Beta-lactam, SUPRAX TAB 400MG Suprax 400 mg cap Antibacterials Cephalosporins Beta-lactam, CEFOTAXIME INJ 10GM cefotaxime 2 gm inj Antibacterials Cephalosporins ERYTHROCIN INJ 1000MG Erythrocin 500 mg inj Antibacterials Macrolides TETRACYCLINE CAP 250MG doxycycline monohydrate cap or tab (50mg, 75mg, 100mg, 150mg), doxycycline hyclate cap (50mg, 100mg), doxycycline hyclate tab (20mg, 100mg), minocycline cap or tab (50mg, 75mg, 100mg) Antibacterials Tetracyclines TETRACYCLINE CAP 500MG doxycycline monohydrate cap or tab (50mg, 75mg, 100mg, 150mg), doxycycline hyclate cap (50mg, 100mg), doxycycline hyclate tab (20mg, 100mg), minocycline cap or tab (50mg, 75mg, 100mg) Antibacterials Tetracyclines fluconazole/inj NACL 200mg/100ml or FLUCONAZOLE/ INJ NACL 100 400mg/200mL Antifungals Antifungals EPIVIR VALCYTE SOL 10MG/ML TAB 450MG SecureBlue Formulary 2016 Master Negative Changes from 2015 to 2016 lamivudine 10mg/ml oral solution Antivirals valganciclovir 450mg tab Antivirals Anti-HIV, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) Anti-cytomegalovirus (CMV) Pg. 1 of 22
Anti-hepatitis B (HBV) BARACLUDE TAB 0.5MG entecavir 0.5 mg tab Antivirals BARACLUDE TAB 1MG entecavir 1 mg tab Antivirals Anti-hepatitis B (HBV) Anti-hepatitis B (HBV) VIRAZOLE INH 6GM check with your doctor Antivirals STROMECTOL TAB 3MG ivermectin 3mg tab Antiparasitics Anthelmintics METRONIDAZOL CAP 375MG metronidazole tab (250mg, 500mg) Antibacterials Antibacterials, VANCOMYC/DEX INJ 500MG vancomycin 500mg inj Antibacterials Antibacterials, VANCOMYC/DEX INJ 750MG vancomycin inj (500mg or 1 gm) Antibacterials Antibacterials, VANCOMYC/DEX INJ 1GM vancomycin 1 gm inj Antibacterials Antibacterials, linezolid tab* *Please note, this formulary alternative www.myprime.com or ZYVOX TAB 600MG for more information. Antibacterials Antibacterials, ZYVOX SOL 2MG/ML linezolid inj Antibacterials Antibacterials, TETANUS TOX INJ 5LF ADS check with your doctor Immunological Vaccines Pg. 2 of 22
CYTARABINE INJ 100MG Not on formulary because does not meet the definition of a Part D drug under CMS regulations Cytarabine inj* (20mg/ml, 100mg/ml) *Please note, this formulary alternative www.myprime.com or for more information. Antineoplastics Antineoplastics, Cytarabine inj* (20mg/ml, 100mg/ml) *Please note, this formulary alternative CYTARABINE INJ 1GM Not on formulary because does not meet the definition of a Part D drug under CMS regulations www.myprime.com or for more information. Antineoplastics Antineoplastics, DOCEFREZ INJ 80MG docetaxel inj Antineoplastics Antineoplastics, VINBLASTINE INJ 10MG Not on formulary because does not meet the definition of a Part D drug under CMS regulations vinblastine 1mg/ml* *Please note, this formulary for more information. Antineoplastics Antineoplastics, Pg. 3 of 22
ANDROGEL GEL 1%(25MG) ANDROGEL GEL 1%(50MG) ANDROGEL GEL PUMP 1% Androderm* *Please note, this formulary alternative www.myprime.com or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androderm* *Please note, this formulary alternative www.myprime.com or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androderm* *Please note, this formulary alternative www.myprime.com or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androgens Androgens Androgens Pg. 4 of 22
ANDROGEL GEL 1.62% ANDROGEL GEL 1.62% Androderm* *Please note, this formulary alternative www.myprime.com or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androderm* *Please note, this formulary alternative www.myprime.com or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ for more information. Modifiers) Androgens Androgens Androderm* *Please note, this formulary alternative www.myprime.com or Hormonal, Stimulant/ Replacement/ Modifying (Sex Hormones/ ANDROGEL GEL 1.62% for more information. Modifiers) Therapeutic Nutrients/ LEVOCARNITIN TAB 330MG check with your doctor Minerals/ Electrolytes LEVOCARNITIN SOL 1GM/10ML check with your doctor Therapeutic Nutrients/ Minerals/ Electrolytes Androgens Therapeutic Nutrients/ Minerals/ Electrolytes Therapeutic Nutrients/ Minerals/ Electrolytes Pg. 5 of 22
PROPRANOLOL TAB 60MG PROPRANOLOL CAP 60MG ER PROPRANOLOL CAP 80MG ER PROPRANOLOL CAP 120MG ER PROPRANOLOL CAP 160MG ER BISOPROL FUM TAB 5MG BISOPROL FUM TAB 10MG CANDESARTAN TAB 4MG CANDESARTAN TAB 8MG CANDESARTAN TAB 16MG CANDESARTAN TAB 32MG EPROSART MES TAB 600MG BENICAR TAB 5MG propranolol 10mg, 20mg, 40mg or 80mg tab propranolol 10mg, 20mg, 40mg or 80mg tab propranolol 10mg, 20mg, 40mg or 80mg tab propranolol 10mg, 20mg, 40mg or 80mg tab propranolol 10mg, 20mg, 40mg or 80mg tab acebutolol, atenolol, metoprolol tartrate or metoprolol succinate ER acebutolol, atenolol, metoprolol tartrate or metoprolol succinate ER irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Beta-adrenergic Blocking Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists Pg. 6 of 22
BENICAR TAB 20MG BENICAR TAB 40MG irbesartan, losartan potassium, telmisartan or valsartan irbesartan, losartan potassium, telmisartan or valsartan AZOR TAB 5-20MG amlodipine/valsartan AZOR TAB 5-40MG amlodipine/valsartan AZOR TAB 10-20MG amlodipine/valsartan AZOR TAB 10-40MG amlodipine/valsartan EXFORGE TAB 5-160MG amlodipine/valsartan tab EXFORGE TAB 5-320MG amlodipine/valsartan tab EXFORGE TAB 10-160MG amlodipine/valsartan tab EXFORGE TAB 10-320MG amlodipine/valsartan tab irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi CANDESA/HCTZ TAB 16-12.5 de Angiotensin II Receptor Antagonists Angiotensin II Receptor Antagonists,,,,,,,,, Pg. 7 of 22
CANDESA/HCTZ TAB 32-12.5 CANDESA/HCTZ TAB 32-25MG BENICAR HCT TAB 20-12.5 BENICAR HCT TAB 40-12.5 irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de,,,, Pg. 8 of 22
BENICAR HCT TAB 40-25MG EXFORGEH/5- TAB 160-12.5 EXFORGEH/5- TAB 160-25 EXFORGEH/10- TAB 160-12.5 EXFORGEH/10- TAB 160-25 EXFORGEH/10- TAB 320-25 TRIBENZOR20- TAB 5-12.5MG TRIBENZOR40- TAB 5-12.5MG TRIBENZOR40- TAB 5-25MG TRIBENZOR40- TAB 10-12.5 TRIBENZOR40- TAB 10-25MG irbesartan/hydrochlorothiazi de, losartan/hydrochlorothiazid e, telmisartan/hydrochlorothia zide or valsartan/hydrochlorothiazi de amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab amlodipine/valsartan/hydro chlorothiazide tab,,,,,,,,,,, WELCHOL TAB 625MG cholestyramine powder, cholestyramine lite powder, Prevalite or colestipol Blood Glucose Regulators Antidiabetic Respiratory Tract/ CLEMASTINE TAB 2.68MG levocetirizine Pulmonary Antihistamines Pg. 9 of 22
NASONEX SPR 50MCG/AC ASTEPRO SPR 0.15% flunisolide or fluticasone nasal spray azelastine nasal spray Respiratory Tract/ Pulmonary Respiratory Tract/ Pulmonary Anti-inflammatories, Inhaled Corticosteroids Antihistamines ALBUTEROL TAB 4MG ER albuterol immediate release tab or terbutaline tab Respiratory Tract/ Pulmonary Bronchodilators, Sympathomimetic ALBUTEROL TAB 8MG ER KALYDECO TAB 150MG authorization KALYDECO PAK 50MG authorization KALYDECO PAK 75MG authorization NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR NEXIUM GRA 20MG DR NEXIUM GRA 40MG DR NEXIUM CAP 20MG NEXIUM CAP 20MG NEXIUM CAP 40MG NEXIUM CAP 40MG albuterol immediate release Respiratory Tract/ Bronchodilators, tab or terbutaline tab Pulmonary Sympathomimetic Respiratory Tract/ check with your doctor Pulmonary Cystic Fibrosis Respiratory Tract/ check with your doctor Pulmonary Cystic Fibrosis Respiratory Tract/ check with your doctor Pulmonary Cystic Fibrosis omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors omeprazole cap or pantoprazole tab Gastrointestinal Proton Pump Inhibitors Pg. 10 of 22
GRANISETRON TAB 1MG ondansetron (regular, ODT) tab* *Please note, this formulary alternative www.myprime.com or for more information. Antiemetics Emetogenic Therapy Adjuncts ONDANSETRON SOL 4MG/5ML LOTRONEX LOTRONEX TAB 0.5MG TAB 1MG ondansetron (regular, ODT) tab* *Please note, this formulary alternative www.myprime.com or for more information. Antiemetics Emetogenic Therapy Adjuncts Irritable Bowel Syndrome alosetron Gastrointestinal Irritable Bowel Syndrome alosetron Gastrointestinal authorization check with your doctor Antibacterials Antibacterials, NITROFURANTN CAP 100MG TERCONAZOLE SUP 80MG terconazole cream Antifungals Antifungals ZAZOLE SUP 80MG terconazole cream Antifungals Antifungals Pg. 11 of 22
ALPRAZOLAM TAB 0.25MG buspirone tab, clorazepate tab*, diazepam tab*, lorazepam tab* *Please note, these formulary alternatives require prior for more information. Anxiolytics Anxiolytics ALPRAZOLAM TAB 0.5MG buspirone tab, clorazepate tab*, diazepam tab*, lorazepam tab* *Please note, these formulary alternatives require prior for more information. Anxiolytics Anxiolytics Pg. 12 of 22
ALPRAZOLAM TAB 1MG buspirone tab, clorazepate tab*, diazepam tab*, lorazepam tab* *Please note, these formulary alternatives require prior for more information. Anxiolytics Anxiolytics ALPRAZOLAM TAB 2MG SEROQUEL XR TAB 50MG SEROQUEL XR TAB 150MG buspirone tab, clorazepate tab*, diazepam tab*, lorazepam tab* *Please note, these formulary alternatives require prior for more information. Anxiolytics Anxiolytics If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical Pg. 13 of 22
SEROQUEL XR TAB 200MG SEROQUEL XR TAB 300MG SEROQUEL XR TAB 400MG If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical ABILIFY TAB 2MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical ABILIFY TAB 5MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical Pg. 14 of 22
ABILIFY TAB 10MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical ABILIFY TAB 15MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical ABILIFY TAB 20MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical Pg. 15 of 22
ABILIFY TAB 30MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical ABILIFY SOL 1MG/ML ABILIFY INJ 9.75MG aripiprazole oral solution* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical Geodon inj* or olanzapine inj* *Please note, these formulary alternatives require prior authorization. www.myprime.com or for more information. Antipsychotics 2nd Generation/Atypical Pg. 16 of 22
ABILIFY DISC TAB 15MG ESZOPICLONE TAB 1MG ESZOPICLONE TAB 2MG ESZOPICLONE TAB 3MG ZALEPLON CAP 5MG ZALEPLON CAP 10MG aripiprazole tab* *Please note, this formulary for more information. Antipsychotics 2nd Generation/Atypical authorization check with your doctor Sleep Disorder GABA Receptor Modulators authorization check with your doctor Sleep Disorder GABA Receptor Modulators authorization check with your doctor Sleep Disorder GABA Receptor Modulators authorization check with your doctor Sleep Disorder GABA Receptor Modulators authorization check with your doctor Sleep Disorder GABA Receptor Modulators EXELON DIS 4.6MG/24 rivastigmine cap (1.5mg, 3mg, 4.5mg, 6mg), donepezil or memantine* *Please note, this formulary for more information. Antidementia Cholinesterase Inhibitors Pg. 17 of 22
EXELON DIS 9.5MG/24 rivastigmine cap (1.5mg, 3mg, 4.5mg, 6mg), donepezil or memantine* *Please note, this formulary for more information. Antidementia Cholinesterase Inhibitors EXELON DIS 13.3/24 MEMANTINE TAB HCL 5MG MEMANTINE HC TAB 10MG rivastigmine cap (1.5mg, 3mg, 4.5mg, 6mg), donepezil or memantine* *Please note, this formulary for more information. Antidementia Cholinesterase Inhibitors authorization check with your doctor Antidementia authorization check with your doctor Antidementia N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist Pg. 18 of 22
MEMANT TITRA PAK 5-10MG NAMENDA SOL 10MG/5ML NAMENDA XR CAP 7MG NAMENDA XR CAP 14MG NAMENDA XR CAP 21MG NAMENDA XR CAP 28MG NAMENDA XR CAP TITRATIO FLURBIPROFEN TAB 50MG FLURBIPROFEN TAB 100MG authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia authorization check with your doctor Antidementia diclofenac, etodolac, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac or tolmetin Analgesics diclofenac, etodolac, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac or tolmetin Analgesics N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist N-methyl-D-aspartate (NMDA) Receptor Antagonist Nonsteroidal Antiinflammatory Drugs Nonsteroidal Antiinflammatory Drugs Pg. 19 of 22
LEVETIRACETA INJ 5MG/ML LEVETIRACETA INJ 10MG/ML LEVETIRACETA INJ 15MG/ML levetiracetam 500mg/5mL inj Anticonvulsants Anticonvulsants, levetiracetam 500mg/5mL inj Anticonvulsants Anticonvulsants, levetiracetam 500mg/5mL inj Anticonvulsants Anticonvulsants, AMANTADINE TAB 100MG amantadine 100mg cap Antiparkinson Antiparkinson, CYCLOBENZAPR TAB 5MG tizanidine tab, baclofen tab or a prescription generic oral NSAID, such as, ibuprofen, meloxicam, naproxen, nabumetone Skeletal Muscle Relaxants Skeletal Muscle Relaxants METHOCARBAM TAB 500MG tizanidine tab, baclofen tab or a prescription generic oral NSAID, such as, ibuprofen, meloxicam, naproxen, nabumetone Skeletal Muscle Relaxants Skeletal Muscle Relaxants METHOCARBAM TAB 750MG tizanidine tab, baclofen tab or a prescription generic oral NSAID, such as, ibuprofen, meloxicam, naproxen, nabumetone Skeletal Muscle Relaxants Skeletal Muscle Relaxants POT CHLORIDE CAP 10MEQ ER potassium chloride 10mEq tab Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Replacement Pg. 20 of 22
LIPOSYN III INJ 30% Not on formulary because does not meet the definition of a Part D drug under CMS regulations VIGAMOX DRO 0.5% LEVOBUNOLOL SOL 0.25% OP RESTASIS EMU 0.05% PATANOL SOL 0.1% OP CLINDAMYCIN SOL 1% fat emulsion 20%* *Please note, this formulary Therapeutic Nutrients/ for more information. Minerals/ Electrolytes ciprofloxacin solution, gentamicin solution, ofloxacin solution or Therapeutic Nutrients/ Minerals/ Electrolytes tobramycin solution Antibacterials Quinolones betaxolol 0.5%, carteolol 1%, levobunolol 0.5%, metipranolol 0.3%, timolol 0.25% or timolol 0.5% Ophthalmic Ophthalmic Antiglaucoma authorization check with your doctor Ophthalmic Ophthalmic, azelastine 0.05%, cromolyn sodium 4%, epinastine 0.05% or Pataday Ophthalmic erythromycin 2% solution, sulfacetamide 10% lotion or Ophthalmic Anti-allergy suspension Antibacterials Antibacterials, erythromycin 2% solution, sulfacetamide 10% lotion or suspension Antibacterials Antibacterials, CLINDAMAX GEL 1% erythromycin 2% solution, sulfacetamide 10% lotion or CLINDAMYCIN GEL 1% suspension Antibacterials Antibacterials, CARAC CRE 0.5% fluorouracil 5% cream Dermatological Dermatological Pg. 21 of 22
On formulary, quantity limit max of 90 patches per 30 LIDOCAINE PAD 5% may apply days Anesthetics Local Anesthetics ULESFIA LOT 5% malathion or permethrin Antiparasitics Pediculicides/Scabicides GLUCAGEN INJ 1MG Glucagen inj 1mg hypokit Blood Glucose Regulators Glycemic CELLCEPT SUS 200MG/ML mycophenolate mofetil suspension* *Please note, this formulary alternative www.myprime.com or for more information. Immunological Immune Suppressants Pg. 22 of 22