Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ACYCLOVIR OIN 5% On formulary, tier change tier 2 to tier 4 Antivirals Antiherpetic Agents
ACYCLOVIR NA INJ
500MG On formulary, tier change tier 2 to tier 4 Antivirals Antiherpetic Agents
ACYCLOVIR NA INJ
50MG/ML On formulary, tier change tier 2 to tier 4 Antivirals Antiherpetic Agents
ALBUTEROL TAB 2MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ALBUTEROL TAB 4MG On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ALBUTEROL TAB 4MG
ER On formulary, tier change tier 2 to tier 4 Respiratory Tract Agents
Bronchodilators,
Sympathomimetic
ALBUTEROL TAB 8MG
ER On formulary, tier change tier 2 to tier 4
Respiratory Tract/
Pulmonary Agents
Bronchodilators,
Sympathomimetic
AMIKACIN INJ
1GM/4ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
AMIKACIN INJ
500/2ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
AMINOSYN-HF INJ 8% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
AMLOD/ATORVA TAB 10-
10MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 10-
20MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 10-
40MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 10-
80MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB
2.5-10MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
HCSC Formulary 2017 Master Negative Changes from 2016 to 2017
Pg. 1 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMLOD/ATORVA TAB
2.5-20MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB
2.5-40MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 5-
10MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 5-
20MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 5-
40MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/ATORVA TAB 5-
80MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
AMLOD/VALSAR TAB
/HCTZ Not on 2017 formulary
amlodipine/valsartan used
in combination with
hydrochlorothiazide Cardiovascular Agents
Cardiovascular Agents,
Other
AMOX/K CLAV CHW
200MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
AMOX/K CLAV CHW
400MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
AMPHET/DEXTR CAP
10MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR CAP
15MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR CAP
20MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR CAP
25MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
Pg. 2 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMPHET/DEXTR CAP
30MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHET/DEXTR CAP
5MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHETAMINE CAP
10MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHETAMINE CAP
15MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHETAMINE CAP
20MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHETAMINE CAP
25MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHETAMINE CAP
30MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPHETAMINE CAP
5MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
AMPICILLIN INJ 10GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
AMPICILLIN INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
AMPICILLIN INJ 250MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
AMPICILLIN INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
AMPICILLIN INJ 500MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
AMP-SULBACTA INJ 2-
1GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
Pg. 3 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AMP-SULBACTA INJ
3GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
ANDROGEL GEL
1%(25MG) Not on 2017 formulary
testosterone 1% gel
(generic Androgel 1%
made by Actavis and Par
brand only)* *This drug
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.
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
ANDROGEL GEL
1%(50MG) Not on 2017 formulary
testosterone 1% gel
(generic Androgel 1%
made by Actavis and Par
brand only)* *This drug
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.
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
Pg. 4 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ANDROID CAP 10MG Not on 2017 formulary
methyltestosterone 10 mg
capsules* *This drug
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.
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
APAP/CODEINE SOL
120-12/5 On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
APAP/CODEINE TAB 300-
15MG On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
APAP/CODEINE TAB 300-
30MG On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
APAP/CODEINE TAB 300-
60MG On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
APTIOM TAB 200MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents
APTIOM TAB 400MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents
APTIOM TAB 600MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents
APTIOM TAB 800MG On formulary, tier change tier 4 to tier 5 Anticonvulsants Sodium Channel Agents
ASCOMP/COD CAP
30MG Not on 2017 formulary
diclofenac, etodolac,
ketoprofen IR, ibuprofen,
naproxen Antimigraine Agents Antimigraine Agents
AVIDOXY TAB 100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
AZITHROMYCIN INJ
500MG On formulary, tier change tier 2 to tier 4 Antibacterials Macrolides
AZTREONAM INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Other
Pg. 5 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
AZTREONAM INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Other
BLEOMYCIN INJ
15UNIT On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
BLEOMYCIN INJ
30UNIT On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
BLINCYTO INJ 35MCG
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics, Other
BUMETANIDE INJ
0.25/ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop
BUT/APAP/CAF CAP
CODEINE Not on 2017 formulary
diclofenac, etodolac,
ibuprofen, ketoprofen IR,
naproxen Antimigraine Agents Antimigraine Agents
BUT/APAP/CAF CAP
CODEINE Not on 2017 formulary
diclofenac, etodolac,
ketoprofen IR, ibuprofen,
naproxen Antimigraine Agents Antimigraine Agents
BUT/ASA/CAF/ CAP COD
30MG Not on 2017 formulary
diclofenac, etodolac,
ketoprofen IR, ibuprofen,
naproxen Antimigraine Agents Antimigraine Agents
Pg. 6 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BUTRANS DIS
10MCG/HR Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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.
Anti-Addiction/ Substance
Abuse Treatment Agents
Opioid Dependence
Treatments
BUTRANS DIS
15MCG/HR Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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.
Anti-Addiction/ Substance
Abuse Treatment Agents
Opioid Dependence
Treatments
Pg. 7 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BUTRANS DIS
20MCG/HR Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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.
Anti-Addiction/ Substance
Abuse Treatment Agents
Opioid Dependence
Treatments
BUTRANS DIS
5MCG/HR Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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.
Anti-Addiction/ Substance
Abuse Treatment Agents
Opioid Dependence
Treatments
Pg. 8 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
BUTRANS DIS 7.5/HR Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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.
Anti-Addiction/ Substance
Abuse Treatment Agents
Opioid Dependence
Treatments
CALCITRIOL INJ
1MCG/ML On formulary, tier change tier 2 to tier 4
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
CARBOPLATIN INJ
150/15ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
CARBOPLATIN INJ
450/45ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
CARBOPLATIN INJ
50MG/5ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
CARBOPLATIN INJ
600/60ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
CEFAZOLIN INJ 10GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFAZOLIN INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFAZOLIN INJ 20GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
Pg. 9 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CEFAZOLIN INJ
500MG On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFEPIME INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFEPIME INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFOTAXIME INJ
10GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFOTAXIME INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFOTAXIME INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFOTAXIME INJ
500MG On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFOXITIN INJ 10GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFOXITIN INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFOXITIN INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFTAZIDIME INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFTAZIDIME INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFTAZIDIME INJ 6GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFTRIAXONE INJ
10GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFTRIAXONE INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
Pg. 10 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CEFTRIAXONE INJ
250MG On formulary, tier change tier 2 to tier 3 Antibacterials
Beta-lactam,
Cephalosporins
CEFTRIAXONE INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFTRIAXONE INJ
500MG On formulary, tier change tier 2 to tier 3 Antibacterials
Beta-lactam,
Cephalosporins
CEFUROXIME INJ
1.5GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFUROXIME INJ
7.5GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CEFUROXIME INJ
750MG On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
CHOR GONADOT INJ
10000UNT On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
CHOR GONADOT INJ
10000UNT
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
CIDOFOVIR INJ
75MG/ML On formulary, tier change tier 2 to tier 5 Antivirals
Anti-cytomegalovirus
(CMV) Agents
CIPROFLOXACN INJ
200MG On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones
CIPROFLOXACN INJ
400MG On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones
CISPLATIN INJ 100MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
CISPLATIN INJ 200MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
CISPLATIN INJ
50/50ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
CLINDAMYCIN INJ
150MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
Pg. 11 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CLINDAMYCIN INJ
300/2ML On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
300MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
600/4ML On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
600MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
900/6ML On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
9000/60 On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
900MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
CLINDAMYCIN INJ
9GM/60ML On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
CLINISOL SF INJ 15% On formulary, tier change tier 2 to tier 3
Therapeutic Nutrients/
Minerals/ Electrolytes
Therapeutic Nutrients/
Minerals/ Electrolytes
CODEINE SULF TAB
15MG On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
CODEINE SULF TAB
30MG On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
CODEINE SULF TAB
60MG On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
COMVAX INJ Not on 2017 formulary check with your doctor Immunological Agents Vaccines
CUPRIMINE CAP
250MG Not on 2017 formulary
Depen Titra 250 mg
tablets Genitourinary Agents
Genitourinary Agents,
Other
CYCLOPHOSPH INJ
1GM On formulary, tier change tier 2 to tier 5 Antineoplastics Alkylating Agents
CYCLOPHOSPH INJ
2GM On formulary, tier change tier 2 to tier 5 Antineoplastics Alkylating Agents
Pg. 12 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
CYCLOPHOSPH INJ
500MG On formulary, tier change tier 2 to tier 5 Antineoplastics Alkylating Agents
CYCLOSERINE CAP
250MG On formulary, tier change tier 4 to tier 5 Antimycobacterials Antituberculars
CYCLOSPORINE INJ
50MG/ML On formulary, tier change tier 2 to tier 4 Immunological Agents Immune Suppressants
CYTARABINE INJ
100MG/ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
CYTARABINE INJ
20MG/ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
CYTARABINE INJ
20MG/ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
D2.5W/NACL INJ 0.45% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
D5W/LR INJ On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
D5W/NACL INJ 0.2% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
D5W/NACL INJ 0.33% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
D5W/NACL INJ 0.45% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
D5W/NACL INJ 0.9% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
DACARBAZINE INJ
200MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DARAPRIM TAB 25MG On formulary, tier change tier 4 to tier 5 Antiparasitics Antiprotozoals
DAUNORUBICIN INJ
5MG/ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
Pg. 13 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DAUNOXOME INJ
2MG/ML Not on 2017 formulary
daunorubicin injection 5
mg/ml Antineoplastics Antineoplastics, Other
DEMECLOCYCL TAB
150MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DEMECLOCYCL TAB
300MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DENAVIR CRE 1% On formulary, tier change tier 4 to tier 5 Antivirals Antiherpetic Agents
DESMOPRESSIN INJ
4MCG/ML On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
DESMOPRESSIN SPR
0.01% Not on 2017 formulary desmopressin tablets
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
DEXAMETH PHO INJ
120MG/30 On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
DEXAMETH PHO INJ
20MG/5ML On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
DEXAMETH PHO INJ
4MG/ML On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
DEXAMETH PHO SOL
0.1% OP On formulary, tier change tier 2 to tier 4 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
DEXEDRINE TAB
10MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXEDRINE TAB 5MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
Pg. 14 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DEXILANT CAP 30MG
DR Not on 2017 formulary
esomeprazole (20 mg, 40
mg), lansoprazole (15 mg,
30 mg), Nexium granules
(2.5mg, 5 mg, 10 mg, 20
mg, 40 mg), omeprazole
(10mg, 20 mg, 40 mg),
pantoprazole (20 mg, 40
mg) Gastrointestinal Agents Proton Pump Inhibitors
DEXILANT CAP 60MG
DR Not on 2017 formulary
esomeprazole (20 mg, 40
mg), lansoprazole (15 mg,
30 mg), Nexium granules
(2.5mg, 5 mg, 10 mg, 20
mg, 40 mg), omeprazole
(10mg, 20 mg, 40 mg),
pantoprazole (20 mg, 40
mg) Gastrointestinal Agents Proton Pump Inhibitors
DEXMETHYLPH TAB
10MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
DEXMETHYLPH TAB
2.5MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
DEXMETHYLPH TAB
5MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
DEXTROAMPHET CAP
10MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
Pg. 15 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DEXTROAMPHET CAP
15MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXTROAMPHET CAP
5MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXTROAMPHET TAB
10MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXTROAMPHET TAB
5MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
DEXTROSE INJ 10% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Therapeutic Nutrients/
Minerals/ Electrolytes
DEXTROSE INJ 5% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Therapeutic Nutrients/
Minerals/ Electrolytes
DEXTROSE INJ 5%
PGBK On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Therapeutic Nutrients/
Minerals/ Electrolytes
DICLO/MISOPR TAB 50-
0.2MG
On formulary, quantity
limit may apply 120 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
DICLO/MISOPR TAB 75-
0.2MG
On formulary, quantity
limit may apply 90 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
DICLOFEN POT TAB
50MG
On formulary, quantity
limit may apply 120 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
DICLOFENAC TAB
100MG ER
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
DICLOFENAC TAB
25MG DR
On formulary, quantity
limit may apply 240 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
DICLOFENAC TAB
50MG DR
On formulary, quantity
limit may apply 120 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
Pg. 16 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DICLOFENAC TAB
75MG DR
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
DICYCLOMINE TAB
20MG On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents
Antispasmodics,
Gastrointestinal
DIPHENHYDRAM INJ
50MG/ML On formulary, tier change tier 2 to tier 4
Respiratory Tract/
Pulmonary Agents Antihistamines
DIVIGEL GEL 0.25MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
DIVIGEL GEL 0.5MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
DIVIGEL GEL
1MG/GM Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
DOXORUBICIN INJ
10/5ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
10MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
10MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
10MG/5ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
150/75ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
Pg. 17 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DOXORUBICIN INJ
20/10ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
200/100 On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
200MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
2MG/ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
2MG/ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
50/25ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
50MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
DOXORUBICIN INJ
50MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
DOXY 100 INJ 100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYC CAP
100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYC CAP 50MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYC MONO CAP
100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYC MONO CAP
50MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYC MONO TAB
100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYC MONO TAB
150MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYC MONO TAB
50MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
Pg. 18 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
DOXYCYC MONO TAB
75MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYCL HYC INJ
100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYCLINE CAP
150MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
DOXYCYCLINE CAP
75MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
ELIDEL CRE 1%
On formulary, requires
prior authorization check with your doctor Dermatological Agents Dermatological Agents
ENOXAPARIN INJ
100MG/ML On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
30/0.3ML On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
300/3ML On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
40/0.4ML On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
60/0.6ML On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
ENOXAPARIN INJ
80/0.8ML On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
EPIRUBICIN INJ 200MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
EPIRUBICIN INJ
50/25ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
Pg. 19 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
EPROSART MES TAB
600MG Not on 2017 formulary
candesartan (4 mg, 8 mg,
16 mg, 32 mg), irbesartan
(75 mg, 150 mg, 300 mg),
losartan (25 mg, 50 mg,
100 mg) , telmisartan (20
mg, 40 mg, 80 mg),
valsartan (40 mg, 80 mg,
160 mg, 320 mg) Cardiovascular Agents
Angiotensin II Receptor
Antagonists
EQUETRO CAP
100MG Not on 2017 formulary
carbamazepine ER
capsules (generic
Carbatrol),
carbamazepine ER
tablets (generic Tegretol-
XR) Bipolar Agents Mood Stabilizers
EQUETRO CAP
200MG Not on 2017 formulary
carbamazepine ER
capsules (generic
Carbatrol),
carbamazepine ER
tablets (generic Tegretol-
XR) Bipolar Agents Mood Stabilizers
EQUETRO CAP
300MG Not on 2017 formulary
carbamazepine ER
capsules (generic
Carbatrol),
carbamazepine ER
tablets (generic Tegretol-
XR) Bipolar Agents Mood Stabilizers
ESOMEPRAZOLE INJ
40MG On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents Proton Pump Inhibitors
Pg. 20 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ESTRADIOL DIS
0.025MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
ESTRADIOL DIS
0.0375MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
ESTRADIOL DIS
0.05MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
ESTRADIOL DIS
0.06MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
ESTRADIOL DIS
0.075MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
ESTRADIOL DIS
0.1MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
Pg. 21 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
ETODOLAC CAP
200MG
On formulary, quantity
limit may apply 150 capsules per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC CAP
300MG
On formulary, quantity
limit may apply 90 capsules per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC TAB
400MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC TAB
500MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC ER TAB
400MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC ER TAB
500MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
ETODOLAC ER TAB
600MG
On formulary, quantity
limit may apply 30 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
ETOPOSIDE INJ
100/5ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors
ETOPOSIDE INJ
1GM/50ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors
ETOPOSIDE INJ
20MG/ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors
ETOPOSIDE INJ
500/25ML On formulary, tier change tier 2 to tier 3 Antineoplastics Enzyme Inhibitors
EXELON DIS 13.3/24 Not on 2017 formulary
rivastigmine 13.3 mg/24
patches Antidementia Agents Cholinesterase Inhibitors
EXELON DIS
4.6MG/24 Not on 2017 formulary
rivastigmine 4.6 mg/24
patches Antidementia Agents Cholinesterase Inhibitors
EXELON DIS
9.5MG/24 Not on 2017 formulary
rivastigmine 9.5 mg/24
patches Antidementia Agents Cholinesterase Inhibitors
FAMOTIDINE INJ
10MG/ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents
Histamine2 (H2) Receptor
Antagonists
Pg. 22 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FAMOTIDINE INJ
200/20ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents
Histamine2 (H2) Receptor
Antagonists
FAMOTIDINE INJ
20MG/2ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents
Histamine2 (H2) Receptor
Antagonists
FAMOTIDINE INJ
40MG/4ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents
Histamine2 (H2) Receptor
Antagonists
FAMOTIDINE SUS
40MG/5ML Not on 2017 formulary
cimetidine tablets and
solution 300mg/5mL,
ranitidine tablets and
syrup, famotidine tablets,
nizatidine capsules Gastrointestinal Agents
Histamine2 (H2) Receptor
Antagonists
FAZACLO TAB 100
ODT Not on 2017 formulary
clozapine 100 mg ODT*
*This drug 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 Treatment-Resistant
Pg. 23 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FAZACLO TAB 12.5
ODT Not on 2017 formulary
clozapine tablets (25 mg,
50 mg, 100 mg, 200 mg)*,
clozapine ODT tablets (25
mg, 100 mg)* *These
drugs 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 Treatment-Resistant
FAZACLO TAB 150
ODT Not on 2017 formulary
clozapine tablets (25 mg,
50 mg, 100 mg, 200 mg)*,
clozapine ODT tablets (25
mg, 100 mg)* *These
drugs 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 Treatment-Resistant
Pg. 24 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FAZACLO TAB 200
ODT Not on 2017 formulary
clozapine tablets (25 mg,
50 mg, 100 mg, 200 mg)*,
clozapine ODT tablets (25
mg, 100 mg)* *These
drugs 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 Treatment-Resistant
FAZACLO TAB 25MG
ODT Not on 2017 formulary
clozapine 25 mg ODT*
*This drug 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 Treatment-Resistant
FLUCONAZOLE/ INJ
DEX 200 On formulary, tier change tier 2 to tier 4 Antifungals Antifungals
FLUCONAZOLE/ INJ
DEX 400 On formulary, tier change tier 2 to tier 4 Antifungals Antifungals
FLUCONAZOLE/ INJ
NACL 200 On formulary, tier change tier 2 to tier 4 Antifungals Antifungals
FLUCONAZOLE/ INJ
NACL 400 On formulary, tier change tier 2 to tier 4 Antifungals Antifungals
Pg. 25 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FLUDARABINE INJ
50MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
FLUDARABINE INJ
50MG/2ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
FLUPHENAZ DE INJ
25MG/ML On formulary, tier change tier 2 to tier 4 Antipsychotics 1st Generation/Typical
FLURBIPROFEN TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
FLURBIPROFEN TAB
50MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
FONDAPARINUX INJ
2.5/0.5 On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
FORTICAL SPR
200/ACT Not on 2017 formulary
calcitonin (salmon) nasal
spray 200units/act
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
FOSPHENYTOIN INJ
100/2ML On formulary, tier change tier 2 to tier 3 Anticonvulsants Sodium Channel Agents
FOSPHENYTOIN INJ
500/10ML On formulary, tier change tier 2 to tier 4 Anticonvulsants Sodium Channel Agents
FOSRENOL CHW
1000MG On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders
FOSRENOL CHW
500MG On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders
FOSRENOL CHW
750MG On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders
FOSRENOL POW
1000MG On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders
FOSRENOL POW
750MG On formulary, tier change tier 3 to tier 5 Genitourinary Agents Phosphate Binders
FUROSEMIDE INJ
100/10ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop
Pg. 26 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
FUROSEMIDE INJ
10MG/ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop
FUROSEMIDE INJ
20MG/2ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop
FUROSEMIDE INJ
40MG/4ML On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Diuretics, Loop
GABAPENTIN CAP
100MG
On formulary, quantity
limit may apply
1080 capsules per 30
days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN CAP
300MG
On formulary, quantity
limit may apply 360 capsules per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN CAP
400MG
On formulary, quantity
limit may apply 270 capsules per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN SOL
250/5ML
On formulary, quantity
limit may apply 2160 mLs per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN SOL
300/6ML
On formulary, quantity
limit may apply 2160 mLs per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN TAB
600MG
On formulary, quantity
limit may apply 180 tablets per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GABAPENTIN TAB
800MG
On formulary, quantity
limit may apply 120 tablets per 30 days Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
GAMUNEX-C INJ
10GM/100 On formulary, tier change tier 3 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
1GM/10ML On formulary, tier change tier 3 to tier 5 Immunological Agents
Immunizing Agents,
Passive
Pg. 27 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GAMUNEX-C INJ
2.5GM/25 On formulary, tier change tier 3 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
20GM/200 On formulary, tier change tier 3 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
40/400ML On formulary, tier change tier 3 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GAMUNEX-C INJ
5GM/50ML On formulary, tier change tier 3 to tier 5 Immunological Agents
Immunizing Agents,
Passive
GANCICLOVIR INJ
500MG On formulary, tier change tier 2 to tier 3 Antivirals
Anti-cytomegalovirus
(CMV) Agents
GENTAM/NACL INJ
0.9MG/ML Not on 2017 formulary
gentamicin in saline
injection (0.8 mg/ml, 1
mg/ml, 1.2 mg/ml, 1.6
mg/ml) Antibacterials Aminoglycosides
GENTAM/NACL INJ
1.4MG/ML Not on 2017 formulary
gentamicin in saline
injection (0.8 mg/ml, 1
mg/ml, 1.2 mg/ml, 1.6
mg/ml) Antibacterials Aminoglycosides
GENTAM/NACL INJ
100MG On formulary, tier change tier 2 to tier 3 Antibacterials Aminoglycosides
GENTAM/NACL INJ
120MG On formulary, tier change tier 2 to tier 3 Antibacterials Aminoglycosides
GENTAM/NACL INJ
60MG On formulary, tier change tier 2 to tier 3 Antibacterials Aminoglycosides
GENTAM/NACL INJ
60MG PB On formulary, tier change tier 2 to tier 3 Antibacterials Aminoglycosides
GENTAM/NACL INJ
80MG On formulary, tier change tier 2 to tier 3 Antibacterials Aminoglycosides
GENTAM/NACL INJ
80MG PB On formulary, tier change tier 2 to tier 3 Antibacterials Aminoglycosides
Pg. 28 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
GENTAMICIN INJ
10MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
GENTAMICIN INJ
40MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
HALOPER DEC INJ
100MG/ML On formulary, tier change tier 2 to tier 4 Antipsychotics 1st Generation/Typical
HALOPER DEC INJ
50MG/ML On formulary, tier change tier 2 to tier 4 Antipsychotics 1st Generation/Typical
HALOPER LAC INJ
5MG/ML On formulary, tier change tier 2 to tier 4 Antipsychotics 1st Generation/Typical
HEP SOD/D5W INJ
20000UNT On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPARIN SOD INJ
1000/ML On formulary, tier change tier 2 to tier 3
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPARIN SOD INJ
10000/ML On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPARIN SOD INJ
10000/ML On formulary, tier change tier 2 to tier 3
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPARIN SOD INJ
20000/ML On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPARIN SOD INJ
5000/0.5 On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPARIN SOD INJ
5000/ML On formulary, tier change tier 2 to tier 3
Blood Products/Modifiers/
Volume Expanders Anticoagulants
HEPATAMINE SOL 8% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
HUMULIN R INJ U-500
On formulary, requires
prior authorization check with your doctor Blood Glucose Regulators Insulins
HYDROMORPHON LIQ
1MG/ML On formulary, tier change tier 2 to tier 4 Analgesics
Opioid Analgesics, Short-
acting
Pg. 29 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
IBANDRONATE INJ
3MG/3ML On formulary, tier change tier 2 to tier 4
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
IBUPROFEN SUS
100/5ML
On formulary, quantity
limit may apply 4800 mLs per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
IBUPROFEN TAB
400MG
On formulary, quantity
limit may apply 240 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
IBUPROFEN TAB
600MG
On formulary, quantity
limit may apply 150 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
IBUPROFEN TAB
800MG
On formulary, quantity
limit may apply 120 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
IFOSFAMIDE INJ 1GM On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
IFOSFAMIDE INJ
1GM/20ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
IFOSFAMIDE INJ
3GM/60ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
IMIPENEM/CIL INJ
250MG On formulary, tier change tier 2 to tier 3 Antibacterials Beta-lactam, Other
IMIPENEM/CIL INJ
500MG On formulary, tier change tier 2 to tier 3 Antibacterials Beta-lactam, Other
INTRALIPID INJ 20% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
ISOSORB DIN TAB
40MG ER Not on 2017 formulary
isosorbide dinitrate IR
tablet (5 mg, 10 mg, 20
mg, 30 mg), isosorbide
mononitrate ER tablet (30
mg, 60 mg, 120 mg) Cardiovascular Agents
Vasodilators, Direct-acting
Arterial/Venous
KCL IN NACL INJ On formulary, tier change tier 2 to tier 3
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL IN NACL INJ .15-
0.45 On formulary, tier change tier 2 to tier 3
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
Pg. 30 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
KCL/D5W INJ 0.15% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W INJ 0.3% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
.075/.45 On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ .15-
.45% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
.15/.33% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
.15/.45% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
.22/.45 On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
.224/.45 On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
0.15/0.2 On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KCL/D5W/NACL INJ
0.3/0.45 On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
KETOPROFEN CAP
50MG
On formulary, quantity
limit may apply 180 capsules per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
KETOPROFEN CAP
75MG
On formulary, quantity
limit may apply 120 capsules per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
LACTATED RIN INJ On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
LAMOTRIGINE TAB
100MG Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
Pg. 31 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LAMOTRIGINE TAB
200MG Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
25MG ODT Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LAMOTRIGINE TAB
50MG ODT Not on 2017 formulary
lamotrigine tablets,
lamotrigine chewable
tablets (5 mg, 25 mg) Anticonvulsants
Glutamate Reducing
Agents
LEUCOVOR CA INJ
100MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
LEUCOVOR CA INJ
200MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
LEUCOVOR CA INJ
350MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
LEUPROLIDE INJ
1MG/0.2 On formulary, tier change tier 2 to tier 3
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
LEVETIRACETM INJ
500/5ML On formulary, tier change tier 2 to tier 3 Anticonvulsants Anticonvulsants, Other
LEVOFLOX/D5W INJ
250/50ML On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones
LEVOFLOX/D5W INJ
500/100M On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones
LEVOFLOX/D5W INJ
750/150 On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones
LEVOFLOXACIN INJ
25MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials Quinolones
LIDOCAINE INJ 1% Not on 2017 formulary check with your doctor Analgesics Local Anesthetics
LINDANE LOT 1% Not on 2017 formulary
Lindane 1% shampoo,
malathion 0.5% lotion Antiparasitics Pediculicides/Scabicides
Pg. 32 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
LIPODOX INJ
2MG/ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics, Other
LIPODOX 50 INJ
2MG/ML On formulary, tier change tier 2 to tier 5 Antineoplastics Antineoplastics, Other
LIVALO TAB 1MG Not on 2017 formulary
atorvastatin, lovastatin,
rosuvastatin, pravastatin,
simvastatin Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LIVALO TAB 2MG Not on 2017 formulary
atorvastatin, lovastatin,
rosuvastatin, pravastatin,
simvastatin Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LIVALO TAB 4MG Not on 2017 formulary
atorvastatin, lovastatin,
rosuvastatin, pravastatin,
simvastatin Cardiovascular Agents
Dyslipidemics, HMG CoA
Reductase Inhibitors
LOTEMAX GEL 0.5% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents
Ophthalmic Anti-
inflammatories
MAGNESIUM SU INJ
50% On formulary, tier change tier 2 to tier 3
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
MAGNESIUM SU INJ
50% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
MECLIZINE TAB 25MG Not on 2017 formulary check with your doctor Antiemetics Antiemetics, Other
MEDROXYPR AC INJ
150MG/ML On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Progestins
MELOXICAM TAB
15MG
On formulary, quantity
limit may apply 30 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
MELOXICAM TAB
7.5MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
Pg. 33 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MENEST TAB 0.3MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
MENEST TAB
0.625MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
MENEST TAB
1.25MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
MENEST TAB 2.5MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
MEROPENEM INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Other
MEROPENEM INJ
500MG On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Other
MESNA INJ 1GM On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
MESTINON TAB
TIMESPAN Not on 2017 formulary
pyridostigmine CR 180
mg tablet Antimyasthenic Agents Parasympathomimetics
METADATE TAB
20MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 34 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHADONE TAB
10MG On formulary, tier change tier 2 to tier 3 Analgesics
Opioid Analgesics, Long-
acting
METHADONE TAB
5MG On formulary, tier change tier 2 to tier 3 Analgesics
Opioid Analgesics, Long-
acting
METHERGINE TAB
0.2MG On formulary, tier change tier 2 to tier 5 Genitourinary Agents
Genitourinary Agents,
Other
METHOCARBAM TAB
500MG
On formulary, requires
prior authorization check with your doctor
Skeletal Muscle
Relaxants
Skeletal Muscle
Relaxants
METHOCARBAM TAB
750MG
On formulary, requires
prior authorization check with your doctor
Skeletal Muscle
Relaxants
Skeletal Muscle
Relaxants
METHYLERGON TAB
0.2MG On formulary, tier change tier 2 to tier 5 Genitourinary Agents
Genitourinary Agents,
Other
METHYLPHENID TAB
10MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID TAB
20MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID TAB
20MG ER On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPHENID TAB
20MG SR On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
Pg. 35 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
METHYLPHENID TAB
5MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Non-
amphetamines
METHYLPR SS INJ
1000MG On formulary, tier change tier 2 to tier 3
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
METHYLPR SS INJ
125MG On formulary, tier change tier 2 to tier 3
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
METHYLPR SS INJ
40MG On formulary, tier change tier 2 to tier 3
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Adrenal)
METOCLOPRAM INJ
10MG/2ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents
Gastrointestinal Agents,
Other
METOCLOPRAM INJ
5MG/ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents
Gastrointestinal Agents,
Other
METOCLOPRAM SOL
10/10ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents
Gastrointestinal Agents,
Other
METOCLOPRAM SOL
5MG/5ML On formulary, tier change tier 2 to tier 4 Gastrointestinal Agents
Gastrointestinal Agents,
Other
METRON/NACL INJ
500MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
MINOCYCLINE CAP
100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
MINOCYCLINE CAP
50MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
MINOCYCLINE CAP
75MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
MINOCYCLINE TAB
100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
Pg. 36 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MINOCYCLINE TAB
50MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
MINOCYCLINE TAB
75MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
MITOMYCIN INJ 20MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
MITOMYCIN INJ 40MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
MITOXANTRON INJ
2MG/ML On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics
MONDOXYNE NL CAP
100MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
MONDOXYNE NL CAP
50MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
MONDOXYNE NL CAP
75MG On formulary, tier change tier 2 to tier 4 Antibacterials Tetracyclines
MORPHINE SUL CAP
120MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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. 37 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
30MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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
MORPHINE SUL CAP
45MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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. 38 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
60MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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
MORPHINE SUL CAP
75MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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. 39 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
MORPHINE SUL CAP
90MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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
MYOZYME INJ 50MG Not on 2017 formulary check with your doctor
Enzyme Replacement/
Modifiers
Enzyme Replacement/
Modifiers
MYRBETRIQ TAB
25MG Not on 2017 formulary
oxybutynin IR 5mg tablet,
oxybutynin ER tablet,
tolterodine IR and ER,
Toviaz, trospium IR and
ER Genitourinary Agents Antispasmodics, Urinary
MYRBETRIQ TAB
50MG Not on 2017 formulary
oxybutynin IR 5mg tablet,
oxybutynin ER tablet,
tolterodine IR and ER,
Toviaz, trospium IR and
ER Genitourinary Agents Antispasmodics, Urinary
NABUMETONE TAB
500MG
On formulary, quantity
limit may apply 120 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
NABUMETONE TAB
750MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
Pg. 40 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NAFCILLIN INJ 10GM On formulary, tier change tier 2 to tier 5 Antibacterials Beta-lactam, Penicillins
NAFCILLIN INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
NAFCILLIN INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
NAMENDA SOL
10MG/5ML Not on 2017 formulary
memantine 2 mg/mL
solution* *This drug
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. Antidementia Agents
N-methyl-D-aspartate
(NMDA) Receptor
Antagonist
NAMENDA TAB 10MG Not on 2017 formulary
memantine 10 mg tablet*
*This drug 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. Antidementia Agents
N-methyl-D-aspartate
(NMDA) Receptor
Antagonist
Pg. 41 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NAMENDA TAB 5-
10MG Not on 2017 formulary
memantine 5-10 mg
titration pack* *This drug
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. Antidementia Agents
N-methyl-D-aspartate
(NMDA) Receptor
Antagonist
NAMENDA TAB 5MG Not on 2017 formulary
memantine 5 mg tablet*
*This drug 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. Antidementia Agents
N-methyl-D-aspartate
(NMDA) Receptor
Antagonist
NAMENDA XR CAP
14MG Not on 2017 formulary
memantine IR tablets*
*This drug 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. Antidementia Agents
N-methyl-D-aspartate
(NMDA) Receptor
Antagonist
Pg. 42 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NAMENDA XR CAP
21MG Not on 2017 formulary
memantine IR tablets*
*This drug 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. Antidementia Agents
N-methyl-D-aspartate
(NMDA) Receptor
Antagonist
NAMENDA XR CAP
28MG Not on 2017 formulary
memantine IR tablets*
*This drug 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. Antidementia Agents
N-methyl-D-aspartate
(NMDA) Receptor
Antagonist
NAMENDA XR CAP
7MG Not on 2017 formulary
memantine IR tablets*
*This drug 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. Antidementia Agents
N-methyl-D-aspartate
(NMDA) Receptor
Antagonist
Pg. 43 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NAMENDA XR CAP
TITRATIO Not on 2017 formulary
memantine IR tablets*
*This drug 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. Antidementia Agents
N-methyl-D-aspartate
(NMDA) Receptor
Antagonist
NAPROXEN SUS
125/5ML
On formulary, quantity
limit may apply 1800 mLs per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN TAB
250MG
On formulary, quantity
limit may apply 180 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN TAB
375MG
On formulary, quantity
limit may apply 120 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN TAB
500MG
On formulary, quantity
limit may apply 90 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN DR TAB
375MG
On formulary, quantity
limit may apply 120 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN DR TAB
500MG
On formulary, quantity
limit may apply 90 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN SOD TAB
275MG
On formulary, quantity
limit may apply 150 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
NAPROXEN SOD TAB
550MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
NASONEX SPR
50MCG/AC Not on 2017 formulary mometasone nasal spray
Respiratory Tract/
Pulmonary Agents
Anti-inflammatories,
Inhaled Corticosteroids
Pg. 44 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NEVANAC SUS 0.1% Not on 2017 formulary
Prolensa, bromfenac
0.09%, diclofenac drops,
flurbiprofen drops,
ketorolac drops, Ilevro Ophthalmic Agents
Ophthalmic Anti-
inflammatories
NEVIRAPINE TAB
100MG
On formulary, quantity
limit may apply 90 tablets per 30 days Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
(NNRTI)
NITROGLYCRN SPR
0.4MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Vasodilators, Direct-acting
Arterial/Venous
NITROGLYCRN SPR
LINGUAL On formulary, tier change tier 2 to tier 4 Cardiovascular Agents
Vasodilators, Direct-acting
Arterial/Venous
NORMOSOL -M INJ
/D5W On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
NUCYNTA ER TAB
100MG Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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. 45 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NUCYNTA ER TAB
150MG Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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
NUCYNTA ER TAB
200MG Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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. 46 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NUCYNTA ER TAB
250MG Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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
NUCYNTA ER TAB
50MG Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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. 47 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NUTRILIPID EMU 20% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
NUVIGIL TAB 150MG Not on 2017 formulary
armodafinil 150 mg* *This
drug 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. Sleep Disorder Agents Sleep Disorders, Other
NUVIGIL TAB 200MG Not on 2017 formulary
armodafinil 200 mg* *This
drug 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. Sleep Disorder Agents Sleep Disorders, Other
Pg. 48 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
NUVIGIL TAB 250MG Not on 2017 formulary
armodafinil 250 mg* *This
drug 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. Sleep Disorder Agents Sleep Disorders, Other
NUVIGIL TAB 50MG Not on 2017 formulary
armodafinil 50 mg* *This
drug 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. Sleep Disorder Agents Sleep Disorders, Other
OCTREOTIDE INJ
100MCG On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
OCTREOTIDE INJ
200MCG On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
OCTREOTIDE INJ
50MCG/ML On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Suppressant (Pituitary)
Hormonal Agents,
Suppressant (Pituitary)
OLANZAPINE INJ 10MG On formulary, tier change tier 2 to tier 4 Antipsychotics 2nd Generation/Atypical
Pg. 49 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
OLEPTRO TAB
24HR150 Not on 2017 formulary trazodone IR tablet Antidepressants
SSRIs/SNRIs (Selective
Serotonin Reuptake
Inhibitors/ Serotonin and
Norepinephrine Reuptake
Inhibitor
OLEPTRO TAB
24HR300 Not on 2017 formulary trazodone IR tablet Antidepressants
SSRIs/SNRIs (Selective
Serotonin Reuptake
Inhibitors/ Serotonin and
Norepinephrine Reuptake
Inhibitor
OMNITROPE INJ
5.8MG On formulary, tier change tier 3 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
ONDANSETRON INJ
40/20ML On formulary, tier change tier 2 to tier 4 Antiemetics
Emetogenic Therapy
Adjuncts
ONDANSETRON INJ
4MG/2ML On formulary, tier change tier 2 to tier 4 Antiemetics
Emetogenic Therapy
Adjuncts
ORAP TAB 1MG Not on 2017 formulary pimozide 1 mg Antipsychotics 1st Generation/Typical
ORAP TAB 2MG Not on 2017 formulary pimozide 2 mg Antipsychotics 1st Generation/Typical
OXALIPLATIN INJ
100MG On formulary, tier change tier 2 to tier 3 Antineoplastics Antineoplastics, Other
OXALIPLATIN INJ
50/10ML On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
OXALIPLATIN INJ 50MG On formulary, tier change tier 2 to tier 4 Antineoplastics Antineoplastics, Other
OXAPROZIN TAB
600MG
On formulary, quantity
limit may apply 90 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
PARICALCITOL INJ
2MCG/ML On formulary, tier change tier 2 to tier 4
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
PARICALCITOL INJ
5MCG/ML On formulary, tier change tier 2 to tier 4
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
Pg. 50 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PAROXETIN ER TAB
12.5MG Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
SSRIs/SNRIs (Selective
Serotonin Reuptake
Inhibitors/ Serotonin and
Norepinephrine Reuptake
Inhibito
PAROXETIN ER TAB
37.5MG Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
SSRIs/SNRIs (Selective
Serotonin Reuptake
Inhibitors/ Serotonin and
Norepinephrine Reuptake
Inhibito
PAROXETINE TAB
25MG ER Not on 2017 formulary
citalopram, escitalopram,
fluoxetine, fluvoxamine
IR, sertraline Antidepressants
SSRIs/SNRIs (Selective
Serotonin Reuptake
Inhibitors/ Serotonin and
Norepinephrine Reuptake
Inhibito
PATANOL SOL 0.1%
OP Not on 2017 formulary olopatadine 0.1% drops Ophthalmic Agents
Ophthalmic Anti-allergy
Agents
PENICILLN GK INJ 20MU On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
PENICILLN GK INJ 5MU On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
PHENOXYBENZA CAP
10MG On formulary, tier change tier 2 to tier 5 Cardiovascular Agents
Alpha-adrenergic Blocking
Agents
PIPER/TAZOBA INJ 2-
0.25GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
PIPER/TAZOBA INJ 3-
0.375G On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
PIPER/TAZOBA INJ 4-
0.5GM On formulary, tier change tier 2 to tier 4 Antibacterials Beta-lactam, Penicillins
PIROXICAM CAP
10MG
On formulary, quantity
limit may apply 60 capsules per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
Pg. 51 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PIROXICAM CAP
20MG
On formulary, quantity
limit may apply 30 capsules per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
PLENAMINE INJ 15% On formulary, tier change tier 2 to tier 3
Therapeutic Nutrients/
Minerals/ Electrolytes
Therapeutic Nutrients/
Minerals/ Electrolytes
POT CHLORIDE INJ
2MEQ/ML On formulary, tier change tier 2 to tier 3
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
PREGNYL INJ
10000UNT On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
PREGNYL INJ
10000UNT
On formulary, requires
prior authorization check with your doctor
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Pituitary)
PREMARIN TAB
0.3MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMARIN TAB
0.45MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMARIN TAB
0.625MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
Pg. 52 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
PREMARIN TAB
0.9MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMARIN TAB
1.25MG Not on 2017 formulary
Estrace vaginal cream,
Premarin vaginal cream,
Vagifem vaginal tablets,
citalopram, gabapentin,
venlafaxine
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Estrogens
PREMASOL SOL 6% On formulary, tier change tier 2 to tier 3
Therapeutic Nutrients/
Minerals/ Electrolytes Nutrients
PROCHLORPER INJ
10MG/2ML On formulary, tier change tier 2 to tier 4 Antiemetics Antiemetics, Other
PROCHLORPER INJ
5MG/ML On formulary, tier change tier 2 to tier 4 Antiemetics Antiemetics, Other
PROLASTIN-C INJ
1000MG
On formulary, requires
prior authorization check with your doctor
Respiratory Tract/
Pulmonary Agents
Respiratory Tract Agents,
Other
PROPRANOLOL INJ
1MG/ML On formulary, tier change tier 2 to tier 3 Cardiovascular Agents
Beta-adrenergic Blocking
Agents
QUINIDINE SU TAB
300MG On formulary, tier change tier 2 to tier 4 Cardiovascular Agents Antiarrhythmics
RABEPRAZOLE TAB
20MG Not on 2017 formulary
esomeprazole (20 mg, 40
mg), lansoprazole (15 mg,
30 mg), Nexium granules
(2.5mg, 5 mg, 10 mg, 20
mg, 40 mg), omeprazole
(10mg, 20 mg, 40 mg),
pantoprazole (20 mg, 40
mg) Gastrointestinal Agents Proton Pump Inhibitors
Pg. 53 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
RESTASIS EMU 0.05% On formulary, tier change tier 3 to tier 4 Ophthalmic Agents Ophthalmic Agents, Other
RESTASIS EMU 0.05%
On formulary, quantity
limit may apply 60 vials per 30 days Ophthalmic Agents Ophthalmic Agents, Other
RIDAURA CAP 3MG On formulary, tier change tier 4 to tier 5 Immunological Agents Immunomodulators
RIFAMPIN INJ 600 MG On formulary, tier change tier 2 to tier 4 Antimycobacterials Antituberculars
SEROQUEL XR TAB
150MG Not on 2017 formulary
quetiapine IR tablets*
*This drug 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
SEROQUEL XR TAB
200MG Not on 2017 formulary
quetiapine IR tablets*
*This drug 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. 54 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SEROQUEL XR TAB
300MG Not on 2017 formulary
quetiapine IR tablets*
*This drug 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
SEROQUEL XR TAB
400MG Not on 2017 formulary
quetiapine IR tablets*
*This drug 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
SEROQUEL XR TAB
50MG Not on 2017 formulary
quetiapine IR tablets*
*This drug 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. 55 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SOD CHLORIDE INJ
0.45% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
SOD CHLORIDE INJ
0.9% On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Electrolyte/Mineral
Replacement
SOTALOL AF TAB
120MG Not on 2017 formulary sotalol hcl tablets Cardiovascular Agents Antiarrhythmics
SOTALOL AF TAB
160MG Not on 2017 formulary sotalol hcl tablets Cardiovascular Agents Antiarrhythmics
SOTALOL AF TAB
80MG Not on 2017 formulary sotalol hcl tablets Cardiovascular Agents Antiarrhythmics
STERIL WATER SOL
IRRIG On formulary, tier change tier 2 to tier 4
Therapeutic Nutrients/
Minerals/ Electrolytes
Therapeutic Nutrients/
Minerals/ Electrolytes
SULINDAC TAB
150MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
SULINDAC TAB
200MG
On formulary, quantity
limit may apply 60 tablets per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
SUMATRIPTAN INJ
4MG/0.5 On formulary, tier change tier 2 to tier 4 Antimigraine Agents
Serotonin (5-HT) 1b/1d
Receptor Agonists
SUMATRIPTAN INJ
6MG/0.5 On formulary, tier change tier 2 to tier 4 Antimigraine Agents
Serotonin (5-HT) 1b/1d
Receptor Agonists
SURMONTIL CAP
100MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
Pg. 56 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
SURMONTIL CAP
25MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
SURMONTIL CAP
50MG Not on 2017 formulary
citalopram, fluoxetine,
escitalopram, sertraline,
duloxetine capsules
(20mg, 30mg, 60mg),
venlafaxine IR tablets, ER
tablets (37.5mg, 75mg,
150mg ), and ER
capsules, mirtazapine,
bupropion Antidepressants Tricyclics
TACROLIMUS OIN
0.03%
On formulary, requires
prior authorization check with your doctor Dermatological Agents Dermatological Agents
TACROLIMUS OIN
0.1%
On formulary, requires
prior authorization check with your doctor Dermatological Agents Dermatological Agents
TAZICEF INJ 1GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
TAZICEF INJ 2GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
TAZICEF INJ 6GM On formulary, tier change tier 2 to tier 4 Antibacterials
Beta-lactam,
Cephalosporins
TEFLARO INJ 400MG On formulary, tier change tier 4 to tier 5 Antibacterials
Beta-lactam,
Cephalosporins
Pg. 57 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TEFLARO INJ 600MG On formulary, tier change tier 4 to tier 5 Antibacterials
Beta-lactam,
Cephalosporins
TEGRETOL-XR TAB
100MG Not on 2017 formulary
carbamazepine ER 100
mg tablets Anticonvulsants Sodium Channel Agents
TESTOST CYP INJ
100MG/ML On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTOST CYP INJ
200MG/ML On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TESTOST ENAN INJ
200MG/ML On formulary, tier change tier 2 to tier 4
Hormonal Agents,
Stimulant/ Replacement/
Modifying (Sex
Hormones/ Modifiers) Androgens
TIKOSYN CAP
125MCG Not on 2017 formulary dofetilide 125 mcg Cardiovascular Agents Antiarrhythmics
TIKOSYN CAP
250MCG Not on 2017 formulary dofetilide 250 mcg Cardiovascular Agents Antiarrhythmics
TIKOSYN CAP
500MCG Not on 2017 formulary dofetilide 500 mcg Cardiovascular Agents Antiarrhythmics
TOBRAMYCIN INJ
1.2/30ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
TOBRAMYCIN INJ
1.2GM On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
TOBRAMYCIN INJ
10MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
TOBRAMYCIN INJ
40MG/ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
Pg. 58 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TOBRAMYCIN INJ
80MG/2ML On formulary, tier change tier 2 to tier 4 Antibacterials Aminoglycosides
TOLMETIN SOD CAP
400MG
On formulary, quantity
limit may apply 120 capsules per 30 days Analgesics
Nonsteroidal Anti-
inflammatory Drugs
TOPOSAR INJ
100/5ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors
TOPOSAR INJ
1GM/50ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors
TOPOSAR INJ
20MG/ML On formulary, tier change tier 2 to tier 3 Antineoplastics Enzyme Inhibitors
TOPOSAR INJ
20MG/ML On formulary, tier change tier 2 to tier 4 Antineoplastics Enzyme Inhibitors
TOPOSAR INJ
500/25ML On formulary, tier change tier 2 to tier 3 Antineoplastics Enzyme Inhibitors
TRAMADOL HCL TAB
100MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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. 59 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TRAMADOL HCL TAB
200MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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
TRAMADOL HCL TAB
300MG ER Not on 2017 formulary
fentanyl patch (12mcg,
25mcg, 50mcg, 75mcg,
100mcg), morphine
sulfate ER tablets,
methadone tablets,
Zohydro ER* *This drug
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. 60 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
TRANEX ACID INJ
1000M/10 On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Coagulants
TRANEX ACID INJ
100MG/ML On formulary, tier change tier 2 to tier 4
Blood Products/Modifiers/
Volume Expanders Coagulants
TYGACIL INJ 50MG On formulary, tier change tier 4 to tier 5 Antibacterials Antibacterials, Other
TYZINE PED DRO
0.05% Not on 2017 formulary check with your doctor
Respiratory Tract/
Pulmonary Agents
Respiratory Tract Agents,
Other
VALPROATE INJ
100MG/ML On formulary, tier change tier 2 to tier 3 Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
VALPROATE INJ
500/5ML On formulary, tier change tier 2 to tier 3 Anticonvulsants
Gamma-aminobutyric
Acid (GABA) Augmenting
Agents
VANCOMYCIN INJ 1
GM On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
VANCOMYCIN INJ
1000MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
VANCOMYCIN INJ
10GM On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
VANCOMYCIN INJ
500MG On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
VANCOMYCIN INJ 5GM On formulary, tier change tier 2 to tier 4 Antibacterials Antibacterials, Other
VESICARE TAB 10MG Not on 2017 formulary
oxybutynin IR 5mg tablet,
oxybutynin ER tablet,
tolterodine IR and ER,
Toviaz, trospium IR and
ER Genitourinary Agents Antispasmodics, Urinary
Pg. 61 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
VESICARE TAB 5MG Not on 2017 formulary
oxybutynin IR 5mg tablet,
oxybutynin ER tablet,
tolterodine IR and ER,
Toviaz, trospium IR and
ER Genitourinary Agents Antispasmodics, Urinary
VINCASAR PFS INJ
1MG/ML
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics, Other
VINCRISTINE INJ
1MG/ML
On formulary, requires
prior authorization check with your doctor Antineoplastics Antineoplastics, Other
VIRAMUNE XR TAB
100MG Not on 2017 formulary
nevirapine SR 100 mg
tablet Antivirals
Anti-HIV Agents, Non-
nucleoside Reverse
Transcriptase Inhibitors
(NNRTI)
VOLTAREN GEL 1% Not on 2017 formulary
diclofenac 1% gel* *This
drug 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
Nonsteroidal Anti-
inflammatory Drugs
VORICONAZOLE INJ
200MG On formulary, tier change tier 2 to tier 4 Antifungals Antifungals
Pg. 62 of 63
Affected Drug Description of ChangeFormulary Alternative, if
ApplicableCategory Class
VRAYLAR CAP 1.5-
3MG Not on 2017 formulary
Vraylar capsules (1.5 mg,
3 mg, 4.5 mg, 6 mg)*
*This drug 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
ZEMPLAR INJ
2MCG/ML Not on 2017 formulary paricalcitol 2 mcg/ml inj
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ZEMPLAR INJ
5MCG/ML Not on 2017 formulary paricalcitol 5 mcg/ml inj
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ZENZEDI TAB 10MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
ZENZEDI TAB 5MG On formulary, tier change tier 2 to tier 4
Central Nervous System
Agents
Attention Deficit
Hyperactivity Disorder
Agents, Amphetamines
ZETIA TAB 10MG On formulary, tier change tier 3 to tier 4 Cardiovascular Agents Dyslipidemics, Other
ZOLEDRONIC INJ
4MG/5ML On formulary, tier change tier 2 to tier 4
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
ZOLEDRONIC INJ
5/100ML On formulary, tier change tier 2 to tier 4
Metabolic Bone Disease
Agents
Metabolic Bone Disease
Agents
Pg. 63 of 63