WVCH Formulary Additions Effective 01/01/2016 Name Strength Dosage Form Route Formulary Restrictions ANORO ELLIPTA 62.5-25MCG BLST W/DEV INHALATION ARCAPTA NEOHALER 75 MCG CAP W/DEV INHALATION CALCIPOTRIENE CREAM/LOTION/SOLUTION TOPICAL PA COSENTYX 150MG/ML INJECTION INJECTION PA, SPEC CYPROHEPTADINE HCL 2 MG/5 ML SYRUP ORAL CYPROHEPTADINE HCL 4 MG TABLET ORAL HARVONI 90MG-400MG TABLET ORAL PA, SPEC INCRUSE ELLIPTA 62.5 MCG BLST W/DEV INHALATION MOMETASONE 0.10% CREAM/LOTION TOPICAL PA PROAIR RESPICLICK 90 MCG HFA AER AD INHALATION QL 17 g (2 devices) per 25 days PULMICORT FLEXHALER 90 MCG, 180 MCG AER POW BA INHALATION SORIATANE VARIOUS CAPSULES ORAL PA SOVALDI 400 MG TABLET ORAL PA, SPEC SPIRIVA RESPIMAT 2.5 MCG MIST INHAL INHALATION STELARA 45 MG, 90 MG INJECTION INJECTION PA, SPEC STIOLTO RESPIMAT 2.5-2.5MCG MIST INHAL INHALATION STRIVERDI RESPIMAT 2.5 MCG MIST INHAL INHALATION SYMBICORT 80-4.5MCG, 160-4.5MCG HFA AER AD INHALATION PA, NSO TUDORZA PRESSAIR 400 MCG AER POW BA INHALATION CRESTOR 5MG, 10MG, 20MG, 40MG TABLETS ORAL PA ZETIA 10MG TABLETS ORAL PA PRALUENT 75MG/ML, 150MG/ML INJECTION INJECTION PA REPATHA 140MG/ML INJECTION INJECTION PA, QL ESTRADIOL VARIOUS PATCH TOPICAL
WVCH Formulary Changes Effective 01/01/2016 Name Strength Dosage Form Route Change BETAMETHASONE/PROPYLENE GLYCOL (DIPROLENE) 0.05% LOTION TOPICAL PA REQUIRED CLOBETASOL PROPIONATE 0.05% SHAMPOO/LOTION/FOAM TOPICAL PA REQUIRED DILANTIN 30 MG CAPSULE ORAL PA REMOVED DULERA 100-5 MCG, 200-5 MCG HFA AER AD INHALATION PA, NSO FLUOCINONIDE 0.05% GEL/OINTMENT/SOLUTION TOPICAL PA REQUIRED MONTELUKAST SODIUM 4 MG GRAN PACK ORAL PA REQUIRED MONTELUKAST SODIUM 4 MG, 5 MG TAB CHEW ORAL PA REQUIRED MONTELUKAST SODIUM 10 MG TABLET ORAL PA REQUIRED NABUMETONE 500 MG, 750 MG TABLET ORAL PA REMOVED NYSTATIN 100000/ML ORAL SUSP ORAL PA REMOVED PROAIR HFA 90 MCG HFA AER AD INHALATION QL 17 g (2 devices) per 25 days TOPIRAMATE 25 MG, 50 MG, 100 MG, 200 MG TABLET ORAL PA REMOVED TOPIRAMATE 15 MG, 25 MG CAP SPRINK ORAL PA REMOVED VENTOLIN HFA 90 MCG HFA AER AD INHALATION QL 36 g (2 devices) per 25 days TRUVADA 200MG-300MG TABLET ORAL PA REMOVED
WVCH Formulary Removals Effective 01/01/2016 Name Strength Dosage Form Route ACNE CLEANSING BAR 10 % BAR TOPICAL ALA-HIST AC 7.5-10MG/5 LIQUID ORAL ALBUTEROL SULFATE 2 MG, 4 MG TABLET ORAL ALBUTEROL SULFATE 4 MG, 8 MG TAB ER 12H ORAL ALBUTEROL SULFATE 2 MG/5 ML SYRUP ORAL ALBUTEROL SULFATE 5 MG/ML SOLUTION INHALATION ARTHROTEC 50 MG-200, 75 MG-200 TAB IR DR ORAL ASPIRIN EC 975 MG TABLET DR ORAL AVALIDE 300MG-25MG TABLET ORAL AVEENO 1 % CREAM (G) TOPICAL BACITRACIN-POLYMYXIN PACKET TOPICAL BAZA CLEAR 96 % OINT. (G) TOPICAL BELLADONNA-PHENOBARBITAL 16.2 MG TABLET ORAL BENZOYL PEROXIDE 2.5%, 5%, 6%, 7%, 10 % CLEANSER TOPICAL BENZOYL PEROXIDE 2.5 %, 4%, 5%, 8% GEL (GRAM) TOPICAL BETAMETHASONE DIPROPRIONATE VARIOUS TOPICAL BETAMETHASONE VALERATE VARIOUS TOPICAL BORO-PACKS 51 %-49 % POWD PACK TOPICAL CELLCEPT 200 MG/ML SUSP RECON ORAL CIPROFLOXACIN ER 500 MG, 1000 MG TBMP 24HR ORAL CLINDACIN P/CLINDACIN PAC 1 % MED. SWAB/KIT TOPICAL CLINDAMYCIN PHOSPHATE 150 MG/ML VIAL INJECTION CLINDAMYCIN PHOSPHATE-D5W 300MG, 600 MG, 900 MG PIGGYBACK INTRAVEN. DARAPRIM 25 MG TABLET ORAL DEXPAK 1.5MG (51) TAB DS PK ORAL DEXTROMETHORPHAN-CONTAINING PRODUCTS VARIOUS LIQUID/TABLETS ORAL DIHYDROERGOTAMINE MESYLATE 1 MG/ML AMPUL INJECTION DILANTIN 50 MG TAB CHEW ORAL DILTIAZEM HCL 5 MG/ML VIAL INTRAVEN.
ERGOTAMINE-CAFFEINE 1 MG-100MG TABLET ORAL Continued Formulary Removals Effective 01/01/2016 ERYTHROMYCIN-SULFISOXAZOLE 200-600/5 SUSP RECON ORAL FLUCYTOSINE 250 MG, 500 MG CAPSULE ORAL FLUOROPLEX 1 % CREAM (G) TOPICAL FORTICAL 200/SPRAY SPRAY/PUMP NASAL FOSAMAX 70 MG/75ML SOLUTION ORAL FRAGMIN 25000/ML VIAL SUBCUTANE. GANCICLOVIR 250 MG, 500 MG CAPSULE ORAL GARAMYCIN 0.3 % OINT. (G) OPHTHALMIC GAVILAX 17G/DOSE POWDER ORAL GRIFULVIN V 500 MG TABLET ORAL GRIS-PEG 125 MG, 250 MG TABLET ORAL GUAIFENESIN VARIOUS TABLETS/LIQUID ORAL HEPARIN SODIUM IN 0.45% NACL 25000/250 IV SOLN INTRAVEN. HEPARIN SODIUM-0.9% NACL VARIOUS IV SOLN INTRAVEN. HEPARIN SODIUM-D5W 20K/500ML IV SOLN INTRAVEN. HYDROCORTISONE 100MG/60ML ENEMA RECTAL HYDROCORTISONE ACETATE 2 % GEL (GRAM) TOPICAL HYDROCORTISONE ACETATE/ALOE VARIOUS TOPICAL HYDROCORTISONE ACETATE/UREA VARIOUS TOPICAL HYDROCORTISONE BUTYRATE VARIOUS TOPICAL HYDROCORTISONE VALERATE VARIOUS TOPICAL ILOTYCIN 5 MG/G OINT. (G) OPHTHALMIC IMITREX 5 MG, 20 MG SPRAY NASAL INDOCIN 25 MG/5 ML ORAL SUSP ORAL INDOCIN 50 MG SUPP.RECT RECTAL INNOHEP 20000/ML VIAL SUBCUTANE. INTRON A VARIOUS VIAL INJECTION LACTASE 3000 UNIT TABLET ORAL LEVOFLOXACIN 25 MG/ML VIAL INTRAVEN. MACRODANTIN 25 MG CAPSULE ORAL MACRODANTIN 25 MG CAPSULE ORAL
MEDI-BROM 5-15-1MG/5 ELIXIR ORAL Continued Formulary Removals Effective 01/01/2016 MIGERGOT 2-100MG SUPP.RECT RECTAL MIRVASO 0.33 % GEL (GRAM) TOPICAL MORGIDOX 100 MG CAPSULE/KIT ORAL NAMENDA 10 MG/5 ML SOLUTION ORAL NAMENDA 5 MG-10 MG TAB DS PK ORAL NEBUPENT 300 MG VIAL-NEB INHALATION NEO-POLYCIN 3.5MG-400 OINT. (G) OPHTHALMIC NYSTATIN 150MM UNIT POWDER(EA) MISCELL. ON-THE-SPOT 2.5 % CREAM (G) TOPICAL PAIN RELIEF 162-110MG TABLET ORAL PENTAM 300 300 MG VIAL INJECTION POVIDONE-IODINE 10 % OINT. (G) TOPICAL PRIMAQUINE 26.3 MG TABLET ORAL PROCAINAMIDE HCL 250MG TABLET SA ORAL PROMETHAZINE HCL 50 MG/ML AMPUL INJECTION PROMETHAZINE VC 5-6.25MG/5 SYRUP ORAL PROPANTHELINE BROMIDE 15 MG TABLET ORAL PROVENTIL HFA 90 MCG HFA AER AD INHALATION PULMICORT 1 MG/2 ML AMPUL-NEB INHALATION QUINIDINE GLUCONATE 324 MG TABLET ER ORAL QUINIDINE SULFATE 300 MG TABLET/ER ORAL REBETOL 40 MG/ML SOLUTION ORAL REGRANEX 0.01 % GEL (GRAM) TOPICAL RELENZA 5 MG BLST W/DEV INHALATION SODIUM SULFACETAMIDE-SULFUR 8 %-4 % SUSPENSION TOPICAL THEOPHYLLINE 80 MG/15ML ELIXIR ORAL VEXOL 1 % DROPS SUSP OPHTHALMIC VITAMIN E OIL TOPICAL