 38
F
FABRAZYME . . . . . . . . . . . . . 41
falmina. . . . . . . . . . . . . . . . . 39
famciclovir. . . . . . . . . . . . . . . 13
famotidine. . . . . . . . . . . . . . . 45
famotidine inj. . . . . . . . . . . . 45
FANAPT. . . . . . . . . . . . . . . . . 33
FANAPT TITRATION PACK. . . 33
FARESTON. . . . . . . . . . . . . . . 18
FASLODEX. . . . . . . . . . . . . . . 18
FAZACLO TAB 100/ODT. . . . . 33
FAZACLO TAB 12.5/ODT . . . . 33
FAZACLO TAB 150MG . . . . . . 33
FAZACLO TAB 200MG. . . . . . 33
FAZACLO TAB 25MG ODT. . . 33
felbamate. . . . . . . . . . . . . . . . 28
felodipine. . . . . . . . . . . . . . . . 25
fenofibrate. . . . . . . . . . . . . . . 23
fenofibrate micronized . . . . . 23
fenofibrate micronized cap. . 23
fentanyl. . . . . . . . . . . . . . . . . . 8
fentanyl citrate. . . . . . . . . . . . . 8
FETZIMA. . . . . . . . . . . . . . . . 31
FETZIMA TITRATION PACK. . 31
finasteride. . . . . . . . . . . . . . . 47
FIRAZYR . . . . . . . . . . . . . . . . 48
FLEBOGAMMA . . . . . . . . . . . 49
67
INDEX OF DRUGS LISTED IN FORMULARY
FLEBOGAMMA DIF. . . . . . . . 49
flecainide acetate . . . . . . . . . 22
FLOVENT DISKUS. . . . . . . . . 58
FLOVENT HFA. . . . . . . . . . . . 58
fluconazole. . . . . . . . . . . . . . 11
fluconazole in dextrose. . . . . 11
fluconazole in nacl. . . . . . . . 11
flucytosine. . . . . . . . . . . . . . . 11
fludarabine phosphate. . . . . . 17
fludrocortisone acetate. . . . . 42
flunisolide (nasal). . . . . . . . . 58
fluocinolone acetonide. . . . . 60
fluocinolone acetonide (otic). 62
fluocinonide . . . . . . . . . . . . . 60
fluocinonide emulsified base. 60
FLUOROMETHOLONE. . . . . . 55
fluorouracil. . . . . . . . . . . . . . 17
fluorouracil (topical). . . . . . . 61
fluoxetine hcl. . . . . . . . . . . . . 31
fluphenazine decanoate. . . . 33
fluphenazine hcl. . . . . . . . . . 33
flurbiprofen. . . . . . . . . . . . . . . 7
flurbiprofen sodium. . . . . . . . 55
flutamide. . . . . . . . . . . . . . . . 18
fluticasone propionate. . . . 60, 61
fluticasone propionate
(nasal). . . . . . . . . . . . . . . 58
fluvoxamine maleate. . . . . . . 27
fondaparinux sodium. . . . . . 48
FORADIL AEROLIZER . . . . . . 57
FORTEO. . . . . . . . . . . . . . . . . 43
FORTICAL . . . . . . . . . . . . . . . 43
FOSAMAX PLUS D. . . . . . . . . 38
foscarnet sodium. . . . . . . . . . 13
fosinopril sodium. . . . . . . . . . 21
fosinopril sodium &
hydrochlorothiazide. . . . . 20
FOSRENOL. . . . . . . . . . . . . . . 43
FREAMINE HBC 6.9%. . . . . . . 53
FREAMINE III . . . . . . . . . . . . 53
furosemide. . . . . . . . . . . . . . . 26
furosemide inj. . . . . . . . . . . . 26
FUZEON. . . . . . . . . . . . . . . . . 11
FYCOMPA. . . . . . . . . . . . . . . . 28
G
gabapentin . . . . . . . . . . . 28, 29
68
GABITRIL. . . . . . . . . . . . . . . . 29
galantamine hydrobromide . 30
GAMASTAN S/D. . . . . . . . . . . 49
GAMMAGARD LIQUID . . . . . 49
GAMMAGARD S/D. . . . . . . . . 49
GAMMAKED. . . . . . . . . . . . . 49
GAMMAPLEX. . . . . . . . . . . . . 49
GAMUNEX-C. . . . . . . . . . . . . 49
GAMUNEX-C 1GM/10ML . . . . 49
ganciclovir inj 500mg . . . . . . 13
GARDASIL. . . . . . . . . . . . . . . 51
gatifloxacin (ophth). . . . . . . . 55
GAUZE PADS 2” X 2” . . . . . . . 37
gaviltye-g. . . . . . . . . . . . . . . . 45
gavilyte-c. . . . . . . . . . . . . . . . 45
gavilyte-n. . . . . . . . . . . . . . . . 46
gemcitabine hcl. . . . . . . . . . . 17
GEMCITABINE HCL. . . . . . . . 17
gemfibrozil. . . . . . . . . . . . . . . 23
generlac. . . . . . . . . . . . . . . . . 46
gengraf. . . . . . . . . . . . . . . . . . 50
GENOTROPIN . . . . . . . . . . . . 43
GENOTROPIN MINIQUICK . . 43
gentak. . . . . . . . . . . . . . . . . . 55
gentamicin in saline . . . . . . . . 9
gentamicin sulfate. . . . . . . . . . 9
gentamicin sulfate (ophth). . . 55
gentamicin sulfate (topical). . 59
GEODON. . . . . . . . . . . . . . . . 33
GIANVI . . . . . . . . . . . . . . . . . 39
gildagia. . . . . . . . . . . . . . . . . 39
gildess 1.5/30 . . . . . . . . . . . . . 39
GILENYA CAP 0.5MG. . . . . . . 36
GILOTRIF TAB 20MG. . . . . . . 19
GILOTRIF TAB 30MG. . . . . . . 19
GILOTRIF TAB 40MG. . . . . . . 19
GLEEVEC. . . . . . . . . . . . . . . . 19
glimepiride . . . . . . . . . . . . . . 37
glip/metform tab 5-500mg . . . 37
glipizide. . . . . . . . . . . . . . . . . 37
glipizide-metformin hcl tab
2.5-250 mg . . . . . . . . . . . . 37
glipizide-metformin hcl tab
2.5-500 mg . . . . . . . . . . . . 37
GLUCAGEN HYPOKIT. . . . . . 42
GLUCAGON EMERGENCY
KIT. . . . . . . . . . . . . . . . . . 42
glycopyrrolate . . . . . . . . . . . . 45
glycopyrrolate inj. . . . . . . . . . 45
GOLYTELY. . . . . . . . . . . . . . . 46
granisetron hcl . . . . . . . . . . . 44
GRANIX. . . . . . . . . . . . . . . . . 48
griseofulvin microsize. . . . . . 11
griseofulvin ultramicrosize. . 11
H
halobetasol propionate . . . . . 61
haloperidol . . . . . . . . . . . . . . 33
haloperidol decanoate . . . . . 33
haloperidol lactate . . . . . . . . 33
haloperidol lactate oral
conc 2 mg/ml. . . . . . . . . . 33
HAVRIX. . . . . . . . . . . . . . . . . 51
heather. . . . . . . . . . . . . . . . . . 39
heparin sod inj 1000/ml. . . . . 48
heparin sod inj 10000/ml. . . . 48
HEPARIN SOD INJ 2000/ML. . 48
heparin sod inj 20000/ml. . . . 48
HEPARIN SOD INJ 2500/ML. . 48
heparin sod inj 5000/ml. . . . . 48
HEPARIN SODIUM/D5W. . . . 48
HEPARIN SODIUM/NACL
0.45% . . . . . . . . . . . . . . . . 48
HEPARIN SODIUM/SODIUM
CHL . . . . . . . . . . . . . . . . . 48
HEPATAMINE. . . . . . . . . . . . . 53
HERCEPTIN. . . . . . . . . . . . . . 18
HEXALEN . . . . . . . . . . . . . . . 16
HIBERIX . . . . . . . . . . . . . . . . 51
HUMIRA . . . . . . . . . . . . . . . . 49
HUMIRA KIT 40MG/0.8 . . . . . 49
HUMIRA PEN. . . . . . . . . . . . . 49
HUMIRA PEN-CROHNS
DISEASE. . . . . . . . . . . . . . 49
HUMIRA PEN-PSORIASIS
STAR. . . . . . . . . . . . . . . . . 49
HUMULIN R INJ U-500. . . . . . 37
hydralazine hcl. . . . . . . . . . . 26
hydrochlorothiazide . . . . . . . 26
hydroco/apap tab 10-325mg. . . 8
hydroco/apap tab 5-325mg. . . . 8
hydroco/apap tab 7.5-325. . . . . 8
2015 SELECT (PPO) PLAN FORMULARY
INDEX OF DRUGS LISTED IN FORMULARY
hydrocodoneacetaminophen 7.5-325
mg/15ml. . . . . . . . . . . . . . . 8
hydrocodone-ibuprofen tab
7.5-200 mg. . . . . . . . . . . . . . 8
hydrocortisone. . . . . . . . . . . . 42
HYDROCORTISONE
(INTRARECTAL). . . . . . . . 45
hydrocortisone (topical) . . . . 61
hydrocortisone butyrate . . . . 61
hydrocortisone valerate. . . . . 61
hydromorphon inj 10mg/ml. . . 8
hydromorphone hcl. . . . . . . . . 8
hydroxychloroquine sulfate. . 49
hydroxyurea . . . . . . . . . . . . . 19
hydroxyzine hcl. . . . . . . . . . . 57
I
ibandronate sodium. . . . . . . 38
ibuprofen. . . . . . . . . . . . . . . . . 7
ibuprofen tab 800 mg. . . . . . . . 7
ICLUSIG. . . . . . . . . . . . . . . . . 19
idarubicin hcl. . . . . . . . . . . . 17
IFEX. . . . . . . . . . . . . . . . . . . . 16
ifosfamide inj 1gm. . . . . . . . . 16
ifosfamide inj 1gm/20ml. . . . . 16
IFOSFAMIDE INJ 3GM. . . . . . 16
ifosfamide inj 3gm/60ml. . . . . 16
ILEVRO . . . . . . . . . . . . . . . . . 55
IMBRUVICA CAP 140MG . . . . 19
imipenem-cilastatin. . . . . . . . 10
imipramine hcl . . . . . . . . . . . 31
imiquimod. . . . . . . . . . . . . . . 61
IMOVAX RABIES (H.D.C.V.) . . 51
INCRELEX. . . . . . . . . . . . . . . 43
indapamide. . . . . . . . . . . . . . 26
INFANRIX . . . . . . . . . . . . . . . 51
INLYTA. . . . . . . . . . . . . . . . . . 19
INSULIN PEN NEEDLE. . . . . . 37
INSULIN SAFETY NEEDLES. . 37
INSULIN SYRINGE. . . . . . . . . 37
INTELENCE. . . . . . . . . . . . . . 11
INTRALIPID INJ 20%. . . . . . . 53
INTRALIPID INJ 30%. . . . . . . 53
INTRON-A INJ 10MU . . . . . . . 50
INTRON-A INJ 18MU . . . . . . . 50
INTRON-A INJ 25MU . . . . . . . 50
INTRON-A INJ 50MU . . . . . . . 50
introvale 91 day. . . . . . . . . . . 39
INTUNIV . . . . . . . . . . . . . . . . 34
INVANZ. . . . . . . . . . . . . . . . . 10
INVEGA. . . . . . . . . . . . . . . . . 33
INVEGA SUST INJ 117
MG/0.75 ML. . . . . . . . . . . . 33
INVEGA SUST INJ 156MG/ML. 33
INVEGA SUST INJ 234
MG/1.5 ML. . . . . . . . . . . . . 33
INVEGA SUST INJ 39
MG/0.25 ML . . . . . . . . . . . 33
INVEGA SUST INJ 78 MG/0.5
ML . . . . . . . . . . . . . . . . . . 33
INVIRASE. . . . . . . . . . . . . . 11, 12
INVOKAMET TAB 150-1000. . 38
INVOKAMET TAB 150-500. . . 38
INVOKAMET TAB 50-1000. . . 38
INVOKAMET TAB 50-500MG. 38
INVOKANA . . . . . . . . . . . . . . 38
IONOSOL-B/DEXTROSE 5%. . 53
IONOSOL-MB/DEXTROSE 5%.53
IPOL INACTIVATED IPV. . . . . 51
ipratropium bromide. . . . . . . 57
ipratropium bromide (nasal).57
ipratropium-albuterol nebu . 57
irinotecan hcl . . . . . . . . . . . . 20
ISENTRESS. . . . . . . . . . . . . . . 12
ISOLYTE P. . . . . . . . . . . . . . . 53
isolyte s. . . . . . . . . . . . . . . . . . 53
isoniazid. . . . . . . . . . . . . . . . 13
isoniazid inj 100 mg/ml. . . . . 13
isoniazid syp 50mg/5ml. . . . . 13
isosorb mononitrate tab . . . . 27
isosorbide dinitrate. . . . . . . . 27
isosorbide mononitrate er tab.27
isradipine . . . . . . . . . . . . . . . 25
ISTALOL. . . . . . . . . . . . . . . . . 56
ISTODAX. . . . . . . . . . . . . . . . 18
itraconazole . . . . . . . . . . . . . 11
IXIARO . . . . . . . . . . . . . . . . . 51
J
JAKAFI. . . . . . . . . . . . . . . . . . 19
JALYN. . . . . . . . . . . . . . . . . . . 47
jantoven. . . . . . . . . . . . . . . . .48
JANUMET. . . . . . . . . . . . . . . . 38
2015 SELECT (PPO) PLAN FORMULARY
JANUMET XR TAB 100-1000. . 38
JANUMET XR TAB 50-1000. . . 38
JANUMET XR TAB 50-500MG. 38
JANUVIA . . . . . . . . . . . . . . . . 38
JENTADUETO . . . . . . . . . . . . 38
JOLIVETTE. . . . . . . . . . . . . . . 39
junel 1.5/30 21 day. . . . . . . . . 39
junel 1/20 21 day . . . . . . . . . . 39
junel fe 1.5/30 28 day . . . . . . . 39
junel fe 1/20 28 day . . . . . . . . 39
K
KADCYLA . . . . . . . . . . . . . . . 18
KALETRA SOL. . . . . . . . . . . . 12
KALETRA TAB 100-25MG. . . . 12
KALETRA TAB 200-50MG. . . . 12
kariva 28 day . . . . . . . . . . . . 39
KCL 0.075%/D5W/NACL 0.45%. 54
KCL 0.15%/D5W/NACL 0.9%. . .54
KCL 0.3%/D5W/NACL 0.45% . . 54
KCL 0.3%/D5W/NACL 0.9%. . . 53
KCL/D5W INJ 0.3%. . . . . . . . . 54
KCL/NACL INJ 0.3-0.9. . . . . . . 54
KCL0.15%/D5W/NACL0.2% . . . 53
KCL0.15%/D5W/NACL0.225%. . 53
ketoconazole. . . . . . . . . . . . . 11
ketoconazole cream . . . . . . . 59
ketoconazole shampoo . . . . . 60
ketoprofen. . . . . . . . . . . . . . . . 7
ketorolac tromethamine
(ophth). . . . . . . . . . . . . . . 55
kionex. . . . . . . . . . . . . . . . . . 38
KLOR-CON 10 . . . . . . . . . . . . 52
KLOR-CON 8 . . . . . . . . . . . . . 52
klor-con m15. . . . . . . . . . . . . 52
klor-con m20. . . . . . . . . . . . . 52
klor-con pow 20meq . . . . . . . 52
KUVAN. . . . . . . . . . . . . . . . . . 41
L
labetalol hcl. . . . . . . . . . . . . . 24
laclotion lotn 12% . . . . . . . . . 61
LACTATED RINGER’S INJ. . . . 54
lactulose . . . . . . . . . . . . . . . . 46
lactulose (encephalopathy) . . 46
lamivudine . . . . . . . . . . . . 12, 13
lamivudine-zidovudine. . . . . 12
lamotrigine. . . . . . . . . . . . . . 29
69
INDEX OF DRUGS LISTED IN FORMULARY
LANOXIN. . . . . . . . . . . . . . . . 25
LANTUS. . . . . . . . . . . . . . . . . 37
LANTUS SOLOSTAR. . . . . . . . 37
larin 1.5/30. . . . . . . . . . . . . . . 39
larin 1/20. . . . . . . . . . . . . . . . 39
larin fe 1.5/30. . . . . . . . . . . . . 39
larin fe 1/20. . . . . . . . . . . . . . 39
LASTACAFT. . . . . . . . . . . . . . 56
latanoprost . . . . . . . . . . . . . . 56
LATUDA. . . . . . . . . . . . . . . . . 33
LAZANDA SPR 100MCG. . . . . . 8
LAZANDA SPR 400MCG. . . . . . 8
LEENA. . . . . . . . . . . . . . . . . . 39
leflunomide. . . . . . . . . . . . . . 49
LESCOL . . . . . . . . . . . . . . . . . 23
LESCOL XL. . . . . . . . . . . . . . . 23
lessina 28 day . . . . . . . . . . . . 39
LETAIRIS. . . . . . . . . . . . . . . . 27
letrozole. . . . . . . . . . . . . . . . . 18
leucovorin calcium. . . . . . . . 20
leucovorin calcium for inj
500 mg. . . . . . . . . . . . . . . 20
LEUKERAN . . . . . . . . . . . . . . 16
LEUKINE. . . . . . . . . . . . . . . . 48
leuprolide acetate . . . . . . . . . 18
levalbuterol conc
1.25mg/0.5ml. . . . . . . . . . . 57
LEVEMIR. . . . . . . . . . . . . . . . 37
LEVEMIR FLEXPEN . . . . . . . . 37
LEVEMIR FLEXTOUCH . . . . . 37
levetiracetam. . . . . . . . . . . . . 29
levobunolol hcl . . . . . . . . . . . 56
LEVOBUNOLOL HCL. . . . . . . 56
levocarnitine (metabolic
modifiers). . . . . . . . . . . . . 41
levocetirizine
dihydrochloride. . . . . . . . 57
levofloxacin. . . . . . . . . . . . . . 15
levofloxacin in d5w. . . . . . . . 15
levofloxacin inj 25mg/ml. . . . 15
levofloxacin oral soln 25 mg/
ml. . . . . . . . . . . . . . . . . . . 15
levonest 28 day . . . . . . . . . . . 39
levonorgestrel
(emergency oc). . . . . . . . . 39
levonorgestrel-ethinyl
estradiol (91-day). . . . . . . 40
70
levora 0.15/30 28 day. . . . . . . 40
levothyroxine sodium . . . . . . 44
LEVOXYL. . . . . . . . . . . . . . . . 44
LEXIVA. . . . . . . . . . . . . . . . . . 12
LIALDA. . . . . . . . . . . . . . . . . . 45
lidocaine. . . . . . . . . . . . . . . . 61
lidocaine hcl . . . . . . . . . . . . . 61
lidocaine hcl (local anesth.). . . 9
lidocaine hcl (mouth-throat). 62
lidocaine inj 0.5%. . . . . . . . . . . 9
lidocaine inj 1.5%. . . . . . . . . . . 9
lidocaine inj 1%. . . . . . . . . . . . 9
lidocaine inj 2%. . . . . . . . . . . . 9
lidocaine oint 5%. . . . . . . . . . 61
lidocaine-prilocaine . . . . . . . 61
LINZESS CAP 145MCG. . . . . . 46
LINZESS CAP 290MCG. . . . . . 46
liothyronine sodium . . . . . . . 44
lisinopril . . . . . . . . . . . . . . . . 20
lisinopril &
hydrochlorothiazide. . . . . 20
lithium carbonate. . . . . . . . . 35
lithium carbonate er. . . . . . . 35
LITHIUM CITRATE . . . . . . . . 35
LOKARA LOTN 0.05%. . . . . . . 61
LOMUSTINE. . . . . . . . . . . . . . 17
loperamide hcl. . . . . . . . . . . . 46
lorazepam. . . . . . . . . . . . . . . 27
lorcet hd tab 10-325mg. . . . . . . 8
lorcet plus tab 7.5-325. . . . . . . . 8
lorcet tab 5-325mg. . . . . . . . . . 8
lortab tab 10-325mg. . . . . . . . . 8
lortab tab 5-325mg. . . . . . . . . . 8
lortab tab 7.5-325. . . . . . . . . . . 8
loryna 28 day . . . . . . . . . . . . 40
losartan potassium . . . . . . . . 22
losartan-hctz 100-12.5mg. . . . 22
losartan-hctz 100-25mg. . . . . 22
losartan-hctz 50-12.5mg. . . . . 22
LOTEMAX. . . . . . . . . . . . . . . 55
LOTRONEX . . . . . . . . . . . . . . 46
lovastatin. . . . . . . . . . . . . . . . 23
low-ogestrel 28 day . . . . . . . . 40
loxapine succinate. . . . . . . . . 33
LUMIGAN. . . . . . . . . . . . . . . . 56
LUMIZYME . . . . . . . . . . . . . . 41
LUPR DEP-PED INJ 30MG
(3-MONTH) . . . . . . . . . . . 18
LUPRON DEPOT. . . . . . . . . . . 18
LUPRON DEPOT INJ
11.25 MG. . . . . . . . . . . . . . 18
LUPRON DEPOT-PED. . . . . . . 18
lutera 28 day. . . . . . . . . . . . . 40
LYRICA. . . . . . . . . . . . . . . . . . 29
LYSODREN. . . . . . . . . . . . . . . 18
lyza . . . . . . . . . . . . . . . . . . . . 40
M
M-M-R II W/DILUENT 10 DOS. 51
mafenide acetate. . . . . . . . . . 59
MAGNESIUM SULFATE . . . . . 52
MAGNESIUM SULFATE IN
D5W. . . . . . . . . . . . . . . . . 52
magnesium sulfate inj 50% . . 52
malathion. . . . . . . . . . . . . . . 61
maprotiline hcl . . . . . . . . . . . 31
marlissa 28 day. . . . . . . . . . . 40
MARPLAN TAB 10MG. . . . . . . 31
MATULANE. . . . . . . . . . . . . . 19
MAXIDEX . . . . . . . . . . . . . . . 55
meclizine hcl. . . . . . . . . . . . . 44
medroxyprogesterone
acetate 150 mg/ml. . . . . . . 40
medroxyprogesterone
acetate tab. . . . . . . . . . . . 43
mefloquine hcl. . . . . . . . . . . . 11
MEGACE ES. . . . . . . . . . . . . . 18
megestrol acetate. . . . . . . . . . 18
MEKINIST . . . . . . . . . . . . . . . 19
meloxicam. . . . . . . . . . . . . . . . 7
MELOXICAM. . . . . . . . . . . . . . 7
melphalan hcl. . . . . . . . . . . . 17
MENACTRA. . . . . . . . . . . . . . 51
MENOMUNE-A/C/Y/W-135. . . 51
MENVEO. . . . . . . . . . . . . . . . 51
mercaptopurine. . . . . . . . . . . 17
meropenem. . . . . . . . . . . . . . 10
mesalamine enema. . . . . . . . 45
mesalamine w/ cleanser . . . . 45
mesna. . . . . . . . . . . . . . . . . . 20
MESNEX. . . . . . . . . . . . . . . . . 20
metadate tab 20mg er. . . . . . 34
metformin hcl . . . . . . . . . . . . 38
2015 SELECT (PPO) PLAN FORMULARY
INDEX OF DRUGS LISTED IN FORMULARY
methadone hcl. . . . . . . . . . . . . 8
methazolamide. . . . . . . . . . . 26
methenamine hippurate . . . . 10
methimazole. . . . . . . . . . . . . 44
methotrexate sodium inj. . . . 17
methotrexate sodium tabs. . . 49
methyclothiazide. . . . . . . . . . 26
methylergonovine maleate . . 43
methylphenidate hcl. . . . . . . . 34
methylphenidate hcl oral soln.34
methylpr ace inj 40mg/ml . . . 42
methylpr ace inj 80mg/ml . . . 42
methylpr ss inj 125mg. . . . . . . 42
methylpr ss inj 1gm . . . . . . . . 42
methylpr ss inj 40mg . . . . . . . 42
methylpred pak 4mg . . . . . . . 42
methylpred tab 16mg. . . . . . . 42
methylpred tab 32mg. . . . . . . 42
methylpred tab 4mg. . . . . . . . 42
methylpred tab 8mg. . . . . . . . 42
metipranolol. . . . . . . . . . . . . 56
metoclopramide hcl. . . . . . . . 44
metoclopramide inj. . . . . . . . 44
metolazone. . . . . . . . . . . . . . 26
metoprolol & hctz tab 10025mg. . . . . . . . . . . . . . . . .23
metoprolol & hctz tab 10050mg . . . . . . . . . . . . . . . . 23
metoprolol & hctz tab 5025mg. . . . . . . . . . . . . . . . .23
metoprolol succinate. . . . . . . 24
metoprolol tartrate . . . . . . . . 24
metronidazole. . . . . . . . . . . . 10
metronidazole (topical). . . . . 61
metronidazole gel 0.75% . . . . 61
metronidazole in nacl. . . . . . 10
metronidazole vaginal . . . . . 47
mexiletine hcl . . . . . . . . . . . . 22
MIACALCIN. . . . . . . . . . . . . . 43
microgestin 1.5/30 21 day. . . . 40
microgestin 1/20 21 day. . . . . 40
microgestin fe 1.5/30 28 day. . 40
microgestin fe 1/20 28 day. . . 40
midodrine hcl . . . . . . . . . . . . 26
minitran . . . . . . . . . . . . . . . . 27
minocycline hcl. . . . . . . . . . . 16
minoxidil. . . . . . . . . . . . . . . . 26
mirtazapine. . . . . . . . . . . . . . 31
misoprostol . . . . . . . . . . . . . . 46
mitomycin. . . . . . . . . . . . . . . 17
mitoxantrone hcl. . . . . . . . . . 19
modafinil. . . . . . . . . . . . . . . . 36
moderiba 800 dose pack. . . . 13
moderiba pak 1000/day. . . . . 13
moderiba pak 1200/day. . . . . 13
moderiba pak 600/day. . . . . . 13
moderiba tab 200mg. . . . . . . 13
moexipril hcl. . . . . . . . . . . . . 21
moexiprilhydrochlorothiazide. . . . . 21
mometasone furoate. . . . . . . 61
MONONESSA. . . . . . . . . . . . . 40
montelukast sodium . . . . . . . 57
morphine ext-rel tab . . . . . . . . 8
morphine sul inj . . . . . . . . . . . 8
MORPHINE SUL INJ. . . . . . . . . 8
morphine sulfate. . . . . . . . . 8, 9
MORPHINE SULFATE. . . . . . . . 9
morphine sulfate beads. . . . . . 9
morphine sulfate cap
100mg er . . . . . . . . . . . . . . 9
MORPHINE SULFATE ORAL
SOL. . . . . . . . . . . . . . . . . . . 9
MOVIPREP. . . . . . . . . . . . . . . 46
MOXEZA . . . . . . . . . . . . . . . . 55
MOZOBIL. . . . . . . . . . . . . . . . 48
MULTAQ . . . . . . . . . . . . . . . . 22
mupirocin. . . . . . . . . . . . . . . 59
MUSTARGEN. . . . . . . . . . . . . 17
my way . . . . . . . . . . . . . . . . . 40
MYCAMINE. . . . . . . . . . . . . . 11
mycophenolate mofetil. . . . . . 50
mycophenolate sodium. . . . . 50
myorisan. . . . . . . . . . . . . . . . 59
MYOZYME. . . . . . . . . . . . . . . 41
MYRBETRIQ . . . . . . . . . . . . . 47
myzilra . . . . . . . . . . . . . . . . . 40
N
nabumetone . . . . . . . . . . . . . . 7
nadolol . . . . . . . . . . . . . . . . . 24
nafcillin sodium. . . . . . . . . . . 16
NAFTIN. . . . . . . . . . . . . . . . . 59
NAGLAZYME. . . . . . . . . . . . . 41
naloxone hcl. . . . . . . . . . . . . 36
2015 SELECT (PPO) PLAN FORMULARY
naltrexone hcl. . . . . . . . . . . . 36
NAMENDA SOL 10MG/5ML. . . 30
NAMENDA TAB. . . . . . . . . . . 30
NAMENDA XR. . . . . . . . . . . . 30
NAMENDA XR TITRATION
PACK. . . . . . . . . . . . . . . . . 30
naphazoline 0.1%. . . . . . . . . . 56
NAPRELAN. . . . . . . . . . . . . . . . 7
naproxen. . . . . . . . . . . . . . . 7, 8
naproxen sodium . . . . . . . . . . 8
naratriptan hcl. . . . . . . . . . . 35
NASONEX . . . . . . . . . . . . . . . 58
NATACYN. . . . . . . . . . . . . . . . 55
nateglinide. . . . . . . . . . . . . . . 38
NEBUPENT . . . . . . . . . . . . . . 10
necon 0.5/35 28 day. . . . . . . . 40
necon 1/35 28 day . . . . . . . . . 40
necon 10/11 28 day. . . . . . . . . 40
NECON 7/7/7 . . . . . . . . . . . . . 40
NECON TAB 1/50-28. . . . . . . . 40
nefazodone hcl . . . . . . . . . . . 31
neomycin sulfate. . . . . . . . . . . 9
neomycin-bacitracin znpolymyxin . . . . . . . . . . . . 55
neomycin-polymy-dexameth. 54
neomycin-polymy-gramicid. . 55
neomycin-polymyxin-hc
(ophth). . . . . . . . . . . . . . . 54
neomycin-polymyxin-hc (otic).62
NEORAL. . . . . . . . . . . . . . . . . 50
NEPHRAMINE. . . . . . . . . . . . 53
NEULASTA. . . . . . . . . . . . . . . 48
NEUMEGA. . . . . . . . . . . . . . . 48
NEUPOGEN. . . . . . . . . . . . . . 48
NEUPRO. . . . . . . . . . . . . . . . . 32
NEVANAC. . . . . . . . . . . . . . . . 56
nevirapine. . . . . . . . . . . . . . . 12
NEVIRAPINE . . . . . . . . . . . . . 12
NEXAVAR. . . . . . . . . . . . . . . . 19
NEXIUM CAP. . . . . . . . . . . . . 46
NEXIUM GRA 10MG DR. . . . . 47
NEXIUM GRA 2.5MG DR . . . . 46
NEXIUM GRA 20MG DR. . . . . 47
NEXIUM GRA 40MG DR. . . . . 47
NEXIUM GRA 5MG DR. . . . . . 47
next choice one dose. . . . . . . 40
nikki 3-0.02mg. . . . . . . . . . . . 40
71
INDEX OF DRUGS LISTED IN FORMULARY
niacin (antihyperlipidemic). . 23
niacor. . . . . . . . . . . . . . . . . . 23
NIASPAN . . . . . . . . . . . . . . . . 23
nicardipine hcl . . . . . . . . . . . 25
NICOTROL INHALER. . . . . . . 36
NICOTROL NS. . . . . . . . . . . . 36
nifedical. . . . . . . . . . . . . . . . . 25
nifedipine. . . . . . . . . . . . . . . . 25
nifedipine er . . . . . . . . . . . . . 25
NILANDRON . . . . . . . . . . . . . 18
nimodipine . . . . . . . . . . . . . . 25
NIPENT . . . . . . . . . . . . . . . . . 17
nitro-bid . . . . . . . . . . . . . . . . 27
NITRO-DUR DIS 0.3MG/HR. . 27
NITRO-DUR DIS 0.8MG/HR. . 27
nitrofurantoin macrocrystal. 10
nitrofurantoin monohyd
macro . . . . . . . . . . . . . . . 10
nitroglycerin . . . . . . . . . . . . . 27
NITROLINGUAL PUMPSPRAY. 27
NITROSTAT. . . . . . . . . . . . . . 27
NORA-BE TAB . . . . . . . . . . . . 40
NORDITROPIN FLEXPRO. . . . 43
NORDITROPIN NORDIFLEX
PEN . . . . . . . . . . . . . . . . . 43
norethindrone
(contraceptive). . . . . . . . . 40
norethindrone acetate. . . . . . 43
norgestimate-ethinyl
estradiol (triphasic) . . . . . 40
norlyroc 0.35mg. . . . . . . . . . . 40
normosol-m. . . . . . . . . . . . . . 54
NORMOSOL-R. . . . . . . . . . . . 54
NORMOSOL-R IN D5W. . . . . . 54
NORPACE CR. . . . . . . . . . . . . 22
nortrel 0.5/35 28 day . . . . . . . 40
nortrel 1/35 21 day. . . . . . . . . 40
nortrel 1/35 28 day. . . . . . . . . 40
nortrel 7/7/7 28 day . . . . . . . . 40
nortriptyline hcl. . . . . . . . . . . 31
NORVIR. . . . . . . . . . . . . . . . . 12
NOVOLIN 70/30. . . . . . . . . . . 37
NOVOLIN N. . . . . . . . . . . . . . 37
NOVOLIN R . . . . . . . . . . . . . . 37
NOVOLOG. . . . . . . . . . . . . . . 37
NOVOLOG FLEXPEN. . . . . . . 37
NOVOLOG MIX 70/30. . . . . . . 37
72
NOVOLOG MIX 70/30
PREFILL . . . . . . . . . . . . . . 37
NOVOLOG PENFILL. . . . . . . . 37
NOXAFIL. . . . . . . . . . . . . . . . 11
NUEDEXTA. . . . . . . . . . . . . . 35
NULOJIX . . . . . . . . . . . . . . . . 50
NULYTELY/FLAVOR PACKS. . . 46
NUVARING . . . . . . . . . . . . . . 40
NUVIGIL . . . . . . . . . . . . . . . . 36
nyamyc . . . . . . . . . . . . . . . . . 59
NYMALIZE. . . . . . . . . . . . . . . 25
nystatin. . . . . . . . . . . . . . . . . 11
nystatin (mouth-throat). . . . . 62
nystatin (topical). . . . . . . . . . 59
nystop . . . . . . . . . . . . . . . . . . 59
O
OCELLA TAB 3-0.03MG . . . . . 40
OCTAGAM. . . . . . . . . . . . . . . 49
octreotide acetate . . . . . . . . . 43
ofloxacin (ophth). . . . . . . . . . 55
ofloxacin (otic). . . . . . . . . . . . 62
olanzapine . . . . . . . . . . . . . . 33
OLYSIO . . . . . . . . . . . . . . . . . 13
omega-3-acid ethyl esters. . . . 23
omeprazole. . . . . . . . . . . . . . 47
ondansetron hcl . . . . . . . . . . 44
ondansetron hcl inj. . . . . . . . 44
ondansetron hcl oral soln. . . 44
ondansetron odt . . . . . . . . . . 44
ONFI . . . . . . . . . . . . . . . . . . . 29
ORAP. . . . . . . . . . . . . . . . . . . 33
ORFADIN. . . . . . . . . . . . . . . . 41
orsythia 28 day . . . . . . . . . . . 40
oxacillin sodium. . . . . . . . . . 16
oxaliplatin. . . . . . . . . . . . . . . 20
oxandrolone. . . . . . . . . . . . . 36
oxcarbazepine. . . . . . . . . . . . 29
oxybutynin chloride . . . . . . . 47
oxycodone hcl. . . . . . . . . . . . . 9
OXYCODONE HCL. . . . . . . . . . 9
oxycodone hcl tab 5 mg. . . . . . 9
oxycodone w/
acetaminophen 10-325mg . 9
oxycodone w/
acetaminophen 2.5-325mg. 9
oxycodone w/
acetaminophen 5-325mg . . 9
oxycodone w/
acetaminophen 7.5-325mg. 9
P
pacerone. . . . . . . . . . . . . . . . 22
paclitaxel. . . . . . . . . . . . . . . . 17
pamidronate disodium. . . . . 38
PANRETIN. . . . . . . . . . . . . . . 61
pantoprazole sodium. . . . . . . 47
paricalcitol . . . . . . . . . . . . . . 54
paromomycin sulfate. . . . . . . . 9
paroxetine hcl. . . . . . . . . . . . 31
paser d/r . . . . . . . . . . . . . . . . 13
PATADAY. . . . . . . . . . . . . . . . 56
PATANASE. . . . . . . . . . . . . . . 57
PATANOL. . . . . . . . . . . . . . . . 56
PAXIL. . . . . . . . . . . . . . . . . . . 31
pedi-dri. . . . . . . . . . . . . . . . . 59
PEDVAX HIB . . . . . . . . . . . . . 51
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate . . . . . 46
peg 3350-potassium chloridesod bicarbonate-sod
chloride. . . . . . . . . . . . . . 46
PEG 3350/ELECTROLYTES. . . 46
PEG-INTRON. . . . . . . . . . . . . 50
PEG-INTRON REDIPEN . . . . . 50
PEGANONE. . . . . . . . . . . . . . 29
PEGASYS. . . . . . . . . . . . . . . . 50
PEGASYS PROCLICK . . . . . . . 50
PENICILLIN G POT IN
DEXTROSE. . . . . . . . . . . . 16
penicillin g potassium. . . . . . 16
penicillin g procaine. . . . . . . 16
penicillin g sodium . . . . . . . . 16
penicillin v potassium. . . . . . 16
penicilln gk inj 5mu. . . . . . . . 16
PENTAM 300 . . . . . . . . . . . . . 10
PENTASA. . . . . . . . . . . . . . . . 45
pentoxifylline. . . . . . . . . . . . . 49
PERFOROMIST. . . . . . . . . . . . 57
perindopril erbumine. . . . . . 21
periogard. . . . . . . . . . . . . . . . 62
permethrin . . . . . . . . . . . . . . 61
perphenazine . . . . . . . . . . . . 33
2015 SELECT (PPO) PLAN FORMULARY
INDEX OF DRUGS LISTED IN FORMULARY
phenelzine sulfate . . . . . . . . . 31
phenobarbital . . . . . . . . . . . . 29
phenobarbital sodium. . . . . . 29
PHENOBARBITAL SODIUM. . 29
phenytek . . . . . . . . . . . . . . . . 29
phenytoin. . . . . . . . . . . . . . . . 29
phenytoin sodium . . . . . . . . . 29
phenytoin sodium extended. . 29
philith. . . . . . . . . . . . . . . . . . . 40
PHOSLYRA. . . . . . . . . . . . . . . 43
PHOSPHOLINE IODIDE. . . . . 56
PILOCARPINE HCL. . . . . . . . . 56
pilocarpine hcl (oral). . . . . . . 62
pimtrea pack. . . . . . . . . . . . . 40
pindolol. . . . . . . . . . . . . . . . . 24
pioglitazone hcl. . . . . . . . . . . 38
piperacillin sodiumtazobactam sodium. . . . . 16
pirmella 1/35 28 day . . . . . . . 40
piroxicam . . . . . . . . . . . . . . . . 8
PLASMA-LYTE A. . . . . . . . . . . 54
PLASMA-LYTE-148 . . . . . . . . . 54
PLASMA-LYTE-56/D5W. . . . . . 54
podofilox. . . . . . . . . . . . . . . . 61
polyethylene glycol 3350. . . . . 46
polymyxin b-trimethoprim. . . 55
POMALYST CAP 1MG. . . . . . . 19
POMALYST CAP 2MG. . . . . . . 19
POMALYST CAP 3MG. . . . . . . 19
POMALYST CAP 4MG. . . . . . . 19
portia 28 day. . . . . . . . . . . . . 40
potassium chloride . . . . . 52, 54
POTASSIUM CHLORIDE . 52, 54
POTASSIUM CHLORIDE
0.15% . . . . . . . . . . . . . . . . 54
POTASSIUM CHLORIDE
0.22%. . . . . . . . . . . . . . . . 54
POTASSIUM CHLORIDE ER. . 52
potassium chloride in nacl . . 54
potassium chloride
microencapsulated
crystals cr. . . . . . . . . . . . . 52
POTASSIUM CITRATE
(ALKALINIZER) . . . . . . . . 47
POTIGA. . . . . . . . . . . . . . . . . 29
PRADAXA . . . . . . . . . . . . . . . 48
pramipexole dihydrochloride.32
pravastatin sodium. . . . . . . . 23
prazosin hcl. . . . . . . . . . . . . . 21
pred sod pho sol 5mg/5ml. . . . 42
PREDNISOLONE ACETATE
(OPHTH). . . . . . . . . . . . . 56
prednisolone sodium
phosphate (ophth). . . . . . . 56
prednisolone sol 15mg/5ml. . . 42
prednisolone sol 25mg/5ml . . 42
prednisolone syp 15mg/5ml. . 42
prednisone con 5mg/ml. . . . . 42
prednisone pak 10mg . . . . . . 42
prednisone pak 5mg . . . . . . . 42
prednisone sol 5mg/5ml. . . . . 42
prednisone tab 10mg. . . . . . . 42
prednisone tab 1mg. . . . . . . . 42
prednisone tab 2.5mg. . . . . . . 42
prednisone tab 20mg. . . . . . . 42
prednisone tab 50mg. . . . . . . 42
prednisone tab 5mg. . . . . . . . 42
PREMARIN CREAM . . . . . . . . 41
premasol sol 10%. . . . . . . . . . 53
premasol sol 6%. . . . . . . . . . . 53
PRENATAL VITAMIN/
FOLIC ACID > 0.8 MG
(GENERIC). . . . . . . . . . . . 54
prevalite. . . . . . . . . . . . . . . . . 23
previfem 28 day. . . . . . . . . . . 40
PREZISTA. . . . . . . . . . . . . . . . 12
PRIFTIN. . . . . . . . . . . . . . . . . 13
PRIMAQUINE PHOSPHATE. . 11
primidone. . . . . . . . . . . . . . . 29
PRISTIQ. . . . . . . . . . . . . . . . . 31
PRIVIGEN. . . . . . . . . . . . . . . . 49
PROAIR HFA. . . . . . . . . . . . . . 57
probenecid. . . . . . . . . . . . . . . . 7
PROCALAMINE . . . . . . . . . . . 53
prochlorperazine inj. . . . . . . 44
prochlorperazine maleate. . . 44
prochlorperazine supp . . . . . 44
PROCRIT . . . . . . . . . . . . . . . . 48
procto-pak. . . . . . . . . . . . . . . 59
proctosol hc. . . . . . . . . . . . . . 59
proctozone hc . . . . . . . . . . . . 59
PROGLYCEM SUS 50MG/ML. . 42
PROGRAF. . . . . . . . . . . . . . . . 50
PROLASTIN-C . . . . . . . . . . . . 58
2015 SELECT (PPO) PLAN FORMULARY
PROLENSA. . . . . . . . . . . . . . . 56
PROLEUKIN. . . . . . . . . . . . . . 18
PROLIA. . . . . . . . . . . . . . . . . . 43
PROMACTA . . . . . . . . . . . . . . 49
promethazine hcl. . . . . . . . . . 44
propafenone hcl. . . . . . . . . . . 22
proparacaine hcl. . . . . . . . . . 56
propranolol &
hydrochlorothiazide. . . . . 23
propranolol cap er . . . . . . . . 24
propranolol hcl. . . . . . . . . . . 24
propylthiouracil. . . . . . . . . . . 44
PROQUAD. . . . . . . . . . . . . . . 51
PROSOL. . . . . . . . . . . . . . . . . 53
protriptyline hcl. . . . . . . . . . . 31
PROVENTIL HFA . . . . . . . . . . 57
PRUDOXIN CRE 5%. . . . . . . . 59
PULMICORT FLEXHALER . . . 58
PULMOZYME. . . . . . . . . . . . . 58
pyrazinamide. . . . . . . . . . . . 13
pyridostigmine bromide . . . . 35
Q
quasense 91 day. . . . . . . . . . . 40
quetiapine fumarate. . . . . . . 33
quinapril hcl. . . . . . . . . . . . . 21
quinaprilhydrochlorothiazide. . . . . 21
quinidine gluconate . . . . . . . 22
quinidine sulfate. . . . . . . . . . 22
quinine sulfate. . . . . . . . . . . . 11
QVAR. . . . . . . . . . . . . . . . . . . 58
R
RABAVERT. . . . . . . . . . . . . . . 51
raloxifene hcl. . . . . . . . . . . . . 43
ramipril. . . . . . . . . . . . . . . . . 21
RANEXA . . . . . . . . . . . . . . . . 26
ranitidine hcl. . . . . . . . . . . . . 45
ranitidine hcl inj. . . . . . . . . . 45
ranitidine syrup. . . . . . . . . . . 45
RAPAMUNE. . . . . . . . . . . . . . 50
REBETOL SOLN. . . . . . . . . . . 13
reclipsen 28 day. . . . . . . . . . . 40
sharobel 0.35mg. . . . . . . . . . . 40
RECOMBIVAX HB . . . . . . . . . 51
REGRANEX . . . . . . . . . . . . . . 62
RELENZA DISKHALER. . . . . . 13
73
INDEX OF DRUGS LISTED IN FORMULARY
RELISTOR . . . . . . . . . . . . . . . 46
RELPAX . . . . . . . . . . . . . . . . . 35
REMICADE. . . . . . . . . . . . . . . 49
REMODULIN. . . . . . . . . . . . . 27
REVATIO SUSR. . . . . . . . . . . . 27
RENVELA PAK 0.8GM. . . . . . . 43
RENVELA PAK 2.4GM. . . . . . . 43
RENVELA TAB 800MG. . . . . . 43
repaglinide . . . . . . . . . . . . . . 38
RESCRIPTOR. . . . . . . . . . . . . 12
RESTASIS. . . . . . . . . . . . . . . . 56
RETROVIR IV INFUSION . . . . 12
REVLIMID. . . . . . . . . . . . . . . 50
REYATAZ. . . . . . . . . . . . . . . . 12
ribapak mis 600/day . . . . . . . 13
ribasphere. . . . . . . . . . . . . . . 13
ribasphere ribapak 1000. . . . 14
ribasphere ribapak 1200. . . . 14
ribasphere ribapak 800. . . . . 14
ribavirin 200mg. . . . . . . . . . . 14
rifabutin . . . . . . . . . . . . . . . . 13
rifampin . . . . . . . . . . . . . . . . 13
RIFATER. . . . . . . . . . . . . . . . . 13
riluzole . . . . . . . . . . . . . . . . . 35
rimantadine hydrochloride. . 14
RINGER’S. . . . . . . . . . . . . . . . 54
RIOMET. . . . . . . . . . . . . . . . . 38
RISPERDAL INJ 12.5MG . . . . . 33
RISPERDAL INJ 25MG. . . . . . . 33
RISPERDAL INJ 37.5MG. . . . . . 33
RISPERDAL INJ 50MG . . . . . . 33
risperidone . . . . . . . . . . . . . . 34
RITUXAN. . . . . . . . . . . . . . . . 18
rivastigmine tartrate. . . . . . . 30
rizatriptan benzoate. . . . . . . 35
ropinirole hydrochloride. . . . 32
rosadan cre 0.75%. . . . . . . . . 61
ROTARIX. . . . . . . . . . . . . . . . 51
ROTATEQ. . . . . . . . . . . . . . . . 51
roxicet soln . . . . . . . . . . . . . . . 9
roxicet tab 5-325mg. . . . . . . . . 9
ROZEREM . . . . . . . . . . . . . . . 35
S
SABRIL. . . . . . . . . . . . . . . . . . 29
SANDIMMUNE. . . . . . . . . . . . 50
SANDOSTATIN LAR DEPOT. . 43
74
SANTYL. . . . . . . . . . . . . . . . . 62
SAPHRIS . . . . . . . . . . . . . . . . 34
selegiline hcl. . . . . . . . . . . . . . 32
selenium sulfide. . . . . . . . . . . 60
SELZENTRY. . . . . . . . . . . . . . 12
SENSIPAR. . . . . . . . . . . . . . . . 38
SEREVENT DISKUS . . . . . . . . 57
SEROQUEL XR. . . . . . . . . . . . 34
sertraline hcl. . . . . . . . . . . . . 31
sildenafil citrate
(pulmonary
hypertension). . . . . . . . . . 27
SILENOR . . . . . . . . . . . . . . . . 35
SILVER SULFADIAZINE . . . . . 59
SIMBRINZA . . . . . . . . . . . . . . 56
simvastatin . . . . . . . . . . . . . . 23
SINGULAIR . . . . . . . . . . . . . . 57
sirolimus. . . . . . . . . . . . . . . . 50
SIRTURO. . . . . . . . . . . . . . . . 13
SIVEXTRO. . . . . . . . . . . . . . . 10
SODIUM CHLORIDE. . . . 52, 54
SODIUM CHLORIDE
0.45% VIA. . . . . . . . . . . . . 54
SODIUM CHLORIDE 0.9% . . . 62
SODIUM CHLORIDE INJ
0.9%. . . . . . . . . . . . . . . . . 54
SODIUM FLUORIDE CHEW. . 52
sodium phenylbutyrate . . . . . 41
sodium polystyrene sulfonate.39
SOLIA. . . . . . . . . . . . . . . . . . . 41
SOLTAMOX . . . . . . . . . . . . . . 18
SOLU-CORTEF. . . . . . . . . . . . 42
SOMATULINE DEPOT. . . . . . 43
SOMAVERT . . . . . . . . . . . . . . 43
sorine. . . . . . . . . . . . . . . . . . . 22
sotalol hcl. . . . . . . . . . . . . . . . 23
sotalol hcl (afib/afl) . . . . . . . . 23
SOVALDI . . . . . . . . . . . . . . . . 14
SPIRIVA HANDIHALER . . . . . 57
spironolactone. . . . . . . . . . . . 21
spironolactone &
hydrochlorothiazide. . . . . 26
sprintec 28 day. . . . . . . . . . . . 41
SPRYCEL. . . . . . . . . . . . . . . . . 19
sps susp 15gm/60ml . . . . . . . . 39
sronyx. . . . . . . . . . . . . . . . . . 41
SSD . . . . . . . . . . . . . . . . . . . . 59
STALEVO 100. . . . . . . . . . . . . 32
STALEVO 125. . . . . . . . . . . . . 32
STALEVO 150. . . . . . . . . . . . . 32
STALEVO 200. . . . . . . . . . . . . 32
STALEVO 50. . . . . . . . . . . . . . 32
STALEVO 75. . . . . . . . . . . . . . 32
stavudine. . . . . . . . . . . . . . . . 12
STERILE WATER IRRIGATION.62
STIVARGA . . . . . . . . . . . . . . . 19
STRATTERA. . . . . . . . . . . . . . 35
streptomycin sulfate. . . . . . . . . 9
STRIBILD. . . . . . . . . . . . . . . . 12
SUBOXONE MIS 12-3MG. . . . 36
SUBOXONE MIS 2-0.5MG. . . . 36
SUBOXONE MIS 4-1MG. . . . . 36
SUBOXONE MIS 8-2MG. . . . . 36
SUCRAID. . . . . . . . . . . . . . . . 46
sucralfate. . . . . . . . . . . . . . . . 46
sulfacetamide sodprednisolone . . . . . . . . . . 54
sulfacetamide sodium (acne). 59
sulfacetamide sodium (ophth).55
sulfadiazine. . . . . . . . . . . . . . . 9
sulfamethoxazoletrimethoprim. . . . . . . . . . 10
sulfamethoxazoletrimethoprim inj . . . . . . . 10
SULFAMYLON. . . . . . . . . . . . 59
sulfasalazine. . . . . . . . . . . . . 45
sulfasalazine ec. . . . . . . . . . . 45
sulindac. . . . . . . . . . . . . . . . . . 8
SUMATRIPTAN . . . . . . . . . . . 35
sumatriptan succinate. . . . . .35
SUMATRIPTAN SUCCINATE. . 35
sumatriptan succinate inj. . . 35
SUMATRIPTAN SUCCINATE
INJ . . . . . . . . . . . . . . . . . . 35
suprax. . . . . . . . . . . . . . . . . . 14
SUPRAX. . . . . . . . . . . . . . . . . 14
SUPREP BOWEL PREP . . . . . . 46
SURMONTIL CAP 100MG. . . . 31
SURMONTIL CAP 25MG. . . . . 31
SURMONTIL CAP 50MG. . . . . 31
SUSTIVA. . . . . . . . . . . . . . . . . 12
SUTENT. . . . . . . . . . . . . . . . . 19
SYLATRON KIT 296MCG . . . . 20
SYLATRON KIT 444MCG. . . . 20
2015 SELECT (PPO) PLAN FORMULARY
INDEX OF DRUGS LISTED IN FORMULARY
SYLATRON KIT 888MCG. . . . 20
SYMBICORT. . . . . . . . . . . . . . 58
SYMLINPEN 120. . . . . . . . . . . 37
SYMLINPEN 60. . . . . . . . . . . . 37
SYNAGIS . . . . . . . . . . . . . . . . 51
SYNAREL. . . . . . . . . . . . . . . . 41
SYNERCID. . . . . . . . . . . . . . . 10
SYNTHROID . . . . . . . . . . . . . 44
SYPRINE . . . . . . . . . . . . . . . . 39
T
TABLOID. . . . . . . . . . . . . . . . 17
TACLONEX. . . . . . . . . . . . . . . 61
tacrolimus. . . . . . . . . . . . . . . 50
TAFINLAR . . . . . . . . . . . . . . . 19
TAMIFLU. . . . . . . . . . . . . . . . 14
tamoxifen citrate. . . . . . . . . . 18
tamsulosin hcl. . . . . . . . . . . . 47
TARCEVA. . . . . . . . . . . . . . . . 19
TARGRETIN. . . . . . . . . . . . 20, 61
TASIGNA . . . . . . . . . . . . . . . . 19
tazicef . . . . . . . . . . . . . . . . . . 14
tazicef vial. . . . . . . . . . . . . . . 14
TAZORAC. . . . . . . . . . . . . . . . 60
taztia. . . . . . . . . . . . . . . . . . . 25
TEFLARO. . . . . . . . . . . . . . . . 14
TEGRETOL. . . . . . . . . . . . . . . 29
TEGRETOL-XR. . . . . . . . . . . . 29
TEKAMLO 300-10MG. . . . . . . 25
TEKAMLO TAB 150-10MG . . . 25
TEKAMLO TAB 150-5MG. . . . 25
TEKAMLO TAB 300-5MG. . . . 25
TEKTURNA . . . . . . . . . . . . 25, 26
TEKTURNA HCT TAB
150-12.5MG. . . . . . . . . . . . 26
TEKTURNA HCT TAB
150-25MG. . . . . . . . . . . . . 26
TEKTURNA HCT TAB
300-12.5MG. . . . . . . . . . . . 26
TEKTURNA HCT TAB
300-25MG. . . . . . . . . . . . . 26
temazepam. . . . . . . . . . . . . . 35
TENIVAC . . . . . . . . . . . . . . . . 51
terazosin hcl . . . . . . . . . . . . . 21
terbinafine hcl. . . . . . . . . . . . 11
terbutaline sulfate. . . . . . . . . 57
terconazole vaginal. . . . . . . . 47
TESTIM . . . . . . . . . . . . . . . . . 37
testosterone cypionate. . . . . . 37
testosterone enanthate. . . . . . 37
TETANUS TOXOID
ADSORBED . . . . . . . . . . . 51
TETANUS/DIPHTHERIA
TOXOID. . . . . . . . . . . . . . 51
TEV-TROPIN. . . . . . . . . . . . . . 43
texacort soln 2.5% . . . . . . . . . 61
THALOMID. . . . . . . . . . . . . . 50
theo-24. . . . . . . . . . . . . . . . . . 58
theophylline. . . . . . . . . . . . . . 58
thioridazine hcl. . . . . . . . . . . 34
thiothixene. . . . . . . . . . . . . . . 34
tiagabine hcl . . . . . . . . . . . . . 29
TIKOSYN. . . . . . . . . . . . . . . . 23
TIMENTIN. . . . . . . . . . . . . . . 16
TIMENTIN INJ 3.1GM. . . . . . . 16
timolol maleate. . . . . . . . . . . 24
timolol maleate (ophth). . . . . 56
TIMOLOL MALEATE GEL. . . . 56
TIVICAY. . . . . . . . . . . . . . . . . 12
tizanidine hcl. . . . . . . . . . . . . 36
TOBRADEX. . . . . . . . . . . . . . 54
TOBRADEX ST. . . . . . . . . . . . 55
tobramycin . . . . . . . . . . . . . . . 9
tobramycin sulfate. . . . . . . . . . 9
tobramycin sulfate (ophth). . . 55
tobramycin sulfate in saline . . 9
tobramycin-dexamethasone . 55
TOBREX. . . . . . . . . . . . . . . . . 55
TOLTERODINE TARTRATE
CAP ER. . . . . . . . . . . . . . . 47
tolterodine tartrate tabs. . . . . 47
topiramate. . . . . . . . . . . . . . . 29
toposar. . . . . . . . . . . . . . . . . . 20
topotecan hcl. . . . . . . . . . . . . 20
torsemide inj. . . . . . . . . . . . . 26
torsemide tabs. . . . . . . . . . . . 26
TOVIAZ. . . . . . . . . . . . . . . . . 47
TPN ELECTROLYTES. . . . . . . 52
TRACLEER. . . . . . . . . . . . . . . 27
TRADJENTA. . . . . . . . . . . . . . 38
tramadol hcl. . . . . . . . . . . . . . 8
tramadol-acetaminophen. . . . 8
trandolapril. . . . . . . . . . . . . . 21
tranexamic acid . . . . . . . . . . 49
2015 SELECT (PPO) PLAN FORMULARY
TRANSDERM-SCOP. . . . . . . . 44
tranylcypromine sulfate. . . . . 31
travasol 10. . . . . . . . . . . . . . . 53
TRAVATAN Z . . . . . . . . . . . . . 56
trazodone hcl. . . . . . . . . . . . . 31
TREANDA . . . . . . . . . . . . . . . 17
TRECATOR. . . . . . . . . . . . . . . 13
TRELSTAR DEP INJ 3.75MG . . 18
TRELSTAR LA INJ 11.25MG. . . 18
tretinoin. . . . . . . . . . . . . . . . . 59
tretinoin (chemotherapy). . . . 20
tri-legest 28 day. . . . . . . . . . . 41
tri-previfem 28 day. . . . . . . . . 41
tri-sprintec 28 day. . . . . . . . . 41
triamcinolone acetonide
(mouth) . . . . . . . . . . . . . . 62
triamcinolone acetonide
(topical). . . . . . . . . . . . . . 61
triamterene &
hydrochlorothiazide. . . . . 26
triamterene &
hydrochlorothiazide cap
37.5-25 mg. . . . . . . . . . . . . 26
TRIBENZOR TAB 20-5-12.5MG.22
TRIBENZOR TAB 40-10-12.5. . 22
TRIBENZOR TAB 40-5-12.5MG.22
TRIBENZOR TAB 40-5-25MG . 22
TRIBENZOR40- TAB 10-25MG.22
triderm . . . . . . . . . . . . . . . . . 61
trifluoperazine hcl. . . . . . . . . 34
trifluridine. . . . . . . . . . . . . . . 55
trilyte. . . . . . . . . . . . . . . . . . . 46
trimethoprim. . . . . . . . . . . . . 10
TRINESSA . . . . . . . . . . . . . . . 41
TRISENOX. . . . . . . . . . . . . . . 20
TRIUMEQ . . . . . . . . . . . . . . . 12
trivora 28 day . . . . . . . . . . . . 41
TROPHAMINE INJ 10% . . . . . 53
trospium chloride . . . . . . . . . 47
TRUVADA. . . . . . . . . . . . . . . . 12
TUDORZA PRESSAIR. . . . . . . 57
TWINRIX INJ. . . . . . . . . . . . . 51
TYBOST. . . . . . . . . . . . . . . . . 12
TYGACIL . . . . . . . . . . . . . . . . 10
TYKERB. . . . . . . . . . . . . . . . . 19
TYPHIM VI. . . . . . . . . . . . . . . 51
TYSABRI . . . . . . . . . . . . . . . . 36
75
INDEX OF DRUGS LISTED IN FORMULARY
TYZEKA. . . . . . . . . . . . . . . . . 14
U
UCERIS . . . . . . . . . . . . . . . . . 45
ULORIC. . . . . . . . . . . . . . . . . . 7
UNITHROID . . . . . . . . . . . . . 44
ursodiol. . . . . . . . . . . . . . . . . 46
V
VAGIFEM. . . . . . . . . . . . . . . . 41
valacyclovir hcl. . . . . . . . . . . 14
VALCHLOR. . . . . . . . . . . . . . . 61
VALCYTE. . . . . . . . . . . . . . . . 14
valproate sodium. . . . . . . . . . 29
valproic acid. . . . . . . . . . . . . 29
valsartan. . . . . . . . . . . . . . . . 22
valsartan & hctz tab 16012.5mg . . . . . . . . . . . . . . . 22
valsartan & hctz tab 160-25mg.22
valsartan & hctz tab 32012.5mg . . . . . . . . . . . . . . . 22
valsartan & hctz tab
320-25mg . . . . . . . . . . . . . 22
valsartan & hctz tab
80-12.5mg. . . . . . . . . . . . . 22
vancomycin hcl. . . . . . . . . . . 10
VANDAZOLE . . . . . . . . . . . . . 47
VAQTA. . . . . . . . . . . . . . . . . . 51
VARIVAX . . . . . . . . . . . . . . . . 51
VASCEPA . . . . . . . . . . . . . . . . 23
VELCADE. . . . . . . . . . . . . . . . 18
velivet 28 day. . . . . . . . . . . . . 41
venlafaxine hcl . . . . . . . . . 31, 32
VENTAVIS . . . . . . . . . . . . . . . 27
verapamil cap er. . . . . . . . . . 25
VERAPAMIL CAP ER. . . . . . . . 25
verapamil hcl. . . . . . . . . . . . . 25
verapamil tab er . . . . . . . . . . 25
VERSACLOZ. . . . . . . . . . . . . . 34
VESICARE . . . . . . . . . . . . . . . 47
vestura. . . . . . . . . . . . . . . . . . 41
VIBRAMYCIN. . . . . . . . . . . . . 16
VICTOZA. . . . . . . . . . . . . . . . 37
VICTRELIS. . . . . . . . . . . . . . . 14
VIDEX PEDIATRIC. . . . . . . . . 12
VIGAMOX . . . . . . . . . . . . . . . 55
VIIBRYD. . . . . . . . . . . . . . . . . 32
VIMPAT . . . . . . . . . . . . . . . . . 29
76
vinblastine sulfate. . . . . . . . . 18
vincasar. . . . . . . . . . . . . . . . . 18
vincristine sulfate . . . . . . . . . 18
vinorelbine tartrate. . . . . . . . 18
viorele. . . . . . . . . . . . . . . . . . 41
VIRACEPT . . . . . . . . . . . . . . . 12
VIRAMUNE XR. . . . . . . . . . . . 12
VIREAD. . . . . . . . . . . . . . . . . 12
VOLTAREN. . . . . . . . . . . . . . . 61
voriconazole. . . . . . . . . . . . . 11
VOTRIENT. . . . . . . . . . . . . . . 19
vyfemia 28 day. . . . . . . . . . . . 41
W
warfarin sodium. . . . . . . . . . 48
WELCHOL. . . . . . . . . . . . . . . 23
X
XALKORI. . . . . . . . . . . . . . . . 19
XARELTO. . . . . . . . . . . . . . . . 48
XARELTO STARTER PACK . . . 48
XENAZINE. . . . . . . . . . . . . . . 35
XGEVA. . . . . . . . . . . . . . . . . . 43
XIFAXAN. . . . . . . . . . . . . . . . 46
XOLAIR . . . . . . . . . . . . . . . . . 58
XOPENEX HFA. . . . . . . . . . . . 57
XTANDI. . . . . . . . . . . . . . . . . 18
xulane. . . . . . . . . . . . . . . . . . 41
XYREM . . . . . . . . . . . . . . . . . 36
zoledronic inj 4mg/5ml. . . . . 38
ZOLINZA. . . . . . . . . . . . . . . . 18
zolmitriptan. . . . . . . . . . . . . . 35
zolmitriptan odt. . . . . . . . . . . 35
zolpidem tartrate. . . . . . . . . . 35
ZOMETA . . . . . . . . . . . . . . . . 38
zonisamide . . . . . . . . . . . . . . 29
ZONTIVITY. . . . . . . . . . . . . . 49
ZORTRESS TAB 0.25MG. . . . . 50
ZORTRESS TAB 0.5MG. . . . . . 50
ZORTRESS TAB 0.75MG. . . . . 50
ZOSTAVAX. . . . . . . . . . . . . . . 51
ZYDELIG. . . . . . . . . . . . . . . . 19
ZYKADIA. . . . . . . . . . . . . . . . 19
ZYLET . . . . . . . . . . . . . . . . . . 55
ZYTIGA . . . . . . . . . . . . . . . . . 18
ZYVOX. . . . . . . . . . . . . . . . . . 10
Y
YF-VAX. . . . . . . . . . . . . . . . . . 51
Z
zafirlukast. . . . . . . . . . . . . . . 57
zarah. . . . . . . . . . . . . . . . . . . 41
ZAVESCA. . . . . . . . . . . . . . . . 41
zazole . . . . . . . . . . . . . . . . . . 47
ZAZOLE. . . . . . . . . . . . . . . . . 47
ZELBORAF. . . . . . . . . . . . . . . 19
ZEMAIRA. . . . . . . . . . . . . . . . 58
zenatane. . . . . . . . . . . . . . . . 59
zenchent 28 day. . . . . . . . . . . 41
ZENPEP. . . . . . . . . . . . . . . . . 46
ZETIA TAB 10MG. . . . . . . . . . 23
ZIAGEN. . . . . . . . . . . . . . . . . 12
zidovudine . . . . . . . . . . . . . . 12
ziprasidone hcl . . . . . . . . . . . 34
ZMAX. . . . . . . . . . . . . . . . . . . 15
2015 SELECT (PPO) PLAN FORMULARY
INDEX OF DRUGS LISTED IN FORMULARY
Martin’s Point Generations, LLC is a health plan with a Medicare
contract offering HMO, HMO-POS, and PPO products. Enrollment in
a Martin’s Point Generations, LLC plan depends on contract renewal.
The benefit information provided is a brief summary, not a complete
description of benefits. For more information contact the plan.
Limitations, copayments and restrictions may apply. Benefits,
formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year. Martin’s Point
Generations Advantage Select covers both brand name drugs and
generic drugs. A generic drug is approved by the FDA as having the
same active ingredient as the brand name drug.
This document is available in other formats such as Braille and large
print. For more information contact our Member Engagement team.
This formulary was updated on 12/18/2014. For more recent
information or other questions, please contact Martin’s Point
Generations Advantage Select Member Engagement at
1-866-544-7504 or, for TTY users, 711. We’re available 8 am to 8 pm,
seven days a week, from October 1 to February 14. From February 14
to September 30, we are available Monday through Friday from 8 am
to 8 pm. Or visit www.MartinsPoint.org/medicare.
H1365_2015_340 2015 SELECT (PPO) PLAN FORMULARY
Accepted: 10/7/2014
77

2015 Comprehensive Formulary

MyPBX U300 Datasheet

Edition 42: Summary of Changes – January 28, 2015

Mulan Papercraft

procurement of various iv antibiotics and nebulizing solutions

fee schedule

Value Based Drug Formulary

Optional Dental Benefits

RB Newsletter February 2015 2-3-15.indd

TriCom GUARDSCAN Visitor Mgt. and Business to Business Visitor

2015 Aetna Three Tier Individual Open (NJ) Formulary