hcsc formulary 2016 master negative changes from … card for more information. ... drug under cms...
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Pg. 1 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
SUPRAX TAB 400MG Not on 2016 formulary Suprax 400 mg cap Antibacterials
Beta-lactam, Cephalosporins
CEFOTAXIME INJ 10GM Not on 2016 formulary cefotaxime 2 gm inj Antibacterials
Beta-lactam, Cephalosporins
ERYTHROCIN INJ 1000MG Not on 2016 formulary Erythrocin 500 mg inj Antibacterials MacrolidesCIPROFLOXACN TAB 100MG On formulary, higher tier tier 1 to tier 2 Antibacterials Quinolones
OFLOXACIN TAB 300MG Not on 2016 formulary
ciprofloxacin tab (100mg, 250mg, 500mg, 750mg), levofloxacin tab (250mg, 500mg, 750mg), moxifloxacin 400mg tab, ofloxacin 400mg tab Antibacterials Quinolones
OFLOXACIN TAB 400MG On formulary, higher tier tier 1 to tier 2 Antibacterials QuinolonesOFLOXACIN TAB 400MG On formulary, higher tier tier 1 to tier 2 Antibacterials QuinolonesFLUCONAZOLE/ INJ NACL 100 Not on 2016 formulary
fluconazole/INJ NACL 200mg/100ml or 400mg/200mL Antifungals Antifungals
SELZENTRY TAB 150MG On formulary, higher tier tier 1 to tier 2 Antivirals Anti-HIV Agents, OtherSELZENTRY TAB 300MG On formulary, higher tier tier 1 to tier 2 Antivirals Anti-HIV Agents, Other
TIVICAY TAB 50MG On formulary, higher tier tier 1 to tier 2 Antivirals
Anti-HIV Agents, Integrase Inhibitors (INSTI)
EPIVIR SOL 10MG/ML
Not on formulary, generic(s) available lamivudine 10mg/ml oral solution Antivirals
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
HCSC Formulary 2016 Master Negative Changes from 2015 to 2016
Pg. 2 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
SUSTIVA CAP 50MG On formulary, higher tier tier 1 to tier 2 Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
SUSTIVA CAP 200MG On formulary, higher tier tier 1 to tier 2 Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
SUSTIVA TAB 600MG On formulary, higher tier tier 1 to tier 2 Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
VALCYTE TAB 450MG
Not on formulary, generic(s) available valganciclovir 450mg tab Antivirals
Anti-cytomegalovirus (CMV) Agents
BARACLUDE TAB 0.5MG
Not on formulary, generic(s) available entecavir 0.5 mg tab Antivirals
Anti-hepatitis B (HBV) Agents
BARACLUDE TAB 1MG
Not on formulary, generic(s) available entecavir 1 mg tab Antivirals
Anti-hepatitis B (HBV) Agents
ACYCLOVIR NA INJ 1000MG Not on 2016 formulary acyclovir 500mg inj Antivirals Antiherpetic AgentsSTROMECTOL TAB 3MG
Not on formulary, generic(s) available ivermectin 3mg tab Antiparasitics Anthelmintics
XIFAXAN TAB 550MG On formulary, higher tier tier 1 to tier 2 Gastrointestinal Agents
Gastrointestinal Agents, Other
ZYVOX TAB 600MG
Not on formulary, generic(s) available
linezolid tab* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antibacterials Antibacterials, Other
ZYVOX SOL 2MG/ML
Not on formulary, generic(s) available linezolid inj Antibacterials Antibacterials, Other
Pg. 3 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
TETANUS TOX INJ 5LF ADS Not on 2016 formulary check with your doctor Immunological Agents Vaccines
ADRIAMYCIN INJ 20MG
Not on formulary because does not meet the definition of a Part D drug under CMS regulations
doxorubicin inj* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antineoplastics Antineoplastics, Other
DOXIL INJ 2MG/MLNot on formulary, generic(s) available
doxorubicin inj* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antineoplastics Antineoplastics, Other
MITOMYCIN INJ 5MG On formulary, higher tier tier 1 to tier 2 Antineoplastics Antineoplastics, Other
MITOMYCIN INJ 5MG On formulary, higher tier tier 1 to tier 2 Antineoplastics Antineoplastics, Other
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 requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antineoplastics Antineoplastics, Other
CYTARABINE INJ 1GM
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 requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antineoplastics Antineoplastics, Other
Pg. 4 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
ARZERRA CON 100/5ML On formulary, higher tier tier 1 to tier 2 Antineoplastics Monoclonal AntibodiesARZERRA CON 1000/50 On formulary, higher tier tier 1 to tier 2 Antineoplastics Monoclonal AntibodiesDOCEFREZ INJ 80MG Not on 2016 formulary docetaxel inj Antineoplastics Antineoplastics, Other
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 alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antineoplastics Antineoplastics, Other
TYKERB TAB 250MG On formulary, higher tier tier 1 to tier 2 Antineoplastics
Molecular Target Inhibitors
VELCADE INJ 3.5MG On formulary, higher tier tier 1 to tier 2 Antineoplastics
Molecular Target Inhibitors
LEUCOVOR CA INJ 50MG On formulary, higher tier tier 1 to tier 2 Antineoplastics Antineoplastics, OtherLEUCOVOR CA INJ 50MG On formulary, higher tier tier 1 to tier 2 Antineoplastics Antineoplastics, OtherGLYBURIDE TAB 1.25MG Not on 2016 formulary glipizide (IR, ER) or glimepiride
Blood Glucose Regulators Antidiabetic Agents
GLYBURIDE TAB 1.25MG Not on 2016 formulary glipizide (IR, ER) or glimepiride
Blood Glucose Regulators Antidiabetic Agents
GLYBURIDE TAB 2.5MG Not on 2016 formulary glipizide (IR, ER) or glimepiride
Blood Glucose Regulators Antidiabetic Agents
GLYBURIDE TAB 2.5MG Not on 2016 formulary glipizide (IR, ER) or glimepiride
Blood Glucose Regulators Antidiabetic Agents
GLYBURIDE TAB 5MG Not on 2016 formulary glipizide (IR, ER) or glimepiride
Blood Glucose Regulators Antidiabetic Agents
GLYBURIDE TAB 5MG Not on 2016 formulary glipizide (IR, ER) or glimepiride
Blood Glucose Regulators Antidiabetic Agents
Pg. 5 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
GLYBURID MCR TAB 1.5MG Not on 2016 formulary glipizide (IR, ER) or glimepiride
Blood Glucose Regulators Antidiabetic Agents
GLYBURID MCR TAB 3MG Not on 2016 formulary glipizide (IR, ER) or glimepiride
Blood Glucose Regulators Antidiabetic Agents
GLYBURID MCR TAB 6MG Not on 2016 formulary glipizide (IR, ER) or glimepiride
Blood Glucose Regulators Antidiabetic Agents
GLYB/METFORM TAB 1.25-250 Not on 2016 formulary glipizide/metformin
Blood Glucose Regulators Antidiabetic Agents
GLYB/METFORM TAB 2.5-500 Not on 2016 formulary glipizide/metformin
Blood Glucose Regulators Antidiabetic Agents
GLYB/METFORM TAB 5-500MG Not on 2016 formulary glipizide/metformin
Blood Glucose Regulators Antidiabetic Agents
ATELVIA TABNot on formulary, generic(s) available
risendronate sodium delayed release 30mg tab
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
DIGOXIN TAB 0.25MG
On formulary, requires prior authorization check with your doctor Cardiovascular Agents
Cardiovascular Agents, Other
DIGITEK TAB 0.25MG
On formulary, requires prior authorization check with your doctor Cardiovascular Agents
Cardiovascular Agents, Other
DIGOX TAB 0.25MG
On formulary, requires prior authorization check with your doctor Cardiovascular Agents
Cardiovascular Agents, Other
BYSTOLIC TAB 2.5MG Not on 2016 formulary
acebutolol, atenolol, betaxolol, bisoprolol, metoprolol succinate ER or metoprolol tartrate Cardiovascular Agents
Beta-adrenergic Blocking Agents
BYSTOLIC TAB 5MG Not on 2016 formulary
acebutolol, atenolol, betaxolol, bisoprolol, metoprolol succinate ER or metoprolol tartrate Cardiovascular Agents
Beta-adrenergic Blocking Agents
BYSTOLIC TAB 10MG Not on 2016 formulary
acebutolol, atenolol, betaxolol, bisoprolol, metoprolol succinate ER or metoprolol tartrate Cardiovascular Agents
Beta-adrenergic Blocking Agents
BYSTOLIC TAB 20MG Not on 2016 formulary
acebutolol, atenolol, betaxolol, bisoprolol, metoprolol succinate ER or metoprolol tartrate Cardiovascular Agents
Beta-adrenergic Blocking Agents
BENICAR TAB 5MG Not on 2016 formularycandesartan, eprosartan, irbesartan, losartan, telmisartan or valsartan Cardiovascular Agents
Angiotensin II Receptor Antagonists
Pg. 6 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
BENICAR TAB 20MG Not on 2016 formulary
candesartan, eprosartan, irbesartan, losartan, telmisartan or valsartan Cardiovascular Agents
Angiotensin II Receptor Antagonists
BENICAR TAB 40MG Not on 2016 formulary
candesartan, eprosartan, irbesartan, losartan, telmisartan or valsartan Cardiovascular Agents
Angiotensin II Receptor Antagonists
AZOR TAB 5-20MG Not on 2016 formulary amlodipine/valsartan Cardiovascular Agents
Cardiovascular Agents, Other
AZOR TAB 5-40MG Not on 2016 formulary amlodipine/valsartan Cardiovascular Agents
Cardiovascular Agents, Other
AZOR TAB 10-20MG Not on 2016 formulary amlodipine/valsartan Cardiovascular Agents
Cardiovascular Agents, Other
AZOR TAB 10-40MG Not on 2016 formulary amlodipine/valsartan Cardiovascular Agents
Cardiovascular Agents, Other
EXFORGE TAB 5-160MG
Not on formulary, generic(s) available amlodipine/valsartan tab Cardiovascular Agents
Cardiovascular Agents, Other
EXFORGE TAB 5-320MG
Not on formulary, generic(s) available amlodipine/valsartan tab Cardiovascular Agents
Cardiovascular Agents, Other
EXFORGE TAB 10-160MG
Not on formulary, generic(s) available amlodipine/valsartan tab Cardiovascular Agents
Cardiovascular Agents, Other
EXFORGE TAB 10-320MG
Not on formulary, generic(s) available amlodipine/valsartan tab Cardiovascular Agents
Cardiovascular Agents, Other
BENICAR HCT TAB 20-12.5 Not on 2016 formulary
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide or valsartan/hydrochlorothiazide Cardiovascular Agents
Cardiovascular Agents, Other
BENICAR HCT TAB 40-12.5 Not on 2016 formulary
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide or valsartan/hydrochlorothiazide Cardiovascular Agents
Cardiovascular Agents, Other
Pg. 7 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
BENICAR HCT TAB 40-25MG Not on 2016 formulary
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide or valsartan/hydrochlorothiazide Cardiovascular Agents
Cardiovascular Agents, Other
EXFORGEH/5- TAB 160-12.5
Not on formulary, generic(s) available
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
EXFORGEH/5- TAB 160-25
Not on formulary, generic(s) available
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
EXFORGEH/10- TAB 160-12.5
Not on formulary, generic(s) available
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
EXFORGEH/10- TAB 160-25
Not on formulary, generic(s) available
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
EXFORGEH/10- TAB 320-25
Not on formulary, generic(s) available
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
TRIBENZOR20- TAB 5-12.5MG Not on 2016 formulary
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
TRIBENZOR40- TAB 5-12.5MG Not on 2016 formulary
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
TRIBENZOR40- TAB 5-25MG Not on 2016 formulary
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
TRIBENZOR40- TAB 10-12.5 Not on 2016 formulary
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
TRIBENZOR40- TAB 10-25MG Not on 2016 formulary
amlodipine/valsartan/hydrochlorothiazide tab Cardiovascular Agents
Cardiovascular Agents, Other
TEKAMLO TAB 150-5MG Not on 2016 formulary
Tekturna used in combination with amlodipine Cardiovascular Agents
Cardiovascular Agents, Other
TEKAMLO TAB 150-10MG Not on 2016 formulary
Tekturna used in combination with amlodipine Cardiovascular Agents
Cardiovascular Agents, Other
TEKAMLO TAB 300-5MG
Not on formulary because does not meet the definition of a Part D drug under CMS regulations
Tekturna used in combination with amlodipine Cardiovascular Agents
Cardiovascular Agents, Other
Pg. 8 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
TEKAMLO TAB 300-10MG
Not on formulary because does not meet the definition of a Part D drug under CMS regulations
Tekturna used in combination with amlodipine Cardiovascular Agents
Cardiovascular Agents, Other
AMTURNIDE150 TAB -5-12.5
Not on formulary because does not meet the definition of a Part D drug under CMS regulations
Tekturna, amlodipine and hydrochlorothiazide used in combination or Tekturna HCT and amlodipine used in combination Cardiovascular Agents
Cardiovascular Agents, Other
AMTURNIDE300 TAB -5-12.5 Not on 2016 formulary
Tekturna, amlodipine and hydrochlorothiazide used in combination or Tekturna HCT and amlodipine used in combination Cardiovascular Agents
Cardiovascular Agents, Other
AMTURNIDE300 TAB -5-25MG Not on 2016 formulary
Tekturna, amlodipine and hydrochlorothiazide used in combination or Tekturna HCT and amlodipine used in combination Cardiovascular Agents
Cardiovascular Agents, Other
AMTURNIDE300 TAB -10-12.5
Not on formulary because does not meet the definition of a Part D drug under CMS regulations
Tekturna, amlodipine and hydrochlorothiazide used in combination or Tekturna HCT and amlodipine used in combination Cardiovascular Agents
Cardiovascular Agents, Other
AMTURNIDE300 TAB -10-25MG Not on 2016 formulary
Tekturna, amlodipine and hydrochlorothiazide used in combination or Tekturna HCT and amlodipine used in combination Cardiovascular Agents
Cardiovascular Agents, Other
WELCHOL TAB 625MG On formulary, higher tier tier 1 to tier 2
Blood Glucose Regulators Antidiabetic Agents
WELCHOL PAK 3.75GM On formulary, higher tier tier 1 to tier 2
Blood Glucose Regulators Antidiabetic Agents
CLEMASTINE TAB 2.68MG
On formulary, requires prior authorization check with your doctor
Respiratory Tract/ Pulmonary Agents Antihistamines
Pg. 9 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
PROMETHAZINE TAB 12.5MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PROMETHAZINE TAB 25MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PROMETHAZINE TAB 50MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PROMETHAZINE SYP 6.25/5ML
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PROMETHAZINE SOL 6.25/5ML
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PHENADOZ SUP 12.5MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PROMETHEGAN SUP 12.5MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PHENERGAN SUP 12.5MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PROMETHAZINE SUP 12.5MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PHENADOZ SUP 25MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PROMETHEGAN SUP 25MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PHENERGAN SUP 25MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
PROMETHAZINE SUP 25MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
ASTEPRO SPR 0.15%
Not on formulary, generic(s) available azelastine nasal spray
Respiratory Tract/ Pulmonary Agents Antihistamines
PATANASE SPR 0.6%
Not on formulary, generic(s) available olopatadine nasal solution
Respiratory Tract/ Pulmonary Agents Antihistamines
CROMOLYN SOD NEB 20MG/2ML On formulary, higher tier tier 1 to tier 2
Respiratory Tract/ Pulmonary Agents Mast Cell Stabilizers
KALYDECO TAB 150MG
On formulary, requires prior authorization check with your doctor
Respiratory Tract/ Pulmonary Agents Cystic Fibrosis Agents
Pg. 10 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
KALYDECO PAK 50MG
On formulary, requires prior authorization check with your doctor
Respiratory Tract/ Pulmonary Agents Cystic Fibrosis Agents
KALYDECO PAK 75MG
On formulary, requires prior authorization check with your doctor
Respiratory Tract/ Pulmonary Agents Cystic Fibrosis Agents
SUPREP BOWEL SOL PREP On formulary, higher tier tier 1 to tier 2 Gastrointestinal Agents LaxativesNEXIUM GRA 2.5MG DR On formulary, higher tier tier 1 to tier 2 Gastrointestinal Agents Proton Pump InhibitorsNEXIUM GRA 5MG DR On formulary, higher tier tier 1 to tier 2 Gastrointestinal Agents Proton Pump InhibitorsNEXIUM GRA 10MG DR On formulary, higher tier tier 1 to tier 2 Gastrointestinal Agents Proton Pump InhibitorsNEXIUM GRA 20MG DR On formulary, higher tier tier 1 to tier 2 Gastrointestinal Agents Proton Pump InhibitorsNEXIUM GRA 40MG DR On formulary, higher tier tier 1 to tier 2 Gastrointestinal Agents Proton Pump Inhibitors
NEXIUM CAP 20MGNot on formulary, generic(s) available esomeprazole cap Gastrointestinal Agents Proton Pump Inhibitors
NEXIUM CAP 20MGNot on formulary, generic(s) available esomeprazole cap Gastrointestinal Agents Proton Pump Inhibitors
NEXIUM CAP 40MGNot on formulary, generic(s) available esomeprazole cap Gastrointestinal Agents Proton Pump Inhibitors
NEXIUM CAP 40MGNot on formulary, generic(s) available esomeprazole cap Gastrointestinal Agents Proton Pump Inhibitors
ESOMEPRAZOLE INJ 20MG On formulary, higher tier tier 1 to tier 2 Gastrointestinal Agents Proton Pump Inhibitors
SANCUSO DIS 3.1MG Not on 2016 formulary
granisetron tab* or ondansetron (regular, ODT) tab* *Please note, these formulary alternatives require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antiemetics
Emetogenic Therapy Adjuncts
Pg. 11 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
EMEND CAP 40MG On formulary, higher tier tier 1 to tier 2 AntiemeticsEmetogenic Therapy Adjuncts
EMEND CAP 80MG On formulary, higher tier tier 1 to tier 2 AntiemeticsEmetogenic Therapy Adjuncts
EMEND CAP 125MG On formulary, higher tier tier 1 to tier 2 Antiemetics
Emetogenic Therapy Adjuncts
EMEND PAK 80 & 125 On formulary, higher tier tier 1 to tier 2 Antiemetics
Emetogenic Therapy Adjuncts
LOTRONEX TAB 0.5MG
Not on formulary, generic(s) available alosetron Gastrointestinal Agents
Irritable Bowel Syndrome Agents
LOTRONEX TAB 1MG
Not on formulary, generic(s) available alosetron Gastrointestinal Agents
Irritable Bowel Syndrome Agents
NITROFURANTN SUS 25MG/5ML
On formulary, requires prior authorization check with your doctor Antibacterials Antibacterials, Other
NITROFUR MAC CAP 50MG
On formulary, requires prior authorization check with your doctor Antibacterials Antibacterials, Other
NITROFUR MAC CAP 100MG
On formulary, requires prior authorization check with your doctor Antibacterials Antibacterials, Other
NITROFURANTN CAP 100MG
On formulary, requires prior authorization check with your doctor Antibacterials Antibacterials, Other
AVODART CAP 0.5MG Not on 2016 formulary finasteride tab Genitourinary Agents
Benign Prostatic Hypertrophy Agents
JALYN CAP Not on 2016 formularyfinasteride tab taken in combination with tamsulosin cap Genitourinary Agents
Benign Prostatic Hypertrophy Agents
HYDROXYZ HCL TAB 10MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
HYDROXYZ HCL TAB 25MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
HYDROXYZ HCL TAB 50MG
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
HYDROXYZ HCL SYP 10MG/5ML
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
HYDROXYZ HCL SOL 10MG/5ML
On formulary, requires prior authorization check with your doctor Antiemetics Antiemetics, Other
Pg. 12 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
FANAPT TAB 1MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
FANAPT TAB 2MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
FANAPT TAB 4MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
FANAPT TAB 6MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
FANAPT TAB 8MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
FANAPT TAB 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 13 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
FANAPT TAB 12MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
FANAPT PAK
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA TAB 1.5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA TAB 3MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA TAB 6MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA TAB 9MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 14 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
INVEGA SUST INJ 39/0.25
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ 78/0.5ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ 117/0.75
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ 156MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA SUST INJ 234/1.5
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ 273MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 15 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
INVEGA TRINZ INJ 410MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ 546MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
INVEGA TRINZ INJ 819MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 0.25MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 0.5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 1MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 16 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
RISPERIDONE TAB 2MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 3MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 4MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE SOL 1MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 0.25 ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 0.5MG OD
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 17 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
RISPERIDONE TAB 1MG ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 2MG ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 3MG ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
RISPERIDONE TAB 4MG ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
HALOPERIDOL TAB 0.5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB 1MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
Pg. 18 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
HALOPERIDOL TAB 2MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB 5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
HALOPERIDOL TAB 20MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
HALOPERIDOL CON 2MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
HALOPER LAC INJ 5MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
Pg. 19 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
HALOPER DEC INJ 50MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
HALOPER DEC INJ 100MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
CLOZAPINE TAB 25MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
CLOZAPINE TAB 50MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
CLOZAPINE TAB 100MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
CLOZAPINE TAB 200MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
Pg. 20 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
VERSACLOZ SUS 50MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
FAZACLO TAB 12.5/ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
FAZACLO TAB 25MG ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
FAZACLO TAB 100/ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
FAZACLO TAB 150MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
FAZACLO TAB 200MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics Treatment-Resistant
Pg. 21 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
QUETIAPINE TAB 25MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB 50MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB 100MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB 200MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB 300MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
QUETIAPINE TAB 400MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 22 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
SEROQUEL XR TAB 50MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB 150MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB 200MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB 300MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
SEROQUEL XR TAB 400MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ADASUVE INH 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
Pg. 23 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
LOXAPINE CAP 5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
LOXAPINE CAP 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
LOXAPINE CAP 25MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
LOXAPINE CAP 50MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
SAPHRIS SUB 2.5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
SAPHRIS SUB 5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 24 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
SAPHRIS SUB 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 2.5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 7.5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 15MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 25 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
OLANZAPINE TAB 20MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE INJ 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 5MG ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 10MG ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 15MG ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
OLANZAPINE TAB 20MG ODT
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 26 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
ZYPREXA RELP INJ 300MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ZYPREXA RELP INJ 405MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
CHLORPROMAZ TAB 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
CHLORPROMAZ TAB 25MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
CHLORPROMAZ TAB 50MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
CHLORPROMAZ TAB 100MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
Pg. 27 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
CHLORPROMAZ TAB 200MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
CHLORPROMAZ INJ 25MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
CHLORPROMAZ INJ 50MG/2ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
FLUPHENAZINE TAB 1MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
FLUPHENAZINE TAB 2.5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
FLUPHENAZINE TAB 5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
Pg. 28 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
FLUPHENAZINE TAB 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
FLUPHENAZINE ELX 2.5/5ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
FLUPHENAZINE CON 5MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
FLUPHENAZINE INJ 2.5MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
FLUPHENAZ DE INJ 25MG/ML
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
PERPHENAZINE TAB 2MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
Pg. 29 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
PERPHENAZINE TAB 4MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
PERPHENAZINE TAB 8MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
PERPHENAZINE TAB 16MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antiemetics Antiemetics, Other
TRIFLUOPERAZ TAB 1MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
TRIFLUOPERAZ TAB 2MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
TRIFLUOPERAZ TAB 5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
Pg. 30 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
TRIFLUOPERAZ TAB 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
ABILIFY TAB 2MGNot on formulary, generic(s) available
aripiprazole tab* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB 2MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ABILIFY TAB 5MGNot on formulary, generic(s) available
aripiprazole tab* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB 5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 31 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
ABILIFY TAB 10MGNot on formulary, generic(s) available
aripiprazole tab* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ABILIFY TAB 15MGNot on formulary, generic(s) available
aripiprazole tab* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB 15MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ABILIFY TAB 20MGNot on formulary, generic(s) available
aripiprazole tab* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical
Pg. 32 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
ARIPIPRAZOLE TAB 20MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ABILIFY TAB 30MGNot on formulary, generic(s) available
aripiprazole tab* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical
ARIPIPRAZOLE TAB 30MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ABILIFY MAIN INJ 300MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ABILIFY MAIN INJ 400MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ABILIFY SOL 1MG/ML
Not on formulary, generic(s) available
aripiprazole oral solution* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical
Pg. 33 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
ABILIFY INJ 9.75MG Not on 2016 formulary
Geodon inj* or olanzapine inj* *Please note, these formulary alternatives require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical
ABILIFY DISC TAB 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ABILIFY DISC TAB 15MG Not on 2016 formulary
aripiprazole tab* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Antipsychotics 2nd Generation/Atypical
REXULTI TAB 0.25MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
REXULTI TAB 0.5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
REXULTI TAB 1MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 34 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
REXULTI TAB 2MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
REXULTI TAB 3MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
REXULTI TAB 4MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
THIOTHIXENE CAP 1MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
THIOTHIXENE CAP 2MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
THIOTHIXENE CAP 5MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
Pg. 35 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
THIOTHIXENE CAP 10MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 1st Generation/Typical
LATUDA TAB 20MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
LATUDA TAB 40MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
LATUDA TAB 60MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
LATUDA TAB 80MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
LATUDA TAB 120MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
Pg. 36 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
ZIPRASIDONE CAP 20MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ZIPRASIDONE CAP 40MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ZIPRASIDONE CAP 60MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ZIPRASIDONE CAP 80MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
GEODON INJ 20MG
If drug taken in 2015, coverage will occur until 2016. On formulary, requires prior authorization. Antipsychotics 2nd Generation/Atypical
ZALEPLON CAP 5MG
On formulary, requires prior authorization check with your doctor Sleep Disorder Agents
GABA Receptor Modulators
ZALEPLON CAP 10MG
On formulary, requires prior authorization check with your doctor Sleep Disorder Agents
GABA Receptor Modulators
ZOLPIDEM TAB 5MGOn formulary, requires prior authorization check with your doctor Sleep Disorder Agents
GABA Receptor Modulators
ZOLPIDEM TAB 10MG
On formulary, requires prior authorization check with your doctor Sleep Disorder Agents
GABA Receptor Modulators
Pg. 37 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
ERGOLOID MES TAB 1MG ORAL
On formulary, requires prior authorization check with your doctor Antidementia Agents
Antidementia Agents, Other
GALANTAMINE SOL 4MG/ML On formulary, higher tier tier 1 to tier 2 Antidementia Agents
Cholinesterase Inhibitors
MEMANTINE TAB HCL 5MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA TAB 5MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
MEMANTINE HC TAB 10MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA TAB 10MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA TAB 5-10MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
MEMANT TITRA PAK 5-10MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA SOL 10MG/5ML
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA XR CAP 7MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA XR CAP 14MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA XR CAP 21MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
Pg. 38 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
NAMENDA XR CAP 28MG
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA XR CAP TITRATIO
On formulary, requires prior authorization check with your doctor Antidementia Agents
N-methyl-D-aspartate (NMDA) Receptor Antagonist
SUBSYS SPR 100MCG Not on 2016 formulary
Abstral sublingual tab*, fentanyl lozenge* or Lazanda nasal spray* *Please note, these formulary alternatives require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Short-acting
SUBSYS SPR 200MCG Not on 2016 formulary
Abstral sublingual tab*, fentanyl lozenge* or Lazanda nasal spray* *Please note, these formulary alternatives require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Short-acting
SUBSYS SPR 400MCG Not on 2016 formulary
Abstral sublingual tab*, fentanyl lozenge* or Lazanda nasal spray* *Please note, these formulary alternatives require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Short-acting
Pg. 39 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
SUBSYS SPR 600MCG Not on 2016 formulary
Abstral sublingual tab*, fentanyl lozenge* or Lazanda nasal spray* *Please note, these formulary alternatives require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Short-acting
SUBSYS SPR 800MCG Not on 2016 formulary
Abstral sublingual tab*, fentanyl lozenge* or Lazanda nasal spray* *Please note, these formulary alternatives require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Short-acting
SUBSYS SPR 1200MCG Not on 2016 formulary
Abstral sublingual tab*, fentanyl lozenge* or Lazanda nasal spray* *Please note, these formulary alternatives require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Short-acting
SUBSYS SPR 1600MCG Not on 2016 formulary
Abstral sublingual tab*, fentanyl lozenge* or Lazanda nasal spray* *Please note, these formulary alternatives require prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Short-acting
FENTANYL DIS 12MCG/HR On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
Pg. 40 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
FENTANYL DIS 25MCG/HR On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
FENTANYL DIS 50MCG/HR On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
FENTANYL DIS 75MCG/HR On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
FENTANYL DIS 100MCG/H On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
HYDROMORPHON TAB 2MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROMORPHON TAB 4MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROMORPHON TAB 8MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROMORPHON INJ 10MG/ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROMORPHON INJ 50MG/5ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROMORPHON INJ 500/50ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
MORPHINE SUL TAB 15MG ER On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
MORPHINE SUL TAB 30MG ER On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
MORPHINE SUL TAB 60MG ER On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
MORPHINE SUL TAB 100MG ER On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
MORPHINE SUL TAB 200MG ER On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Long-acting
MORPHINE SUL INJ 0.5MG/ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
DURAMORPH INJ 0.5MG/ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
Pg. 41 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
MORPHINE SUL INJ 1MG/ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
DURAMORPH INJ 1MG/ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
MORPHINE SUL SOL 10MG/5ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
MORPHINE SUL SOL 20MG/5ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
MORPHINE SUL SOL 100/5ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
MORPHINE SUL CAP 10MG ER Not on 2016 formulary
morphine sulfate ER tab (15mg, 30mg, 60mg, 100mg, 200mg), Nucynta ER, tramadol ER, Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
OXYCODONE TAB 5MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
OXYCODONE TAB 10MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
OXYCODONE TAB 15MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
OXYCODONE TAB 20MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
OXYCODONE TAB 30MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
BUTORPHANOL INJ 1MG/ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
BUTORPHANOL INJ 2MG/ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
Pg. 42 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
BUTORPHANOL SOL 10MG/ML On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
OXYCOD/APAP TAB 2.5-325 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
ENDOCET TAB 2.5-325 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
OXYCOD/APAP TAB 5-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
ROXICET TAB 5-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
ENDOCET TAB 5-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
OXYCOD/APAP TAB 7.5-325 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
ENDOCET TAB 7.5-325 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
OXYCOD/APAP TAB 10-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
ENDOCET TAB 10-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
OXYCOD/ASA TAB On formulary, higher tier tier 1 to tier 2 AnalgesicsOpioid Analgesics, Short-acting
ENDODAN TAB On formulary, higher tier tier 1 to tier 2 AnalgesicsOpioid Analgesics, Short-acting
BUT/APAP/CAF CAP CODEINE
On formulary, requires prior authorization check with your doctor Antimigraine Agents Antimigraine Agents
BUT/APAP/CAF CAP CODEINE
On formulary, requires prior authorization check with your doctor Antimigraine Agents Antimigraine Agents
BUT/ASA/CAF/ CAP COD 30MG
On formulary, requires prior authorization check with your doctor Antimigraine Agents Antimigraine Agents
ASCOMP/COD CAP 30MG
On formulary, requires prior authorization check with your doctor Antimigraine Agents Antimigraine Agents
HYDROCO/APAP TAB 10-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
Pg. 43 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
LORTAB TAB 10-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
LORCET HD TAB 10-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
VICODIN TAB 5-300MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCO/APAP TAB 5-300MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
VICODIN ES TAB 7.5-300 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCO/APAP TAB 7.5-300 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCO/APAP TAB 5-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
LORTAB TAB 5-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
LORCET TAB 5-325MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCO/APAP TAB 7.5-325 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
LORTAB TAB 7.5-325 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
LORCET PLUS TAB 7.5-325 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
VICODIN HP TAB 10-300MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCO/APAP TAB 10-300MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCO/APAP SOL 7.5-325 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCO/APAP SOL On formulary, higher tier tier 1 to tier 2 AnalgesicsOpioid Analgesics, Short-acting
HYDROCO/APAP SOL 5-217/10 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
Pg. 44 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
HYDROCOD/IBU TAB 2.5-200 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
IBUDONE TAB 5-200MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCOD/IBU TAB 5-200MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCOD/IBU TAB 7.5-200 On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
REPREXAIN TAB 10-200MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
XYLON TAB 10-200MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
HYDROCOD/IBU TAB 10-200MG On formulary, higher tier tier 1 to tier 2 Analgesics
Opioid Analgesics, Short-acting
KETOROLAC TAB 10MG Not on 2016 formulary check with your doctor Analgesics
Nonsteroidal Anti-inflammatory Drugs
CELEBREX CAP 50MG
Not on formulary, generic(s) available celecoxib 50 mg cap Analgesics
Nonsteroidal Anti-inflammatory Drugs
CELEBREX CAP 100MG
Not on formulary, generic(s) available celecoxib 100 mg cap Analgesics
Nonsteroidal Anti-inflammatory Drugs
CELEBREX CAP 200MG
Not on formulary, generic(s) available celecoxib 200 mg cap Analgesics
Nonsteroidal Anti-inflammatory Drugs
CELEBREX CAP 400MG
Not on formulary, generic(s) available celecoxib 400 mg cap Analgesics
Nonsteroidal Anti-inflammatory Drugs
LAMICTAL ODT TAB 25MG
Not on formulary, generic(s) available lamotrigine ODT Anticonvulsants
Glutamate Reducing Agents
LAMICTAL ODT TAB 50MG
Not on formulary, generic(s) available lamotrigine ODT Anticonvulsants
Glutamate Reducing Agents
LAMICTAL ODT TAB 100MG
Not on formulary, generic(s) available lamotrigine ODT Anticonvulsants
Glutamate Reducing Agents
LAMICTAL ODT TAB 200MG
Not on formulary, generic(s) available lamotrigine ODT Anticonvulsants
Glutamate Reducing Agents
BENZTROPINE TAB 0.5MG
On formulary, requires prior authorization check with your doctor Antiparkinson Agents
Antiparkinson Agents, Other
Pg. 45 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
BENZTROPINE TAB 1MG
On formulary, requires prior authorization check with your doctor Antiparkinson Agents
Antiparkinson Agents, Other
BENZTROPINE TAB 2MG
On formulary, requires prior authorization check with your doctor Antiparkinson Agents
Antiparkinson Agents, Other
TASMAR TAB 100MG
Not on formulary, generic(s) available tolcapone Antiparkinson Agents
Antiparkinson Agents, Other
CYCLOBENZAPR TAB 5MG
On formulary, requires prior authorization check with your doctor
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
CYCLOBENZAPR TAB 7.5MG
On formulary, requires prior authorization check with your doctor
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
CYCLOBENZAPR TAB 10MG
On formulary, requires prior authorization check with your doctor
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
DANTROLENE CAP 100MG On formulary, higher tier tier 1 to tier 2 Antispasticity Agents Antispasticity Agents
LIPOSYN III INJ 30%
Not on formulary because does not meet the definition of a Part D drug under CMS regulations
fat emulsion 20%* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information.
Therapeutic Nutrients/ Minerals/ Electrolytes
Therapeutic Nutrients/ Minerals/ Electrolytes
ARANESP INJ 10MCG On formulary, higher tier tier 1 to tier 2
Blood Products/Modifiers/ Volume Expanders
Blood Formation Modifiers
ARANESP INJ 25MCG On formulary, higher tier tier 1 to tier 2
Blood Products/Modifiers/ Volume Expanders
Blood Formation Modifiers
ARANESP INJ 25MCG On formulary, higher tier tier 1 to tier 2
Blood Products/Modifiers/ Volume Expanders
Blood Formation Modifiers
ARANESP INJ 40MCG On formulary, higher tier tier 1 to tier 2
Blood Products/Modifiers/ Volume Expanders
Blood Formation Modifiers
Pg. 46 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
ARANESP INJ 40MCG On formulary, higher tier tier 1 to tier 2
Blood Products/Modifiers/ Volume Expanders
Blood Formation Modifiers
ARANESP INJ 60MCG On formulary, higher tier tier 1 to tier 2
Blood Products/Modifiers/ Volume Expanders
Blood Formation Modifiers
ARANESP INJ 60MCG On formulary, higher tier tier 1 to tier 2
Blood Products/Modifiers/ Volume Expanders
Blood Formation Modifiers
PRADAXA CAP 75MG On formulary, higher tier tier 1 to tier 2
Blood Products/Modifiers/ Volume Expanders Anticoagulants
PRADAXA CAP 150MG On formulary, higher tier tier 1 to tier 2
Blood Products/Modifiers/ Volume Expanders Anticoagulants
LEVOBUNOLOL SOL 0.25% OP Not on 2016 formulary
Betoptic-S, betaxolol 0.5%, carteolol 1%, Istalol, levobunolol 0.5%, timolol 0.25% or timolol 0.5% Ophthalmic Agents
Ophthalmic Antiglaucoma Agents
RESTASIS EMU 0.05%
On formulary, requires prior authorization check with your doctor Ophthalmic Agents
Ophthalmic Agents, Other
CORTIFOAM AER 90MG Not on 2016 formulary
Colocort 100mg enema or hydrocortisone 100mg enema
Inflammatory Bowel Disease Agents Glucocorticoids
VOLTAREN GEL 1% On formulary, higher tier tier 1 to tier 2 AnalgesicsNonsteroidal Anti-inflammatory Drugs
VECTICAL OIN 3MCG/GM Not on 2016 formulary
calcipotriene 0.005% (cream, ointment), calcitrene 0.005% ointment, Tazorac 0.05% (cream, gel) or Tazorac 0.1 % (cream, gel) Dermatological Agents Dermatological Agents
Pg. 47 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
AMCINONIDE CRE 0.1% Not on 2016 formulary
alclometasone cream/ointment, betamethasone dipropionate cream/lotion/ointment, augmented betamethasone cream/gel/ointment, betamethasone valerate cream/lotion/ointment, clobetasol cream/gel/ointment/solution, clobetasol E cream, desonide cream/lotion/ointment, desoximetasone cream/gel/ointment, diflorasone ointment, fluocinolone cream, fluocinonide cream/gel/ointment/solution, fluocinonide E cream, fluticasone cream/ointment, Lokara lotion, halobetasol cream/ointment, hydrocortisone cream/lotion/ointment, hydrocortisone butyrate cream/ointment/solution, hydrocortisone valerate cream/ointment, mometasone cream/ointment/solution, prednicarbate cream/ointment or triamcinolone cream/lotion/ointment
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
DIFLORASONE OIN 0.05% On formulary, higher tier tier 1 to tier 2
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
LIDOCAINE PAD 5%On formulary, quantity limit may apply max of 90 patches per 30 days Anesthetics Local Anesthetics
ULESFIA LOT 5% Not on 2016 formulary Lindane, malathion or permethrin AntiparasiticsPediculicides/Scabicides
Pg. 48 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
NALOXONE INJ 1MG/ML On formulary, higher tier tier 1 to tier 2
Anti-Addiction/ Substance Abuse Treatment Agents Opioid Reversal Agents
GLUCAGEN INJ 1MG Not on 2016 formulary Glucagen inj 1mg hypokit
Blood Glucose Regulators Glycemic Agents
CUPRIMINE CAP 250MG On formulary, higher tier tier 1 to tier 2 Genitourinary Agents
Genitourinary Agents, Other
THALOMID CAP 50MG On formulary, higher tier tier 1 to tier 2 Antineoplastics Antiangiogenic AgentsTHALOMID CAP 100MG On formulary, higher tier tier 1 to tier 2 Antineoplastics Antiangiogenic AgentsTHALOMID CAP 150MG On formulary, higher tier tier 1 to tier 2 Antineoplastics Antiangiogenic AgentsTHALOMID CAP 200MG On formulary, higher tier tier 1 to tier 2 Antineoplastics Antiangiogenic Agents
CELLCEPT SUS 200MG/ML
Not on formulary, generic(s) available
mycophenolate mofetil suspension* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Immunological Agents Immune Suppressants
OXYCONTIN TAB 10MG CR Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
Pg. 49 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
OXYCONTIN TAB 15MG CR Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
OXYCONTIN TAB 20MG CR Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
OXYCONTIN TAB 30MG CR Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
Pg. 50 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
OXYCONTIN TAB 40MG CR Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
OXYCONTIN TAB 60MG CR Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
OXYCONTIN TAB 80MG CR Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
Pg. 51 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
OPANA ER TAB 5MG Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
OPANA ER TAB 7.5MG Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
OPANA ER TAB 10MG Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
Pg. 52 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
OPANA ER TAB 15MG Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
OPANA ER TAB 20MG Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
OPANA ER TAB 30MG Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting
Pg. 53 of 53
Affected Drug Description of Change Formulary Alternative, if Applicable Category Class
OPANA ER TAB 40MG Not on 2016 formulary
codeine sulfate, hydromorphone, methadone, morphine sulfate, morphine sulfate ER tab, Nucynta ER, oxycodone IR, tramadol, tramadol ER or Zohydro ER* *Please note, this formulary alternative requires prior authorization. To download the specific form, please visit www.MyPrime.com or contact the number on the back of your insurance card for more information. Analgesics
Opioid Analgesics, Long-acting