anti-infectives - ascellahealth hcl meropenem [inj] methenamine hippurate methenamine mandelate...

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2016 Enhanced Formulary The 2016 AscellaHealth Enhanced Formulary list is listed below. Last updated October 2015 and subject to change at any time. Inclusion on this list does not guarantee coverage. Coverage is based on your specific benefit plan. KEY: [INJ], [inj] - Injectable Drug [OTC], [otc] - Over the Counter [SP], [sp] - Specialty Drug Brand name drugs are listed in CAPITAL letters. Example: ABILIFY. Generic drugs are listed in lower-case letters. Example: altavera Generic medications contain the same active ingredients as their corresponding brand- name medications, though they may appear different in shape and color. They have been FDA- approved under strict standards. Anti-Infectives abacavir [sp] ACETIC ACID/OXYQUINOLINE acyclovir acyclovir [inj] adefovir dipivoxil ALBENZA ALINIA amantadine hcl AMBISOME [INJ] amikacin [inj] amoxicillin amoxicillin-clavulanate er amphotericin [inj] ampicillin [inj] ampicillin/sulbactam [inj] APTIVUS [SP] atovaquone atovaquone-proguanil hcl ATRIPLA [INJ] AUGMENTIN 125-31.25 MG/5ML AVELOX AVELOX IV [INJ] AVYCAZ AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] azithromycin [inj] azithromycin [sp] aztreonam [inj] bacitracin [inj] BETHKIS BICILLIN C-R [INJ] BICILLIN L-A [INJ] CANCIDAS [INJ] CAPASTAT SULFATE [INJ] CAYSTON [SP] cefaclor cefazolin [inj] cefazolin/dextrose [inj] cefdinir cefepime [inj] cefepime/dextrose [inj] cefotaxime [inj] cefotetan [inj] cefoxitin [inj] cefoxitin/dextrose [inj] cefpodoxime proxetil cefprozil CEFTAZIDIME ceftazidime [inj] ceftibuten ceftriaxone [inj] ceftriaxone/dextrose [inj] cefuroxime axetil cefuroxime sodium cefuroxime sodium [inj] CEFUROXIME SODIUM 75 G [INJ] cephalexin chloramphenicol [inj] chloroquine phosphate cidofovir [inj] ciprofloxacin ciprofloxacin er ciprofloxacin/dextrose [inj] ciprofloxacin suspension clarithromycin clarithromycin er clindamycin hcl clindamycin palmitate hcl clindamycin phosphate [inj] clindamycin phosphate/dextrose [inj] clotrimazole COARTEM colistimethate [inj] COMPLERA [SP] CRESEMBA CRIXIVAN [SP] CUBICIN [INJ] DALVANCE [INJ] DAPSONE DARAPRIM

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2016 Enhanced Formulary

The 2016 AscellaHealth Enhanced Formulary list is listed below. Last updated October 2015 and subject to change at any time. Inclusion on this list does not guarantee coverage. Coverage is based on your specific benefit plan.

KEY: [INJ], [inj] - Injectable Drug [OTC], [otc] - Over the Counter [SP], [sp] - Specialty Drug Brand name drugs are listed in CAPITAL letters. Example: ABILIFY. Generic drugs are listed in lower-case letters. Example: altavera

Generic medications contain the same active ingredients as their corresponding brand-name medications, though they may appear different in shape and color. They have been FDA-approved under strict standards.

Anti-Infectives

abacavir [sp]

ACETIC

ACID/OXYQUINOLINE

acyclovir

acyclovir [inj]

adefovir dipivoxil

ALBENZA

ALINIA

amantadine hcl

AMBISOME [INJ]

amikacin [inj]

amoxicillin

amoxicillin-clavulanate er

amphotericin [inj]

ampicillin [inj]

ampicillin/sulbactam [inj]

APTIVUS [SP]

atovaquone

atovaquone-proguanil hcl

ATRIPLA [INJ]

AUGMENTIN 125-31.25

MG/5ML

AVELOX

AVELOX IV [INJ]

AVYCAZ

AZACTAM-ISO-OSMOTIC

DEXTROSE [INJ]

azithromycin [inj]

azithromycin [sp]

aztreonam [inj]

bacitracin [inj]

BETHKIS

BICILLIN C-R [INJ]

BICILLIN L-A [INJ]

CANCIDAS [INJ]

CAPASTAT SULFATE [INJ]

CAYSTON [SP]

cefaclor

cefazolin [inj]

cefazolin/dextrose [inj]

cefdinir

cefepime [inj]

cefepime/dextrose [inj]

cefotaxime [inj]

cefotetan [inj]

cefoxitin [inj]

cefoxitin/dextrose [inj]

cefpodoxime proxetil

cefprozil

CEFTAZIDIME

ceftazidime [inj]

ceftibuten

ceftriaxone [inj]

ceftriaxone/dextrose [inj]

cefuroxime axetil

cefuroxime sodium

cefuroxime sodium [inj]

CEFUROXIME SODIUM 75

G [INJ]

cephalexin

chloramphenicol [inj]

chloroquine phosphate

cidofovir [inj]

ciprofloxacin

ciprofloxacin er

ciprofloxacin/dextrose [inj]

ciprofloxacin suspension

clarithromycin

clarithromycin er

clindamycin hcl

clindamycin palmitate hcl

clindamycin phosphate

[inj]

clindamycin

phosphate/dextrose [inj]

clotrimazole

COARTEM

colistimethate [inj]

COMPLERA [SP]

CRESEMBA

CRIXIVAN [SP]

CUBICIN [INJ]

DALVANCE [INJ]

DAPSONE

DARAPRIM

2016 Enhanced Formulary

demeclocycline hcl

dicloxacillin sodium

didanosine

DORIBAX

doxycycline hyclate

doxycycline hyclate [inj]

doxycycline monohydrate

EDURANT

EMTRIVA

entecavir

EPIVIR HBV SOLUTION

EPIVIR SOLUTION

ERYTHROCIN

LACTOBIONATE [INJ]

erythromycin

erythromycin del-rel

erythromycin

ethylsuccinate

erythromycin stearate

erythromycin

w/sulfisoxazole

ethambutol hcl

famciclovir

fluconazole, in dextrose,

saline

flucytosine

FORTAZ IN ISO-OSMOTIC

DEXTROSE [INJ]

foscarnet sodium

FUZEON [INJ]

ganciclovir

gentamicin sulfate [inj]

gentamicin sulfate in ns

GENTAMICIN SULFATE IN

NS 100 MG/0.1l [INJ]

griseofulvin

griseofulvin ultramicrosize

HARVONI

hydroxychloroquine

sulfate

imipenem-cilastatin [inj]

INTELENCE

INVANZ [INJ]

INVIRASE

ISENTRESS

isoniazid

isoniazid [inj]

itraconazole

KALETRA

kanamycin sulfate [inj]

ketoconazole

LAMISIL

lamivudine

lamivudine-zidovudine

levofloxacin hemihydrate

levofloxacin hemihydrate

[inj]

levofloxacin-d5w [inj]

LEXIVA

mefloquine hcl

meropenem [inj]

methenamine hippurate

methenamine mandelate

methylene blue [inj]

metronidazole

metronidazole [inj]

MINOCIN

minocycline hcl, er

moxifloxacin hcl

MYCAMINE [INJ]

nafcillin dextrose [inj]

nafcillin sodium [inj]

NEBUPENT [INJ]

neomycin sulfate

nevirapine, er

nitrofurantoin

nitrofurantoin

macrocrystal

NORVIR

NOXAFIL

nystatin tablet

ocudox

ofloxacin tablets

ORACEA

ORABACTIV [INJ]

oxacillin sodium [inj]

1g/50ml

oxacillin sodium [inj]

paromomycin sulfate

penicillin g potassium [inj]

penicillin g procaine

penicillin g sodium [inj]

PENICILLIN GK-ISO-OSM

DEXTROSE

penicillin v potassium

piperacillin-tazobactam

[inj]

polymyxin b sulfate [inj]

PREZISTA

PRIFTIN

PRIMAQUINE

pyrazinamide

quinine sulfate

RAPIVAB

RELENZA

RESCRIPTOR

RETROVIR [INJ]

REYATAZ

ribavirin

rifabutin

RIFADIN

RIFADIN[INJ]

rimantadine hcl

SELZENTRY

SIRTURO

SIVEXTRO [INJ]

SYLVANT [INJ]

SOLODYN 55, 65, 80, 105,

115MG ER

SOVALDI

SPORANOX

stavudine

2016 Enhanced Formulary

STREPTOMYCIN SULFATE

[INJ]

STRIBILD

STROMECTOL

sulfadiazine

sulfamethoxazole/trimeth

oprim

sulfamethoxazole/trimeth

oprim [inj]

SUSTIVA

SYNERCID [INJ]

TEFLARO [INJ]

terbinafine

TETRACYCLINE

TIMENTIN [INJ]

tinidazole

TIVICAY

TOBI PODHALER

tobramycin sulfate [inj]

trimethoprim

TRIUMEQ

TRUVADA

TYGACIL [INJ]

TYZEKA

valacyclovir

valganciclovir hcl

vancomycin hcl [inj]

VIBATIV [INJ]

VICTRELIS

VIDEX

VIRACEPT

VIREAD

voriconazole

voriconazole [inj]

XIFAXAN

ZERBAXA

ZIAGEN

zidovudine

ZOSYN [INJ]

ZYVOX

ZYVOX [INJ]

Antineoplastic &

Immunosuppresants

ABRAXANE [INJ] [SP]

ADCETRIS [INJ] [SP]

AFINITOR [SP]

AFINITOR DISPERZ [SP]

ALIMTA [INJ]

ALKERAN

amifostine [inj]

anastrozole

ARRANON [INJ] [SP]

ARZERRA [INJ] [SP]

AVASTIN [INJ] [SP]

azacitidine [inj] [sp]

AZASAN

azathioprine [sp]

azathioprine sodium [inj]

[sp]

BEXXAR [INJ]

bicalutamide

BICNU [INJ]

bleomycin [inj]

BLINCYTO

BOSULIF [SP]

BUSULFEX [INJ]

calcium folinate [inj]

CAPRELSA [SP]

carboplatin [inj]

CEENU

CELLCEPT [INJ] [SP]

CELLCEPT SUSPENSION

[SP]

cisplatin [inj]

cladribine [inj]

CLOLAR [INJ]

cyclophosphamide [inj]

cyclophosphamide tablets,

capsules

cyclosporine [inj] [sp]

cyclosporine [sp]

cyclosporine modified [sp]

CYRAMZA

cytarabine [inj]

dacarbazine [inj]

dactinomycin [inj]

daunorubicin [inj]

DAUNOXOME [INJ]

decitabine [inj] [sp]

DEPOCYT [INJ]

dexrazoxane [inj]

DOCEFREZ [INJ]

docetaxel [inj]

doxorubicin hcl [inj]

doxorubicin hcl liposomal

[inj]

DROXIA

ELIGARD

ELITEK [INJ]

ELSPAR

EMCYT

epirubicin hcl [inj]

ERIVEDGE

ETOPOPHOS [INJ]

etoposide

etoposide [inj]

exemestane

FARESTON

FASLODEX

floxuridine [inj]

fludarabine phosphate

[inj]

fluorouracil [inj]

flutamide

FOLOTYN [INJ]

FUSILEV [INJ]

GAZYVA [INJ]

gemcitabine hcl [inj]

GILOTRIF

GLEEVEC

HALAVEN [INJ]

2016 Enhanced Formulary

HERCEPTIN [INJ]

HEXALEN

HYCAMTIN CAPSULES [SP]

hydroxyurea

IBRANCE

ICLUSIG

idarubicin hcl [inj]

ifosfamide [inj]

ifosfamide-mesna

IMBRUVICA

INLYTA

IODOPEN [INJ]

irinotecan hcl [inj]

ISTODAX [INJ]

IXEMPRA

JAKAFI

JEVTANA [INJ]

KADCYLA [INJ]

KEPIVANCE [INJ]

KEYTRUDA

KYPROLIS [INJ]

LEMTRADA

LENVIMA

letrozole

leucovorin calcium

leucovorin calcium [inj]

LEUKERAN

leuprolide acetate

levoleucovorin calcium

lomustine

LUPRON DEPOT

LUPRON DEPOT 11.25MG

LUPRON DEPOT-PED

LYNPARZA

LYSODREN

MARQIBO

MATULANE

megestrol acetate

MEKINIST

melphalan hcl [inj]

mercaptopurine

mesna [inj]

MESNEX

methotrexate

methotrexate [inj]

mitomycin [inj]

mitoxantrone [inj]

MUSTARGEN [INJ]

mycophenolate mofetil

mycophenolate acid

delayed-release

MYLERAN

NEXAVAR

NILANDRON

NULOJIX [INJ]

octreotide acetate[inj]

ONCASPAR

ONTAK [INJ]

OPDIVO

oxaliplatin

paclitaxel [inj]

PERJETA [INJ]

PHOTOFRIN [INJ]

POMALYST

PROGRAF

PROVENGE [INJ]

PURIXAN

REVLIMID

RITUXAN [INJ]

SANDIMMUNE SOLUTION

SANDOSTATIN [INJ]

SANDOSTATIN LAR DEPOT

SIGNIFOR [INJ]

SIMULECT [INJ]

SOMATULINE DEPOT [INJ]

SPRYCEL

STIVARGA

SUTENT

SYNRIBO [INJ]

SYLVANT [INJ]

TABLOID

tacrolimus

TAFINLAR

tamoxifen citrate

TARCEVA

TASIGNA

TEMODAR [INJ]

temozolomide

TENIPOSIDE [INJ]

THALOMID

thiotepa [inj]

topotecan hcl [inj]

TORISEL [INJ]

TREANDA [INJ]

TRELSTAR, DEPOT [INJ], LA

tretinoin caps

TREXALL

TRISENOX [INJ]

TYKERB

UNITUXIN

VANTAS

VECTIBIX [INJ]

VELCADE [INJ]

vinblastine sulfate

VORAXAZE [INJ]

VOTRIENT

VUMON [INJ]

XALKORI

XGEVA [INJ]

XOFIGO [INJ]

XTANDI

YERVOY [INJ]

ZALTRAP [INJ]

ZANOSAR [INJ]

ZELBORAF

ZEVALIN

ZOLADEX

ZOLINZA

ZORTRESS

ZYDELIG

ZYKADIA

ZYTIGA

2016 Enhanced Formulary

Autonomic, Neurology

and Psych

ABILIFY DISCMELT

ABILIFY MAINTENA, ER

acetaminophen w/codeine

acetaminophen-

diphenhydra-alfentanil

[inj]

alprazolam

alprazolam er

alprazolam orally

disintegrating tablet

amitriptyline hcl

amitriptyline/chlordiazepo

xide

amoxapine

amphetamine salt combo,

er

AMPYRA [SP]

AMYTAL [INJ]

anectine [inj]

APOKYN [INJ] [SP]

aripiprazole

AZILECT

baclofen

BANZEL

benztropine [inj]

benztropine mesylate

BRISDELLE

buprenorphine [inj]

buprenorphine

hydrochloride

buprenorphine-naloxone

bupropion ext-release (12

hour)

bupropion hcl

bupropion hcl xl er

bupropion sr er

buspirone hcl

butalbital compound

butalbital compound

w/codeine

butalbital-aspirin-caffeine

butalbital/apap/caffeine

butalbital/caff/apap/codei

ne

butorphanol [inj]

butorphanol nasal

BUTRANS

calcium-folic acid plus d

carbamazepine

carbamazepine ext-release

carbidopa-levodopa er

carbidopa-levodopa-

entacapone

carbidopa/levodopa

carbidopa/levodopa orally

disintegrating tablets

celecoxib

CELONTIN

chlordiazepoxide hcl

chlorpromazine [inj]

chlorpromazine hcl

chlorzoxazone

choline mag trisalicylate

citalopram hbr

clomipramine hcl

clonazepam

clonazepam orally

disintegrating tablets

clonidine [inj]

clonidine hcl er

clorazepate dipotassium

clozapine

clozapine odt

codeine sulfate

COPAXONE [INJ] [SP]

cyclobenzaprine hcl

dantrolene sodium

DAYTRANA

desipramine hcl

dexmethylphenidate, er

dextroamphetamine

sulfate

dextroamphetamine

sulfate er

diazepam

diazepam rectal gel

diclofenac potassium

diclofenac sodium

diclofenac sodium-

misoprostol delayed

release

diflunisal

dihydroergotamine

mesylate

DILANTIN

DILAUDID-HP 250 MG [INJ]

diltiazem [inj]

diphenhydramine hcl

divalproex sodium

divalproex sodium er

donepezil hcl

doxepin hcl

DOXYLAMINE SUCCINATE

duloxetine

EDROPHONIUM CHLORIDE

entacapone

ERGOLOID MESYLATES

ergotamine-caffeine

escitalopram oxalate

estrazolam

ethosuximide

etodolac

etodolac er

EXELON PATCHES

felbamate

fenoprofen calcium

fentanyl [inj]

fentanyl citrate, [inj],

lozenge

FETZIMA

2016 Enhanced Formulary

flumazenil [inj]

fluoxetine dr

fluoxetine hcl

fluphenazine decanoate

[inj]

fluphenazine hcl

flurazepam hcl

flurbiprofen

fluvoxamine maleate er 24

hr

fosphenytoin sodium

FYCOMPA

gabapentin

GABITRIL 12MG, 16MG

GABLOFEN [INJ]

galantamine

GILENYA

GRALISE

guanidine hcl

haloperidol

haloperidol [inj]

haloperidol decanoate [inj]

haloperidol lactate [inj]

HYCAMTIN CAPSULES [SP]

hydrocodone bit-

ibuprofen

hydrocodone

w/acetaminophen

hydromorphone hcl,

rectal, [inj]

HYSINGLA ER

ibuprofen

imipramine hcl

imipramine pamoate

indomethacin

indomethacin [inj]

indomethacin er

INFUMORPH

INTUNIV

ISOMETHEPTENE MUCATE

ketoprofen er

ketorolac tromethamine

ketorolac tromethamine

[inj]

lamotrigine

lamotrigine er

LATUDA

levetiracetam, [inj], er

levorphanol tartrate

LIORESAL [INJ]

lithium carbonate tab, er,

caps

lorazepam

lorazepam [inj]

loxapine succinate

LYRICA

maprotiline hcl

meclofenamate sodium

mefenamic acid

meloxicam

memantine

meperidine hcl [inj]

MESTINON

MESTINON ER

methamphetamine hcl

methocarbamol

methadone hcl

methadone hcl [inj]

methylphenidate er

methylphenidate hcl

midazolam

mirtazapine

mirtazapine disintegrating

tablets

modafinil

morphine sulfate [inj]

morphine sulfate cr, er

morphine sulfate tablet

MOVANTIK

nalbuphine hcl [inj]

naloxone hcl [inj]

naltrexone hydrochloride

nabumetone

NAMENDA XR

NAMZARIC

NAPROSYN

naproxen

naproxen sodium

naratriptan hcl

NEMBUTAL SODIUM [INJ]

NEOPROFEN [INJ]

neostigmine methylsulfate

[inj]

nortriptyline hcl

NUCYNTA

NUCYNTA ER

NUEDEXTA

NUVIGIL

OFIRMEV [INJ]

olanzapine

olanzapine [inj]

olanzapine odt

olanzapine-fluoxetine hcl

ONFI

OPANA ER

oxaprozin

OXTELLAR ER

oxycodone hcl

oxycodone hcl-ibuprofen

oxycodone

w/acetaminophen

oxycodone w/aspirin

OXYCONTIN ER

oxymorphone hcl

oxymorphone hcl er

orphenadrine citrate [inj]

orphenadrine citrate er

orphenadrine compound

ORTHOVISC [INJ]

oxazepam

oxcarbazepine

paroxetine hcl

paroxetine hcl er

2016 Enhanced Formulary

PEGANONE

pentazocine lactate

perphenazine

perphenazine/amitriptylin

e

phenelzine sulfate

phenobarbital

phenobarbital sodium [inj]

phenytoin

phenytoin sodium

phenytoin sodium [inj]

piroxicam

POTIGA

pramipexol

pramipexol er

PRIALT [INJ]

primidone

PRISTIQ ER

pyridostigmine bromide

QUADRAMET [INJ]

quetiapine fumarate

QUILLIVANT XR

RELPAX

RISPERDAL

RISPERDAL CONSTA [INJ]

RISPERDAL M-TAB

DISINTEGRATING

rivastigmine

rizatriptan

rizatriptan disintegrating

tablets

ROBAXIN [INJ]

ropinirole hcl

ropinirole hcl er

ROZEREM

SABRIL

SALICYLAMIDE

salsalate

seconal sodium

selegiline hcl

SEROQUEL XR

SUBOXONE

sulindac

sumatriptan succinate

sumatriptan succinate

spray non-aerosol

sumatriptan succinate [inj]

SUMAVEL DOSEPRO [INJ]

SYNVISC [INJ]

SYNVISC-ONE [INJ]

TECFIDERA DELAYED

RELEASE

TEGRETOL XR

temazepam

thioridazine hcl

thiothixene

tiagabine hcl

tizanidine hcl

tolmetin sodium

topiramate

tramadol hcl

tramadol hcl er

tramadol hcl-

acetaminophen

tranylcypromine sulfate

trazodone hcl

triazolam

trifluoperazine hcl

trihexyphenidyl hcl

trimipramine maleate

TYSABRI [INJ]

ULTIVA [INJ]

VALPROATE SODIUM

valproate sodium [inj]

valproic acid

venlafaxine hcl

venlafaxine hcl er

VIIBRYD

VIMPAT [INJ]

VIVITROL [INJ]

VOLTAREN

VYVANSE

XENAZINE

XYREM

zaleplon

ziprasidone hcl

zolmitriptan

zolmitriptan odt

zolpidem tartrate

zolpidem tartrate er

ZOMIG

zonisamide

ZORVOLEX

ZUBSOLV

Cardiovascular,

Hypertension & Lipids

acebutolol hcl

ACTIVASE [INJ]

adenosine [inj]

ADVATE [INJ] [SP]

ADVATE H [INJ] [SP]

ADVATE L [INJ] [SP]

ADVATE N [INJ] [SP]

ADVATE SH [INJ] [SP]

ADVATE UH [INJ] [SP]

AGGRASTAT [INJ]

AGGRENOX ER

ALPHANATE [INJ] [SP]

ALPHANINE SD [INJ] [SP]

ALPROLIX

amiloride hcl

amiloride hcl w/hctz

amiodarone hcl

amiodarone hcl [inj]

amlodipine besylate

amlodipine-atorvastatin

ANGIOMAX [INJ] [SP]

ARGATROBAN [INJ]

atenolol

atenolol w/chlorthalidone

atorvastatin calcium

2016 Enhanced Formulary

ATRYN

AZOR

BEBULIN [INJ] [SP]

BEBULIN VH IMMUNO

[INJ] [SP]

benazepril hcl

benazepril hcl-hctz

BENEFIX [INJ] [SP]

BENICAR

BENICAR HCT

betaxolol hcl

bisoprolol fumarate

bisoprolol fumarate/hctz

BRILINTA

bumetanide

bumetanide [inj]

BYSTOLIC

candesartan cilexetil

candesartan-

hydrochlorothiazid

captopril

captopril/hydrochlorothiaz

ide

CATHFLO ACTIVASE [INJ]

CEPROTIN [INJ] [SP]

chlorothiazide

chlorothiazide

chlorothiazide sodium [inj]

chlorthalidone

cholestyramine

cholestyramine light

cilostazol

CLEVIPREX [INJ]

clonidine hcl

clopidogrel

colestipol hcl

COREG CR ER

CORIFACT [INJ] [SP]

CORLANOR

COUMADIN [INJ]

CRESTOR

DEMSER

digoxin

DILATRATE-SR EXT-REL

diltiazem [inj]

diltiazem 24hr cd

diltiazem er

diltiazem er 24 hour

diltiazem hcl

dipyridamole [inj]

dobutamine [inj]

dobutamine/dextrose [inj]

dopamine hcl [inj]

dopamine hcl in 5%

dextrose

doxazosin mesylate

EDARBI

EDARBYCHLOR

EDECRIN[INJ]

EFFIENT

ELIQUIS

ELOCTATE [INJ]

enalapril maleate

enalapril maleate/hctz

enalaprilat [inj]

enoxaparin sodium

ENTRESTO

eplerenone

epoprostenol [inj]

EXFORGE

EXFORGE HCT

FEIBA NF [INJ]

felodipine er

fenofibrate

fenofibrate caps

fenofibric acid

fenofibric acid delayed

release

flecainide acetate

fluvastatin sodium

fondaparinux sodium

fosinopril sodium

fosinopril/hydrochlorothia

zide

FRAGMIN

furosemide

furosemide [inj]

gemfibrozil

guanfacine hcl

HELIXATE FS [INJ]

HEMOFIL [INJ]

heparin lock flush [inj]

heparin sodium in 0.45%

nacl [inj]

heparin sodium in 5%

dextrose [inj]

HUMATE-P [INJ] [SP]

hydralazine hcl

hydrochlorothiazide

ibutilide fumarate [inj]

indapamide

INTEGRILIN [INJ]

irbesartan

irbesartan/hydrochlorothi

azide

isosorbide dinitrate

isosorbide mononitrate

isosorbide mononitrate er

isradipine

IXINITY

JUXTAPID

KOATE-DVI [INJ]

labetalol hcl

labetalol hcl [inj]

LANOXIN PEDIATRIC

lidocaine hcl in 7.5%

dextrose [inj]

LIPOFEN

LIPTRUZET

lisinopril

lisinopril-hctz

losartan potassium

2016 Enhanced Formulary

losartan-

hydrochlorothiazide

lovastatin

mannitol

MEPHYTON

methyclothiazide

methyldopa

methyldopa/hydrochlorot

hiazide

methyldopate hcl [inj]

metolazone

metoprolol succinate er

metoprolol tartrate

metoprolol tartrate [inj]

metoprolol-

hydrochlorothiazide

mexiletine hcl

milrinone in 5% dextrose

milrinone lactate [inj]

minoxidil

moexipril hcl

moexipril/hydrochlorothia

zide

MONOCLATE-P [INJ]

MONONINE

MONONINE [INJ]

MONOVISC [INJ]

nadolol

nadolol/bendroflumethiazi

de

NATRECOR [INJ]

NEXTERONE

niacin er

nicardipine hcl

nicardipine hcl [inj]

nifedipine er

nimodipine

nitroglycerin

nitroglycerin tablets

nitroglycerin [inj]

nitroglycerin er

nitroglycerin in d5w [inj]

nitroglycerin spray

NITROLINGUAL

NITROSTAT

norepinephrine bitartrate

[inj]

NOVOSEVEN [INJ]

NPLATE [INJ]

OBIZUR

omega-3-acid ethyl esters

papaverine hcl [inj]

papaverine hcl er

pentoxifylline er

perindopril erbumine

PHENTOLAMINE

MESYLATE [INJ]

phenylephrine hcl [inj]

PHYTONADIONE

pindolol

PRADAXA

PRALUENT PEN

PRALUENT SYRINGE

pravastatin sodium

prazosin hcl

procainamide hcl [inj]

PROFILNINE SD [INJ]

PROMACTA

propafenone hcl

propafenone hcl er

propranolol hcl

propranolol hcl er

propranolol hcl-hctz

protamine sulfate [inj]

quinapril

quinapril/hydrochlorothiaz

ide

quinidine gluconate [inj]

quinidine gluconate er

quinidine sulfate

quinidine sulfate er

ramipril

RANEXA

RECOMBINATE [INJ]

REFLUDAN [INJ]

REMODULIN [INJ]

REOPRO [INJ]

REPATHA SYRINGE

REPATHA SURECLICK

RESECTISOL

reserpine

RETAVASE

RIASTAP

SIMCOR ER

simvastatin

sotalol

SOTALOL HCL [INJ]

SOTYLIZE

spironolactone

spironolactone/hydrochlor

othiazide

TARKA

TEKAMLO

TEKTURNA

TEKTURNA HCT

terazosin hcl

THROMBATE III [INJ]

TIKOSYN

timolol maleate

torsemide

torsemide [inj]

trandolapril

TRANEXAMIC ACID

tranexamic acid [inj]

TRETTEN

TRIBENZOR

valsartan

valsartan/hydrochlorothia

zide

VASCEPA

verapamil er

verapamil er pm

verapamil hcl [inj]

2016 Enhanced Formulary

VYTORIN

warfarin sodium

WELCHOL

WILATE

XARELTO

XYNTHA

XYNTHA SOLOFUSE

ZETIA

ZONTIVITY

Dermatological &

Topical Therapy

ABSORICA

acitretin

acyclovir ointment

adapalene

alclometasone

dipropionate

alphaquin hp

aluminum chloride 20%

topical

amcinonide

ammonium lactate 12%

topical

ABSORICA

ANTHRALIN

ATRALIN

avo cream

bacitracin eye ointment

bacitracin/polymyxin eye

ointment

benprox

BENZOCAINE

benzoyl peroxide

betamethasone

dipropionate augmented

betamethasone valerate

bupivacaine hcl

bupivacaine/epinephrine

[inj]

calcipotriene

calcitriol

CARAC

CARBOCAINE 2% [INJ]

CHLORHEXIDINE

GLUCONATE

chloroprocaine [inj]

ciclopirox

clindamycin phosphate

topical

clindamycin-benzoyl

peroxide

clobetasol e

clobetasol propionate

clotrimazole

clotrimazole/betamethaso

ne

cocaine hcl topical solution

CONDYLOX GEL

COSENTYX

desonide

desoximetasone

DEXPANTHENOL

diclofenac sodium gel

DIFFERIN 0.1% LOTION

diflorasone diacetate

diflorason

diacetate/emollient

econazole nitrate

eletone

ELIDEL

emulsion sb

EPIDUO

EPIDUO FORTE

erythromycin solution

erythromycin-benzoyl

peroxide

ETHYL ALCOHOL

ethyl chloride

FINACEA

FINACEA PLUS

fluocinolone acetonide

cream

fluocinolone acetonide

ointment

fluocinonide

fluorouracil

fluticasone propionate

gentamicin sulfate cream

gentamicin sulfate

ointment

halobetasol propionate

hpr foam

hpr plus

hydrocortisone

hydrocortisone butyrate

hydrocortisone

butyrate/emoll

hydrocortisone

acetate/lidocaine

hydrocortisone

acetate/pramoxine

hydrocortisone valerate

hydroquinone cream

hydroquinone ER

imiquimod

isotretinoin

ketoconazole cream

lactic acid

lidocaine hcl, jelly,

ointment

lidocaine hcl

w/epinephrine [inj]

lidocaine-prilocaine

lindane

lustra-ultra

mafenide acetate

malathion

mb hydrogel

mepivacaine hcl

metronidazole cream

MIRVASO

2016 Enhanced Formulary

mometasone furoate

mupirocin

NESACAINE

nuquin hp

nystatin ointment

nystatin w/triamcinolone

ONEXTON

OXSORALEN 1% LOTION

permethrin

podofilox

prednicarbate

pruclair

prumyx

prutect

REGRANEX

ropivacaine hcl [INJ]

salicylic acid

SANTYL

selenium sulfide

sensorcaine [inj]

silver sulfadiazine

sodium

sulfacetamide/sulfur

sonafine

spinosad

STELARA [INJ] [SP]

sulfacetamide sodium

topical

sulfacetamide sodium-

sulfur

SULFAMYLON

TACLONEX SUSPENSION

tacrolimus ointment

TAZORAC

tl-cermide

TRETIN-X

tretinoin cream

tretinoin microsphere

triamcinolone acetonide

0.1% cream

urea

ZIANA

ZOVIRAX CREAM

Ear, Nose & Throat

acetic acid ear solution

acetic acid/aluminum ear

solution

acetic acid/hydrocortisone

ear solution

antipyrine w/benzocaine

ear solution

antipyrine

w/benzocaine/poly ear

solution

ASTEPRO

ATROVENT SPRAY

azelastine hcl nasal spray

chloroxylenol/benzocaine/

hc acet ear susp

CIPRODEX

ciprofloxacin hcl

FIRST-BXN

FIRST-MOUTHWASH BLM

hydrocortisone/pramoxine

ear solution

hydrocortisone/pramoxine

/chloroxylenol

ipratropium bromide spray

MYALEPT

neomycin/polymyxin/hc

ofloxacin otic drops

oxymetazoline hcl 12 hour

sodium fluoride

sodium fluoride cream

Endocrine/Diabetes

1ST CHOICE LANCETS

A-HYDROCORT [INJ]

acarbose

ACCU-CHEK FASTCLIX,

MULTICLIX, SOFTCLIX

LANCETS [OTC]

ACCU-CHEK SOFTCLIX

LANCETS DEVICE [OTC]

ACTHAR H.P. [INJ] [SP]

ACTHREL [INJ]

ACTOPLUS MET XR

ALDURAZYME [INJ] [SP]

ANDROGEL

ARISTOSPAN [INJ]

ARMOUR THYROID

AXIRON

BETAMETHASONE

BETAMETHASONE

ACETATE

betamethasone

acetate/betamethasone

sodium phosphate [inj]

BETAMETHASONE

SODIUM PHOSPHATE

BRAVELLE [INJ]

BYDUREON [INJ]

BYDUREON PEN

BYETTA [INJ]

cabergoline

calcitonin salmon nasal

calcitriol [inj]

CERDELGA [SP]

CEREZYME [INJ] [SP]

chorionic gonadotropin

[inj] [sp]

clomiphene citrate

cortisone acetate

cosyntropin [INJ]

danazol

DEPO-MEDROL 20 MG/ML

[INJ]

desmopressin acetate

desmopressin acetate [inj]

DEXCOM G4, SENSOR

2016 Enhanced Formulary

dexamethasone

dexamethasone sodium

phosphate

doxercalciferol

ELAPRASE [INJ]

ELELYSO [INJ]

FABRAZYME [INJ]

FARXIGA

FEMCAP

fludrocortisone acetate

FLUOXYMESTERONE

FOLLISTIM AQ [INJ]

FORA LANCING DEVICE

FREESTYLE FREEDOM KIT

[OTC]

FREESTYLE FREEDOM LITE

METER [OTC]

FREESTYLE INSULINX

GLUCOSE SYSTEM [OTC]

FREESTYLE INSULINX TEST

STRIPS [OTC]

FREESTYLE LITE METER

[OTC]

FREESTYLE LITE TEST

STRIPS [OTC]

FREESTYLE TEST STRIPS

[OTC]

glimepiride

glipizide

glipizide er

GLUCAGEN [INJ]

GLUCAGON

glyburide

glyburide micronized

glyburide-metformin hcl

GLYXAMBI

HUMALOG [INJ]

HUMULIN [INJ] [OTC]

HUMULIN R 500 UNITS

[INJ]

hyoscyamine/phenyltoloxa

mine

INVOKANA

INVOKAMET

JANUMET

JANUMET XR

JANUVIA

JENTADUETO

JUVISYNC

KENALOG [INJ]

KOMBIGLYZE XR

KUVAN

LANTUS [INJ]

LANTUS SOLOSTAR [INJ]

LEVEMIR [INJ]

LEVOTHROID

levothyroxine sodium

levothyroxine sodium [inj]

liothyronine [inj]

liothyronine tablet

LUMIZYME [INJ]

MEDROL

MENOPUR [INJ]

metformin hcl

metformin hcl er

methimazole

METHITEST

methylprednisolone

methylprednisolone

acetate [inj]

methylprednisolone sod

succ [inj]

MIACALCIN [INJ]

MINIMED

MINIMED RESERVOIR

MYOZYME [INJ]

NAGLAZYME [INJ]

nateglinide [INJ]

NOVOFINE

NOVOFINE AUTOCOVER

NOVOLOG [INJ]

NOVOLOG FLEXPEN

NOVOLOG MIX 70-30

ONE TOUCH ULTRA 2

ONE TOUCH ULTRA

SMART

ONE TOUCH ULTRA

SYSTEM

ONE TOUCH ULTRA TEST

STRIPS

ONE TOUCH ULTRAMINI

ONE TOUCH VERIO

ONE TOUCH VERIO IQ

ONE TOUCH VERIO SYNC

ONGLYZA

OPTIUM

OPTIUM EZ

ORTHO-DIAPHRAGM

oxandrolone

pamidronate disodium

[inj]

PARADIGM INFUSION

PARADIGM INSULIN PUMP

PARADIGM SILHOUETTE

paricalcitol

pioglitazone hcl

pioglitazone-glimepiride

pioglitazone-metformin

POLYFIN QR

PRANDIMET

PRECISION PCX, PCX PLUS,

POINT OF CARE,Q-I-D

PRECISION XTRA B-

KETONE STRIPS [OTC]

PRECISION XTRA

MONITOR [OTC]

PRECISION XTRA TEST

STRIPS [OTC]

prednisolone

prednisolone sodium

phosphate [inj]

prednisone

2016 Enhanced Formulary

PRODIGY INSULIN SYRINGE

PRODIGY PEN NEEDLE

PROGLYCEM

propylthiouracil

QUICK RELEASE SOFT

TEFLON

repaglinide

RIOMET

SAMSCA

SENSIPAR

SILHOUETTE

SILHOUETTE [INJ]

SOF-SET

SOF-SET MICRO

SOFT TOUCH

SOLOSITE

SOLU-CORTEF [INJ]

SOLU-MEDROL [INJ]

SOMAVERT [INJ]

STIMATE SPRAY

SURE-T PARADIGM

SYMLINPEN 60 [INJ]

SYNAREL

SYNJARDY

testosterone cypionate

[inj]

testosterone enanthate

[inj]

testosterone gel pump

THYROID

tolazamide

tolbutamide

TOUJEO SOLOSTAR

TRADJENTA

vasopressin [inj]

veripred 20

VGO 20

VGO 30

VGO 40

VICTOZA [INJ]

VIMIZIM [INJ] [SP]

VPRIV [INJ]

XIGDUO XR

ZAVESCA

ZEMPLAR [INJ]

ZOLEDRONIC ACID [INJ]

ZOMETA [INJ]

Gastroenterology

AKYNZEO

ALOXI [INJ]

AMITIZA

ANALPRAM ADVANCED

CREAM KIT

ANALPRAM 2.5% LOTION

ANALPRAM-HC 1% CREAM

SINGLES

ASACOL HD

balsalazide disodium

budesonide ec

CANASA

carafate

CHOLBAM

CHENODAL [SP]

cimetidine

CITRA PH

CORTIFOAM

CREON

cromolyn sodium oral

solution

CYSTADANE [SP]

DELZICOL

dicyclomine hcl

dimenhydrinate [inj]

diphenoxylate w/atropine

dronabinol

droperidol [inj]

EMEND [INJ]

ENTYVIO

ENTYVIO [INJ]

famotidine

famotidine [inj]

glycopyrrolate

glycopyrrolate [inj]

granisetron hcl

granisetron hcl [inj]

GRANISOL

hydrocortisone

hydrocortisone acetate

hyoscyamine sulfate, odt,

er

KINEVAC [INJ]

lactulose

lansoprazol-amoxicil-

clarithromycin

lansoprazole delayed

release

LEVSIN

LIALDA

LINZESS

loperamide hcl

LOTRONEX

meclizine hcl

mesalamine

metoclopramide hcl

metoclopramide hcl [inj]

misoprostol

NEXIUM

NEXIUM [INJ]

nizatidine

omeprazole delayed

release

omeprazole/sodium

bicarbonate

ondansetron hcl

ondansetron hcl [inj]

ondansetron hcl in

dextrose [inj]

ondansetron in sodium

chloride[inj]

ondansetron odt

opium

2016 Enhanced Formulary

pancrelipase

pantoprazole sodium

paregoric

peg 3350-electrolyte

PENTASA

phenobarb/hyoscyamine/

atropine/scoplamine

polyethylene glycol

PREPOPIK

prochlorperazine edisylate

[inj]

prochlorperazine maleate

PROCTOFOAM-HC

ranitidine

ranitidine hcl [inj]

RECTIV

RELISTOR [INJ]

REMICADE [INJ]

SANCUSO

SCOPOLAMINE

HYDROBROMIDE

sodium bicarbonate

sodium chloride/sodium

bicarb

SUCLEAR

SUCRAID

sucralfate

sulfasalazine

sulfasalazine del rel

SUPREP

trimethobenzamide hcl

trimethobenzamide hcl

[inj]

UCERIS

ursodiol

VIOKACE

ZENPEP DEL-REL

Immunology, Vaccines

& Biotechnology

ACTHIB [INJ]

ACTIMMUNE [INJ] [SP]

ADACEL [INJ]

AFLURIA [INJ]

ALFERON N [INJ]

APLISOL [INJ]

ARANESP [INJ] [SP]

ARCALYST [INJ] [SP]

ATGAM [INJ]

AVONEX [INJ] [SP]

BETASERON

BEXSERO

BIOTHRAX [INJ]

BOOSTRIX [INJ]

BOTOX [INJ] [SP]

candin

CERVARIX [INJ]

COMVAX [INJ]

CROFAB [INJ]

CYTOGAM [INJ] [SP]

DIPHTHERIA-TETANUS

TOXOIDS-PED

EGRIFTA [INJ] [SP]

ENGERIX-B [INJ]

FLUARIX [INJ]

FLULAVAL [INJ]

FLULAVAL QUAD [INJ]

FLUMIST

FLUVIRIN [INJ]

FLUZONE [INJ]

FLUZONE INTRADERM

QUAD [INJ]

fomepizole

GAMASTAN S-D [INJ]

GAMMAGARD LIQUID

[INJ]

GAMMAGARD S-D [INJ]

GAMUNEX [INJ]

GAMUNEX-C [INJ]

GARDASIL 9 [INJ]

GENOTROPIN [INJ] [SP]

GRASTEK

HAVRIX

HEPAGAM B [INJ]

HIZENTRA [INJ]

HUMATROPE [INJ] [SP]

HYPERHEP B S-D [INJ]

HYPERRAB S-D [INJ]

HYPERRHO S-D

HYPERTET S-D

ILARIS [INJ]

IMOGAM RABIES-HT [INJ]

IMOVAX RABIES VACCINE

[INJ]

INFANRIX [INJ]

INFERGEN [INJ] [SP]

INTRON A [INJ] [SP]

IPOL [INJ]

IXIARO

LEUKINE [INJ]

M-M-R II VACCINE

W/DILUENT [INJ]

MENACTRA [INJ]

MENOMUNE-A-C-Y-W-135

[INJ]

MOZOBIL [INJ]

MYOBLOC [INJ]

OMNITROPE [INJ] [SP]

NEULASTA [INJ]

NEUMEGA [INJ]

NEUPOGEN [INJ]

NORDITROPIN [INJ] [SP]

PEDIARIX [INJ]

PEDVAXHIB [INJ]

PEGASYS [INJ] [SP]

PEGASYS PROCLICK [INJ]

[SP]

PLEGRIDY [SP]

PNEUMOVAX 23 [INJ]

PREVNAR 13

PRIVIGEN [INJ]

PROCRIT [INJ]

2016 Enhanced Formulary

PROLEUKIN [INJ]

PROQUAD [INJ]

QUADRACEL DTAP-IPV

RABAVERT

RAGWITEK

REBIF [INJ] [SP]

REBIF REBIDOSE [INJ] [SP]

RECOMBIVAX HB

ROTATEQ

SEROSTIM [INJ] [SP]

SYLATRON [INJ] [SP]

TETANUS DIPHTHERIA

TOXOIDS [INJ]

tetanus toxoid

THERACYS [INJ]

THYMOGLOBULIN [INJ]

TICE BCG [INJ]

TRUMENBA

TUBERSOL [INJ]

TWINRIX [INJ]

TYPHIM VI [INJ]

VAQTA

VARIVAX VACCINE [INJ]

VARIZIG [INJ]

VIVOTIF BERNA DEL-REL

YF-VAX [INJ]

Musculoskeletal &

Rheumatology

ACTEMRA [INJ] [SP]

alendronate sodium

allopurinol

ATELVIA

BENLYSTA [INJ] [SP]

colchicine

COLCRYS

CUPRIMINE

dihydrocodeine/aspirin/ca

ffeine

ENBREL [INJ] [SP]

FORTEO [INJ] [SP]

HUMIRA [INJ] [SP]

ibandronate[inj]

ibandronate sodium

KRYSTEXXA [INJ] [SP]

leflunomide

ORENCIA [INJ] [SP]

OTREXUP

naproxen delayed release

probenecid

RIDAURA

risedronate

risedronate sodium

SAVELLA

SIMPONI 100MG

ULORIC

Obstetrics &

Gynecology

altavera

alyacen

amethia

amethia lo

amethyst

apri

aranelle

aubra [inj]

aviane

azurette

balziva

BEYAZ

briellyn

caldolor [inj]

camrese

camrese lo

caziant

CENESTIN

chateal

clindamycin phosphate

vaginal

COMBIPATCH

CRINONE

cryselle

cyclafem

dasetta

daysee

DEPO-ESTRADIOL [INJ]

DEPO-PROVERA 400

MG/ML [INJ]

DIVIGEL

DUAVEE

elinest

emoquette

ENDOMETRIN

ENJUVIA

enpresse

enskyce

ERGONOVINE MALEATE

errin

estarylla

ESTRACE CREAM

ESTRACE TABLET

estradiol

estradiol patch

0.05mg/day

estradiol valerate [inj]

estradiol-norethindrone

acetate

estrogen &

methyltestosterone

estropipate

falmina

gianvi

gildagia

gildess

gildess fe

heather

HEMABATE [INJ]

IMPLANON

introvale

isoxsuprine hcl

2016 Enhanced Formulary

jencycla

jolessa

jolivette

junel

junel fe

kariva

kelnor 1-35

kurvelo

leena

lessina

levonorgestrel

levora

LO LOESTRIN FE

LO MINASTRIN FE

loryna

low-ogestrel

lutera

lyza

MAKENA [INJ]

marlissa

medroxyprogesterone

acetate [inj]

methylergonovine maleate

METHYLERGONOVINE

MALEATE [INJ]

metronidazole gel

MICONAZOLE 1

microgestin

microgestin fe

MINIVELLE

MIRENA

mono-linyah

mononessa

myzilra

NATAZIA

necon

NEXPLANON

nora-be

norethindrone acetate

norethindrone/ethinyl

estradiol

norethindrone/ethinyl

estradiol-iron

NUVARING

ocella

ogestrel

orsythia

OSPHENA

oxytocin [inj]

philith

pirmella

portia

PREMARIN

PREMARIN [INJ]

PREMARIN CREAM

PREMPHASE

PREMPRO

progesterone

quasense

reclipsen

SAFYRAL

sprintec

sronyx

syeda

terconazole

tilia fe

tri-estarylla

tri-legest fe

tri-linyah

trinessa

trivora

VAGIFEM

velivet

vestura

viorele

wera

wymzya fe

zarah

zenchent

zenchent fe

zeosa

zovia

Ophthalmology

acetazolamide, er, [inj]

ALPHAGAN P 0.1%

ALREX

apraclonidine eye solution

atropine sulfate eye

solution

atropine sulfate eye

ointment

azelastine hcl eye solution

balanced salt eye irrigation

BEPREVE

BESIVANCE

betaxolol eye solution

brimonidine eye solution

bromfenac eye solution

carbachol [INJ]

carteolol hcl

ciprofloxacin eye solution

COMBIGAN

cromolyn sodium eye

solution

cyclopentolate eye

solution

CYSTARAN [SP]

dexamethasone sodium

phosphate

diclofenac sodium gel

dorzolamide hcl

dorzolamide-timolol

epinastine hcl

erythromycin ointment

EYLEA [INJ]

FLUORESCEIN SODIUM

fluorometholone

flurbiprofen sodium

FML S.O.P.

gatifloxacin

gentasol

2016 Enhanced Formulary

homatropine

hydrobromide

ILEVRO

ISOPTO CARBACHOL

JETREA [INJ]

ketorolac eye solution

latanoprost drops

levobunolol hcl drops

levofloxacin hemihydrate

rops

LOTEMAX

LUCENTIS [INJ]

LUMIGAN

methazolamide

metipranolol drops

MOXEZA

naphazoline hcl

NATACYN

neomycin/polymyxin/dexa

methasone

neomycin/bacitracin/poly

myxin/hc

neomycin/polymyxin/gra

micidin

NEVANAC

ofloxacin

PATADAY

PATANOL

PAZEO

phenylephrine hcl

PHOSPHOLINE IODIDE

drops

physostigmine salicylate

[inj]

pilocarpine hcl drops

PILOPINE HS

polymyxin/trimethoprim

eye solution

PRED MILD

prednisolone acetate

prednisolone sodium

phosphate drops

PROLENSA

proparacaine hcl

proparacaine-fluorescein

RESTASIS

sodium chloride drops

sulfacetamide sodium

ointment

sulfacetamide sodium

drops

sulfacetamide/prednisolon

e

tetracaine drops

timolol maleate drops

TOBRADEX

TOBRADEX ST

tobramycin

tobramycin sulfate drops

tobramycin-

dexamethasone

TRAVATAN Z

travoprost

TRIFLURIDINE

tropicamide

VIGAMOX

VISUDYNE [INJ]

ZYLET

Respiratory, Allergy,

Cough & Cold

acetylcysteine

ADCIRCA [SP]

ADVAIR DISKUS

ADVAIR HFA

albuterol sulfate

aminophylline [inj]

ANORO ELLIPTA

arbinoxa

ARCAPTA NEOHALER

ARNUITY ELLIPTA

ASMANEX, HFA

AUVI-Q

benzonatate

BREO ELLIPTA

brompheniramine/pseudo

ephedrine

budesonide

caffeine/sodium benzoate

[inj]

carbinoxamine

cetirizine syrup

chlorphen-pse-dm tannate

CINRYZE [INJ] [SP]

clemastine fumarate

COMBIVENT RESPIMAT

cromolyn sodium

nebulization solution

cyproheptadine hcl

D-

CHLORPHENIRA/PSE/CHLO

PHEDIAN 12.5CPD-

1DCPM-30PSE

DALIRESP

desloratadine, odt

dexchlorpheniramine

maleate er

DEXTROMETHORPHAN

HBR

difil-g

dihydrocodeine-bpm-pe

diphenhydramine [inj]

DM/PHENYLEPH/CHLORPH

ENIRAMINE 10PEH-4CPM-

20DM

DULERA

DYMISTA

ephedrine sulfate

epinephrine [inj]

EPIPEN

EPIPEN JR.

2016 Enhanced Formulary

epoprostenol diluent [inj]

[sp]

FIRAZYR

FLOVENT

FLOVENT DISKUS

FLOVENT HFA

flunisolide

fluticasone propionate

FORADIL

guaifenesin/codeine

hydrocodone/chlorphenira

mine er

hydrocodone/homatropin

e

hydroxyzine hcl

hydroxyzine pamoate

ipratropium bromide

ipratropium-albuterol

nebulization

KALBITOR [INJ]

KALYDECO

LETAIRIS

levalbuterol hcl

levocetirizine

dihydrochloride

metaproterenol sulfate

montelukast sodium

NASONEX

OPSUMIT

ORKAMBI

PERFOROMIST [INJ]

phenylephrine/chlorphenir

amine 10peh-4cpm

phenylephrine/chlorphenir

amine

phenylephrine/dihydrocod

eine/chlorphenir

PROAIR HFA

PROAIR RESPICLICK

promethazine hcl, sup,

tablets, [inj]

promethazine vc

w/codeine

promethazine w/dm

promethegan

PSEUDOEPH/CHLOPHEDIA

NOL/GG 12.5CPD-100GFN-

30PSE

pseudoephedrine hcl 12

hour ER

pseudoephedrine hcl-d 12

hour

pseudoephedrine sulfate

ER

PULMICORT

PULMICORT FLEXHALER

PULMOZYME

QVAR

REVATIO [INJ]

SEREVENT DISKUS

sildenafil citrate

sodium chloride nebulizer

SPIRIVA, RESPIMAT

STIOLTO RESPIMAT

SYMBICORT

terbutaline sulfate

terbutaline sulfate [inj]

theophylline anhydrous

elixir

theophylline anhydrous

drops er 12 hr

TRACLEER

triamcinolone acetonide

spray

TUDORZA PRESSAIR

TUSSICAPS

TYVASO

VENTAVIS

VENTOLIN HFA

VERAMYST

XOLAIR [INJ]

zafirlukast

Urologicals

alfuzosin hcl er

alprostadil [inj]

AMINOACETIC ACID

aminoacetic acid [inj]

AMMONIUM CHLORIDE

[INJ]

bethanechol chloride

CAVERJECT [INJ]

CIALIS

CYSTAGON [SP]

ELMIRON

finasteride

flavoxate hcl

GELNIQUE

glycine

hyophen

k-phos neutral

K-PHOS ORIGINAL

MUSE

MYRBETRIQ ER 24 HR

oxybutynin chloride

oxybutynin chloride er

phenazopyridine hcl

phenazopyridine plus

phosphasal

potassium citrate er

RAPAFLO

RENACIDIN

tamsulosin er

tolterodine tartrate

TOVIAZ

tricitrates

trospium chloride er

uretron d-s

urimar-t

urin d.s.

urogesic

ustell

2016 Enhanced Formulary

VESICARE

VIAGRA

Vitamins, Hematinics

& Electrolytes

ADDAMEL N [INJ]

advanced am/pm

albumin human [inj]

ALZ-NAC

amino acid [inj]

AMINOSYN [INJ]

AQUASOL A [INJ] [SP]

ascorbic acid [inj]

b-complex

BAL IN OIL [INJ]

bal-care dha

calcium acetate

calcium chloride [inj]

calcium gluconate [inj]

cavan-alpha kit

cavan-ec sod dha

CENOLATE [INJ]

centratex

choice-ob + dha

choice-tabs

chromium chloride [inj]

CLINIMIX [INJ]

complete natal dha

CONCEPTION XR MOTILITY

copper chloride [inj]

corvita

CUPRIC SULFATE [INJ]

cyanocobalamin [inj]

DAILYVITE

dexferrum

DIALYVITE 800

DULEEK-MET NEW

eliphos

elite ob

elite-ob 400

fabb

fe 90 plus

fe c

FERAHEME

ferocon

ferotrinsic

ferraplus 90

ferrex 150 forte

ferrex 150 forte plus

ferrex 28

ferrocite plus

ferrogels forte

folbecal

folbee

folbee plus

folbic

folbic rf

folcaps

folcaps omega-3

folic acid

folic acid [inj]

folic acid-cyancobal-

pyridoxine

folivane-f

folivane-ob

folivane-plus

folivane-prx dha nf

folplex 2.2

foltanx

FREAMINE HBC

FREAMINE III

GLYCOPHOS [INJ]

hematinic plus

hematinic with folic acid

hematogen

hematogen fa

hematogen forte

hemenatal ob

hemenatal ob + dha

hemetab

HEPATAMINE [INJ]

HEPATASOL [INJ]

hetastarch w/sodium

chloride [inj]

hydroxocobalamin

iferex 150 forte

inatal advance

inatal gt

inatal ultra

infed [inj]

INFUVITE [INJ]

intralipid

IONOSOL B WITH

DEXTROSE 5%

ISOLYTE S [INJ]

k-phos neutral

L-MEFOLATE-PYRIDOX-

MECOBALAMIN-NAC

L-METHYLFOLATE

CALCIUM

m.v.i. adult [inj]

M.V.I. PEDIATRIC [INJ]

M.V.I.-12 [INJ]

macnatal cn dha

magnesium chloride [inj]

magnesium sulfate [inj]

MAGNESIUM SULFATE IN

DEXTROSE [INJ]

manganese [inj]

manganese sulfate [inj]

metafolbic

metafolbic plus

multigen

multigen folic

multigen plus

MULTITRACE-4 [INJ]

MULTITRACE-5 [INJ]

multivitamin w/fluoride &

iron

multivitamin with fluoride

mynatal

mynatal caps

2016 Enhanced Formulary

mynatal advance

mynatal plus

mynatal-z

mynate 90 plus er

mynephrocaps

NASCOBAL

NATAL-V RX

natalvirt 90 dha

natalvirt ca

natalvirt flt

nephplex rx

NEPHRAMINE [INJ]

nephro-vite rx

NEUT [INJ]

NORMOSOL-M AND

DEXTROSE [INJ]

NORMOSOL-R AND

DEXTROSE [INJ]

NORMOSOL-R PH 7.4 [INJ]

nutri-tab ob

nutrilyte [inj]

nutrilyte ii [inj]

obstetrix dha

PEDITRACE [INJ]

PLASMA-LYTE 148 [INJ]

pnv ob+dha

pnv-dha

pnv-first

pnv-omega

pnv-select

pnv-total

polysaccharide iron forte

poly-iron 150 forte

pot chloride/dextrose/ns

[inj]

potassium acetate [inj]

potassium bicarbonate

potassium chl-normal

saline [inj]

potassium chloride

potassium

chloride/dextrose [inj]

pr natal 400

pr natal 400 ec

pr natal 430

pr natal 430 ec

prefol-dha

premasol [inj]

prena1

prena1 chew

prena1 plus

prenaissance

prenaissance 90 dha

prenaissance balance

prenaissance dha

prenaissance harmony dha

prenaissance next

prenaissance plus

prenaplus

prenatabs fa

prenatabs rx

prenatal ad

prenatal low iron

prenatal plus

prenatal-u

PROCALAMINE

PROSOL

pyridoxine hcl

relnate dha

RENA-VITE RX

renal caps

renalpren

reno caps

ringers [inj]

se-tan dha pernatal

se-tan plus

se-natal 19

selenium [inj]

setonet

setonet-ec

sodium acetate [inj]

sodium chloride 3%

sodium chloride0.45%

sodium lactate [inj]

strovite

STUART ONE

taron forte

taron prenatal

taron-bc

taron-c dha

taron-duo ec

therapeutic hematinic

therapeutic

vitamin/minerals

thiamine hcl

tl g-fol os

tl gard rx

tl icon

tl-care dha

tl-fol 500 er

tl-hem 150 er 24 hr

tl-select

TPN ELECTROLYTES [INJ]

TRACE ELEMENTS [INJ]

travasol [inj]

tri rx

triadvance

tricon

trigels-f forte

trinatal gt

trinatal rx 1

trinatal ultra

trinate

triphrocaps

triveen-duo dha

triveen-one

triveen-prx rnf

triveen-ten

triveen-u

trust natal dha

ultimate ob dha

ultimatecare one

2016 Enhanced Formulary

ultimatecare one nf

v-c forte

v-natal

vemavite-prx 2

vena-bal dha

venatal complete dha

venatal-fa

VENOFER [INJ]

vinacal

vinate az

vinate c

vinate calcium

vinate dha

vinate gt

vinate ic

vinate ii

vinate one

vinate ultra

vinate-m

virt-bal dha

virt-bal dha plus

virt-pn

virt-pn dha

virt-pn plus

virt-select

virt-vite

virt-vite forte

vitafol-ob

vitafol-pn

vitamin a

vitaspire

vol-care rx

vol-nate

vol-plus

vol-tab rx

vp-ch plus

vp-ch-pnv

vp-era ob plus

vp-ggr-b6

vp-heme one

vp-zel

vynatal-fa

zatean-ch

zatean-pn

zatean-pn dha

zatean-pn plus

zinc chloride

zinc sulfate

Miscellaneous &

Diagnostic Agents

acamprosate calcium

acetic acid irrigation

ADAGEN [INJ] [SP]

AMMONUL [INJ]

anagrelide hydrochloride

ARALAST NP [INJ] [SP]

atropen [inj]

benzphetamine hcl

BREVITAL [INJ]

bromhexine hydrochloride

BUPHENYL TABLETS

bupivacaine/dextrose [inj]

caffeine citrated

caffeine citrated [inj]

CARBAGLU [SP]

cevimeline hcl

CHANTIX

CHEMET

citric acid

CLINIMIX E [INJ]

deferoxamine [inj]

DELFLEX/DEXTROSE

dextrose in lactated

ringers

dextrose in water

dextrose/sodium chloride

diethylpropion hcl

EDARBYCLOR

EOVIST [INJ]

ETHAMOLIN

etidronate disodium

etomidate [inj]

EXJADE

EXTRANEAL ICODEXTRIN

DIALYSIS

FERRIPROX

FOSRENOL

HEXTEND LACTATED

ELECTROLYTE

INCRELEX [INJ]

ISOVUE [INJ]

ISOVUE-M [INJ]

JADENU

ketamine hcl [inj]

levocarnitine

levocarnitine [inj]

LEXISCAN

MAGNEVIST [INJ]

md-gastroview

midodrine hcl

NATPARA [INJ]

neomycin-polymyxin b

[inj]

OMNIPAQUE

ORFADIN

PANHEMATIN [INJ]

phendimetrazine tartrate

phendimetrazine tartrate

er

phentermine hcl

pilocarpine hcl

PROHANCE [INJ]

PROLASTIN [INJ]

PROLASTIN C [INJ]

propofol

PROSTAMEN

PROTOPAM CHLORIDE

[INJ]

RAVICTI

RENVELA

riluzole

2016 Enhanced Formulary

ringers irrigation

serotonin hcl

sodium chloride

sodium chloride [inj]

sodium chloride irrigation

SODIUM PHOSPHATE

sodium polystyrene

sulfonate

sodium thiosulfate [inj]

SOLIRIS [INJ]

SOTRADECOL [INJ]

THALLOUS CHLORIDE TL-

201

THYROGEN [INJ]

TRYPSIN

UVA URSI LEAF FLUID

EXTRACT

VISIPAQUE [INJ]

water [inj]

water intravenous solution

water solution irrigation

XIAFLEX [INJ]

ZEMAIRA [INJ]

The 2016 AscellaHealth Enhanced Formulary list is listed below. Last updated October 2015 and subject to change at any time. Inclusion on this list does not guarantee coverage. Coverage is based on your specific benefit plan.

KEY: [INJ], [inj] - Injectable Drug [OTC], [otc] - Over the Counter [SP], [sp] - Specialty Drug Brand name drugs are listed in CAPITAL letters. Example: ABILIFY Generic drugs are listed in lower-case letters. Example: altavera

Generic medications contain the same active ingredients as their corresponding brand-name medications, though they may appear different in shape and color. They have been FDA-approved under strict standards.