Providence prescription drug coverage
Providence Health Plan wants to help you to make the most of your prescription drug coverage.
That’s why we strive to provide you with the information you need to make smart decisions about
medications.
Know more, save more
We encourage you to be knowledgeable about your prescription drug benefits. Information is
available on your benefit summary, in your member handbook and on the Providence Health Plan
website.
When you require a prescription, be sure to let your doctor know cost matters to you. Choosing a
generic when possible can help manage your costs.
Retail pharmacies
You have access to more than 25,000 participating pharmacies nationwide at discounted rates.
Search the provider directory to locate participating pharmacies near you.
Maintenance drugs
Maintenance medications are those typically prescribed to treat long-term or chronic conditions,
such as diabetes, high blood pressure and high cholesterol. A 90-day supply of maintenance
medication is available through participating mail-order pharmacies, as well as through preferred
retail pharmacies. Your 90-day supply copay or coinsurance applies. Not all covered prescription
drugs are available in a 90-day supply.
Learn more about mail-order pharmacies and preferred retail pharmacies.
Specialty drugs
Specialty drugs are prescriptions that require special delivery, handling, administration and
monitoring by your pharmacist. These drugs are listed in the Providence formulary with a status of
“Specialty,” and are available through Providence Specialty Pharmacy Services.
Learn more about specialty drugs.
Generic drugs
Making the switch from brand to generic medication can save you money. Generic drugs, which are
available only after the brand-name patent expires:
•
•
Have the same active ingredient formula as the brand-name drug and
Are tested by the Food and Drug Administration (FDA) to be as safe and effective as the
brand-name drug.
There are two types of generic drugs:
•
Generic equivalent - A generic equivalent is a generic drug that has the same active
ingredient, dosage form and strength as its brand-name counterpart. The FDA assures
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sameness between brand-name and generic equivalent products. Generic equivalents are an
important option to brand-name prescription drugs because they cost less.
Example: Zocor®, a brand-name drug commonly used to treat high cholesterol, is now
available in generic form under the name simvastatin. Zocor® and simvastatin are identical
drugs – the only difference is that one costs more than the other.
•
Generic alternative - A generic alternative is a generic drug used to treat the same
condition as a brand-name drug. It is not, however, the exact same medication as the brandname drug. According to clinical evidence, a generic alternative can be expected to treat the
same condition as well as the brand-name option.
Example: Simvastatin, the generic form of Zocor®, may be prescribed instead of Crestor® in
the treatment of high cholesterol. Generic alternatives are an important option for
prescription drugs for which there is no generic available.
Visit the Consumer Reports Best-Buy Drug website for more information regarding safe and effective
drug treatment options.
The Providence formulary
Your prescription drug plan provides coverage for medications listed on the Providence formulary.
Developed in collaboration with Providence Health Plans, physicians and pharmacists, the formulary
includes FDA-approved prescription generic, brand-name and specialty medications. The formulary
can help you and your physician choose effective, quality medications that minimize your out-ofpocket expense.
Search the formulary
There are two ways to search the formulary. They include:
1. By medical condition category (e.g., drugs used to treat heart conditions are listed under the
category, Cardiovascular Agents); and
2. By index (provides an alphabetical listing of drugs included in the formulary).
Formulary updates
The formulary is updated every two months. Providence’s Oregon Regional Pharmacy and
Therapeutics committee (comprised of doctors and pharmacists who practice in the communities we
serve) continuously reviews the latest evidence to identify opportunities to promote safe, effective
and affordable drug therapy. Generally, the formulary status of a drug covered by your Providence
Health Plan prescription drug coverage will not change during the year unless:
•
•
•
The medication becomes available in generic form;
There are safety or effectiveness concerns raised about the prescription drug; or
The Pharmacy and Therapeutics committee determines that changes to the formulary would
be in the best overall interest of Providence Health Plan members.
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If a change to the formulary results in a reduction of benefits or an increase in member copay,
affected individuals are notified in writing.
Formulary brand-name drugs
The Providence formulary includes prescription drugs that are proven safe, effective and that offer
value. Refer to your benefit summary for your brand-name drug copay or coinsurance amount.
Remember, even if a generic equivalent is not yet available, safe and effective generic alternatives may
be available to treat most common conditions. Using these options can provide cost savings.
Non-approved drugs
Your prescription drug benefit covers only FDA-approved prescription drugs. It is possible for
medications to be on the market without FDA approval. The FDA is taking action to ensure these
drugs become approved or are removed from the market. In the meantime, many remain on
pharmacy shelves. If the drug you are taking is not FDA approved, know that there are likely
approved prescription drugs available to treat your condition. We encourage you to discuss
alternative medications with your doctor. Should you and your doctor determine that there is no
covered alternative and you choose to continue to take a medication that is not FDA approved, your
health plan will not cover that expense.
More information regarding medications that are not FDA approved can be found on our website,
in the related article and in the FAQ document, which includes links to the FDA website. You may
also call the Providence Health Plan pharmacy team for more information and to discuss potential
alternatives.
Prior authorization
Prior authorization is a process to review a prescription drug for coverage before it is dispensed. The
prior authorization process is initiated by the prescribing medical provider.
Many factors – including the potential for serious health risks, FDA-approved indications and costeffectiveness – are considered before making the decision to require prior authorization of a
prescription medication. A limited number of medications require prior authorization review; any
medications requiring prior authorization are indicated as such in the Providence formulary.
Keep in mind, the formulary may contain other suitable options. You and your doctor may wish to
discuss the possibility of changing your prescription to an effective formulary alternative. Otherwise,
your doctor may submit a prior authorization request on your behalf.
Formulary exceptions
There may be times that you require a medication that is not on the Providence formulary. If you
currently take a prescription drug that is not on the formulary, contact customer service to confirm
that drug is not covered. If the prescription drug is not covered, your doctor may request a formulary
exception.
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Step therapy
Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered
"first-line" therapy based on clinical evidence already have been tried. If they have, the drug
requiring prior authorization will automatically be approved. In the event these drugs are not tried
first, cannot be tried first or the individual’s prescription medication history is not part of Providence
Health Plan claims history, prior authorization is required.
Quantity limit
For certain drugs, Providence Health Plan limits the amount of the drug covered for a specified
time frame [e.g., Providence Health Plan provides two inhalers per 30 days for Proair® or
Proventil® HFA (albuterol HFA)]. Quantity limits are in place to ensure safe and appropriate use of a
drug.
Answers to frequently asked questions
Learn more about your prescription drug coverage by reviewing answers to frequently asked
questions.
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Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Analgesics
alagesic lq
Generic
butalbital/acetaminophen
Generic
butalbital/acetaminophen/caffeine (50325-40 capsule, 50-325-40 tablet, 50500-40 tablet)
Generic
butalbital/aspirin/caffeine
Generic
capacet
Generic
fioricet 50-325-40 mg tablet
Generic
tencon 50-325 mg tablet
Generic
tramadol hcl/acetaminophen
Generic
QL (240 PER 30 DAYS)
celecoxib (50 mg capsule, 100 mg
capsule, 200 mg capsule)
Generic
PA, QL (60 PER 30 DAYS)
celecoxib 400 mg capsule
Generic
PA, QL (30 PER 30 DAYS)
diclofenac potassium
Generic
diclofenac sodium (25 mg tablet dr, 50
mg tablet dr, 75 mg tablet dr, 100 mg
tab er 24h)
Generic
diflunisal
Generic
etodolac (200 mg capsule, 300 mg
capsule, 400 mg tab er 24h, 400 mg
tablet, 500 mg tab er 24h, 500 mg
tablet, 600 mg tab er 24h)
Generic
fenoprofen calcium 600 mg tablet
Generic
flurbiprofen (50 mg tablet, 100 mg
tablet)
Generic
ibuprofen (400 mg tablet, 600 mg
tablet, 800 mg tablet)
Generic
ibuprofen/oxycodone hcl
Generic
indomethacin (25 mg capsule, 50 mg
capsule, 75 mg capsule er)
Generic
Nonsteroidal Anti-inflammatory Drugs
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
5
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ketoprofen (50 mg capsule, 75 mg
capsule, 200 mg cap24h pel)
Generic
ketorolac tromethamine 10 mg tablet
Generic
meclofenamate sodium (50 mg capsule,
100 mg capsule)
Generic
meloxicam (7.5 mg tablet, 7.5 mg/5ml
oral susp, 15 mg tablet)
Generic
nabumetone (500 mg tablet, 750 mg
tablet)
Generic
NAPRELAN CR 500 MG TABLET
BRAND
naproxen (125 mg/5ml oral susp, 250
mg tablet, 375 mg tablet, 375 mg tablet
dr, 500 mg tablet, 500 mg tablet dr)
Generic
naproxen sodium (275 mg tablet, 550
mg tablet)
Generic
oxaprozin
Generic
piroxicam (10 mg capsule, 20 mg
capsule)
Generic
sulindac (150 mg tablet, 200 mg tablet)
Generic
tolmetin sodium
Generic
Requirements/Limits
Opioid Analgesics, Long-acting
fentanyl (12 mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr, 100 mcg/hr)
Generic
levorphanol tartrate 2 mg tablet
Generic
methadone hcl (5 mg tablet, 5 mg/5 ml
solution, 10 mg tablet, 10 mg/5 ml
solution, 10 mg/ml oral conc, 40 mg
tablet sol)
Generic
methadone intensol
Generic
methadose 40 mg tablet dispr
Generic
morphine sulfate (5 mg supp.rect, 10
mg supp.rect, 15 mg tablet er, 20 mg
supp.rect, 30 mg supp.rect, 30 mg
tablet er, 60 mg tablet er, 100 mg
tablet er, 200 mg tablet er)
Generic
QL (15 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
6
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
oxycodone hcl (10 mg tab er, 20 mg tab
er, 40 mg tab er, 80 mg tab er)
Generic
PA, QL (90 PER 30 DAYS)
OXYCONTIN (15 MG TABLET, 30 MG
TABLET, 60 MG TABLET)
BRAND
PA, QL (90 PER 30 DAYS)
tramadol hcl (100 mg tab er 24h, 100
mg tbmp 24hr, 200 mg tab er 24h, 200
mg tbmp 24hr, 300 mg tab er 24h, 300
mg tbmp 24hr)
Generic
Opioid Analgesics, Short-acting
acetaminophen with codeine phosphate
(120-12mg/5 solution, 240-24/10
solution, 300mg-15mg tablet, 300mg30mg tablet, 300mg-60mg tablet,
300mg/12.5 solution, 360-36/15
solution)
Generic
ascomp with codeine
Generic
butalbit/acetamin/caff/codeine 50-32530 capsule
Generic
butorphanol tartrate 10 mg/ml spray
Generic
co-gesic
Generic
codeine
phosphate/butalbital/aspirin/caffeine
Generic
codeine phosphate/carisoprodol/aspirin
Generic
codeine sulfate (15 mg tablet, 30 mg
tablet, 60 mg tablet)
Generic
dihydrocodeine
bitartrate/acetaminophen/caffeine
Generic
endocet (5-325 tablet, 7.5-325 mg
tablet, 7.5-500 mg tablet, 10-325 mg
tablet, 10-650 mg tablet)
Generic
endodan
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
7
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
hydrocodone bitartrate/acetaminophen
(2.5-167/5 solution, 2.5-500 mg tablet,
5 mg-500mg tablet, 5-334mg/10
solution, 5mg-325mg tablet, 7.5-325/15
solution, 7.5-325mg tablet, 7.5-500/15
solution, 7.5-500mg tablet, 7.5-650 mg
tablet, 7.5-750mg tablet, 10-660mg
tablet, 10-750mg tablet, 10mg-325mg
tablet, 10mg-500mg tablet, 10mg650mg tablet)
Generic
hydrocodone/ibuprofen
Generic
hydromorphone hcl (1 mg/ml liquid, 2
mg tablet, 3 mg supp.rect, 4 mg tablet,
8 mg tablet)
Generic
ibudone 5-200 mg tablet
Generic
lorcet
Generic
lorcet hd
Generic
lorcet plus 7.5-325 mg tablet
Generic
lortab (5-325 mg tablet, 5-500 tablet,
7.5-325 mg tablet, 10-325 mg tablet)
Generic
meperidine hcl (50 mg tablet, 100 mg
tablet)
Generic
meperitab
Generic
morphine sulfate (10 mg/5 ml solution,
15 mg tablet, 20 mg/5 ml solution, 30
mg tablet, 100 mg/5ml solution)
Generic
oxycodone hcl (5 mg capsule, 5 mg
tablet, 5 mg/5 ml solution, 10 mg
tablet, 15 mg tablet, 20 mg tablet, 20
mg/ml oral conc, 30 mg tablet)
Generic
oxycodone hcl/acetaminophen (5 mg500mg capsule, 5mg-325mg tablet, 7.5325mg tablet, 7.5-500mg tablet, 10mg325mg tablet, 10mg-650mg tablet)
Generic
oxycodone hcl/aspirin
Generic
oxymorphone hcl (5 mg tablet, 10 mg
tablet)
Generic
Requirements/Limits
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
8
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
reprexain 10-200 mg tablet
Generic
ROXICET 5-325 ORAL SOLUTION
BRAND
roxicet 5-325 tablet
Generic
stagesic
Generic
tramadol hcl 50 mg tablet
Generic
xylon 10
Generic
Requirements/Limits
Anesthetics
Local Anesthetics
glydo
Generic
lidocaine 5 % oint. (g)
Generic
lidocaine 5%(700mg) adh. patch
Generic
lidocaine hcl (2 % jel (ml), 2 % jel/pf
app, 2 % solution, 4 % solution, 40
mg/ml solution)
Generic
lidocaine/prilocaine (2.5 %-2.5% cream
(g), 2.5 %-2.5% kit)
Generic
PA, QL (90 PER 30 DAYS)
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium
Generic
disulfiram (250 mg tablet, 500 mg
tablet)
Generic
buprenorphine hcl/naloxone hcl
Generic
SUBOXONE (2 MG-0.5 MG, 8 MG-2 MG)
BRAND
Opioid Antagonists
buprenorphine hcl (2 mg tab, 8 mg tab)
Generic
depade
Generic
naltrexone hcl 50 mg tablet
Generic
QL (90 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
9
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
revia
Generic
Requirements/Limits
Smoking Cessation Agents
BUPROBAN
Value
CHANTIX
BRAND
Anti-inflammatory Agents
Glucocorticoids
alclometasone dipropionate
Generic
amcinonide 0.1 % cream (g)
Generic
apexicon e
Generic
betamethasone dipropionate (0.05 %
cream (g), 0.05 % gel (gram), 0.05 %
lotion, 0.05 % oint. (g))
Generic
betamethasone dipropionate/propylene
glycol (0.05 % cream (g), 0.05 % lotion,
0.05 % oint. (g))
Generic
betamethasone valerate (0.1 % cream
(g), 0.1 % lotion, 0.1 % oint. (g))
Generic
clobetasol propionate (0.05 % cream
(g), 0.05 % foam, 0.05 % gel (gram),
0.05 % oint. (g), 0.05 % shampoo, 0.05
% solution)
Generic
clobetasol propionate/emoll 0.05 %
cream (g)
Generic
clobetasol propionate/emoll 0.05 %
foam
Generic
clodan 0.05% shampoo
Generic
cormax
Generic
cortisone acetate 25 mg tablet
Generic
desonide (0.05 % cream (g), 0.05 %
lotion, 0.05 % oint. (g))
Generic
desoximetasone
Generic
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
10
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
diflorasone diacetate
Generic
fludrocortisone acetate 0.1 mg tablet
Generic
fluocinolone acetonide (0.01 % cream
(g), 0.01 % solution, 0.025 % cream (g),
0.025 % oint. (g))
Generic
fluocinonide (0.05 % cream (g), 0.05 %
gel (gram), 0.05 % oint. (g), 0.05 %
solution)
Generic
fluocinonide/emollient base
Generic
fluticasone propionate (0.005 % oint.
(g), 0.05 % cream (g), 0.05 % lotion)
Generic
halobetasol propionate
Generic
hydrocortisone (2.5 % cream (g), 2.5 %
lotion, 2.5 % oint. (g))
Generic
hydrocortisone butyrate 0.1 % cream
(g)
Generic
millipred 5 mg tablet
Generic
millipred dp
Generic
nystatin/triamcinolone acetonide
Generic
oralone
Generic
prednisolone 15 mg/5 ml solution
Generic
prednisolone sod phosphate (5 mg/5 ml
solution, 10 mg tab rapdis, 15 mg tab
rapdis, 15 mg/5 ml solution, 30 mg tab
rapdis)
Generic
prednisone (1 mg tablet, 2.5 mg tablet,
5 mg tab ds pk, 5 mg tablet, 5 mg/5 ml
solution, 10 mg tab ds pk, 10 mg tablet,
20 mg tablet, 50 mg tablet)
Generic
prednisone intensol
Generic
triamcinolone acetonide (0.025 %
cream (g), 0.025 % lotion, 0.025 % oint.
(g), 0.1 % cream (g), 0.1 % lotion, 0.1 %
oint. (g), 0.1 % paste (g), 0.5 % cream
(g), 0.5 % oint. (g))
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
11
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
triderm
Generic
Requirements/Limits
Antibacterials
Aminoglycosides
garamycin 0.3% eye drops
Generic
gentak (0.3 % ointment, 3 mg/ml drops)
Generic
gentamicin sulfate (0.1 % cream (g), 0.1
% oint. (g), 0.3 % drops, 0.3 % oint. (g))
Generic
neomycin sulfate 500 mg tablet
Generic
TOBI PODHALER
Specialty
tobramycin 0.3 % drops
Generic
tobramycin in 0.225 % sodium chloride
Generic
TOBREX 0.3% EYE OINTMENT
BRAND
LA
Antibacterials, Other
acetasol hc
Generic
acetic acid/aluminum acetate
Generic
acetic acid/hydrocortisone
Generic
bacitracin 500 unit/g oint. (g)
Generic
chlorhexidine gluconate 0.12 %
mouthwash
Generic
clinda-derm
Generic
clindacin etz 1% pledget
Generic
clindacin p
Generic
clindamycin hcl (75 mg capsule, 150 mg
capsule, 300 mg capsule)
Generic
clindamycin palmitate hcl
Generic
clindamycin phosphate (1 % foam, 1 %
gel (gram), 1 % lotion, 1 % med. swab, 1
% solution, 2 % cream/appl)
Generic
cycloserine 250 mg capsule
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
12
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
methenamine hippurate
Generic
metronidazole (0.75 % cream (g), 0.75
% gel (gram))
Generic
metronidazole (0.75 % gel w/appl, 0.75
% lotion, 250 mg tablet, 375 mg
capsule, 500 mg tablet)
Generic
MONUROL
BRAND
mupirocin 2 % oint. (g)
Generic
nitrofurantoin 25 mg/5 ml oral susp
Generic
nitrofurantoin macrocrystal (50 mg
capsule, 100 mg capsule)
Generic
nitrofurantoin
monohydrate/macrocrystals
Generic
paroex
Generic
periogard
Generic
rosadan (0.75% cream, 0.75% gel)
Generic
trimethoprim 100 mg tablet
Generic
vancomycin hcl (125 mg capsule, 250
mg capsule)
Generic
vandazole
Generic
vitazol
Generic
PA
XIFAXAN 200 MG TABLET
BRAND
PA, QL (90 PER 30 DAYS)
XIFAXAN 550 MG TABLET
BRAND
PA, QL (60 PER 30 DAYS)
ZYVOX (100 MG/5 ML SUSPENSION,
600 MG TABLET)
BRAND
PA
PA
Beta-lactam, Cephalosporins
cefaclor (125 mg/5ml susp recon, 250
mg capsule, 250 mg/5ml susp recon,
375 mg/5ml susp recon, 500 mg
capsule)
Generic
cefadroxil (1 g tablet, 250 mg/5ml susp
recon, 500 mg capsule, 500 mg/5ml
susp recon)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
13
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
cefdinir (125 mg/5ml susp recon, 250
mg/5ml susp recon, 300 mg capsule)
Generic
cefpodoxime proxetil (50 mg/5 ml susp
recon, 100 mg tablet, 100 mg/5ml susp
recon, 200 mg tablet)
Generic
cefprozil (125 mg/5ml susp recon, 250
mg tablet, 250 mg/5ml susp recon, 500
mg tablet)
Generic
ceftibuten dihydrate (180 mg/5ml susp
recon, 400 mg capsule)
Generic
CEFTIN (125 ML, 250 ML)
BRAND
cefuroxime axetil
Generic
cephalexin (125 mg/5ml susp recon,
250 mg capsule, 250 mg tablet, 250
mg/5ml susp recon, 500 mg capsule,
500 mg tablet)
Generic
Requirements/Limits
Beta-lactam, Penicillins
amoxicillin (125 mg tab chew, 125
mg/5ml susp recon, 200 mg/5ml susp
recon, 250 mg capsule, 250 mg tab
chew, 250 mg/5ml susp recon, 400 mg
tab chew, 400 mg/5ml susp recon, 500
mg capsule, 500 mg tablet, 875 mg
tablet)
Generic
amoxicillin/potassium clavulanate (20028.5/5 susp recon, 200-28.5mg tab
chew, 250-125 mg tablet, 250-62.5/5
susp recon, 400-57mg tab chew, 40057mg/5 susp recon, 500-125 mg tablet,
600-42.9/5 susp recon, 875-125 mg
tablet, 1000-62.5 tab er 12h)
Generic
ampicillin trihydrate (250 mg capsule,
500 mg capsule)
Generic
dicloxacillin sodium
Generic
penicillin v potassium (125 mg/5ml soln
recon, 250 mg tablet, 250 mg/5ml soln
recon, 500 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
14
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Macrolides
AZASITE
BRAND
azithromycin (1 g packet, 100 mg/5ml
susp recon, 200 mg/5ml susp recon, 250
mg tablet, 500 mg tablet, 600 mg
tablet)
Generic
clarithromycin (125 mg/5ml susp recon,
250 mg tablet, 250 mg/5ml susp recon,
500 mg tab er 24h, 500 mg tablet)
Generic
E.E.S. 200
BRAND
ERY-TAB
BRAND
erygel
Generic
ERYPED 200
BRAND
erythromycin base (5 mg/g oint. (g),
250 mg capsule dr, 250 mg tablet, 500
mg tablet)
Generic
erythromycin base/ethyl alcohol (2 %
gel (gram), 2 % solution)
Generic
erythromycin ethylsuccinate 400 mg
tablet
Generic
erythromycin
ethylsuccinate/sulfisoxazole acetyl
Generic
Quinolones
ciprofloxacin hcl (0.3 % drops, 100 mg
tablet, 250 mg tablet, 500 mg tablet,
750 mg tablet)
Generic
ciprofloxacin/ciprofloxa hcl 500 mg
tbmp 24hr
Generic
levofloxacin (0.5 % drops, 250 mg
tablet, 250mg/10ml solution, 500 mg
tablet, 750 mg tablet)
Generic
moxifloxacin hcl 400 mg tablet
Generic
ofloxacin (0.3 % drops, 200 mg tablet,
300 mg tablet, 400 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
15
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Sulfonamides
bleph-10
Generic
silver sulfadiazine 1 % cream (g)
Generic
sulfacetamide sodium (10 % drops, 10 %
suspension)
Generic
sulfadiazine 500 mg tablet
Generic
sulfamethoxazole/trimethoprim (20040mg/5 oral susp, 400mg-80mg tablet,
800-160 mg tablet, 800-160/20 oral
susp)
Generic
sulfamide
Generic
Tetracyclines
avidoxy
Generic
demeclocycline hcl (150 mg tablet, 300
mg tablet)
Generic
doxycycline hyclate (20 mg tablet, 50
mg capsule, 100 mg capsule, 100 mg
tablet)
Generic
doxycycline monohydrate (50 mg
capsule, 50 mg tablet, 75 mg tablet,
100 mg capsule, 100 mg tablet, 150 mg
tablet)
Generic
dynacin 100 mg tablet
Generic
minocycline hcl (50 mg capsule, 75 mg
capsule, 100 mg capsule, 100 mg
tablet)
Generic
morgidox 100 mg capsule
Generic
OCUDOX
BRAND
tetracycline hcl (250 mg capsule, 500
mg capsule)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
16
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Anticonvulsants
Anticonvulsants, Other
acetazolamide (125 mg tablet, 250 mg
tablet)
Generic
levetiracetam (100 mg/ml solution, 250
mg tablet, 500 mg tablet, 500 mg/5ml
solution, 750 mg tablet, 1000 mg
tablet)
Generic
primidone (50 mg tablet, 250 mg tablet)
Generic
Calcium Channel Modifying Agents
CELONTIN
BRAND
ethosuximide (250 mg capsule, 250
mg/5ml solution)
Generic
LYRICA (20 MG/ML ORAL SOLUTION, 25
MG CAPSULE, 50 MG CAPSULE, 75 MG
CAPSULE, 100 MG CAPSULE, 150 MG
CAPSULE, 200 MG CAPSULE, 225 MG
CAPSULE, 300 MG CAPSULE)
BRAND
zonisamide
Generic
PA
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam (0.125 mg tab rapdis, 0.25
mg tab rapdis, 0.5 mg tab rapdis, 0.5
mg tablet, 1 mg tab rapdis, 1 mg tablet,
2 mg tab rapdis, 2 mg tablet)
Generic
clorazepate dipotassium
Generic
DIASTAT
BRAND
diazepam (2 mg tablet, 5 mg tablet, 5
mg/5 ml solution, 5-7.5-10mg kit, 10
mg tablet, 12.5-15-20 kit)
Generic
diazepam 2.5 mg kit
BRAND
divalproex sodium
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
17
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
gabapentin (100 mg capsule, 250
mg/5ml solution, 300 mg capsule, 400
mg capsule, 600 mg tablet, 800 mg
tablet)
Generic
GABITRIL (12 MG TABLET, 16 MG
TABLET)
BRAND
lorazepam (0.5 mg tablet, 1 mg tablet,
2 mg tablet, 2 mg/ml oral conc)
Generic
lorazepam intensol
Generic
ONFI (5 MG TABLET, 10 MG TABLET, 20
MG TABLET)
BRAND
PA, QL (60 PER 30 DAYS)
ONFI 2.5 MG/ML SUSPENSION
BRAND
PA
phenobarbital (15 mg tablet, 16.2 mg
tablet, 20 mg/5 ml elixir, 30 mg tablet,
32.4 mg tablet, 60 mg tablet, 64.8 mg
tablet, 97.2mg tablet, 100 mg tablet)
Generic
SABRIL
BRAND
tiagabine hcl
Generic
valproic acid (as sodium salt) (valproate
sodium) (250 mg/5ml solution, 500
mg/5ml vial, 500mg/10ml solution)
Generic
valproic acid 250 mg capsule
Generic
LA
Glutamate Reducing Agents
felbamate (400 mg tablet, 600 mg
tablet, 600 mg/5ml oral susp)
Generic
lamotrigine (5 mg tb chw dsp, 25 mg
tablet, 25 mg tb chw dsp, 25mg (35) tab
ds pk, 100 mg tablet, 150 mg tablet,
200 mg tablet)
Generic
QUDEXY XR 200 MG CAPSULE
BRAND
topiragen
Generic
topiramate (15 mg cap sprink, 25 mg
cap sprink, 25 mg tablet, 50 mg tablet,
100 mg tablet, 200 mg tablet)
Generic
topiramate (25 mg cap 24, 50 mg cap
24, 100 mg cap 24, 150 mg cap 24)
Generic
PA
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
18
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
topiramate 200 mg cap spr 24
BRAND
PA
APTIOM
BRAND
PA
BANZEL (40 MG/ML SUSPENSION, 200
MG TABLET, 400 MG TABLET)
BRAND
PA
carbamazepine (100 mg cpmp 12hr,
100 mg tab chew, 100 mg/5ml oral
susp, 200 mg cpmp 12hr, 200 mg tab er
12h, 200 mg tablet, 300 mg cpmp 12hr,
400 mg tab er 12h)
Generic
DILANTIN 30 MG CAPSULE
BRAND
epitol
Generic
EQUETRO
BRAND
oxcarbazepine (150 mg tablet, 300 mg
tablet, 300 mg/5ml oral susp, 600 mg
tablet)
Generic
phenytoin (50 mg tab chew, 100
mg/4ml oral susp, 125 mg/5ml oral
susp)
Generic
phenytoin sodium extended (100 mg
capsule, 200 mg capsule)
Generic
VIMPAT (10 MG/ML SOLUTION, 50 MG
TABLET, 100 MG TABLET, 150 MG
TABLET, 200 MG TABLET)
BRAND
ziprasidone hcl 20 mg capsule
Generic
Sodium Channel Agents
PA
Antidementia Agents
Cholinesterase Inhibitors
donepezil hcl (5 mg tab rapdis, 5 mg
tablet, 10 mg tab rapdis, 10 mg tablet)
Generic
EXELON (2 MG/ML ORAL SOLUTION, 4.6
MG/24HR PATCH, 9.5 MG/24HR PATCH,
13.3 MG/24HR PATCH)
BRAND
rivastigmine tartrate
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
19
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA (5 MG TABLET, 5-10 MG
TITRATION PK, 10 MG TABLET)
BRAND
PA, QL (60 PER 30 DAYS)
NAMENDA 10 MG/5 ML SOLUTION
BRAND
PA, QL (360 ML PER 30 DAYS)
Antidepressants
Antidepressants, Other
ABILIFY (1 MG/ML SOLUTION, 2 MG
TABLET, 5 MG TABLET, 10 MG TABLET,
15 MG TABLET, 20 MG TABLET, 30 MG
TABLET)
BRAND
ABILIFY DISCMELT
BRAND
BUDEPRION SR
Value
BUDEPRION XL
Value
bupropion hcl (75 mg tablet, 100 mg
tablet, 100 mg tablet er, 150 mg tab er
24h, 150 mg tablet er, 200 mg tablet er,
300 mg tab er 24h)
Value
maprotiline hcl 75 mg tablet
Value
mirtazapine (15 mg tab rapdis, 30 mg
tab rapdis, 45 mg tab rapdis)
Generic
mirtazapine (7.5 mg tablet, 15 mg
tablet, 30 mg tablet, 45 mg tablet)
Value
nefazodone hcl
Value
trazodone hcl (50 mg tablet, 100 mg
tablet, 150 mg tablet, 300 mg tablet)
Value
Monoamine Oxidase Inhibitors
MARPLAN
BRAND
phenelzine sulfate 15 mg tablet
Generic
tranylcypromine sulfate
Value
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
20
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Serotonin/Norepinephrine Reuptake Inhibitors
citalopram hydrobromide (10 mg tablet,
10 mg/5 ml solution, 20 mg tablet, 40
mg tablet)
Value
duloxetine hcl (20 mg capsule dr, 30 mg
capsule dr)
Generic
QL (60 PER 30 DAYS)
duloxetine hcl 60 mg capsule dr
Generic
QL (30 PER 30 DAYS)
escitalopram oxalate (5 mg tablet, 5
mg/5 ml solution, 10 mg tablet, 20 mg
tablet)
Generic
fluoxetine hcl (10 mg capsule, 10 mg
tablet, 20 mg capsule, 20 mg tablet, 20
mg/5 ml solution, 40 mg capsule, 60 mg
tablet)
Value
fluoxetine hcl 90 mg capsule dr
Generic
fluvoxamine maleate (25 mg tablet, 50
mg tablet, 100 mg tablet)
Value
olanzapine/fluoxetine hcl
Generic
paroxetine hcl (10 mg tablet, 20 mg
tablet, 30 mg tablet, 40 mg tablet)
Value
PAXIL 10 MG/5 ML SUSPENSION
Value
sertraline hcl (20 mg/ml oral conc, 25
mg tablet, 50 mg tablet, 100 mg tablet)
Value
venlafaxine hcl (25 mg tablet, 37.5 mg
cap er 24h, 37.5 mg tab er 24, 37.5 mg
tablet, 50 mg tablet, 75 mg cap er 24h,
75 mg tab er 24, 75 mg tablet, 100 mg
tablet, 150 mg cap er 24h, 150 mg tab
er 24)
Generic
venlafaxine hcl 225 mg tab er 24
BRAND
Tricyclics
amitriptyline hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet, 75 mg tablet, 100
mg tablet, 150 mg tablet)
Value
amoxapine
Value
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
21
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
clomipramine hcl (25 mg capsule, 50
mg capsule, 75 mg capsule)
Value
desipramine hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet, 75 mg tablet, 100
mg tablet, 150 mg tablet)
Generic
doxepin hcl (10 mg capsule, 25 mg
capsule, 50 mg capsule, 75 mg capsule,
100 mg capsule)
Value
doxepin hcl (10 mg/ml oral conc, 150
mg capsule)
Generic
imipramine hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet)
Value
imipramine pamoate
Value
nortriptyline hcl (10 mg capsule, 10
mg/5 ml solution, 25 mg capsule, 50 mg
capsule, 75 mg capsule)
Value
protriptyline hcl
Generic
trimipramine maleate (25 mg capsule,
50 mg capsule)
Value
Requirements/Limits
Antiemetics
Antiemetics, Other
chlorpromazine hcl (10 mg tablet, 25
mg tablet, 50 mg tablet, 100 mg tablet,
200 mg tablet)
Generic
compro
Generic
DICLEGIS
BRAND
hydroxyzine hcl (10 mg tablet, 10 mg/5
ml syrup, 25 mg tablet, 50 mg tablet)
Generic
hydroxyzine pamoate (25 mg capsule,
50 mg capsule, 100 mg capsule)
Generic
metoclopramide hcl (5 mg tablet, 5
mg/5 ml solution, 10 mg tablet, 10
mg/10ml solution)
Generic
QL (60 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
22
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
perphenazine (2 mg tablet, 4 mg tablet,
8 mg tablet, 16 mg tablet)
Generic
phenadoz
Generic
prochlorperazine maleate (5 mg tablet,
10 mg tablet, 25 mg supp.rect)
Generic
promethazine hcl (6.25mg/5ml syrup,
12.5 mg supp.rect, 12.5 mg tablet, 25
mg supp.rect, 25 mg tablet, 50 mg
supp.rect, 50 mg tablet)
Generic
promethegan
Generic
TRANSDERM-SCOP
BRAND
trimethobenzamide hcl 300 mg capsule
Generic
Requirements/Limits
Emetogenic Therapy Adjuncts
EMEND (80 MG CAPSULE, 125 MG
CAPSULE, TRIFOLD PACK)
BRAND
QL (4 PER 30 DAYS)
granisetron hcl 1 mg tablet
Generic
PA, QL (8 PER 30 DAYS)
ondansetron
Generic
ondansetron hcl (4 mg tablet, 4 mg/5
ml solution, 8 mg tablet)
Generic
Antifungals
ciclodan 0.77% cream
Generic
ciclopirox (0.77 % gel (gram), 1 %
shampoo)
Generic
ciclopirox olamine (0.77 % cream (g),
0.77 % suspension)
Generic
clotrimazole 10 mg troche
Generic
clotrimazole/betamethasone
dipropionate (1 %-0.05 % cream (g), 1
%-0.05 % lotion)
Generic
econazole nitrate 1 % cream (g)
Generic
fluconazole (10 mg/ml susp recon, 40
mg/ml susp recon, 50 mg tablet, 100
mg tablet, 150 mg tablet, 200 mg
tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
23
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
griseofulvin ultramicrosize 250 mg
tablet
Generic
griseofulvin, microsize (125 mg/5ml oral
susp, 500 mg tablet)
Generic
itraconazole 100 mg capsule
Generic
ketoconazole (2 % cream (g), 2 %
shampoo)
Generic
LAMISIL 187.5 MG GRANULES PACK
BRAND
NATACYN
BRAND
NOXAFIL 40 MG/ML SUSPENSION
BRAND
nyamyc
Generic
nystatin (50mm unit powder(ea),
150mm unit powder(ea), 500k unit
tablet, 500mm unit powder(ea),
100000/g cream (g), 100000/g oint. (g),
100000/g powder, 100000/ml oral
susp)
Generic
nystop
Generic
pedi-dri
Generic
SPORANOX 10 MG/ML SOLUTION
BRAND
terbinafine hcl 250 mg tablet
Generic
terconazole (0.4 % cream/appl, 0.8 %
cream/appl, 80 mg supp.vag)
Generic
voriconazole 200 mg/5ml susp recon
Generic
Requirements/Limits
PA
PA
PA
Antigout Agents
allopurinol (100 mg tablet, 300 mg
tablet)
Generic
colchicine/probenecid
Generic
COLCRYS
BRAND
probenecid
Generic
QL (60 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
24
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Antimigraine Agents
Ergot Alkaloids
cafergot
Generic
dihydroergotamine mesylate
0.5mg/spry spray/pump
BRAND
ergotamine tartrate/caffeine
Generic
migergot
Generic
MIGRANAL
BRAND
QL (3.5 ML PER 30 DAYS)
QL (3.5 ML PER 30 DAYS)
Serotonin (5-HT) 1b/1d Receptor Agonists
rizatriptan benzoate
Generic
QL (24 PER 30 DAYS)
sumatriptan (5 mg, 20 mg)
Generic
QL (6 PER 30 DAYS)
sumatriptan succinate (25 mg tablet, 50
mg tablet, 100 mg tablet)
Generic
QL (18 PER 30 DAYS)
sumatriptan succinate (4 cartridge, 4
pen injctr, 6 cartridge, 6 pen injctr, 6
syringe, 6 vial)
Generic
QL (2 ML PER 30 DAYS)
zolmitriptan (2.5 mg tab rapdis, 2.5 mg
tablet, 5 mg tab rapdis, 5 mg tablet)
Generic
QL (12 PER 30 DAYS)
ZOMIG (2.5 MG, 5 MG)
BRAND
QL (12 PER 30 DAYS)
Antimyasthenic Agents
Parasympathomimetics
guanidine hcl
Generic
MESTINON (60 MG/5 ML SYRUP, 180
MG TIMESPAN)
BRAND
pyridostigmine bromide 60 mg tablet
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
25
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Antimycobacterials
Antimycobacterials, Other
dapsone (25 mg tablet, 100 mg tablet)
Generic
rifabutin
Generic
Antituberculars
ethambutol hcl
Generic
isonarif
Generic
isoniazid (50 mg/5 ml solution, 100 mg
tablet, 300 mg tablet)
Generic
PRIFTIN
BRAND
rifampin (150 mg capsule, 300 mg
capsule)
Generic
RIFATER
BRAND
SIRTURO
Specialty
TRECATOR
BRAND
LA
Antineoplastics
Alkylating Agents
ALKERAN 2 MG TABLET
BRAND
CEENU
BRAND
cyclophosphamide capsules
Generic
cyclophosphamide tablets
Generic
LEUKERAN
BRAND
lomustine
BRAND
MATULANE
Specialty
Antiangiogenic Agents
REVLIMID
Specialty
PA, LA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
26
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
THALOMID
Specialty
Requirements/Limits
Antiestrogens/Modifiers
EMCYT
Specialty
FARESTON
BRAND
SOLTAMOX
BRAND
tamoxifen citrate (10 mg tablet, 20 mg
tablet)
Generic
Antimetabolites
capecitabine
Generic
decitabine
Generic
DROXIA
BRAND
hydroxyurea 500 mg capsule
Generic
mercaptopurine 50 mg tablet
Generic
methotrexate sodium (2.5 mg tablet, 25
mg/ml vial)
Generic
methotrexate sodium/pf (1 g vial, 25
mg/ml vial)
Generic
PURIXAN
BRAND
RHEUMATREX
BRAND
Antineoplastics, Other
HEXALEN
Specialty
imiquimod 5 % cream pack
Generic
leucovorin calcium (5 mg tablet, 10 mg
tablet, 15 mg tablet, 25 mg tablet)
Generic
MESNEX 400 MG TABLET
BRAND
temozolomide
Specialty
PA
VALCHLOR
Specialty
PA, LA
Aromatase Inhibitors, 3rd Generation
anastrozole 1 mg tablet
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
27
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
exemestane
Generic
letrozole 2.5 mg tablet
Generic
Requirements/Limits
Enzyme Inhibitors
GILOTRIF
Specialty
PA, LA
HYCAMTIN 0.25 MG CAPSULE
BRAND
PA
HYCAMTIN 1 MG CAPSULE
Specialty
PA
IRESSA
Specialty
PA
JAKAFI
Specialty
PA, LA
MEKINIST
Specialty
PA
TAFINLAR
Specialty
PA
VOTRIENT
Specialty
PA
ZYDELIG
Specialty
PA, QL (60 PER 30 DAYS)
ZYTIGA
Specialty
PA
AFINITOR (2.5 MG TABLET, 5 MG
TABLET, 10 MG TABLET)
Specialty
PA, QL (30 PER 30 DAYS)
AFINITOR 7.5 MG TABLET
BRAND
PA, QL (30 PER 30 DAYS)
AFINITOR DISPERZ
Specialty
PA, QL (30 PER 30 DAYS)
BOSULIF
Specialty
PA
CAPRELSA 100 MG TABLET
Specialty
PA
CAPRELSA 300 MG TABLET
BRAND
PA
COMETRIQ
Specialty
PA, LA
ERIVEDGE
Specialty
PA, LA
GLEEVEC
Specialty
PA
ICLUSIG
Specialty
PA, LA
IMBRUVICA
Specialty
PA, LA
INLYTA
Specialty
PA, LA
NEXAVAR
Specialty
PA
Molecular Target Inhibitors
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
28
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
SPRYCEL
Specialty
PA
STIVARGA
Specialty
PA
SUTENT
Specialty
PA
TARCEVA
Specialty
PA
TASIGNA
Specialty
PA
TYKERB
Specialty
PA
vandetanib
Specialty
PA
ZELBORAF
Specialty
PA
ZOLINZA
Specialty
PA
ZYKADIA
Specialty
PA
Retinoids
PANRETIN
BRAND
TARGRETIN (1% GEL, 75 MG CAPSULE,
75 MG SOFTGEL)
Specialty
PA
tretinoin 10 mg capsule
Specialty
PA
Antiparasitics
Anthelmintics
ALBENZA
BRAND
ivermectin 3 mg tablet
Generic
Antiprotozoals
ALINIA (100 MG/5 ML SUSPENSION,
500 MG TABLET)
BRAND
atovaquone
Generic
PA
chloroquine phosphate (250 mg tablet,
500 mg tablet)
Generic
PA
DARAPRIM
BRAND
PA
hydroxychloroquine sulfate 200 mg
tablet
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
29
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
mefloquine hcl
Generic
PA
tinidazole (250 mg tablet, 500 mg
tablet)
Generic
PA
Pediculicides/Scabicides
elimite
Generic
lindane
Generic
permethrin 5 % cream (g)
Generic
ULESFIA
BRAND
Antiparkinson Agents
Anticholinergics
benztropine mesylate (0.5 mg tablet, 1
mg tablet, 2 mg tablet)
Generic
trihexyphenidyl hcl (2 mg tablet, 5 mg
tablet)
Generic
Antiparkinson Agents, Other
amantadine hcl (50 mg/5 ml syrup, 100
mg capsule, 100 mg tablet)
Generic
carbidopa/levodopa/entacapone
Generic
entacapone
Generic
Dopamine Agonists
bromocriptine mesylate (2.5 mg tablet,
5 mg capsule)
Generic
pramipexole di-hcl
Generic
ropinirole hcl (0.25 mg tablet, 0.5 mg
tablet, 1 mg tablet, 2 mg tablet, 3 mg
tablet, 4 mg tablet, 5 mg tablet)
Generic
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa 25 mg tablet
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
30
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
carbidopa/levodopa (10mg-100mg
tablet, 25mg-100mg tablet, 25mg100mg tablet er, 25mg-250mg tablet,
50mg-200mg tablet er)
Generic
Requirements/Limits
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
BRAND
selegiline hcl (5 mg capsule, 5 mg
tablet)
Generic
Antipsychotics
1st Generation/Typical
fluphenazine hcl (1 mg tablet, 2.5 mg
tablet, 5 mg tablet, 10 mg tablet)
Generic
haloperidol (0.5 mg tablet, 1 mg tablet,
2 mg tablet, 5 mg tablet, 10 mg tablet,
20 mg tablet)
Generic
haloperidol lactate 2 mg/ml oral conc
Generic
loxapine succinate (5 mg capsule, 10
mg capsule, 25 mg capsule, 50 mg
capsule)
Generic
ORAP
BRAND
perphenazine/amitriptyline hcl
Generic
thioridazine hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet, 100 mg tablet)
Generic
thiothixene
Generic
trifluoperazine hcl
Generic
2nd Generation/Atypical
INVEGA
BRAND
LATUDA
BRAND
olanzapine (2.5 mg tablet, 5 mg tab
rapdis, 5 mg tablet, 7.5 mg tablet, 10
mg tab rapdis, 10 mg tablet, 15 mg tab
rapdis, 15 mg tablet, 20 mg tab rapdis,
20 mg tablet)
Generic
PA, QL (30 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
31
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
quetiapine fumarate
Generic
RISPERDAL CONSTA 12.5 MG SYR
BRAND
risperidone (0.25 mg tablet, 0.5 mg
tablet, 1 mg tablet, 1 mg/ml solution, 2
mg tablet, 3 mg tab rapdis, 3 mg tablet,
4 mg tablet)
Generic
SAPHRIS
BRAND
ziprasidone hcl (40 mg capsule, 60 mg
capsule, 80 mg capsule)
Generic
Requirements/Limits
PA
Treatment-Resistant
clozapine
Generic
FAZACLO (150 MG ODT, 200 MG ODT)
BRAND
VERSACLOZ
BRAND
Antispasticity Agents
baclofen (10 mg tablet, 20 mg tablet)
Generic
dantrolene sodium (25 mg capsule, 50
mg capsule)
Generic
MYRBETRIQ
BRAND
tizanidine hcl (2 mg tablet, 4 mg tablet)
Generic
PA
Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors
EDURANT
BRAND
INTELENCE
BRAND
nevirapine (200 mg tablet, 400 mg tab
er 24h)
Generic
SUSTIVA
BRAND
VIRAMUNE XR 100 MG TABLET
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
32
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
abacavir sulfate
Generic
abacavir sulfate/lamivudine/zidovudine
Generic
didanosine
Generic
EMTRIVA (10 MG/ML SOLUTION, 200
MG CAPSULE)
BRAND
EPZICOM
BRAND
lamivudine (150 mg tablet, 300 mg
tablet)
Generic
lamivudine/zidovudine
Generic
stavudine (20 mg capsule, 30 mg
capsule, 40 mg capsule)
Generic
TRUVADA
BRAND
VIREAD (150 MG TABLET, 200 MG
TABLET, 250 MG TABLET, 300 MG
TABLET, POWDER)
BRAND
zidovudine (100 mg capsule, 300 mg
tablet)
Generic
Anti-HIV Agents, Other
ATRIPLA
BRAND
COMPLERA
BRAND
FUZEON
BRAND
ISENTRESS (100 MG POWDER PACKET,
400 MG TABLET)
BRAND
SELZENTRY
BRAND
STRIBILD
BRAND
TIVICAY
BRAND
Anti-HIV Agents, Protease Inhibitors
APTIVUS (100 MG/ML SOLUTION, 250
MG CAPSULE)
BRAND
CRIXIVAN 400 MG CAPSULE
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
33
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
INVIRASE
BRAND
KALETRA (100-25 MG TABLET, 200-50
MG TABLET)
BRAND
LEXIVA (50 MG/ML SUSPENSION, 700
MG TABLET)
BRAND
NORVIR (100 MG SOFTGEL CAP, 100
MG TABLET)
BRAND
PREZISTA (75 MG TABLET, 100 MG/ML
SUSPENSION, 150 MG TABLET, 400 MG
TABLET, 600 MG TABLET, 800 MG
TABLET)
BRAND
REYATAZ
BRAND
VIRACEPT
BRAND
Requirements/Limits
Anti-cytomegalovirus (CMV) Agents
VALCYTE 50 MG/ML SOLUTION
BRAND
valganciclovir hcl
Generic
ZIRGAN
BRAND
QL (60 PER 30 DAYS)
Anti-influenza Agents
rimantadine hcl
Generic
TAMIFLU (6 MG/ML SUSPENSION, 30
MG CAPSULE, 45 MG CAPSULE, 75 MG
CAPSULE)
BRAND
Antihepatitis Agents
adefovir dipivoxil
Specialty
BARACLUDE 0.05 MG/ML SOLUTION
Specialty
entecavir
Specialty
EPIVIR HBV 25 MG/5 ML SOLN
BRAND
INCIVEK
Specialty
INFERGEN
Specialty
INTRON A (6 MILLION UNIT/ML VL, 10
MILLION UNIT/ML, 10 MILLION UNITS
VIL, 18 MILLION UNITS VIL, 50 MILLION
UNITS VIL)
Specialty
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
34
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
lamivudine 100 mg tablet
Generic
MODERIBA
Specialty
OLYSIO
Specialty
PEGASYS (180 MCG/0.5 ML SYRINGE,
180 MCG/ML VIAL)
Specialty
PEGASYS PROCLICK
Specialty
PEGINTRON
Specialty
PEGINTRON REDIPEN
Specialty
REBETOL 40 MG/ML SOLUTION
Specialty
RIBAPAK
Specialty
RIBASPHERE
Specialty
RIBATAB
Specialty
ribavirin (200 mg capsule, 200 mg
tablet, 400 mg tablet, 600 mg tablet)
Specialty
SOVALDI
Specialty
PA
SYLATRON
Specialty
PA, QL (1 PER 28 DAYS)
SYLATRON 4-PACK
Specialty
PA, QL (1 PER 28 DAYS)
TYZEKA
BRAND
VICTRELIS
Specialty
PA
PA
Antiherpetic Agents
acyclovir (200 mg capsule, 200 mg/5ml
oral susp, 400 mg tablet, 800 mg tablet)
Generic
DENAVIR
BRAND
famciclovir
Generic
trifluridine 1 % drops
Generic
valacyclovir hcl (500 mg tablet, 1000
mg tablet)
Generic
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
35
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Anxiolytics
Anxiolytics, Other
alprazolam (0.25 mg tablet, 0.5 mg tab
er 24h, 0.5 mg tablet, 1 mg tab er 24h,
1 mg tablet, 2 mg tab er 24h, 2 mg
tablet, 3 mg tab er 24h)
Generic
buspirone hcl (5 mg tablet, 7.5 mg
tablet, 10 mg tablet, 15 mg tablet, 30
mg tablet)
Generic
chlordiazepoxide hcl
Generic
meprobamate 400 mg tablet
Generic
oxazepam
Generic
Bipolar Agents
Mood Stabilizers
lithium carbonate (150 mg capsule, 300
mg capsule, 300 mg tablet, 300 mg
tablet er, 450 mg tablet er, 600 mg
capsule)
Generic
lithium citrate
Generic
Blood Glucose Regulators
Antidiabetic Agents
acarbose
Generic
ACTOPLUS MET XR
BRAND
BYDUREON
BRAND
PA
BYDUREON PEN
BRAND
PA
BYETTA
BRAND
PA
chlorpropamide
Value
FARXIGA
BRAND
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
36
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
glimepiride
Value
glipizide (2.5 mg tab er 24, 5 mg tab er
24, 5 mg tablet, 10 mg tab er 24, 10 mg
tablet)
Value
glipizide/metformin hcl
Generic
glyburide
Value
glyburide,micronized
Value
glyburide/metformin hcl
Generic
INVOKANA
BRAND
PA
JANUMET
BRAND
PA
JANUMET XR
BRAND
PA
JANUVIA
BRAND
PA
JENTADUETO
BRAND
PA
JUVISYNC (50-10 MG TABLET, 50-20 MG
TABLET, 50-40 MG TABLET)
BRAND
KAZANO
BRAND
PA
KOMBIGLYZE XR
BRAND
PA
metformin hcl (500 mg tab er 24h, 500
mg tablet, 750 mg tab er 24h, 850 mg
tablet, 1000 mg tablet)
Value
nateglinide
Generic
NESINA
BRAND
PA
ONGLYZA
BRAND
PA
OSENI
BRAND
PA
pioglitazone hcl
Generic
pioglitazone hcl/glimepiride
Generic
pioglitazone hcl/metformin hcl
Generic
RIOMET
BRAND
SYMLINPEN 120
BRAND
PA
SYMLINPEN 60
BRAND
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
37
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
TRADJENTA
BRAND
PA
VICTOZA 2-PAK
BRAND
PA
VICTOZA 3-PAK
BRAND
PA
Glycemic Agents
GLUCAGEN
BRAND
GLUCAGON EMERGENCY KIT
BRAND
PROGLYCEM
BRAND
Insulins
APIDRA
BRAND
APIDRA SOLOSTAR
BRAND
HUMALOG
BRAND
HUMALOG MIX 50-50
BRAND
HUMALOG MIX 75-25
BRAND
HUMULIN R
Value
LANTUS
BRAND
LANTUS SOLOSTAR
BRAND
LEVEMIR
BRAND
LEVEMIR FLEXPEN
BRAND
LEVEMIR FLEXTOUCH
BRAND
NOVOLOG
BRAND
NOVOLOG FLEXPEN
BRAND
NOVOLOG MIX 70-30
BRAND
NOVOLOG MIX 70-30 FLEXPEN
BRAND
Blood Products/Modifiers/ Volume Expanders
Anticoagulants
ELIQUIS
BRAND
enoxaparin sodium (30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml,
100 mg/ml, 120mg/.8ml, 150 mg/ml)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
38
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
fondaparinux sodium
Generic
FRAGMIN
Specialty
jantoven
Generic
PRADAXA
BRAND
warfarin sodium (1 mg tablet, 2 mg
tablet, 2.5 mg tablet, 3 mg tablet, 4 mg
tablet, 5 mg tablet, 6 mg tablet, 7.5 mg
tablet, 10 mg tablet)
Generic
XARELTO
BRAND
Requirements/Limits
Blood Formation Modifiers
anagrelide hcl
Generic
ARANESP
Specialty
PA
EPOGEN
Specialty
PA
GRANIX
BRAND
LEUKINE (250 MCG VIAL, 500 MCG/ML
VIAL)
Specialty
NEULASTA
Specialty
NEUMEGA
Specialty
NEUPOGEN
Specialty
PROCRIT
Specialty
PA
PROMACTA
Specialty
PA
Coagulants
tranexamic acid 650 mg tablet
Generic
Platelet Modifying Agents
AGGRENOX
BRAND
BRILINTA
BRAND
cilostazol
Generic
clopidogrel bisulfate 75 mg tablet
Generic
dipyridamole (25 mg tablet, 50 mg
tablet, 75 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
39
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
EFFIENT
BRAND
ticlopidine hcl
Generic
Requirements/Limits
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine
Generic
clonidine hcl (0.1 mg tablet, 0.2 mg
tablet, 0.3 mg tablet)
Generic
guanfacine hcl (1 mg tablet, 2 mg
tablet)
Generic
methyldopa
Generic
methyldopa/hydrochlorothiazide
Generic
midodrine hcl
Generic
Alpha-adrenergic Blocking Agents
doxazosin mesylate
Generic
prazosin hcl (1 mg capsule, 2 mg
capsule, 5 mg capsule)
Generic
terazosin hcl
Generic
Angiotensin II Receptor Antagonists
candesartan cilexetil
Generic
irbesartan
Generic
irbesartan/hydrochlorothiazide
Generic
losartan potassium
Value
losartan potassium/hydrochlorothiazide
Value
valsartan
Generic
valsartan/hydrochlorothiazide
Generic
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl (5 mg tablet, 10 mg
tablet, 20 mg tablet, 40 mg tablet)
Value
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
40
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
benazepril hcl/hydrochlorothiazide
Value
captopril (12.5 mg tablet, 25 mg tablet,
50 mg tablet, 100 mg tablet)
Value
captopril/hydrochlorothiazide
Value
enalapril maleate (2.5 mg tablet, 5 mg
tablet, 10 mg tablet, 20 mg tablet)
Value
enalapril maleate/hydrochlorothiazide
Value
EPANED
BRAND
fosinopril sodium
Value
fosinopril sodium/hydrochlorothiazide
Value
lisinopril (2.5 mg tablet, 5 mg tablet, 10
mg tablet, 20 mg tablet, 30 mg tablet,
40 mg tablet)
Value
lisinopril/hydrochlorothiazide
Value
moexipril hcl
Value
moexipril hcl/hydrochlorothiazide
Value
perindopril erbumine
Generic
quinapril hcl
Value
quinapril hcl/hydrochlorothiazide
Value
ramipril
Value
trandolapril
Value
Requirements/Limits
Antiarrhythmics
amiodarone hcl (100 mg tablet, 200 mg
tablet, 400 mg tablet)
Generic
disopyramide phosphate
Generic
flecainide acetate
Generic
mexiletine hcl (150 mg capsule, 200 mg
capsule, 250 mg capsule)
Generic
MULTAQ
BRAND
NORPACE CR
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
41
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
pacerone 200 mg tablet
Generic
propafenone hcl
Generic
quinidine gluconate 324 mg tablet er
Generic
quinidine sulfate (200 mg tablet, 300
mg tablet, 300 mg tablet er)
Generic
sorine
Generic
sotalol hcl (80 mg tablet, 120 mg tablet,
160 mg tablet, 240 mg tablet)
Generic
TIKOSYN
BRAND
verapamil hcl (40 mg tablet, 80 mg
tablet, 120 mg tablet)
Generic
Requirements/Limits
Beta-adrenergic Blocking Agents
acebutolol hcl (200 mg capsule, 400 mg
capsule)
Value
atenolol (25 mg tablet, 50 mg tablet,
100 mg tablet)
Value
atenolol/chlorthalidone
Value
betaxolol hcl (10 mg tablet, 20 mg
tablet)
Generic
bisoprolol fumarate
Value
bisoprolol
fumarate/hydrochlorothiazide
Generic
carvedilol
Value
COREG CR
BRAND
labetalol hcl (100 mg tablet, 200 mg
tablet, 300 mg tablet)
Value
LEVATOL
BRAND
metoprolol succinate
Value
metoprolol tartrate (25 mg tablet, 50
mg tablet, 100 mg tablet)
Value
metoprolol
tartrate/hydrochlorothiazide
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
42
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
nadolol (20 mg tablet, 40 mg tablet, 80
mg tablet)
Value
nadolol/bendroflumethiazide
Generic
pindolol
Value
propranolol hcl (10 mg tablet, 20 mg
tablet, 40 mg tablet, 40mg/5ml
solution, 60 mg cap sa 24h, 60 mg
tablet, 80 mg cap sa 24h, 80 mg tablet,
120 mg cap sa 24h, 160 mg cap sa 24h)
Value
propranolol hcl/hydrochlorothiazide
Generic
timolol maleate (5 mg tablet, 10 mg
tablet, 20 mg tablet)
Value
Requirements/Limits
Calcium Channel Blocking Agents
afeditab cr
Generic
amlodipine besylate (2.5 mg tablet, 5
mg tablet, 10 mg tablet)
Value
amlodipine besylate/benazepril hcl
Generic
cartia xt
Generic
dilt-cd
Generic
dilt-xr
Generic
diltia xt
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
43
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
diltiazem hcl (30 mg tablet, 60 mg cap
er 12h, 60 mg tablet, 90 mg cap er 12h,
90 mg tablet, 120 mg cap er 12h, 120
mg cap er 24h, 120 mg cap er deg, 120
mg capsule er, 120 mg tablet, 180 mg
cap er 24h, 180 mg cap er deg, 180 mg
capsule er, 180 mg tab er 24h, 240 mg
cap er 24h, 240 mg cap er deg, 240 mg
capsule er, 240 mg tab er 24h, 300 mg
cap er 24h, 300 mg capsule er, 300 mg
tab er 24h, 360 mg cap er 24h, 360 mg
capsule er, 360 mg tab er 24h, 420mg
capsule er, 420mg tab er 24h)
Generic
diltzac er
Generic
felodipine
Generic
isradipine
Generic
matzim la
Generic
nicardipine hcl (20 mg capsule, 30 mg
capsule)
Generic
nifediac cc
Generic
nifedical xl
Generic
nifedipine (30 mg tab er 24, 30 mg
tablet er, 60 mg tab er 24, 60 mg tablet
er, 90 mg tab er 24, 90 mg tablet er)
Generic
nimodipine 30 mg capsule
Generic
nisoldipine
Generic
taztia xt
Generic
verapamil hcl (100 mg cap24h pct, 120
mg cap24h pel, 120 mg tablet er, 180
mg cap24h pel, 180 mg tablet er, 200
mg cap24h pct, 240 mg cap24h pel, 240
mg tablet er, 300 mg cap24h pct, 360
mg cap24h pel)
Generic
Requirements/Limits
Cardiovascular Agents, Other
amlodipine besylate/atorvastatin
calcium
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
44
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
digitek
Generic
digox
Generic
digoxin (50 mcg/ml solution, 125 mcg
tablet, 250 mcg tablet)
Generic
LANOXIN (62.5 MCG TABLET, 187.5
MCG TABLET)
BRAND
pentoxifylline 400 mg tablet er
Generic
RANEXA
BRAND
Requirements/Limits
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide 500 mg capsule er
Generic
methazolamide (25 mg tablet, 50 mg
tablet)
Generic
Diuretics, Loop
bumetanide (0.5 mg tablet, 1 mg tablet,
2 mg tablet)
Generic
EDECRIN
BRAND
furosemide (20 mg tablet, 40 mg tablet,
80 mg tablet)
Value
furosemide 10 mg/ml solution
Generic
torsemide (5 mg tablet, 10 mg tablet,
20 mg tablet, 100 mg tablet)
Generic
Diuretics, Potassium-sparing
amiloride hcl 5 mg tablet
Generic
amiloride hcl/hydrochlorothiazide
Generic
DYRENIUM
BRAND
eplerenone
Generic
spironolactone (25 mg tablet, 50 mg
tablet, 100 mg tablet)
Value
spironolactone/hydrochlorothiazide
Generic
triamterene/hydrochlorothiazide
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
45
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Diuretics, Thiazide
chlorothiazide
Generic
chlorthalidone
Value
hydrochlorothiazide (12.5 mg capsule,
12.5 mg tablet, 25 mg tablet, 50 mg
tablet)
Value
indapamide
Generic
methyclothiazide
Generic
metolazone
Generic
Dyslipidemics, Fibric Acid Derivatives
fenofibrate (54 mg tablet, 160 mg
tablet)
Generic
fenofibrate nanocrystallized
Generic
fenofibrate,micronized (67 mg capsule,
134mg capsule, 200 mg capsule)
Generic
fenofibric acid
Generic
fenofibric acid (choline)
Generic
gemfibrozil 600 mg tablet
Generic
lofibra
Generic
TRIGLIDE 160 MG TABLET
BRAND
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
Value
fluvastatin sodium
Generic
lovastatin
Value
pravastatin sodium
Value
simvastatin (5 mg tablet, 10 mg tablet,
20 mg tablet, 40 mg tablet)
Value
Dyslipidemics, Other
cholestyramine (with sugar) (suar) 4
powd pack, suar) 4 powder)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
46
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
cholestyramine/aspartame (4 powd
pack, 4 powder)
Generic
COLESTID FLAVORED GRANULES
BRAND
colestid granules
Generic
colestipol hcl (1 tablet, 5 packet, 5
ranules)
Generic
JUXTAPID
Specialty
PA, LA
KYNAMRO
Specialty
PA, LA
prevalite (packet, powder)
Generic
Vasodilators, Direct-acting Arterial
hydralazine hcl (10 mg tablet, 25 mg
tablet, 50 mg tablet, 100 mg tablet)
Generic
minoxidil (2.5 mg tablet, 10 mg tablet)
Generic
RECTIV
BRAND
Vasodilators, Direct-acting Arterial/Venous
DILATRATE-SR
BRAND
isochron
Generic
isosorbide dinitrate
Generic
isosorbide mononitrate
Generic
minitran
Generic
NITRO-BID
BRAND
NITRO-DUR (0.3, 0.8)
BRAND
nitro-time
Generic
nitroglycerin (0.1mg/hr patch td24,
0.2mg/hr patch td24, 0.4mg/hr patch
td24, 0.6mg/hr patch td24, 2.5 mg
capsule er, 6.5 mg capsule er, 9 mg
capsule er, 400mcg/spr spray)
Generic
NITROSTAT
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
47
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
dextroamphetamine sulfsaccharate/amphetamine sulfaspartate
Generic
dextroamphetamine sulfate (5 mg
capsule er, 10 mg capsule er, 15 mg
capsule er)
Generic
dextroamphetamine sulfate (5 mg
tablet, 10 mg tablet)
Generic
VYVANSE
BRAND
zenzedi (5 mg tablet, 10 mg tablet)
Generic
PA
PA
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
DAYTRANA
BRAND
PA, QL (30 PER 30 DAYS)
dexmethylphenidate hcl (2.5 mg tablet,
5 mg tablet, 10 mg tablet)
Generic
dexmethylphenidate hcl (5 mg, 15 mg,
30 mg, 40 mg)
Generic
PA
FOCALIN XR (10 MG CAPSULE, 20 MG
CAPSULE, 25 MG CAPSULE, 35 MG
CAPSULE)
BRAND
PA
guanfacine hcl (1 mg tab er, 2 mg tab
er, 3 mg tab er, 4 mg tab er)
Generic
PA, QL (30 PER 30 DAYS)
metadate er
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
48
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
methylphenidate hcl (5 mg tablet, 5
mg/5 ml solution, 10 mg cpbp 30-70, 10
mg tablet, 10 mg tablet er, 10 mg/5 ml
solution, 18 mg tab er 24, 20 mg cpbp
30-70, 20 mg cpbp 50-50, 20 mg tablet,
20 mg tablet er, 27 mg tab er 24, 30 mg
cpbp 30-70, 30 mg cpbp 50-50, 36 mg
tab er 24, 40 mg cpbp 30-70, 40 mg
cpbp 50-50, 50 mg cpbp 30-70, 54 mg
tab er 24, 60 mg cpbp 30-70)
Generic
RITALIN LA 10 MG CAPSULE
BRAND
STRATTERA
BRAND
PA, QL (30 PER 30 DAYS)
NUEDEXTA
BRAND
PA
riluzole
Generic
XENAZINE
Specialty
PA
SAVELLA (12.5 MG TABLET, 25 MG
TABLET, 50 MG TABLET, 100 MG
TABLET)
BRAND
PA, QL (60 PER 30 DAYS)
SAVELLA TITRATION PACK
BRAND
PA, QL (55 PER 30 DAYS)
AMPYRA
Specialty
PA, LA, QL (60 PER 30 DAYS)
AUBAGIO
Specialty
PA, LA, QL (30 PER 30 DAYS)
AVONEX (30 MCG, 30 MCG KT)
Specialty
AVONEX ADMINISTRATION PACK
Specialty
AVONEX PEN
Specialty
BETASERON 0.3 MG KIT
Specialty
PA, QL (14 PER 30 DAYS)
BETASERON 0.3 MG VIAL
Specialty
PA, QL (15 PER 30 DAYS)
COPAXONE 20 MG/ML SYRINGE
Specialty
QL (30 ML PER 30 DAYS)
COPAXONE 40 MG/ML SYRINGE
Specialty
QL (12 ML PER 28 DAYS)
EXTAVIA 0.3 MG KIT
Specialty
PA, QL (14 PER 30 DAYS)
Central Nervous System Agents, Other
Fibromyalgia Agents
Multiple Sclerosis Agents
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
49
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
EXTAVIA 0.3 MG VIAL
Specialty
PA, QL (15 PER 30 DAYS)
FIRAZYR
Specialty
PA, QL (9 ML PER 30 DAYS)
GILENYA
Specialty
PA, QL (30 PER 30 DAYS)
PLEGRIDY
Specialty
QL (1 ML PER 28 DAYS)
PLEGRIDY PEN
Specialty
QL (1 ML PER 28 DAYS)
REBIF (22 ML, 44 ML)
Specialty
QL (6 ML PER 30 DAYS)
REBIF REBIDOSE (22 ML, 44 ML)
Specialty
QL (6 ML PER 30 DAYS)
REBIF REBIDOSE TITRATION PACK
Specialty
QL (4.2 ML PER 30 DAYS)
REBIF TITRATION PACK
Specialty
QL (4.2 ML PER 30 DAYS)
TECFIDERA
Specialty
QL (60 PER 30 DAYS)
Dental and Oral Agents
pilocarpine hcl (5 mg tablet, 7.5 mg
tablet)
Generic
Dermatological Agents
acitretin
Generic
adapalene (0.1 % cream (g), 0.1 % gel
(gram), 0.3 % gel (gram))
Generic
adapalene 0.3 % gel w/pump
BRAND
amnesteem
Generic
avita 0.025% cream
Generic
calcipotriene (0.005 % cream (g), 0.005
% solution)
Generic
claravis
Generic
clindamycin phos/benzoyl perox 1 %-5
% gel (gram)
Generic
DIFFERIN 0.3% GEL PUMP
BRAND
ELIDEL
BRAND
EPIFOAM
BRAND
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
50
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
erythromycin base/benzoyl peroxide
Generic
FINACEA
BRAND
FLUOROPLEX
BRAND
fluorouracil (0.5 % cream (g), 2 %
solution, 5 % cream (g), 5 % solution)
Generic
gengraf 100 mg capsule
Generic
hypercare
Generic
methoxsalen, rapid
Specialty
mometasone furoate (0.1 % cream (g),
0.1 % oint. (g), 0.1 % solution)
Generic
myorisan
Generic
OTEZLA
Specialty
OXSORALEN
BRAND
PICATO
BRAND
podofilox 0.5 % solution
Generic
refissa
Generic
REGRANEX
BRAND
PA
SANTYL
BRAND
QL (30 GM PER 30 DAYS)
STELARA 45 MG/0.5 ML SYRINGE
Specialty
PA, QL (0.5 ML PER 90 DAYS)
STELARA 90 MG/ML SYRINGE
Specialty
PA, QL (1 ML PER 90 DAYS)
tacrolimus (0.03 %, 0.1 %)
Generic
PA
TAZORAC
BRAND
tretinoin (0.01 % gel (gram), 0.025 %
cream (g), 0.025 % gel (gram), 0.05 %
cream (g), 0.1 % cream (g))
Generic
tretinoin/emollient base
Generic
trianex
Generic
VOLTAREN
BRAND
zenatane
Generic
PA
PA, QL (60 PER 30 DAYS)
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
51
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Enzyme Replacement/ Modifiers
ADAGEN
Specialty
BUPHENYL 500 MG TABLET
Specialty
CARBAGLU
BRAND
CEREZYME 400 UNITS VIAL
BRAND
CREON
BRAND
ELELYSO
Specialty
KUVAN
Specialty
ORFADIN
Specialty
pancrelipase 5,000
Generic
RAVICTI
Specialty
sodium phenylbutyrate 0.94 g/g powder
Specialty
SUCRAID
Specialty
ZAVESCA
Specialty
ZENPEP (DR 10,000 CAPSULE, DR
15,000 CAPSULE, DR 20,000 CAPSULE,
DR 25,000 CAPSULE, DR 3,000 CAPSULE,
DR 40,000 CAPSULE)
BRAND
PA, LA
LA
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
CUVPOSA
BRAND
dicyclomine hcl (10 mg capsule, 10
mg/5 ml solution, 20 mg tablet)
Generic
glycopyrrolate (1 mg tablet, 2 mg
tablet)
Generic
PA
Gastrointestinal Agents, Other
APRISO
BRAND
ASACOL
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
52
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
ASACOL HD
BRAND
CANASA
BRAND
DELZICOL
BRAND
diphenoxylate hcl/atropine sulfate (2.5.025/5 liquid, 2.5-.025mg tablet)
Generic
FULYZAQ
BRAND
PA
GATTEX
Specialty
PA, LA
gavilyte-c
Generic
gavilyte-g
Generic
gavilyte-n
Generic
GOLYTELY PACKET
BRAND
LIALDA
BRAND
mesalamine 4 g/60 ml enema
Generic
mesalamine with cleansing wipes
Generic
nulytely with flavor packs
Generic
peg 3350/sod sulf/sod bicarbonate/sod
chloride/potassium chl
Generic
PENTASA
BRAND
propantheline bromide 15 mg tablet
Generic
PYLERA
BRAND
sodium chloride/sodium
bicarbonate/potassium chloride/peg
Generic
sulfasalazine (500 mg tablet, 500 mg
tablet dr)
Generic
sulfazine
Generic
sulfazine ec
Generic
trilyte with flavor packets
Generic
ursodiol (250 mg tablet, 300 mg
capsule, 500 mg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
53
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Histamine2 (H2) Receptor Antagonists
cimetidine (300 mg tablet, 400 mg
tablet, 800 mg tablet)
Generic
cimetidine hcl
Generic
famotidine 40 mg tablet
Generic
nizatidine (150 mg capsule, 300 mg
capsule)
Generic
ranitidine hcl (15 mg/ml syrup, 300 mg
tablet)
Generic
Irritable Bowel Syndrome Agents
LOTRONEX
BRAND
PA
Laxatives
constulose
Generic
enulose
Generic
generlac
Generic
lactulose
Generic
MOVIPREP
BRAND
SUPREP
BRAND
Protectants
misoprostol (100 mcg tablet, 200 mcg
tablet)
Generic
sucralfate (1 g tablet, 1 g/10 ml oral
susp)
Generic
Proton Pump Inhibitors
FIRST-LANSOPRAZOLE
BRAND
FIRST-OMEPRAZOLE
BRAND
lansoprazole 30 mg capsule dr
Generic
lansoprazole/amoxicillin
trihydrate/clarithromycin
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
54
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
omeprazole (10 mg capsule dr, 20 mg
capsule dr, 40 mg capsule dr)
Generic
OMEPRAZOLE+SYRSPEND SF ALKA
BRAND
pantoprazole sodium (20 mg tablet dr,
40 mg tablet dr)
Generic
PROTONIX 40 MG SUSPENSION
BRAND
rabeprazole sodium
Generic
Requirements/Limits
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
Generic
oxybutynin chloride (5 mg tab er 24, 5
mg tablet, 5 mg/5 ml syrup, 10 mg tab
er 24, 15 mg tab er 24)
Generic
OXYTROL
BRAND
tolterodine tartrate
Generic
trospium chloride 20 mg tablet
Generic
Benign Prostatic Hypertrophy Agents
alfuzosin hcl
Generic
finasteride 5 mg tablet
Generic
tamsulosin hcl
Generic
Genitourinary Agents, Other
bethanechol chloride (5 mg tablet, 10
mg tablet, 25 mg tablet, 50 mg tablet)
Generic
CUPRIMINE
BRAND
CYSTAGON
Specialty
DEPEN
BRAND
ELMIRON
BRAND
PROCYSBI
BRAND
THIOLA
BRAND
PA
PA, LA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
55
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Phosphate Binders
calcium acetate 667 mg capsule
Generic
RENAGEL
BRAND
PA
RENVELA
BRAND
PA
sevelamer carbonate
BRAND
PA
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids
betamethasone
acetate/betamethasone sodium
phosphate
Generic
budesonide 3 mg capdr - er
Generic
CELESTONE 0.6 MG/5 ML SOLUTION
BRAND
dexamethasone (0.5 mg tablet, 0.5
mg/5ml elixir, 0.5 mg/5ml solution, 0.75
mg tablet, 1 mg tablet, 1.5 mg tablet, 2
mg tablet, 4 mg tablet, 6 mg tablet)
Generic
FLAREX
BRAND
fluocinolone acetonide oil
Generic
fluorometholone 0.1 % drops susp
Generic
fluticasone propionate 50 mcg spray
susp
Generic
FML FORTE
BRAND
FML S.O.P.
BRAND
hydrocortisone (5 mg tablet, 10 mg
tablet, 20 mg tablet)
Generic
hydrocortisone butyrate (0.1 % oint. (g),
0.1 % solution)
Generic
hydrocortisone valerate
Generic
methylprednisolone
Generic
triamcinolone acetonide 55 mcg spray
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
56
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
UCERIS 9 MG ER TABLET
BRAND
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Other)
MYALEPT
BRAND
PA, LA
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate (0.1 mg tablet,
0.2 mg tablet, 10/spray spray/pump)
Generic
PA
desmopressin acetate (0.1 mg/ml
solution, 4mcg/ml ampul, 4mcg/ml vial)
Generic
desmopressin acetate (nonrefrigerated)
Generic
PA
EGRIFTA
Specialty
PA
GENOTROPIN
Specialty
PA
HUMATROPE
Specialty
PA
INCRELEX
Specialty
PA, LA
NORDITROPIN
Specialty
PA
NORDITROPIN FLEXPRO
Specialty
PA
NORDITROPIN NORDIFLEX (NORDIFLEX
5, NORDIFLX 10, NORDIFLX 15)
Specialty
PA
NUTROPIN
Specialty
PA
NUTROPIN AQ
Specialty
PA
NUTROPIN AQ NUSPIN
Specialty
PA
OMNITROPE 5 MG/1.5 ML CRTG
Specialty
PA
SAIZEN
Specialty
PA
SEROSTIM
Specialty
PA
STIMATE
BRAND
TEV-TROPIN
Specialty
PA
ZORBTIVE
Specialty
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
57
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50
Specialty
oxandrolone 10 mg tablet
Generic
Androgens
ANDROGEL (1.62% GEL PUMP,
1.62%(1.25G) GEL PCKT, 1.62%(2.5G)
GEL PCKT)
BRAND
danazol (50 mg capsule, 100 mg
capsule, 200 mg capsule)
Generic
testosterone (1.25g (1%) gel md pmp,
25mg(1%) gel packet, 50 mg (1%) gel
(gram), 50 mg (1%) gel packet)
Generic
testosterone cypionate (100 mg/ml vial,
200 mg/ml vial)
Generic
testosterone enanthate 200 mg/ml vial
Generic
Estrogens
altavera
Generic
alyacen
Generic
amethia
Generic
amethia lo
Generic
amethyst
Generic
apri
Generic
aranelle
Generic
aubra
Generic
aviane
Generic
azurette
Generic
balziva
Generic
briellyn
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
58
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
camrese
Generic
camrese lo
Generic
caziant
Generic
chateal
Generic
COMBIPATCH
BRAND
cryselle
Generic
cyclafem
Generic
dasetta
Generic
daysee
Generic
delyla
Generic
desogestrel-ethinyl estradiol
Generic
desogestrel-ethinyl estradiol/ethinyl
estradiol
Generic
DUAVEE
BRAND
elinest
Generic
emoquette
Generic
enpresse
Generic
enskyce
Generic
estarylla
Generic
ESTRACE 0.01% CREAM
BRAND
estradiol (.025mg/24h patch tdsw,
.025mg/24h patch tdwk, .0375mg/24
patch tdsw, .0375mg/24 patch tdwk,
0.05mg/24h patch tdsw, 0.05mg/24h
patch tdwk, 0.06mg/24h patch tdwk,
.075mg/24h patch tdsw, .075mg/24h
patch tdwk, 0.1mg/24hr patch tdsw,
0.1mg/24hr patch tdwk, 0.5 mg tablet,
1 mg tablet, 2 mg tablet)
Generic
estradiol/norethindrone acetate
Generic
ESTRING
BRAND
estropipate (0.75 mg tablet, 1.5 mg
tablet, 3 mg tablet)
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
59
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ethinyl estradiol/drospirenone
Generic
falmina
Generic
gianvi
Generic
gildagia
Generic
gildess
Generic
gildess fe
Generic
introvale
Generic
jolessa
Generic
junel
Generic
junel fe
Generic
kariva
Generic
kelnor 1-35
Generic
kurvelo
Generic
larin
Generic
larin fe
Generic
leena
Generic
lessina
Generic
levonest
Generic
levonorgestrel-eth estra/ethinyl
estradiol
Generic
levonorgestrel-ethinyl estradiol
Generic
levora-28
Generic
lomedia 24 fe
Generic
lopreeza
Generic
loryna
Generic
low-ogestrel
Generic
lutera
Generic
marlissa
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
60
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
microgestin
Generic
microgestin fe
Generic
mimvey
Generic
mimvey lo
Generic
mono-linyah
Generic
mononessa
Generic
myzilra
Generic
necon
Generic
nikki
Generic
norethindrone acetate-ethinyl estradiol
Generic
norethindrone acetate-ethinyl
estradiol/ferrous fumarate
Generic
norgestimate-ethinyl estradiol
Generic
nortrel
Generic
NUVARING
BRAND
ocella
Generic
ogestrel
Generic
orsythia
Generic
ORTHO TRI-CYCLEN LO
BRAND
philith
Generic
pimtrea
Generic
pirmella
Generic
portia
Generic
PREMARIN (0.3 MG TABLET, 0.45 MG
TABLET, 0.625 MG TABLET, 0.9 MG
TABLET, 1.25 MG TABLET, VAGINAL
CREAM-APPL)
BRAND
PREMPHASE
BRAND
PREMPRO
BRAND
previfem
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
61
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
quasense
Generic
reclipsen
Generic
sprintec
Generic
sronyx
Generic
syeda
Generic
tarina fe
Generic
tilia fe
Generic
tri-estarylla
Generic
tri-legest fe
Generic
tri-linyah
Generic
tri-previfem
Generic
tri-sprintec
Generic
trinessa
Generic
trivora-28
Generic
VAGIFEM
BRAND
velivet
Generic
vestura
Generic
viorele
Generic
vyfemla
Generic
wera
Generic
xulane
Generic
zarah
Generic
zenchent
Generic
zovia 1-35e
Generic
zovia 1-50e
Generic
Requirements/Limits
Progestins
camila
Generic
deblitane
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
62
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
DEPO-SUBQ PROVERA 104
BRAND
errin
Generic
heather
Generic
jencycla
Generic
jolivette
Generic
lyza
Generic
medroxyprogesterone acetate (2.5 mg
tablet, 5 mg tablet, 10 mg tablet, 150
mg/ml syringe, 150 mg/ml vial)
Generic
megestrol acetate (20 mg tablet, 40 mg
tablet, 400mg/10ml oral susp)
Generic
nora-be
Generic
norethindrone 0.35 mg tablet
Generic
norethindrone acetate 5 mg tablet
Generic
norlyroc
Generic
progesterone,micronized (100 mg
capsule, 200 mg capsule)
Generic
sharobel
Generic
Requirements/Limits
Selective Estrogen Receptor Modifying Agents
raloxifene hcl
Generic
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothroid
Generic
levothyroxine sodium (25 mcg tablet, 50
mcg tablet, 75 mcg tablet, 88 mcg
tablet, 100 mcg tablet, 112 mcg tablet,
125 mcg tablet, 137 mcg tablet, 150
mcg tablet, 175mcg tablet, 200 mcg
tablet, 300 mcg tablet)
Generic
levoxyl
Generic
liothyronine sodium (5 mcg tablet, 25
mcg tablet, 50 mcg tablet)
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
63
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
unithroid (25 mcg tablet, 50 mcg tablet,
75 mcg tablet, 88 mcg tablet, 100 mcg
tablet, 112 mcg tablet, 125 mcg tablet,
150 mcg tablet, 175 mcg tablet, 200
mcg tablet, 300 mcg tablet)
Generic
Requirements/Limits
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
BRAND
SIGNIFOR
Specialty
PA, LA
Hormonal Agents, Suppressant (Parathyroid)
calcitriol (0.25 mcg capsule, 0.5 mcg
capsule, 1 mcg/ml solution)
Generic
paricalcitol (1 mcg capsule, 2 mcg
capsule, 4mcg capsule)
Generic
ST
SENSIPAR (30 MG TABLET, 60 MG
TABLET)
Specialty
QL (60 PER 30 DAYS)
SENSIPAR 90 MG TABLET
Specialty
Hormonal Agents, Suppressant (Pituitary)
cabergoline
Generic
ELIGARD
BRAND
PA
leuprolide acetate 1 mg/0.2ml kit
Generic
PA
octreotide acetate (50 mcg/ml ampul,
50 mcg/ml vial, 100 mcg/ml ampul, 100
mcg/ml vial, 200 mcg/ml vial, 500
mcg/ml ampul, 500 mcg/ml vial,
1000mcg/ml vial)
Specialty
PA
SOMAVERT
Specialty
PA, LA
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogens
bicalutamide
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
64
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
NILANDRON
BRAND
XTANDI
Specialty
Requirements/Limits
PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole (5 mg tablet, 10 mg
tablet)
Generic
propylthiouracil 50 mg tablet
Generic
Immunological Agents
Angioedema (HAE) Agents
BERINERT 500 UNIT KIT
Specialty
PA, QL (3 PER 30 DAYS)
Immune Suppressants
ASTAGRAF XL
BRAND
azathioprine 50 mg tablet
Generic
cyclosporine (25 mg capsule, 100 mg
capsule)
Generic
cyclosporine, modified (25 mg capsule,
50 mg capsule, 100 mg capsule, 100
mg/ml solution)
Generic
ENBREL (25 MG/0.5 ML SYRINGE, 50
MG/ML SURECLICK SYR, 50 MG/ML
SYRINGE)
Specialty
QL (4 ML PER 28 DAYS)
ENBREL 25 MG KIT
Specialty
QL (8 PER 28 DAYS)
gengraf (25 mg capsule, 100 mg/ml
solution)
Generic
GRASTEK
BRAND
hecoria
Generic
HUMIRA
Specialty
HUMIRA PEDIATRIC
Specialty
mycophenolate mofetil (200 mg/ml
susp recon, 250 mg capsule, 500 mg
tablet)
Generic
PA
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
65
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
mycophenolate sodium
Generic
ORALAIR 300 IR SUBLINGUAL TAB
Specialty
PROGRAF 5 MG/ML AMPULE
BRAND
RAGWITEK
BRAND
RAPAMUNE 1 MG/ML ORAL SOLN
BRAND
RESTASIS
BRAND
SANDIMMUNE 100 MG/ML SOLN
BRAND
sirolimus (0.5 mg tablet, 1 mg tablet, 2
mg tablet)
Generic
tacrolimus (0.5 mg capsule, 1 mg
capsule, 5 mg capsule)
Generic
ZORTRESS
Specialty
Requirements/Limits
PA, LA
PA
QL (60 PER 30 DAYS)
Immunizing Agents, Passive
GAMMAGARD S-D
BRAND
PA
GAMMAKED
Specialty
PA
GAMUNEX-C
Specialty
PA
ACTIMMUNE
Specialty
PA
ALFERON N
Specialty
leflunomide
Generic
Immunomodulators
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium
Generic
DIPENTUM
BRAND
Glucocorticoids
anusol-hc 2.5% cream
Generic
procto-pak
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
66
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
proctocream-hc
Generic
PROCTOFOAM-HC
BRAND
proctosol-hc
Generic
proctozone-hc
Generic
Requirements/Limits
Metabolic Bone Disease Agents
ACTONEL (5 MG TABLET, 30 MG
TABLET, 35 MG TABLET)
BRAND
alendronate sodium (5 mg tablet, 10
mg tablet, 35 mg tablet, 40 mg tablet,
70 mg tablet, 70 mg/75ml solution)
Generic
calcitonin,salmon,synthetic
Generic
doxercalciferol (0.5 mcg capsule, 1 mcg
capsule, 2.5 mcg capsule)
Generic
doxercalciferol 4mcg/2ml vial
Generic
etidronate disodium
Generic
FORTEO
Specialty
ibandronate sodium 150 mg tablet
Generic
PA
ST
PA
Miscellaneous
Glucose Testing
ACCU-CHECK (METERS & TEST STRIPS)
DME Benefit
QL
LIFESCAN (METERS & TEST STRIPS)
DME Benefit
QL
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost
Generic
LUMIGAN 0.01% EYE DROPS
BRAND
ST
LUMIGAN 0.03% EYE DROPS
BRAND
ST
TRAVATAN Z
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
67
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
travoprost (benzalkonium)
Generic
Requirements/Limits
Ophthalmic Agents, Other
ak-poly-bac
Generic
bacitracin/polymyxin b sulfate
Generic
BLEPHAMIDE
BRAND
BLEPHAMIDE S.O.P.
BRAND
CYSTARAN
BRAND
gatifloxacin
Generic
LACRISERT
BRAND
MOXEZA
BRAND
naphazoline hcl 0.1 % drops
Generic
neo-polycin
Generic
neo-polycin hc
Generic
neomycin sulfate/bacitracin
zinc/polymyxin b/hydrocortisone
Generic
neomycin sulfate/bacitracin/polymyxin
b
Generic
neomycin sulfate/polymyxin b
sulfate/gramicidin d
Generic
neomycin/polymyxin b sulf/hc 3.5-10k10 drops susp
Generic
neomycin/polymyxin b
sulfate/dexamethasone (0.1 % drops
susp, 3.5-10k-.1 oint. (g))
Generic
neosporin
Generic
polycin
Generic
polymyxin b sulfate/trimethoprim
Generic
sulfacetamide sodium/prednisolone
sodium phosphate
Generic
TOBRADEX EYE OINTMENT
BRAND
TOBRADEX ST
BRAND
PA, LA, QL (60 ML PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
68
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
tobramycin/dexamethasone
Generic
tropicamide (0.5 % drops, 1 % drops)
Generic
VIGAMOX
BRAND
ZYLET
BRAND
Requirements/Limits
Ophthalmic Anti-allergy Agents
ALOMIDE
BRAND
azelastine hcl 0.05 % drops
Generic
cromolyn sodium 4 % drops
Generic
PATANOL
BRAND
PA
Ophthalmic Anti-inflammatories
ALREX
BRAND
bromfenac sodium
Generic
dexamethasone sod phosphate 0.1 %
drops
Generic
diclofenac sodium 0.1 % drops
Generic
flurbiprofen sodium
Generic
ketorolac tromethamine (0.4 % drops,
0.5 % drops)
Generic
LOTEMAX (0.5% EYE DROPS, 0.5% EYE
OINTMENT, 0.5% OPHTHALMIC GEL)
BRAND
prednisolone acetate 1 % drops susp
Generic
prednisolone sod phosphate 1 % drops
Generic
VEXOL
BRAND
Ophthalmic Antiglaucoma Agents
ALPHAGAN P 0.1% DROPS
BRAND
AZOPT
BRAND
betaxolol hcl 0.5 % drops
Generic
BETIMOL
BRAND
BETOPTIC S
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
69
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
brimonidine tartrate (0.15 % drops, 0.2
% drops)
Generic
carteolol hcl
Generic
dorzolamide hcl
Generic
dorzolamide hcl/timolol maleate
Generic
ISTALOL
BRAND
levobunolol hcl
Generic
metipranolol
Generic
pilocarpine hcl (1 % drops, 2 % drops, 4
% drops)
Generic
PILOPINE HS
BRAND
timolol maleate (0.25 % drops, 0.25 %
sol-gel, 0.5 % drops, 0.5 % sol-gel)
Generic
Requirements/Limits
Otic Agents
antipyrine/benzocaine 5.4 %-1.4% drops
Generic
aurodex
Generic
auroguard
Generic
CIPRO HC
BRAND
CIPRODEX
BRAND
ciprofloxacin hcl 0.2 % droperette
Generic
neomycin sulfate/polymyxin b
sulfate/hydrocortisone (drops susp,
solution)
Generic
otic care
Generic
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
BRAND
ADVAIR HFA
BRAND
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
70
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
AEROSPAN
BRAND
ALVESCO
BRAND
ASMANEX
BRAND
ASMANEX HFA
BRAND
BREO ELLIPTA
BRAND
budesonide (0.25mg/2ml ampul-neb,
0.5 mg/2ml ampul-neb, 32mcg
spray/pump)
Generic
FLOVENT DISKUS
Value
FLOVENT HFA
Value
flunisolide (25 mcg, 29mcg)
Generic
NASONEX
BRAND
PULMICORT 1 MG/2 ML RESPULE
BRAND
PULMICORT FLEXHALER
BRAND
QVAR
BRAND
Requirements/Limits
QL (17 GM PER 30 DAYS)
Antihistamines
azelastine hcl 137 mcg spray/pump
Generic
clemastine fumarate (0.67mg/5ml
syrup, 2.68 mg tablet)
Generic
cyproheptadine hcl (2 mg/5 ml syrup, 4
mg tablet)
Generic
levocetirizine dihydrochloride (2.5
mg/5ml solution, 5 mg tablet)
Generic
promethazine hcl/codeine
Generic
promethazine/phenylephrine
hcl/codeine
Generic
Antileukotrienes
montelukast sodium (4 mg gran pack, 4
mg tab chew, 5 mg tab chew, 10 mg
tablet)
Generic
zafirlukast
Generic
QL (60 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
71
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
ZYFLO CR
BRAND
Requirements/Limits
Bronchodilators, Anticholinergic
ATROVENT HFA
BRAND
COMBIVENT
BRAND
QL (14.7 GM PER 30 DAYS)
COMBIVENT RESPIMAT
BRAND
QL (4 GM PER 30 DAYS)
hydrocodone bit/homatrop me-br 5-1.5
mg/5 syrup
Generic
hydromet
Generic
ipratropium bromide (0.2 mg/ml
solution, 21 mcg spray, 42mcg spray)
Generic
ipratropium bromide/albuterol sulfate
Generic
SPIRIVA
BRAND
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
theochron
Generic
theophylline anhydrous (100 mg tab er
12h, 200 mg tab er 12h, 300 mg tab er
12h, 400 mg tablet er, 450 mg tab er
12h, 600 mg tablet er)
Generic
Bronchodilators, Sympathomimetic
albuterol sulfate (0.63mg/3ml vial-neb,
1.25mg/3ml vial-neb, 2 mg tablet, 2
mg/5 ml syrup, 2.5 mg/0.5 vial-neb, 2.5
mg/3ml vial-neb, 4 mg tab er 12h, 4 mg
tablet, 5 mg/ml solution, 8 mg tab er
12h)
Generic
EPIPEN 2-PAK
BRAND
EPIPEN JR 2-PAK
BRAND
levalbuterol hcl (0.31mg/3ml,
0.63mg/3ml, 1.25mg/0.5, 1.25mg/3ml)
Generic
PROAIR HFA
Value
SEREVENT DISKUS
BRAND
terbutaline sulfate (2.5 mg tablet, 5 mg
tablet)
Generic
QL (17 GM PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
72
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
VENTOLIN HFA
Value
QL (36 GM PER 30 DAYS)
XOPENEX HFA
BRAND
Mast Cell Stabilizers
cromolyn sodium (20 mg/2 ml ampulneb, 20 mg/ml solution)
Generic
Pulmonary Antihypertensives
ADCIRCA
Specialty
PA, QL (60 PER 30 DAYS)
ADEMPAS
Specialty
PA
LETAIRIS
Specialty
PA
OPSUMIT
Specialty
PA, LA
ORENITRAM ER
Specialty
PA, LA
sildenafil citrate 20 mg tablet
Specialty
PA, QL (90 PER 30 DAYS)
TRACLEER
Specialty
PA, LA
VELETRI 0.5 MG VIAL
Specialty
VENTAVIS
Specialty
PA
Respiratory Tract Agents, Other
ANORO ELLIPTA
BRAND
benzonatate
Generic
dextromethorphan hbr/promethazine
hcl
Generic
HYPER-SAL 3.5% VIAL
BRAND
KALYDECO
Specialty
phenylephrine hcl/promethazine hcl
Generic
pulmosal
Generic
PULMOZYME
Specialty
sodium chloride for inhalation 7 % vialneb
Generic
sski
Generic
SYMBICORT
BRAND
PA, LA, QL (60 PER 30 DAYS)
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
73
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
TYZINE
BRAND
Requirements/Limits
Skeletal Muscle Relaxants
carisoprodol (250 mg tablet, 350 mg
tablet)
Generic
carisoprodol/aspirin
Generic
chlorzoxazone
Generic
cyclobenzaprine hcl (5 mg tablet, 7.5
mg tablet, 10 mg tablet)
Generic
metaxalone
Generic
methocarbamol (500 mg tablet, 750 mg
tablet)
Generic
orphenadrine citrate 100 mg tablet er
Generic
orphenadrine/aspirin/caffeine 50-77060 tablet
Generic
Sleep Disorder Agents
GABA Receptor Modulators
estazolam
Generic
eszopiclone
Generic
flurazepam hcl
Generic
temazepam
Generic
triazolam
Generic
zaleplon
Generic
QL (30 PER 30 DAYS)
zolpidem tartrate (5 mg tablet, 10 mg
tablet)
Generic
QL (30 PER 30 DAYS)
modafinil
Generic
PA, QL (30 PER 30 DAYS)
ROZEREM
BRAND
PA, QL (30 PER 30 DAYS)
XYREM
Specialty
PA, LA, QL (540 ML PER 30 DAYS)
QL (30 PER 30 DAYS)
Sleep Disorders, Other
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
74
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
Requirements/Limits
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/Mineral Modifiers
EXJADE
Specialty
kionex 15 gm/60 ml suspension
Generic
sodium polystyrene sulfonate
(15g/60ml oral susp, 30g/120ml enema,
50g/200ml enema)
Generic
sps 15 gm/60 ml suspension
Generic
SYPRINE
BRAND
Electrolyte/Mineral Replacement
cyanocobalamin (vitamin b-12)
1000mcg/ml vial
Generic
ergocalciferol (vitamin d2) 50000 unit
capsule
Generic
FLUOR-A-DAY (0.25 MG TAB, 0.5 MG
TAB, 1 MG TABLET)
BRAND
fluoride/iron/vitamins a,c,and d
Generic
fluoritab 0.5 mg tablet chew
Generic
flura-drops
Generic
klor-con 10
Generic
klor-con 8
Generic
klor-con m10
Generic
klor-con m20
Generic
levocarnitine 330 mg tablet
Generic
ludent fluoride
Generic
maternity
Generic
pediatric multivitamin combination
no.2/sodium fluoride
Generic
pediatric multivitamins a,c,& d3 no.21
with sodium fluoride
Generic
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
75
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
pediatric multivitamins no.16 with
sodium fluoride
Generic
pediatric multivitamins no.17 with
sodium fluoride
Generic
pediatric multivitamins no.82 with
sodium fluoride
Generic
pnv-vp-u
Generic
potassium chloride (8 meq capsule er, 8
meq tablet er, 10 meq capsule er, 10
meq tab er prt, 10 meq tablet er, 20
meq tab er prt, 20 meq tablet er,
20meq/15ml liquid, 40meq/15ml liquid)
Generic
potassium citrate (5 tablet er, 10 tablet
er)
Generic
prenaplus
Generic
prenatal vitamins comb no.115/iron
fumarate/folic acid
Generic
prenatal vitamins comb no.115/iron
fumarate/folic acid/dss
Generic
prenatal vitamins combo no.60/ferrous
fumarate/folic acid
Generic
prenatal vits with calcium #72/ferrous
fumarate/folic acid
Generic
prenatal vits with calcium
#72/iron,carbonyl/folic acid
Generic
prenatal vits without calc no5/ferrous
fumarate/folic acid
Generic
preplus
Generic
QUFLORA (0.25 MG/ML, 0.5 MG/ML)
BRAND
sodium fluoride (0.25(0.55) tab chew,
0.5 mg/ml drops, 0.5(1.1)mg tab chew,
1mg(2.2mg) tab chew, 1mg(2.2mg)
tablet)
Generic
TL FOLATE
BRAND
tl-fluorivite
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
76
LAST UPDATE 01/2015
Providence Health Plan Value Based Formulary
[To help find a drug see the back of the document for an alphabetical listing]
Drug Name
Status*
TRICARE
BRAND
trinatal rx 1
Generic
triveen-u
Generic
vinate one
Generic
vinate-m
Generic
vol-plus
Generic
Requirements/Limits
*Specialty medications are only available through the Providence specialty network. See introduction.
^A formulary brand drug becomes non-formulary when it becomes available as a generic drug.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
77
LAST UPDATE 01/2015
Non-Formulary Drugs That Require Prior Authorization
ABSTRAL
ACANYA
ACIPHEX SPRINKLE
ACTIQ
ACTONEL 150 MG TABLET
ACYCLOVIR 5% OINTMENT
ACZONE
ADOXA
ALTABAX
AMBIEN CR
AMITIZA
AMRIX
ANZEMET 50 MG TABLET
ANZEMET 100 MG TABLET
APLENZIN
APOKYN
ARICEPT 23 MG TABLET
ARTHROTEC 50
ARTHROTEC 75
ASTEPRO
ATELVIA
ATOVAQUONE-PROGUANIL HCL
ATRALIN
AVINZA
AZACITIDINE
AZELASTINE 0.15% NASAL SPRAY
BENICAR 20 MG TABLET
BENICAR 5 MG TABLET
BENICAR HCT
BENZACLIN GEL 50G PUMP
BENZACLIN GEL 35G PUMP
BEPREVE
BIDIL
BINOSTO
BRINTELLIX
BRISDELLE
BUTALB-ACETAMIN-CAFF 50-300-40
BUTRANS 15 MCG/HR PATCH
BUTRANS 10 MCG/HR PATCH
BUTRANS 20 MCG/HR PATCH
BUTRANS 5 MCG/HR PATCH
BYSTOLIC
CALCIPOTRIENE-BETAMETHASONE DP
CALCITRIOL 3 MCG/G OINTMENT
CAMBIA
CARDIZEM LA 120 MG TABLET
CARDURA XL
CENTANY AT
CESAMET
CIALIS 5 MG TABLET
CIMZIA
CLARINEX
CLARINEX-D 12 HOUR
CLARINEX-D 24 HOUR
CLOBEX 0.05% SPRAY
CLONIDINE HCL ER
COARTEM
COMBIGAN
CONZIP
CRESTOR
CRINONE
CYCLOSET
DALIRESP
DERMASORB HC
DERMASORB TA
DESLORATADINE
DESONATE
DESVENLAFAXINE FUMARATE ER
DEXILANT
DICLOFENAC 1.5% TOPICAL SOLN
DICLOFENAC SODIUM 3% GEL
DICLOFENAC SODIUM-MISOPROSTOL
DIFFERIN 0.1% LOTION
DIFICID
DONEPEZIL HCL 23 MG TABLET
DORYX
DOXYCYCLINE HYC DR 150 MG TAB
DOXYCYCLINE HYC DR 75 MG TAB
DOXYCYCLINE HYC DR 100 MG TAB
DOXYCYCLINE IR-DR
DOXYCYCLINE MONO 75 MG CAPSULE
DOXYCYCLINE MONO 150 MG CAP
78
DRONABINOL
DUEXIS
ECOZA
EDARBI
EDARBYCLOR
EDLUAR
ENABLEX
ENDOMETRIN
EPIDUO
EPROSARTAN MESYLATE
ESOMEPRAZOLE STRONTIUM
EXALGO
FENOFIBRATE 50 MG CAPSULE
FENOFIBRATE 150 MG CAPSULE
FENTANYL CITRATE OTFC 400 MCG
FENTANYL CIT OTFC 1
600 MCG
FENTANYL CIT OTFC 1
200 MCG
FENTANYL CITRATE OTFC 800 MCG
FENTANYL CITRATE OTFC 600 MCG
FENTANYL CITRATE OTFC 200 MCG
FENTORA
FETZIMA
FIORICET 50-300-40 MG CAPSULE
FLECTOR
FLO-PRED
FLUOCINONIDE 0.1% CREAM
FLUVOXAMINE MALEATE ER
FORFIVO XL
FORTAMET
FOSAMAX PLUS D
FOSRENOL
FYCOMPA
GELNIQUE
GLUMETZA
GRALISE
HETLIOZ
HORIZANT
HYDROMORPHONE ER
INTERMEZZO
INTUNIV
JALYN
KAPVAY
KETEK
KORLYM
LAMICTAL ODT
LAMICTAL ODT (BLUE)
LAMICTAL ODT (GREEN)
LAMICTAL ODT (ORANGE)
LASTACAFT
LAZANDA
LIPOFEN
LIPTRUZET
LIVALO
LOVAZA
LUPRON DEPOT
LUPRON DEPOT-PED
LUVOX CR
MALARONE
MARINOL
METFORMIN HCL ER 500 MG OSM-TB
METFORMIN ER 1
000 MG OSM-TAB
METOZOLV ODT
METROGEL
METRONIDAZOLE TOPICAL 1% GEL
MICARDIS
MICARDIS HCT
MIRAPEX ER
MONODOX 75 MG CAPSULE
MORGIDOX 1X100 MG KIT
MORGIDOX 2X100 MG KIT
MORPHINE SULFATE ER 45 MG CAP
MORPHINE SULFATE ER 30 MG CAP
MORPHINE SULFATE ER 75 MG CAP
MORPHINE SULFATE ER 120 MG CAP
MORPHINE SULFATE ER 60 MG CAP
MORPHINE SULFATE ER 90 MG CAP
MOZOBIL
NAMENDA XR
NATROBA
79
NEXIUM
NIACIN ER
NIASPAN
NORDITROPIN NORDIFLEX 30 MG/3
NUCYNTA
NUCYNTA ER
NUVIGIL
OCTREOTIDE ACET 50 MCG/ML SYR
OCTREOTIDE ACET 500 MCG/ML SYR
OCTREOTIDE ACET 100 MCG/ML SYR
OLEPTRO ER
OLOPATADINE HCL
OMEGA-3 ACID ETHYL ESTERS
OMNARIS
OMNITROPE 10 MG/1.5 ML CRTG
OMNITROPE 5.8 MG VIAL
ONEXTON
ONSOLIS
OPANA ER
ORACEA
ORALAIR 100 IR STARTER PACK
ORALAIR 300 IR STARTER PACK
ORBIVAN
OXECTA
OXTELLAR XR
OXYMORPHONE HCL ER
PAROXETINE CR 12.5 MG TABLET
PAROXETINE CR 25 MG TABLET
PAROXETINE ER 37.5 MG TABLET
PAROXETINE CR 37.5 MG TABLET
PATADAY
PATANASE
PAXIL CR
PENNSAID
PEXEVA
POMALYST
POTIGA
PRIMAQUINE
PRISTIQ ER
QUALAQUIN
QUININE SULFATE 324 MG CAPSULE
QUTENZA
RAPAFLO
RELISTOR
RENOVA
RENOVA PUMP
REQUIP XL
RETIN-A MICRO
RETIN-A MICRO PUMP
RISEDRONATE SODIUM
ROPINIROLE HCL ER 8 MG TABLET
ROPINIROLE HCL ER 6 MG TABLET
ROPINIROLE HCL ER 4 MG TABLET
ROPINIROLE HCL ER 2 MG TABLET
ROPINIROLE HCL ER 12 MG TABLET
ROSADAN 0.75% GEL KIT
ROSADAN 0.75% CREAM KIT
SAMSCA
SANCTURA XR
SANCUSO
SEROQUEL XR
SILENOR
SIMPONI
SIMPONI ARIA
SIMVASTATIN 80 MG TABLET
SOLARAZE
SOLODYN ER 80 MG TABLET
SOLODYN ER 105 MG TABLET
SOLODYN ER 55 MG TABLET
SOLODYN ER 65 MG TABLET
SOLODYN ER 115 MG TABLET
SORILUX
SPINOSAD
STAVZOR
SUBSYS
SUMAVEL DOSEPRO
SYNALAR 0.025% OINTMENT KIT
SYNALAR 0.025% CREAM KIT
SYNALAR TS
TACLONEX
TELMISARTAN
TELMISARTAN-AMLODIPINE
80
TELMISARTAN-HYDROCHLOROTHIAZID
TEVETEN
TEVETEN HCT
TIZANIDINE HCL 4 MG CAPSULE
TIZANIDINE HCL 2 MG CAPSULE
TIZANIDINE HCL 6 MG CAPSULE
TOPICORT 0.25% SPRAY
TOVIAZ
TRAMADOL HCL ER 150 MG CAPSULE
TRETIN-X
TRETINOIN MICROSPHERE
TREXIMET
TRIBENZOR
TROSPIUM CHLORIDE ER
TWYNSTA
TYVASO INHALATION REFILL KIT
TYVASO 1.74 MG/2.9 ML SOLUTION
TYVASO INHALATION STARTER KIT
ULORIC
ULTRAVATE X CREAM COMBO PACK
VANOS
VASCEPA
VECTICAL
VELPHORO
VELTIN
VERAMYST
VERDESO
VESICARE
VIDAZA
VIIBRYD
VIMOVO
VYTORIN
WELCHOL
XALKORI
XARTEMIS XR
XERESE
XOLEGEL
ZANAFLEX 4 MG CAPSULE
ZANAFLEX 2 MG CAPSULE
ZANAFLEX 6 MG CAPSULE
ZELAPAR
ZENZEDI 2.5 MG TABLET
ZENZEDI 15 MG TABLET
ZENZEDI 7.5 MG TABLET
ZENZEDI 20 MG TABLET
ZENZEDI 30 MG TABLET
ZETIA
ZETONNA
ZIANA
ZIPSOR
ZMAX
ZOCOR 80 MG TABLET
ZOHYDRO ER
ZOLPIDEM TARTRATE ER
ZOLPIMIST
ZORVOLEX
ZOVIRAX 5% CREAM
ZOVIRAX 5% OINTMENT
ZUPLENZ
ZYCLARA 3.75% CREAM
ZYCLARA 3.75% CREAM PUMP
81
Alphabetical Listing
A
allopurinol
24
ALOMIDE
69
abacavir sulfate
33
ALPHAGAN P
69
abacavir sulfate/lamivudine/zidovudine
33
alprazolam
36
ABILIFY
20
ALREX
69
ABILIFY DISCMELT
20
altavera
58
acamprosate calcium
9
ALVESCO
71
acarbose
36
alyacen
58
acebutolol hcl
42
amantadine hcl
30
amcinonide
10
amethia
58
amethia lo
58
acetaminophen with codeine phosphate
acetasol hc
acetazolamide
7
12
17,45
acetic acid/aluminum acetate
12
amethyst
58
acetic acid/hydrocortisone
12
amiloride hcl
45
acitretin
50
amiloride hcl/hydrochlorothiazide
45
ACTIMMUNE
66
amiodarone hcl
41
ACTONEL
67
amitriptyline hcl
21
ACTOPLUS MET XR
36
amlodipine besylate
43
acyclovir
35
amlodipine besylate/atorvastatin calcium
44
ADAGEN
52
amlodipine besylate/benazepril hcl
43
adapalene
50
amnesteem
50
ADCIRCA
73
amoxapine
21
adefovir dipivoxil
34
amoxicillin
14
ADEMPAS
73
amoxicillin/potassium clavulanate
14
ADVAIR DISKUS
70
ampicillin trihydrate
14
ADVAIR HFA
70
AMPYRA
49
AEROSPAN
71
ANADROL-50
58
afeditab cr
43
anagrelide hcl
39
AFINITOR
28
anastrozole
27
AFINITOR DISPERZ
28
ANDROGEL
58
AGGRENOX
39
ANORO ELLIPTA
73
ak-poly-bac
68
antipyrine/benzocaine
70
alagesic lq
5
anusol-hc
66
ALBENZA
29
apexicon e
10
albuterol sulfate
72
APIDRA
38
alclometasone dipropionate
10
APIDRA SOLOSTAR
38
alendronate sodium
67
apri
58
ALFERON N
66
APRISO
52
alfuzosin hcl
55
APTIOM
19
ALINIA
29
APTIVUS
33
ALKERAN
26
aranelle
58
82
ARANESP
39
benzonatate
73
ASACOL
52
benztropine mesylate
30
ASACOL HD
53
BERINERT
65
ascomp with codeine
7
betamethasone acetate/betamethasone sodium
ASMANEX
71
phosphate
56
ASMANEX HFA
71
betamethasone dipropionate
10
ASTAGRAF XL
65
betamethasone dipropionate/propylene glycol
10
atenolol
42
betamethasone valerate
10
atenolol/chlorthalidone
42
BETASERON
49
atorvastatin calcium
46
betaxolol hcl
atovaquone
29
bethanechol chloride
55
ATRIPLA
33
BETIMOL
69
ATROVENT HFA
72
BETOPTIC S
69
AUBAGIO
49
bicalutamide
64
aubra
58
bisoprolol fumarate
42
aurodex
70
bisoprolol fumarate/hydrochlorothiazide
42
auroguard
70
bleph-10
16
aviane
58
BLEPHAMIDE
68
avidoxy
16
BLEPHAMIDE S.O.P.
68
avita
50
blood sugar diagnostic
67
AVONEX
49
BOSULIF
28
AVONEX ADMINISTRATION PACK
49
BREO ELLIPTA
71
AVONEX PEN
49
briellyn
58
AZASITE
15
BRILINTA
39
azathioprine
65
brimonidine tartrate
70
bromfenac sodium
69
azelastine hcl
69,71
42,69
AZILECT
31
bromocriptine mesylate
30
azithromycin
15
BUDEPRION SR
20
AZOPT
69
BUDEPRION XL
20
azurette
58
budesonide
56,71
bumetanide
45
BUPHENYL
52
B
bacitracin
12
buprenorphine hcl
9
bacitracin/polymyxin b sulfate
68
buprenorphine hcl/naloxone hcl
9
baclofen
32
BUPROBAN
10
balsalazide disodium
66
bupropion hcl
20
balziva
58
buspirone hcl
36
BANZEL
19
butalbital/acetaminophen
5
BARACLUDE
34
butalbital/acetaminophen/caffeine
5
benazepril hcl
40
butalbital/acetaminophen/caffeine/codeine phosphate 7
benazepril hcl/hydrochlorothiazide
41
butalbital/aspirin/caffeine
83
5
butorphanol tartrate
7
cefuroxime axetil
14
BYDUREON
36
celecoxib
BYDUREON PEN
36
CELESTONE
56
BYETTA
36
CELONTIN
17
cephalexin
14
CEREZYME
52
C
5
cabergoline
64
CHANTIX
10
cafergot
25
chateal
59
calcipotriene
50
chlordiazepoxide hcl
36
calcitonin,salmon,synthetic
67
chlorhexidine gluconate
12
calcitriol
64
chloroquine phosphate
29
calcium acetate
56
chlorothiazide
46
camila
62
chlorpromazine hcl
22
camrese
59
chlorpropamide
36
camrese lo
59
chlorthalidone
46
CANASA
53
chlorzoxazone
74
candesartan cilexetil
40
cholestyramine (with sugar)
46
5
cholestyramine/aspartame
47
capacet
capecitabine
27
ciclodan
23
CAPRELSA
28
ciclopirox
23
captopril
41
ciclopirox olamine
23
captopril/hydrochlorothiazide
41
cilostazol
39
CARBAGLU
52
cimetidine
54
carbamazepine
19
cimetidine hcl
54
carbidopa
30
CIPRO HC
70
carbidopa/levodopa
31
CIPRODEX
70
carbidopa/levodopa/entacapone
30
ciprofloxacin hcl
carisoprodol
74
ciprofloxacin/ciprofloxacin hcl
15
carisoprodol/aspirin
74
citalopram hydrobromide
21
carteolol hcl
70
claravis
50
cartia xt
43
clarithromycin
15
carvedilol
42
clemastine fumarate
71
caziant
59
clinda-derm
12
CEENU
26
clindacin etz
12
cefaclor
13
clindacin p
12
cefadroxil
13
clindamycin hcl
12
cefdinir
14
clindamycin palmitate hcl
12
cefpodoxime proxetil
14
clindamycin phosphate
12
cefprozil
14
clindamycin phosphate/benzoyl peroxide
50
ceftibuten dihydrate
14
clobetasol propionate
10
CEFTIN
14
clobetasol propionate/emollient base
10
84
15,70
clodan
10
cycloserine
12
clomipramine hcl
22
cyclosporine
65
clonazepam
17
cyclosporine, modified
65
clonidine
40
cyproheptadine hcl
71
clonidine hcl
40
CYSTAGON
55
clopidogrel bisulfate
39
CYSTARAN
68
clorazepate dipotassium
17
clotrimazole
23
D
clotrimazole/betamethasone dipropionate
23
danazol
58
clozapine
32
dantrolene sodium
32
co-gesic
7
dapsone
26
codeine phosphate/butalbital/aspirin/caffeine
7
DARAPRIM
29
codeine phosphate/carisoprodol/aspirin
7
dasetta
59
codeine sulfate
7
daysee
59
colchicine/probenecid
24
DAYTRANA
48
COLCRYS
24
deblitane
62
COLESTID
47
decitabine
27
colestid
47
delyla
59
colestipol hcl
47
DELZICOL
53
COMBIPATCH
59
demeclocycline hcl
16
COMBIVENT
72
DENAVIR
35
COMBIVENT RESPIMAT
72
depade
9
COMETRIQ
28
DEPEN
55
COMPLERA
33
DEPO-SUBQ PROVERA 104
63
compro
22
desipramine hcl
22
constulose
54
desmopressin acetate
57
COPAXONE
49
desmopressin acetate (non-refrigerated)
57
COREG CR
42
desogestrel-ethinyl estradiol
59
cormax
10
desogestrel-ethinyl estradiol/ethinyl estradiol
59
cortisone acetate
10
desonide
10
CREON
52
desoximetasone
10
CRIXIVAN
33
dexamethasone
56
dexamethasone sod phosphate
69
48
cromolyn sodium
69,73
cryselle
59
dexmethylphenidate hcl
CUPRIMINE
55
dextroamphetamine sulf-saccharate/amphetamine sulf-
CUVPOSA
52
aspartate
48
cyanocobalamin (vitamin b-12)
75
dextroamphetamine sulfate
48
cyclafem
59
dextromethorphan hbr/promethazine hcl
73
cyclobenzaprine hcl
74
DIASTAT
17
cyclophosphamide capsules
26
diazepam
17
cyclophosphamide tablets
26
DICLEGIS
22
85
diclofenac potassium
diclofenac sodium
5
5,69
E
dicloxacillin sodium
14
E.E.S. 200
15
dicyclomine hcl
52
econazole nitrate
23
didanosine
33
EDECRIN
45
DIFFERIN
50
EDURANT
32
diflorasone diacetate
11
EFFIENT
40
5
EGRIFTA
57
digitek
45
ELELYSO
52
digox
45
ELIDEL
50
digoxin
45
ELIGARD
64
7
elimite
30
dihydroergotamine mesylate
25
elinest
59
DILANTIN
19
ELIQUIS
38
DILATRATE-SR
47
ELMIRON
55
dilt-cd
43
EMCYT
27
dilt-xr
43
EMEND
23
diltia xt
43
emoquette
59
diltiazem hcl
44
EMTRIVA
33
diltzac er
44
enalapril maleate
41
DIPENTUM
66
enalapril maleate/hydrochlorothiazide
41
diphenoxylate hcl/atropine sulfate
53
ENBREL
65
dipyridamole
39
endocet
7
disopyramide phosphate
41
endodan
7
diflunisal
dihydrocodeine bitartrate/acetaminophen/caffeine
disulfiram
9
enoxaparin sodium
38
divalproex sodium
17
enpresse
59
donepezil hcl
19
enskyce
59
dorzolamide hcl
70
entacapone
30
dorzolamide hcl/timolol maleate
70
entecavir
34
doxazosin mesylate
40
enulose
54
doxepin hcl
22
EPANED
41
doxercalciferol
67
EPIFOAM
50
doxycycline hyclate
16
EPIPEN 2-PAK
72
doxycycline monohydrate
16
EPIPEN JR 2-PAK
72
DROXIA
27
epitol
19
DUAVEE
59
EPIVIR HBV
34
duloxetine hcl
21
eplerenone
45
dynacin
16
EPOGEN
39
DYRENIUM
45
EPZICOM
33
EQUETRO
19
ergocalciferol (vitamin d2)
75
86
ergotamine tartrate/caffeine
25
fenofibrate,micronized
46
ERIVEDGE
28
fenofibric acid
46
errin
63
fenofibric acid (choline)
46
ERY-TAB
15
fenoprofen calcium
5
erygel
15
fentanyl
6
ERYPED 200
15
FINACEA
51
erythromycin base
15
finasteride
55
erythromycin base/benzoyl peroxide
51
fioricet
erythromycin base/ethyl alcohol
15
FIRAZYR
50
erythromycin ethylsuccinate
15
FIRST-LANSOPRAZOLE
54
erythromycin ethylsuccinate/sulfisoxazole acetyl
15
FIRST-OMEPRAZOLE
54
escitalopram oxalate
21
FLAREX
56
estarylla
59
flavoxate hcl
55
estazolam
74
flecainide acetate
41
ESTRACE
59
FLOVENT DISKUS
71
estradiol
59
FLOVENT HFA
71
estradiol/norethindrone acetate
59
fluconazole
23
ESTRING
59
fludrocortisone acetate
11
estropipate
59
flunisolide
71
eszopiclone
74
fluocinolone acetonide
11
ethambutol hcl
26
fluocinolone acetonide oil
56
ethinyl estradiol/drospirenone
60
fluocinonide
11
ethosuximide
17
fluocinonide/emollient base
11
etidronate disodium
67
FLUOR-A-DAY
75
fluoride/iron/vitamins a,c,and d
75
5
etodolac
5
EXELON
19
fluoritab
75
exemestane
28
fluorometholone
56
EXJADE
75
FLUOROPLEX
51
fluorouracil
51
fluoxetine hcl
21
fluphenazine hcl
31
EXTAVIA
49,50
F
falmina
60
flura-drops
75
famciclovir
35
flurazepam hcl
74
famotidine
54
flurbiprofen
FARESTON
27
flurbiprofen sodium
FARXIGA
36
fluticasone propionate
FAZACLO
32
fluvastatin sodium
46
felbamate
18
fluvoxamine maleate
21
felodipine
44
FML FORTE
56
fenofibrate
46
FML S.O.P.
56
fenofibrate nanocrystallized
46
FOCALIN XR
48
87
5
69
11,56
fondaparinux sodium
39
glyburide/metformin hcl
37
FORTEO
67
glycopyrrolate
52
fosinopril sodium
41
glydo
fosinopril sodium/hydrochlorothiazide
41
GOLYTELY
53
FRAGMIN
39
granisetron hcl
23
FULYZAQ
53
GRANIX
39
furosemide
45
GRASTEK
65
FUZEON
33
griseofulvin ultramicrosize
24
griseofulvin, microsize
24
G
guanfacine hcl
40,48
gabapentin
18
GABITRIL
18
GAMMAGARD S-D
66
H
GAMMAKED
66
halobetasol propionate
11
GAMUNEX-C
66
haloperidol
31
garamycin
12
haloperidol lactate
31
gatifloxacin
68
heather
63
GATTEX
53
hecoria
65
gavilyte-c
53
HEXALEN
27
gavilyte-g
53
HUMALOG
38
gavilyte-n
53
HUMALOG MIX 50-50
38
gemfibrozil
46
HUMALOG MIX 75-25
38
generlac
54
HUMATROPE
57
HUMIRA
65
gengraf
51,65
guanidine hcl
9
25
GENOTROPIN
57
HUMIRA PEDIATRIC
65
gentak
12
HUMULIN R
38
gentamicin sulfate
12
HYCAMTIN
28
gianvi
60
hydralazine hcl
47
gildagia
60
hydrochlorothiazide
46
gildess
60
hydrocodone bitartrate/acetaminophen
gildess fe
60
hydrocodone bitartrate/homatropine methylbromide 72
GILENYA
50
hydrocodone/ibuprofen
GILOTRIF
28
hydrocortisone
11,56
GLEEVEC
28
hydrocortisone butyrate
11,56
glimepiride
37
hydrocortisone valerate
56
glipizide
37
hydromet
72
glipizide/metformin hcl
37
hydromorphone hcl
GLUCAGEN
38
hydroxychloroquine sulfate
29
GLUCAGON EMERGENCY KIT
38
hydroxyurea
27
glyburide
37
hydroxyzine hcl
22
glyburide,micronized
37
hydroxyzine pamoate
22
88
8
8
8
HYPER-SAL
73
hypercare
51
I
ibandronate sodium
67
J
JAKAFI
28
jantoven
39
JANUMET
37
ibudone
8
JANUMET XR
37
ibuprofen
5
JANUVIA
37
ibuprofen/oxycodone hcl
5
jencycla
63
ICLUSIG
28
JENTADUETO
37
IMBRUVICA
28
jolessa
60
imipramine hcl
22
jolivette
63
imipramine pamoate
22
junel
60
imiquimod
27
junel fe
60
INCIVEK
34
JUVISYNC
37
INCRELEX
57
JUXTAPID
47
indapamide
46
indomethacin
5
K
INFERGEN
34
KALETRA
34
INLYTA
28
KALYDECO
73
INTELENCE
32
kariva
60
INTRON A
34
KAZANO
37
introvale
60
kelnor 1-35
60
INVEGA
31
ketoconazole
24
INVIRASE
34
ketoprofen
INVOKANA
37
ketorolac tromethamine
ipratropium bromide
72
kionex
75
ipratropium bromide/albuterol sulfate
72
klor-con 10
75
irbesartan
40
klor-con 8
75
irbesartan/hydrochlorothiazide
40
klor-con m10
75
IRESSA
28
klor-con m20
75
ISENTRESS
33
KOMBIGLYZE XR
37
isochron
47
kurvelo
60
isonarif
26
KUVAN
52
isoniazid
26
KYNAMRO
47
isosorbide dinitrate
47
isosorbide mononitrate
47
L
isradipine
44
labetalol hcl
42
ISTALOL
70
LACRISERT
68
itraconazole
24
lactulose
54
ivermectin
29
LAMISIL
24
lamivudine
89
6
6,69
33,35
lamivudine/zidovudine
33
lidocaine hcl
9
lamotrigine
18
lidocaine/prilocaine
9
LANOXIN
45
lindane
30
lansoprazole
54
liothyronine sodium
63
lansoprazole/amoxicillin trihydrate/clarithromycin
54
lisinopril
41
LANTUS
38
lisinopril/hydrochlorothiazide
41
LANTUS SOLOSTAR
38
lithium carbonate
36
larin
60
lithium citrate
36
larin fe
60
lofibra
46
latanoprost
67
lomedia 24 fe
60
LATUDA
31
lomustine
26
leena
60
lopreeza
60
leflunomide
66
lorazepam
18
lessina
60
lorazepam intensol
18
LETAIRIS
73
lorcet
8
letrozole
28
lorcet hd
8
leucovorin calcium
27
lorcet plus
8
LEUKERAN
26
lortab
8
LEUKINE
39
loryna
60
leuprolide acetate
64
losartan potassium
40
levalbuterol hcl
72
losartan potassium/hydrochlorothiazide
40
LEVATOL
42
LOTEMAX
69
LEVEMIR
38
LOTRONEX
54
LEVEMIR FLEXPEN
38
lovastatin
46
LEVEMIR FLEXTOUCH
38
low-ogestrel
60
levetiracetam
17
loxapine succinate
31
levobunolol hcl
70
ludent fluoride
75
levocarnitine
75
LUMIGAN
67
levocetirizine dihydrochloride
71
lutera
60
levofloxacin
15
LYRICA
17
levonest
60
LYSODREN
64
levonorgestrel-eth estra/ethinyl estradiol
60
lyza
63
levonorgestrel-ethinyl estradiol
60
levora-28
60
levorphanol tartrate
6
M
maprotiline hcl
20
levothroid
63
marlissa
60
levothyroxine sodium
63
MARPLAN
20
levoxyl
63
maternity
75
LEXIVA
34
MATULANE
26
LIALDA
53
matzim la
44
lidocaine
9
90
meclofenamate sodium
6
medroxyprogesterone acetate
63
midodrine hcl
40
mefloquine hcl
30
migergot
25
megestrol acetate
63
MIGRANAL
25
MEKINIST
28
millipred
11
meloxicam
6
millipred dp
11
meperidine hcl
8
mimvey
61
meperitab
8
mimvey lo
61
meprobamate
36
minitran
47
mercaptopurine
27
minocycline hcl
16
mesalamine
53
minoxidil
47
mesalamine with cleansing wipes
53
mirtazapine
20
MESNEX
27
misoprostol
54
MESTINON
25
modafinil
74
metadate er
48
MODERIBA
35
metaxalone
74
moexipril hcl
41
metformin hcl
37
moexipril hcl/hydrochlorothiazide
41
methadone hcl
6
mometasone furoate
51
methadone intensol
6
mono-linyah
61
methadose
6
mononessa
61
methazolamide
45
montelukast sodium
71
methenamine hippurate
13
MONUROL
13
methimazole
65
morgidox
16
methocarbamol
74
morphine sulfate
6,8
methotrexate sodium
27
MOVIPREP
54
methotrexate sodium/pf
27
MOXEZA
68
methoxsalen, rapid
51
moxifloxacin hcl
15
methyclothiazide
46
MULTAQ
41
methyldopa
40
mupirocin
13
methyldopa/hydrochlorothiazide
40
MYALEPT
57
methylphenidate hcl
49
mycophenolate mofetil
65
methylprednisolone
56
mycophenolate sodium
66
metipranolol
70
myorisan
51
metoclopramide hcl
22
MYRBETRIQ
32
metolazone
46
myzilra
61
metoprolol succinate
42
metoprolol tartrate
42
N
metoprolol tartrate/hydrochlorothiazide
42
nabumetone
metronidazole
13
nadolol
43
mexiletine hcl
41
nadolol/bendroflumethiazide
43
microgestin
61
naltrexone hcl
microgestin fe
61
NAMENDA
91
6
9
20
naphazoline hcl
68
NITROSTAT
47
NAPRELAN
6
nizatidine
54
naproxen
6
nora-be
63
naproxen sodium
6
NORDITROPIN
57
NASONEX
71
NORDITROPIN FLEXPRO
57
NATACYN
24
NORDITROPIN NORDIFLEX
57
nateglinide
37
norethindrone
63
necon
61
norethindrone acetate
63
nefazodone hcl
20
norethindrone acetate-ethinyl estradiol
61
neo-polycin
68
norethindrone acetate-ethinyl estradiol/ferrous
neo-polycin hc
68
fumarate
61
neomycin sulfate
12
norgestimate-ethinyl estradiol
61
norlyroc
63
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone
68
NORPACE CR
41
neomycin sulfate/bacitracin/polymyxin b
68
nortrel
61
neomycin sulfate/polymyxin b sulfate/gramicidin d
68
nortriptyline hcl
22
NORVIR
34
NOVOLOG
38
neomycin sulfate/polymyxin b
sulfate/hydrocortisone
68,70
neomycin/polymyxin b sulfate/dexamethasone
68
NOVOLOG FLEXPEN
38
neosporin
68
NOVOLOG MIX 70-30
38
NESINA
37
NOVOLOG MIX 70-30 FLEXPEN
38
NEULASTA
39
NOXAFIL
24
NEUMEGA
39
NUEDEXTA
49
NEUPOGEN
39
nulytely with flavor packs
53
nevirapine
32
NUTROPIN
57
NEXAVAR
28
NUTROPIN AQ
57
nicardipine hcl
44
NUTROPIN AQ NUSPIN
57
nifediac cc
44
NUVARING
61
nifedical xl
44
nyamyc
24
nifedipine
44
nystatin
24
nikki
61
nystatin/triamcinolone acetonide
11
NILANDRON
65
nystop
24
nimodipine
44
nisoldipine
44
O
NITRO-BID
47
ocella
61
NITRO-DUR
47
octreotide acetate
64
nitro-time
47
OCUDOX
16
nitrofurantoin
13
ofloxacin
15
nitrofurantoin macrocrystal
13
ogestrel
61
nitrofurantoin monohydrate/macrocrystals
13
olanzapine
31
nitroglycerin
47
olanzapine/fluoxetine hcl
21
92
OLYSIO
35
paroxetine hcl
21
omeprazole
55
PATANOL
69
OMEPRAZOLE+SYRSPEND SF ALKA
55
PAXIL
21
OMNITROPE
57
pedi-dri
24
ondansetron
23
pediatric multivitamin combination no.2/sodium
ondansetron hcl
23
fluoride
ONFI
18
pediatric multivitamins a,c,& d3 no.21 with sodium
ONGLYZA
37
fluoride
75
OPSUMIT
73
pediatric multivitamins no.16 with sodium fluoride
76
ORALAIR
66
pediatric multivitamins no.17 with sodium fluoride
76
oralone
11
pediatric multivitamins no.82 with sodium fluoride
76
ORAP
31
peg 3350/sod sulf/sod bicarbonate/sod
ORENITRAM ER
73
chloride/potassium chl
53
ORFADIN
52
PEGASYS
35
orphenadrine citrate
74
PEGASYS PROCLICK
35
orphenadrine citrate/aspirin/caffeine
74
PEGINTRON
35
orsythia
61
PEGINTRON REDIPEN
35
ORTHO TRI-CYCLEN LO
61
penicillin v potassium
14
OSENI
37
PENTASA
53
OTEZLA
51
pentoxifylline
45
otic care
70
perindopril erbumine
41
oxandrolone
58
periogard
13
oxaprozin
6
permethrin
30
oxazepam
36
perphenazine
23
oxcarbazepine
19
perphenazine/amitriptyline hcl
31
OXSORALEN
51
phenadoz
23
oxybutynin chloride
55
phenelzine sulfate
20
oxycodone hcl
7,8
phenobarbital
18
75
oxycodone hcl/acetaminophen
8
phenylephrine hcl/promethazine hcl
73
oxycodone hcl/aspirin
8
phenytoin
19
OXYCONTIN
7
phenytoin sodium extended
19
oxymorphone hcl
8
philith
61
PICATO
51
OXYTROL
55
P
pilocarpine hcl
50,70
PILOPINE HS
70
pacerone
42
pimtrea
61
pancrelipase 5,000
52
pindolol
43
PANRETIN
29
pioglitazone hcl
37
pantoprazole sodium
55
pioglitazone hcl/glimepiride
37
paricalcitol
64
pioglitazone hcl/metformin hcl
37
paroex
13
pirmella
61
93
piroxicam
6
probenecid
24
PLEGRIDY
50
prochlorperazine maleate
23
PLEGRIDY PEN
50
PROCRIT
39
pnv-vp-u
76
procto-pak
66
podofilox
51
proctocream-hc
67
polycin
68
PROCTOFOAM-HC
67
polymyxin b sulfate/trimethoprim
68
proctosol-hc
67
portia
61
proctozone-hc
67
potassium chloride
76
PROCYSBI
55
potassium citrate
76
progesterone,micronized
63
PRADAXA
39
PROGLYCEM
38
pramipexole di-hcl
30
PROGRAF
66
pravastatin sodium
46
PROMACTA
39
prazosin hcl
40
promethazine hcl
23
prednisolone
11
promethazine hcl/codeine
71
prednisolone acetate
69
promethazine/phenylephrine hcl/codeine
71
promethegan
23
prednisolone sod phosphate
11,69
prednisone
11
propafenone hcl
42
prednisone intensol
11
propantheline bromide
53
PREMARIN
61
propranolol hcl
43
PREMPHASE
61
propranolol hcl/hydrochlorothiazide
43
PREMPRO
61
propylthiouracil
65
prenaplus
76
PROTONIX
55
protriptyline hcl
22
PULMICORT
71
PULMICORT FLEXHALER
71
pulmosal
73
PULMOZYME
73
PURIXAN
27
PYLERA
53
pyridostigmine bromide
25
prenatal vitamins comb no.115/iron fumarate/folic
acid
76
prenatal vitamins comb no.115/iron fumarate/folic
acid/dss
76
prenatal vitamins combo no.60/ferrous fumarate/folic
acid
76
prenatal vits with calcium #72/ferrous fumarate/folic
acid
76
prenatal vits with calcium #72/iron,carbonyl/folic acid 76
prenatal vits without calc no5/ferrous fumarate/folic
Q
acid
76
quasense
62
preplus
76
QUDEXY XR
18
prevalite
47
quetiapine fumarate
32
previfem
61
QUFLORA
76
PREZISTA
34
quinapril hcl
41
PRIFTIN
26
quinapril hcl/hydrochlorothiazide
41
primidone
17
quinidine gluconate
42
PROAIR HFA
72
quinidine sulfate
42
94
QVAR
71
R
ropinirole hcl
30
rosadan
13
ROXICET
9
9
rabeprazole sodium
55
roxicet
RAGWITEK
66
ROZEREM
raloxifene hcl
63
ramipril
41
S
RANEXA
45
SABRIL
18
ranitidine hcl
54
SAIZEN
57
RAPAMUNE
66
SANDIMMUNE
66
RAVICTI
52
SANTYL
51
REBETOL
35
SAPHRIS
32
REBIF
50
SAVELLA
49
REBIF REBIDOSE
50
selegiline hcl
31
reclipsen
62
SELZENTRY
33
RECTIV
47
SENSIPAR
64
refissa
51
SEREVENT DISKUS
72
REGRANEX
51
SEROSTIM
57
RENAGEL
56
sertraline hcl
21
RENVELA
56
sevelamer carbonate
56
reprexain
9
sharobel
63
74
RESTASIS
66
SIGNIFOR
64
revia
10
sildenafil citrate
73
REVLIMID
26
silver sulfadiazine
16
REYATAZ
34
simvastatin
46
RHEUMATREX
27
sirolimus
66
RIBAPAK
35
SIRTURO
26
RIBASPHERE
35
sodium chloride for inhalation
73
RIBATAB
35
sodium chloride/sodium bicarbonate/potassium
ribavirin
35
chloride/peg
53
rifabutin
26
sodium fluoride
76
rifampin
26
sodium phenylbutyrate
52
RIFATER
26
sodium polystyrene sulfonate
75
riluzole
49
SOLTAMOX
27
rimantadine hcl
34
SOMAVERT
64
RIOMET
37
sorine
42
RISPERDAL CONSTA
32
sotalol hcl
42
risperidone
32
SOVALDI
35
RITALIN LA
49
SPIRIVA
72
rivastigmine tartrate
19
spironolactone
45
rizatriptan benzoate
25
spironolactone/hydrochlorothiazide
45
95
SPORANOX
24
TAFINLAR
28
sprintec
62
TAMIFLU
34
SPRYCEL
29
tamoxifen citrate
27
sps
75
tamsulosin hcl
55
sronyx
62
TARCEVA
29
sski
73
TARGRETIN
29
tarina fe
62
stagesic
9
stavudine
33
TASIGNA
29
STELARA
51
TAZORAC
51
STIMATE
57
taztia xt
44
STIVARGA
29
TECFIDERA
50
STRATTERA
49
temazepam
74
STRIBILD
33
temozolomide
27
SUBOXONE
9
tencon
5
SUCRAID
52
terazosin hcl
40
sucralfate
54
terbinafine hcl
24
sulfacetamide sodium
16
terbutaline sulfate
72
terconazole
24
sulfacetamide sodium/prednisolone sodium
phosphate
68
testosterone
58
sulfadiazine
16
testosterone cypionate
58
sulfamethoxazole/trimethoprim
16
testosterone enanthate
58
sulfamide
16
tetracycline hcl
16
sulfasalazine
53
TEV-TROPIN
57
sulfazine
53
THALOMID
27
sulfazine ec
53
theochron
72
theophylline anhydrous
72
sulindac
6
sumatriptan
25
THIOLA
55
sumatriptan succinate
25
thioridazine hcl
31
SUPREP
54
thiothixene
31
SUSTIVA
32
tiagabine hcl
18
SUTENT
29
ticlopidine hcl
40
syeda
62
TIKOSYN
42
SYLATRON
35
tilia fe
62
SYLATRON 4-PACK
35
timolol maleate
SYMBICORT
73
tinidazole
30
SYMLINPEN 120
37
TIVICAY
33
SYMLINPEN 60
37
tizanidine hcl
32
SYPRINE
75
TL FOLATE
76
tl-fluorivite
76
TOBI PODHALER
12
TOBRADEX
68
T
tacrolimus
51,66
96
43,70
TOBRADEX ST
68
trimethoprim
13
tobramycin
12
trimipramine maleate
22
tobramycin in 0.225 % sodium chloride
12
trinatal rx 1
77
tobramycin/dexamethasone
69
trinessa
62
TOBREX
12
triveen-u
77
6
trivora-28
62
tolmetin sodium
tolterodine tartrate
55
tropicamide
69
topiragen
18
trospium chloride
55
TRUVADA
33
topiramate
18,19
torsemide
45
TYKERB
29
TRACLEER
73
TYZEKA
35
TRADJENTA
38
TYZINE
74
tramadol hcl
7,9
tramadol hcl/acetaminophen
5
U
trandolapril
41
UCERIS
57
tranexamic acid
39
ULESFIA
30
TRANSDERM-SCOP
23
unithroid
64
tranylcypromine sulfate
20
ursodiol
53
TRAVATAN Z
67
travoprost (benzalkonium)
68
V
trazodone hcl
20
VAGIFEM
62
TRECATOR
26
valacyclovir hcl
35
VALCHLOR
27
tretinoin
29,51
tretinoin/emollient base
51
VALCYTE
34
tri-estarylla
62
valganciclovir hcl
34
tri-legest fe
62
valproic acid
18
tri-linyah
62
valproic acid (as sodium salt) (valproate sodium)
18
tri-previfem
62
valsartan
40
tri-sprintec
62
valsartan/hydrochlorothiazide
40
vancomycin hcl
13
triamcinolone acetonide
11,56
triamterene/hydrochlorothiazide
45
vandazole
13
trianex
51
vandetanib
29
triazolam
74
VELETRI
73
TRICARE
77
velivet
62
triderm
12
venlafaxine hcl
21
trifluoperazine hcl
31
VENTAVIS
73
trifluridine
35
VENTOLIN HFA
73
TRIGLIDE
46
verapamil hcl
42,44
trihexyphenidyl hcl
30
VERSACLOZ
32
trilyte with flavor packets
53
vestura
62
trimethobenzamide hcl
23
VEXOL
69
97
VICTOZA 2-PAK
38
ZENPEP
52
VICTOZA 3-PAK
38
zenzedi
48
VICTRELIS
35
zidovudine
33
VIGAMOX
69
ziprasidone hcl
VIMPAT
19
ZIRGAN
34
vinate one
77
ZOLINZA
29
vinate-m
77
zolmitriptan
25
viorele
62
zolpidem tartrate
74
VIRACEPT
34
ZOMIG
25
VIRAMUNE XR
32
zonisamide
17
VIREAD
33
ZORBTIVE
57
vitazol
13
ZORTRESS
66
vol-plus
77
zovia 1-35e
62
VOLTAREN
51
zovia 1-50e
62
voriconazole
24
ZYDELIG
28
VOTRIENT
28
ZYFLO CR
72
vyfemla
62
ZYKADIA
29
VYVANSE
48
ZYLET
69
ZYTIGA
28
ZYVOX
13
W
warfarin sodium
39
wera
62
X
XARELTO
39
XENAZINE
49
XIFAXAN
13
XOPENEX HFA
73
XTANDI
65
xulane
62
xylon 10
9
XYREM
74
Z
zafirlukast
71
zaleplon
74
zarah
62
ZAVESCA
52
ZELBORAF
29
zenatane
51
zenchent
62
98
19,32
Category Listing
Analgesics
Anesthetics
Anti-Addiction/Substance Abuse Treatment Agents
Anti-inflammatory Agents
Antibacterials
Anticonvulsants
Antidementia Agents
Antidepressants
Antiemetics
Antifungals
Antigout Agents
Antimigraine Agents
Antimyasthenic Agents
Antimycobacterials
Antineoplastics
Antiparasitics
Antiparkinson Agents
Antipsychotics
Antispasticity Agents
Antivirals
Anxiolytics
Bipolar Agents
Blood Glucose Regulators
Blood Products/Modifiers/ Volume Expanders
Cardiovascular Agents
Central Nervous System Agents
Dental and Oral Agents
Dermatological Agents
Enzyme Replacement/ Modifiers
Gastrointestinal Agents
Genitourinary Agents
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Other)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Hormonal Agents, Suppressant (Thyroid)
Immunological Agents
99
5
9
9
10
12
17
19
20
22
23
24
25
25
26
26
29
30
31
32
32
36
36
36
38
40
48
50
50
52
52
55
56
57
57
58
63
64
64
64
64
65
65
Inflammatory Bowel Disease Agents
Metabolic Bone Disease Agents
Miscellaneous
Ophthalmic Agents
Otic Agents
Respiratory Tract Agents
Skeletal Muscle Relaxants
Sleep Disorder Agents
Therapeutic Nutrients/ Minerals/ Electrolytes
66
67
67
67
70
70
74
74
75
100

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