First+Plus
2013 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN
THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document to make sure
that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy
network, premium and/or copayments/coinsurance may change on January 1, 2013.
A Medicare-approved Part D sponsor
This document may be available in other formats such as Braille, large print or other alternate formats.
This document may be available in a non-English language. For additional information, call customer service at
1-888-767-7717, Monday through Friday from 8:00 am to 8:00 pm. TTY users should call 1-877-672-4242. Este
documento puede estar disponible en otro idioma distinto al inglés. Para más información llame a Servicio al
Cliente al 1-888-767-7717, de lunes a viernes de 8:00 am a 8:00 pm. Usuarios de TTY deben llamar al
1-877-672-4242.
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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What is the First+Plus Formulary?
A formulary is a list of covered drugs selected by First+Plus in consultation with a team of health care providers,
which represents the prescription therapies believed to be a necessary part of a quality treatment program.
First+Plus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the
prescription is filled at a First+Plus network pharmacy, and other plan rules are followed. For more information on
how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2012 formulary that was covered at the beginning of the year, we will not
discontinue or reduce coverage of the drug during 2013 coverage year except when a new, less expensive generic
drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.
Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are
currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the
remainder of the coverage year. We feel it is important that you have continued access for the remainder of the
coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can
save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on
a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days
before the change becomes effective, or at the time the member requests a refill of the drug, at which time the
member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our
formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove
the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as
of February 2013. To get updated information about the drugs covered by First+Plus, please visit our Web site at
www.firstpluspr.com or call Member Services at 1-888-767-7717, Monday through Friday from 8:00 am to 8:00
pm. TTY/TDD users should call 1-877-672-4242. If changes are made during all year these will be mailed to all
members in separated notification. Updates are also published on our web site www.firstpluspr.com during all year
2013.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type
of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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under the category, cardiovascular agents. If you know what your drug is used for, look for the category name in
the list that begins on page number 7. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page
58. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name
drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you
will see the page number where you can find coverage information. Turn to the page listed in the Index and find
the name of your drug in the first column of the list.
What are generic drugs?
First+Plus covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having
the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may
include:

Prior Authorization: First+Plus requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval from First+Plus before you fill your prescriptions. If you
don’t get approval, First+Plus may not cover the drug.

Quantity Limits: For certain drugs, First+Plus limits the amount of the drug that First+Plus will cover. For
example, First+Plus provides 12 tablets per prescription for Maxalt 5mg. This may be in addition to a
standard one month or three month supply.

Step Therapy: In some cases, First+Plus requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both
treat your medical condition, First+Plus may not cover Drug B unless you try Drug A first. If Drug A does
not work for you, First+Plus will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on
page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our
Web site at www.firstpluspr.com.
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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You can ask First+Plus to make an exception to these restrictions or limits. See the section, “How do I request an
exception to the First+Plus formulary?” on page 4 for information about how to request an exception.
What are over-the counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan.
First+Plus pays for certain OTC drugs. First+Plus will provide these OTC drugs at no cost to you. The cost to
First+Plus of these OTC drugs will not count toward your total drug costs.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug
is not covered. If you learn that First+Plus does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by First+Plus. When you receive
the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by First+Plus.

You can ask First+Plus to make an exception and cover your drug. See below for information about how to
request an exception.
How do I request an exception to the First+Plus Formulary?
You can ask First+Plus to make an exception to our coverage rules. There are several types of exceptions that you
can ask us to make.

You can ask us to cover your drug even if it is not on our formulary.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
First+Plus limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us
to waive the limit and cover more.

You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our nonpreferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier
instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to
cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the
drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the tier designated
as the high-cost drug tier.
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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Generally, First+Plus will only approve your request for an exception if the alternative drugs included on the plan’s
formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your
condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction
exception. When you are requesting a formulary, tiering or utilization restriction exception you should
submit a statement from your physician supporting your request. Generally, we must make our decision within
72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited
(fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours
for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get
your prescriber’s or prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be
taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior
authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should
switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take.
While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain
cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a
temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the
plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided
you with a 91-day transition supply, consistent with the dispensing increment, (unless you have a prescription
written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of
our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are
past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you
have a prescription for fewer days) while you pursue a formulary exception.
For more information
For more detailed information about your First+Plus prescription drug coverage, please review your Evidence of
Coverage and other plan materials.
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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If you have questions about First+Plus, please call Member Services at 1-888-767-7717, Monday through Friday
8:00 am to 8:00 pm. TTY/TDD users should call 1-877-672-4242. Or visit www.firstpluspr.com.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048.
Or, visit www.medicare.gov.
First+Plus Formulary
The formulary that begins on the next page provides coverage information about some of the drugs covered by
First+Plus. If you have trouble finding your drug in the list, turn to the Index that begins on page 58.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic
drugs are listed in lower-case italics (e.g., glimepiride).
The information in the Requirements/Limits column tells you if First+Plus has any special requirements for
coverage of your drug.
PA- Indicates if Prior Authorization is required
QL- Indicates Quantity Limits
ST- Indicates if Step Therapy is required
LA- Indicates Limited Access drugs
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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Drug Name
THERAPEUTIC CATEGORY
Therapeutic Class
BRAND NAME DRUG
generic drug
ANTIHISTAMINE DRUGS
Derivatives, Miscellaneous
cyproheptadine hcl 4 mg oral tablet
cyproheptadine hcl 2 mg/5ml oral syrup
Ethanolamine Derivatives
carbinoxamine maleate oral tablet, oral liquid
clemastine fumarate 0.67 mg/5ml oral syrup, 2.68 mg oral tablet
diphenhydramine hcl 50 mg oral capsule
diphenhydramine hcl 50 mg/ml injection solution
Phenothiazine Derivatives
PHENADOZ RECTAL SUPPOSITORY
promethazine hcl 50 mg oral tablet
promethazine hcl 12.5 mg rectal suppository, 12.5 mg oral tablet,
25 mg rectal suppository, 25 mg oral tablet
Drug Tier
1
PA, QL(240 per 30
days)
PA, QL(2400 per 30
days)
1
1
1
1
PA
PA(*)
1
1
PA, QL(90 per 15 days)
PA, QL(45 per 15 days)
1
PA, QL(90 per 15 days)
PA, QL(2400 per 30
days)
PA(*), QL(60 per 30
days)
PA(*), QL(120 per 30
days)
PA, QL(45 per 15 days)
PA, QL(90 per 15 days)
1
promethazine hcl 6.25 mg/5ml oral syrup
1
promethazine hcl 50 mg/ml injection solution
1
promethazine hcl 25 mg/ml injection solution
PROMETHEGAN 50 MG RECTAL SUPPOSITORY
PROMETHEGAN 25 MG RECTAL SUPPOSITORY
Second Generation Antihistamines
cetirizine hcl 5 mg/5ml oral syrup
levocetirizine dihydrochloride oral solution, oral tablet
ANTI-INFECTIVE AGENTS
Adamantanes
rimantadine hcl oral tablet
Allylamines
LAMISIL 125 MG, 187.5 MG ORAL PACKET
terbinafine hcl oral tablet
Amebicides
paromomycin sulfate oral capsule
Requirements/Limits
1
1
1
1
1
1
3
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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Drug Name
Aminoglycosides
gentamicin in saline 0.9-0.9 mg/ml-%, 1.6-0.9 mg/ml-%
intravenous solution
gentamicin in saline 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9
mg/ml-% intravenous solution
gentamicin sulfate 10 mg/ml intravenous solution, 40 mg/ml
injection solution
neomycin sulfate oral tablet
streptomycin sulfate intramuscular solution
TOBI INHALATION NEBULIZATION SOLUTION
tobramycin sulfate 10 mg/ml, 80 mg/2ml injection solution
tobramycin sulfate in saline 1.2-0.9 mg/ml-% intravenous solution
tobramycin sulfate in saline 0.8-0.9 mg/ml-% intravenous solution
Anthelmintics
ALBENZA ORAL TABLET
BILTRICIDE ORAL TABLET
STROMECTOL ORAL TABLET
Antibacterials, Miscellaneous
CLEOCIN 75 MG ORAL CAPSULE
CLEOCIN IN D5W INTRAVENOUS SOLUTION
clindamycin hcl 150 mg, 300 mg oral capsule
colistimethate sodium injection solution
CUBICIN INTRAVENOUS SOLUTION
polymyxin b sulfate injection solution
SYNERCID INTRAVENOUS SOLUTION
VANCOCIN HCL ORAL CAPSULE
vancomycin hcl 125 mg, 250 mg oral capsule
vancomycin hcl 10 gm, 1000 mg intravenous solution
vancomycin hcl 500 mg intravenous solution
XIFAXAN ORAL TABLET
ZYVOX 2 MG/ML INTRAVENOUS SOLUTION
ZYVOX 600 MG ORAL TABLET
ZYVOX 100 MG/5ML ORAL SUSPENSION
Antifungals, Miscellaneous
griseofulvin microsize 125 mg/5ml oral suspension
GRIS-PEG ORAL TABLET
Antimalarials
atovaquone-proguanil hcl 250-100 mg oral tablet
chloroquine phosphate oral tablet
DARAPRIM ORAL TABLET
Drug Tier
Requirements/Limits
1
1
PA(*)
1
1
1
4
1
1
1
PA(*)
PA(*)
PA(*)
PA(*)
3
3
2
3
3
1
3
4
1
3
3
1
1
3
3
4
4
4
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA
PA, QL(56 per 28 days)
PA, QL(1800 per 28
days)
1
3
1
1
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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Drug Name
hydroxychloroquine sulfate oral tablet
MALARONE ORAL TABLET
mefloquine hcl oral tablet
primaquine phosphate oral tablet
Antimycobacterials, Miscellaneous
dapsone oral tablet
Antiprotozoals, Miscellaneous
ALINIA 500 MG ORAL TABLET
ALINIA 100 MG/5ML ORAL SUSPENSION
MEPRON ORAL SUSPENSION
metronidazole oral tablet, oral capsule
NEBUPENT INHALATION SOLUTION
Antiretrovirals
APTIVUS ORAL SOLUTION, ORAL CAPSULE
ATRIPLA ORAL TABLET
COMPLERA ORAL TABLET
CRIXIVAN 200 MG, 400 MG ORAL CAPSULE
didanosine oral capsule delayed release
EDURANT ORAL TABLET
EMTRIVA ORAL SOLUTION, ORAL CAPSULE
EPIVIR 10 MG/ML ORAL SOLUTION
EPIVIR HBV ORAL TABLET, ORAL SOLUTION
EPZICOM ORAL TABLET
FUZEON 90 MG SUBCUTANEOUS KIT
INTELENCE 100 MG, 200 MG ORAL TABLET
INVIRASE 200 MG ORAL CAPSULE
INVIRASE 500 MG ORAL TABLET
ISENTRESS 400 MG ORAL TABLET
KALETRA 100-25 MG ORAL TABLET
KALETRA 200-50 MG ORAL TABLET, 400-100 MG/5ML
ORAL SOLUTION
lamivudine oral tablet
lamivudine-zidovudine oral tablet
LEXIVA ORAL SUSPENSION, ORAL TABLET
nevirapine 200 mg oral tablet
NORVIR ORAL CAPSULE, ORAL TABLET, ORAL
SOLUTION
PREZISTA 150 MG, 400 MG, 600 MG, 75 MG ORAL TABLET
RESCRIPTOR ORAL TABLET
RETROVIR 10 MG/ML INTRAVENOUS SOLUTION
REYATAZ 100 MG ORAL CAPSULE
Drug Tier
1
3
1
1
Requirements/Limits
1
3
3
4
1
3
QL(6 per 30 days)
QL(180 per 30 days)
PA(*)
4
4
4
3
1
4
3
3
3
4
4
4
3
4
4
3
4
1
1
2
1
3
3
2
3
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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Drug Name
REYATAZ 150 MG, 200 MG, 300 MG ORAL CAPSULE
SELZENTRY ORAL TABLET
stavudine 15 mg, 20 mg, 30 mg, 40 mg oral capsule
SUSTIVA ORAL CAPSULE, ORAL TABLET
TRIZIVIR ORAL TABLET
TRUVADA ORAL TABLET
VIDEX 2 GM ORAL SOLUTION
VIRACEPT 250 MG, 625 MG ORAL TABLET
VIRAMUNE ORAL TABLET, ORAL SUSPENSION
VIRAMUNE XR ORAL TABLET ER 24 HOUR
VIREAD ORAL TABLET, ORAL POWDER
ZERIT 1 MG/ML ORAL SOLUTION
ZIAGEN ORAL SOLUTION, ORAL TABLET
zidovudine oral capsule, oral tablet, oral syrup
Antituberculosis Agents
CAPASTAT SULFATE INJECTION SOLUTION
ethambutol hcl oral tablet
isoniazid oral tablet, injection solution, oral syrup
MYCOBUTIN ORAL CAPSULE
PASER ORAL PACKET
PRIFTIN ORAL TABLET
RIFADIN 600 MG INTRAVENOUS SOLUTION
rifampin 150 mg, 300 mg oral capsule
rifampin 600 mg intravenous solution
RIFATER ORAL TABLET
SEROMYCIN ORAL CAPSULE
TRECATOR ORAL TABLET
Antivirals, Miscellaneous
foscarnet sodium intravenous solution
Azoles
fluconazole oral suspension , oral tablet
itraconazole oral capsule
ketoconazole oral tablet
NOXAFIL ORAL SUSPENSION
SPORANOX 10 MG/ML ORAL SOLUTION
VFEND ORAL TABLET, ORAL SUSPENSION
VFEND IV INTRAVENOUS SOLUTION
Cephalosporins
CEDAX 400 MG ORAL CAPSULE
cefaclor 250 mg, 500 mg oral capsule
cefaclor er oral tablet er 12 hour
Drug Tier
4
4
1
3
3
4
3
4
3
3
3
3
3
1
3
1
1
3
3
3
1
1
1
3
3
3
1
1
1
1
3
3
4
3
Requirements/Limits
PA(*)
PA(*)
PA(*)
PA
PA
PA(*)
3
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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Drug Name
cefadroxil oral tablet, oral suspension , oral capsule
cefazolin sodium 1 gm injection solution , 1-5 gm-% intravenous
solution, 10 gm injection solution , 500 mg injection solution
cefdinir oral suspension , oral capsule
cefepime hcl 1 gm, 2 gm injection solution
cefotaxime sodium 1 gm, 10 gm, 2 gm injection solution
cefpodoxime proxetil oral tablet, oral suspension
cefprozil oral suspension , oral tablet
ceftazidime 2 gm, 6 gm injection solution
ceftazidime 1 gm injection solution
ceftazidime and dextrose intravenous solution
CEFTIN 125 MG/5ML, 250 MG/5ML ORAL SUSPENSION
ceftriaxone sodium 1 gm intravenous solution , 10 gm intravenous
solution , 2 gm intravenous solution , 250 mg injection solution ,
500 mg injection solution
cefuroxime axetil 250 mg, 500 mg oral tablet
cefuroxime sodium 1.5 gm, 7.5 gm, 750 mg injection solution
cephalexin oral suspension , oral capsule, oral tablet
SUPRAX 100 MG/5ML ORAL SUSPENSION , 200 MG/5ML
ORAL SUSPENSION , 400 MG ORAL TABLET
Echinocandins
CANCIDAS INTRAVENOUS SOLUTION
MYCAMINE INTRAVENOUS SOLUTION
HCV Protease Inhibitors
INCIVEK ORAL TABLET
VICTRELIS ORAL CAPSULE
Interferons
INFERGEN 15 MCG/0.5ML SUBCUTANEOUS INJECTABLE
PEGASYS 180 MCG/0.5ML SUBCUTANEOUS KIT, 180
MCG/ML SUBCUTANEOUS SOLUTION
PEGASYS PROCLICK 135 MCG/0.5ML SUBCUTANEOUS
SOLUTION
PEG-INTRON 50 MCG/0.5ML SUBCUTANEOUS KIT
PEG-INTRON REDIPEN SUBCUTANEOUS KIT
Macrolides
azithromycin 100 mg/5ml oral suspension , 200 mg/5ml oral
suspension , 250 mg oral tablet, 500 mg oral tablet, 600 mg oral
tablet
azithromycin 500 mg intravenous solution
clarithromycin oral suspension , oral tablet
clarithromycin er oral tablet er 24 hour
Drug Tier
1
Requirements/Limits
1
1
1
1
1
1
1
1
1
3
PA(*)
1
1
1
1
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
3
3
3
PA(*)
PA(*)
4
4
PA
PA
4
PA
4
PA
4
4
4
PA
PA
PA
1
1
1
1
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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Drug Name
E.E.S. 400 ORAL TABLET
ERYPED 400 ORAL SUSPENSION
ERY-TAB ORAL TABLET DELAYED RELEASE
ERYTHROCIN STEARATE ORAL TABLET
erythromycin base 250 mg, 500 mg oral tablet
PCE ORAL TABLET DELAYED RELEASE
Miscellaneous B-Lactam Antibiotics
AZACTAM 2 GM INJECTION SOLUTION
AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION
cefoxitin sodium 1 gm, 2 gm intravenous solution
DORIBAX 500 MG INTRAVENOUS SOLUTION
imipenem-cilastatin intravenous solution
INVANZ 1 GM INJECTION SOLUTION
meropenem 500 mg intravenous solution
Monoclonal Antibodies
SYNAGIS 50 MG/0.5ML INTRAMUSCULAR SOLUTION
Neuraminidase Inhibitors
RELENZA DISKHALER INHALATION AEROSOL POWDER
BREATH ACTIVATED
TAMIFLU 45 MG, 75 MG ORAL CAPSULE
TAMIFLU 30 MG ORAL CAPSULE
TAMIFLU 6 MG/ML ORAL SUSPENSION
Nucleosides And Nucleotides
acyclovir oral capsule, oral suspension, oral tablet
acyclovir sodium 500 mg intravenous solution
BARACLUDE ORAL SOLUTION, ORAL TABLET
famciclovir oral tablet
ganciclovir sodium intravenous solution
HEPSERA ORAL TABLET
REBETOL 40 MG/ML ORAL SOLUTION
RIBAPAK 400 MG, 400 & 600 MG, 600 MG ORAL TABLET
RIBASPHERE 200 MG ORAL CAPSULE, 200 MG ORAL
TABLET, 400 MG ORAL TABLET
RIBASPHERE 600 MG ORAL TABLET
ribavirin oral capsule, oral tablet
TYZEKA ORAL TABLET
valacyclovir hcl oral tablet
VALCYTE ORAL TABLET, ORAL SOLUTION
VISTIDE INTRAVENOUS SOLUTION
Penicillins
amoxicillin oral tablet chewable, oral suspension , oral capsule,
Drug Tier
1
3
3
1
1
3
3
3
1
3
1
3
1
Requirements/Limits
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
4
2
3
3
3
1
1
2
1
1
2
3
4
3
4
1
4
1
4
3
QL(60 per 180 days)
QL(42 per 180 days)
QL(84 per 180 days)
QL(360 per 180 days)
PA(*)
PA
PA(*)
PA
PA
PA
PA
PA
PA
PA
PA(*)
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
12 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
oral tablet
amoxicillin-pot clavulanate oral tablet chewable, oral suspension ,
oral tablet
amoxicillin-pot clavulanate er oral tablet er 12 hour
ampicillin oral suspension , oral capsule
ampicillin sodium 1 gm injection solution , 10 gm intravenous
solution , 125 mg injection solution
ampicillin-sulbactam sodium 3 (2-1) gm injection solution
BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION
BICILLIN C-R INTRAMUSCULAR SUSPENSION
BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION
BICILLIN L-A INTRAMUSCULAR SUSPENSION
dicloxacillin sodium oral capsule
nafcillin sodium 1 gm, 10 gm injection solution
NALLPEN IN DEXTROSE 1 GM/50ML INTRAVENOUS
SOLUTION
oxacillin sodium 1 gm, 10 gm injection solution
penicillin g pot in dextrose 40000 unit/ml, 60000 unit/ml
intravenous solution
penicillin g potassium 5000000 unit injection solution
penicillin g procaine intramuscular suspension
penicillin v potassium oral solution , oral tablet
PFIZERPEN-G 20000000 UNIT INJECTION SOLUTION
piperacillin sod-tazobactam so 3-0.375 gm, 4-0.5 gm intravenous
solution
TIMENTIN 3.1 GM INTRAVENOUS SOLUTION
Polyenes
ABELCET INTRAVENOUS SUSPENSION
AMBISOME INTRAVENOUS SUSPENSION
AMPHOTEC 50 MG INTRAVENOUS SUSPENSION
amphotericin b 50 mg injection solution
nystatin mouth/throat suspension, oral tablet
Pyrimidines
flucytosine oral capsule
Quinolones
AVELOX 400 MG ORAL TABLET
AVELOX 400 MG/250ML INTRAVENOUS SOLUTION
AVELOX ABC PACK ORAL TABLET
ciprofloxacin 400 mg/40ml intravenous solution
ciprofloxacin hcl oral tablet
ciprofloxacin-ciproflox hcl er oral tablet er 24 hour
Drug Tier
Requirements/Limits
1
1
1
1
1
3
3
3
3
1
1
PA(*)
PA(*)
PA(*)
3
1
3
1
1
1
2
1
3
3
3
3
1
1
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
1
3
3
3
1
1
1
PA(*)
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
13 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
levofloxacin 25 mg/ml oral solution, 250 mg oral tablet, 500 mg
oral tablet, 750 mg oral tablet
levofloxacin 25 mg/ml intravenous solution
levofloxacin in d5w 500 mg/100ml intravenous solution
ofloxacin oral tablet
Sulfonamides
sulfadiazine oral tablet
sulfamethoxazole-tmp ds oral tablet
sulfamethoxazole-trimethoprim 200-40 mg/5ml oral suspension,
400-80 mg oral tablet, 400-80 mg/5ml intravenous solution
sulfasalazine 500 mg oral tablet
SULFAZINE EC ORAL TABLET DELAYED RELEASE
Tetracyclines
demeclocycline hcl oral tablet
doxycycline hyclate 100 mg oral capsule, 100 mg oral tablet, 100
mg oral tablet delayed release, 150 mg oral tablet delayed release,
20 mg oral tablet, 50 mg oral capsule, 75 mg oral tablet delayed
release
doxycycline hyclate 100 mg intravenous solution
doxycycline monohydrate 150 mg oral tablet, 50 mg oral tablet, 75
mg oral capsule, 75 mg oral tablet
minocycline hcl oral capsule, oral tablet
tetracycline hcl oral capsule
TYGACIL INTRAVENOUS SOLUTION
VIBRAMYCIN 25 MG/5ML ORAL SUSPENSION , 50 MG/5ML
ORAL SYRUP
Urinary Anti-Infectives
FURADANTIN ORAL SUSPENSION
MACRODANTIN 25 MG ORAL CAPSULE
methenamine hippurate oral tablet
MONUROL ORAL PACKET
nitrofurantoin oral suspension
nitrofurantoin macrocrystal 50 mg oral capsule
nitrofurantoin monohyd macro oral capsule
PRIMSOL ORAL SOLUTION
trimethoprim oral tablet
ANTINEOPLASTIC AGENTS
Antineoplastic Agents
ABRAXANE INTRAVENOUS SUSPENSION
ADRIAMYCIN 2 MG/ML INTRAVENOUS SOLUTION
AFINITOR ORAL TABLET
Drug Tier
1
1
1
1
Requirements/Limits
PA(*)
PA(*)
1
1
1
1
1
1
1
1
PA(*)
1
1
1
3
PA(*)
3
3
3
1
3
1
1
1
3
1
4
1
4
PA(*)
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
14 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
ALIMTA 500 MG INTRAVENOUS SOLUTION
anastrozole oral tablet
ARRANON INTRAVENOUS SOLUTION
AVASTIN 100 MG/4ML INTRAVENOUS SOLUTION
bicalutamide oral tablet
bleomycin sulfate 30 unit injection solution
BUSULFEX INTRAVENOUS SOLUTION
CAMPATH INTRAVENOUS SOLUTION
CAPRELSA ORAL TABLET
carboplatin 150 mg/15ml intravenous solution
CEENU ORAL CAPSULE
cladribine intravenous solution
CLOLAR INTRAVENOUS SOLUTION
COSMEGEN INTRAVENOUS SOLUTION
cyclophosphamide 25 mg, 50 mg oral tablet
dacarbazine 200 mg intravenous solution
DACOGEN INTRAVENOUS SOLUTION
daunorubicin hcl 5 mg/ml intravenous injectable
DOCEFREZ INTRAVENOUS SOLUTION
docetaxel 80 mg/4ml intravenous concentrate
DOXIL INTRAVENOUS INJECTABLE
doxorubicin hcl 2 mg/ml intravenous solution
DROXIA ORAL CAPSULE
ELIGARD SUBCUTANEOUS KIT
EMCYT ORAL CAPSULE
epirubicin hcl 50 mg/25ml intravenous solution
ERBITUX 100 MG/50ML INTRAVENOUS SOLUTION
ERIVEDGE ORAL CAPSULE
ETOPOPHOS INTRAVENOUS SOLUTION
etoposide 20 mg/ml intravenous solution
exemestane oral tablet
FARESTON ORAL TABLET
FASLODEX INTRAMUSCULAR SOLUTION
FIRMAGON SUBCUTANEOUS SOLUTION
fludarabine phosphate 50 mg intravenous solution
fluorouracil 500 mg/10ml intravenous solution
flutamide oral capsule
gemcitabine hcl 1 gm intravenous solution
GEMZAR 1 GM INTRAVENOUS SOLUTION
GLEEVEC ORAL TABLET
HALAVEN INTRAVENOUS SOLUTION
Drug Tier
4
1
4
4
1
1
4
4
4
1
2
1
4
4
1
1
4
1
4
1
4
1
2
3
3
1
4
4
4
1
1
3
4
3
1
1
1
4
4
4
4
Requirements/Limits
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
15 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
HERCEPTIN INTRAVENOUS SOLUTION
HEXALEN ORAL CAPSULE
HYCAMTIN 4 MG INTRAVENOUS SOLUTION
hydroxyurea oral capsule
idarubicin hcl 10 mg/10ml intravenous solution
INLYTA ORAL TABLET
INTRON-A 10000000 UNIT INJECTION SOLUTION , 6000000
UNIT/ML INJECTION SOLUTION
irinotecan hcl 100 mg/5ml intravenous solution
IXEMPRA KIT 45 MG INTRAVENOUS SOLUTION
JAKAFI ORAL TABLET
JEVTANA INTRAVENOUS SOLUTION
letrozole oral tablet
LEUKERAN ORAL TABLET
leuprolide acetate injection kit
LUPRON DEPOT 30 MG INTRAMUSCULAR KIT
LUPRON DEPOT 22.5 MG, 3.75 MG, 45 MG, 7.5 MG
INTRAMUSCULAR KIT
LUPRON DEPOT-PED 11.25 MG, 11.25 MG (PED), 15 MG
INTRAMUSCULAR KIT
LYSODREN ORAL TABLET
MATULANE ORAL CAPSULE
megestrol acetate 20 mg oral tablet, 40 mg oral tablet, 40 mg/ml
oral suspension
melphalan hcl intravenous solution
mercaptopurine oral tablet
methotrexate oral tablet
methotrexate sodium 1 gm injection solution
methotrexate sodium (pf) 25 mg/ml injection solution
mitomycin 20 mg intravenous solution
mitoxantrone hcl 25 mg/12.5ml intravenous concentrate
NEXAVAR ORAL TABLET
NILANDRON ORAL TABLET
ONTAK INTRAVENOUS SOLUTION
oxaliplatin 100 mg/20ml intravenous solution
paclitaxel 300 mg/50ml intravenous concentrate
PROLEUKIN INTRAVENOUS SOLUTION
REVLIMID 10 MG, 15 MG, 25 MG, 5 MG ORAL CAPSULE
RHEUMATREX ORAL TABLET
RITUXAN INTRAVENOUS CONCENTRATE
SPRYCEL ORAL TABLET
Drug Tier
2
4
4
1
1
4
Requirements/Limits
PA(*)
PA(*)
PA(*)
3
1
4
4
4
1
3
1
2
PA
PA(*)
PA(*)
4
PA
2
2
2
PA
1
1
1
1
1
1
1
1
2
2
4
1
1
4
4
3
2
4
PA(*)
PA
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
LA
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
16 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
SUTENT ORAL CAPSULE
SYLATRON 296 MCG, 444 MCG, 888 MCG SUBCUTANEOUS
KIT
TABLOID ORAL TABLET
tamoxifen citrate oral tablet
TARCEVA ORAL TABLET
TARGRETIN ORAL CAPSULE
TASIGNA ORAL CAPSULE
thiotepa injection solution
TOPOSAR INTRAVENOUS SOLUTION
topotecan hcl 4 mg intravenous solution
TORISEL INTRAVENOUS SOLUTION
TREANDA 100 MG INTRAVENOUS SOLUTION
TRELSTAR DEPOT MIXJECT INTRAMUSCULAR
SUSPENSION
TRELSTAR LA MIXJECT INTRAMUSCULAR SUSPENSION
TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION
tretinoin oral capsule
TREXALL ORAL TABLET
TRISENOX INTRAVENOUS SOLUTION
TYKERB ORAL TABLET
VECTIBIX 100 MG/5ML INTRAVENOUS SOLUTION
VELCADE INTRAVENOUS SOLUTION
VIDAZA INJECTION SUSPENSION
vinblastine sulfate 10 mg intravenous solution
VINCASAR PFS INTRAVENOUS SOLUTION
vincristine sulfate intravenous solution
vinorelbine tartrate 50 mg/5ml intravenous solution
VOTRIENT ORAL TABLET
XALKORI ORAL CAPSULE
YERVOY 50 MG/10ML INTRAVENOUS SOLUTION
ZANOSAR INTRAVENOUS SOLUTION
ZELBORAF ORAL TABLET
ZOLINZA ORAL CAPSULE
ZYTIGA ORAL TABLET
AUTONOMIC DRUGS
Alpha- And Beta-Adrenergic Agonists
EPIPEN 2-PAK INJECTION DEVICE
EPIPEN JR 2-PAK INJECTION DEVICE
Alpha-Adrenergic Agonists
midodrine hcl oral tablet
Drug Tier
4
4
3
1
4
3
4
1
3
4
4
4
3
3
3
1
2
3
4
2
4
4
1
1
1
1
4
4
4
4
4
4
4
Requirements/Limits
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA
PA
PA
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
2
2
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
17 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
Alpha-Adrenergic Blocking Agents
alfuzosin hcl er oral tablet er 24 hour
dihydroergotamine mesylate injection solution
ergoloid mesylates oral tablet
MIGRANAL NASAL SOLUTION
RAPAFLO ORAL CAPSULE
tamsulosin hcl oral capsule
Antimuscarinics/Antispasmodics
atropine sulfate 0.05 mg/ml, 0.1 mg/ml injection solution
ATROVENT HFA INHALATION AEROSOL SOLUTION
BENTYL 10 MG/ML INTRAMUSCULAR SOLUTION
CANTIL ORAL TABLET
dicyclomine hcl 10 mg oral capsule, 20 mg oral tablet
dicyclomine hcl 10 mg/5ml oral solution
glycopyrrolate injection solution, oral tablet
ipratropium bromide 0.03 %, 0.06 % nasal solution
ipratropium bromide 0.02 % inhalation solution
methscopolamine bromide oral tablet
SPIRIVA HANDIHALER INHALATION CAPSULE
Autonomic Drugs, Miscellaneous
CHANTIX ORAL TABLET
CHANTIX STARTING MONTH PAK ORAL TABLET
NICOTROL NS NASAL SOLUTION
Beta-Adrenergic Agonists
ADVAIR DISKUS INHALATION AEROSOL POWDER
BREATH ACTIVATED
ADVAIR HFA INHALATION AEROSOL
albuterol sulfate 2 mg oral tablet, 2 mg/5ml oral syrup, 4 mg oral
tablet, 4 mg oral tablet er 12 hour, 8 mg oral tablet er 12 hour
albuterol sulfate (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63
mg/3ml, 1.25 mg/3ml inhalation nebulization solution
COMBIVENT INHALATION AEROSOL
FORADIL AEROLIZER INHALATION CAPSULE
ipratropium-albuterol inhalation solution
levalbuterol hcl 1.25 mg/0.5ml inhalation nebulization solution
MAXAIR AUTOHALER INHALATION AEROSOL BREATH
ACTIVATED
metaproterenol sulfate oral tablet, oral syrup
Drug Tier
1
1
1
3
3
1
1
2
3
3
1
1
1
1
1
1
3
3
3
3
Requirements/Limits
PA
QL(25.8 per 30 days)
PA(*), QL(80 per 10
days)
PA, QL(120 per 15
days)
PA, QL(1200 per 15
days)
PA(*)
QL(60 per 30 days)
PA
PA
3
3
1
1
3
3
1
1
PA(*)
3
1
QL(14 per 30 days)
PA(*)
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
18 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
PERFOROMIST INHALATION NEBULIZATION SOLUTION
PROAIR HFA INHALATION AEROSOL SOLUTION
PROVENTIL HFA INHALATION AEROSOL SOLUTION
SEREVENT DISKUS INHALATION AEROSOL POWDER
BREATH ACTIVATED
terbutaline sulfate 2.5 mg, 5 mg oral tablet
terbutaline sulfate 1 mg/ml injection solution
VENTOLIN HFA INHALATION AEROSOL SOLUTION
XOPENEX HFA INHALATION AEROSOL
Centrally Acting Skeletal Muscle Relaxants
Drug Tier
3
2
2
3
1
1
3
3
carisoprodol 350 mg oral tablet
carisoprodol-aspirin oral tablet
carisoprodol-aspirin-codeine oral tablet
1
1
1
chlorzoxazone oral tablet
cyclobenzaprine hcl 10 mg, 5 mg oral tablet
1
1
methocarbamol 750 mg oral tablet
1
methocarbamol 500 mg oral tablet
tizanidine hcl oral capsule, oral tablet
Direct-Acting Skeletal Muscle Relaxants
dantrolene sodium oral capsule
GABA-Derivative Skeletal Muscle Relaxant
baclofen oral tablet
Parasympathomimetic (Cholinergic) Agents
bethanechol chloride oral tablet
donepezil hcl oral tablet, oral tablet dispersible
EVOXAC ORAL CAPSULE
EXELON 2 MG/ML ORAL SOLUTION, 4.6 MG/24HR
TRANSDERMAL PATCH 24 HOUR, 9.5 MG/24HR
TRANSDERMAL PATCH 24 HOUR
galantamine hydrobromide oral tablet, oral solution
galantamine hydrobromide er oral capsule er 24 hour
MESTINON 180 MG ORAL TABLET ER, 60 MG/5ML ORAL
SYRUP
MYTELASE ORAL TABLET
pilocarpine hcl oral tablet
pyridostigmine bromide oral tablet
REGONOL INJECTION SOLUTION
1
1
Requirements/Limits
PA(*)
QL(17 per 30 days)
QL(13.4 per 30 days)
QL(60 per 30 days)
PA(*)
QL(36 per 30 days)
PA, QL(120 per 30
days)
PA
PA
PA, QL(180 per 30
days)
PA, QL(45 per 15 days)
PA, QL(180 per 30
days)
PA, QL(240 per 30
days)
1
1
1
1
3
2
1
1
3
3
1
1
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
19 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
rivastigmine tartrate oral capsule
Skeletal Muscle Relaxants, Miscellaneous
orphenadrine citrate er oral tablet er 12 hour
BLOOD FORMATION,COAGULATION & THROMBOSIS
Anticoagulants
COUMADIN 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG,
6 MG, 7.5 MG ORAL TABLET
COUMADIN 5 MG INTRAVENOUS SOLUTION
enoxaparin sodium 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30
mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml subcutaneous
solution
fondaparinux sodium subcutaneous solution
FRAGMIN 2500 UNIT/0.2ML, 25000 UNIT/ML, 5000
UNIT/0.2ML SUBCUTANEOUS SOLUTION
FRAGMIN 10000 UNIT/ML, 7500 UNIT/0.3ML
SUBCUTANEOUS SOLUTION
heparin (porcine) in nacl injection solution
heparin sodium (porcine) 1000 unit/ml, 10000 unit/ml, 20000
unit/ml, 5000 unit/ml injection solution
JANTOVEN ORAL TABLET
PRADAXA ORAL CAPSULE
warfarin sodium oral tablet
Hematopoietic Agents
ARANESP (ALBUMIN FREE) 100 MCG/ML, 150 MCG/0.3ML,
200 MCG/0.4ML, 200 MCG/ML, 25 MCG/0.42ML, 25 MCG/ML,
300 MCG/ML, 40 MCG/0.4ML, 40 MCG/ML, 500 MCG/ML, 60
MCG/ML INJECTION SOLUTION
EPOGEN INJECTION SOLUTION
LEUKINE INTRAVENOUS SOLUTION , INJECTION
SOLUTION
MOZOBIL SUBCUTANEOUS SOLUTION
NEULASTA SUBCUTANEOUS SOLUTION
NEUMEGA SUBCUTANEOUS SOLUTION
NEUPOGEN 300 MCG/0.5ML, 480 MCG/0.8ML, 480
MCG/1.6ML INJECTION SOLUTION
PROCRIT 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML,
4000 UNIT/ML INJECTION SOLUTION
PROCRIT 20000 UNIT/ML, 40000 UNIT/ML INJECTION
SOLUTION
PROMACTA ORAL TABLET
Drug Tier
1
Requirements/Limits
1
PA, QL(60 per 30 days)
2
2
PA(*)
1
1
PA
PA
3
4
1
PA(*)
1
1
3
1
PA(*)
2
3
PA
PA
4
4
4
4
PA(*)
PA(*)
PA(*)
PA
4
PA
3
PA
4
4
PA
PA
PA
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
20 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
Hemorrheologic Agents
pentoxifylline er oral tablet er
Hemostatics
tranexamic acid intravenous solution
Platelet-Aggregation Inhibitors
AGGRENOX ORAL CAPSULE ER 12 HOUR
cilostazol oral tablet
clopidogrel bisulfate 75 mg oral tablet
EFFIENT ORAL TABLET
ticlopidine hcl oral tablet
Platelet-Reducing Agents
anagrelide hcl oral capsule
CARDIOVASCULAR DRUGS
Alpha-Adrenergic Blocking Agents
doxazosin mesylate oral tablet
prazosin hcl oral capsule
terazosin hcl oral capsule
Angiotensin II Receptor Antagonists
ATACAND ORAL TABLET
ATACAND HCT ORAL TABLET
BENICAR ORAL TABLET
BENICAR HCT ORAL TABLET
DIOVAN ORAL TABLET
DIOVAN HCT ORAL TABLET
irbesartan oral tablet
irbesartan-hydrochlorothiazide oral tablet
losartan potassium oral tablet
losartan potassium-hctz oral tablet
MICARDIS ORAL TABLET
MICARDIS HCT ORAL TABLET
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl oral tablet
benazepril-hydrochlorothiazide oral tablet
captopril oral tablet
captopril-hydrochlorothiazide oral tablet
enalapril maleate oral tablet
enalapril-hydrochlorothiazide oral tablet
fosinopril sodium oral tablet
fosinopril sodium-hctz oral tablet
lisinopril oral tablet
lisinopril-hydrochlorothiazide oral tablet
Drug Tier
Requirements/Limits
1
1
2
1
1
3
1
PA(*)
PA
2
1
1
1
3
3
3
3
3
3
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
21 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
moexipril hcl oral tablet
moexipril-hydrochlorothiazide oral tablet
perindopril erbumine oral tablet
quinapril hcl oral tablet
quinapril-hydrochlorothiazide oral tablet
ramipril oral capsule
trandolapril oral tablet
Antiarrhythmic Agents
amiodarone hcl 200 mg, 400 mg oral tablet
amiodarone hcl 150 mg/3ml intravenous solution
disopyramide phosphate oral capsule
flecainide acetate oral tablet
mexiletine hcl oral capsule
MULTAQ ORAL TABLET
NORPACE CR ORAL CAPSULE ER 12 HOUR
PACERONE ORAL TABLET
propafenone hcl oral tablet
propafenone hcl er oral capsule er 12 hour
quinidine gluconate injection solution
quinidine gluconate er oral tablet er
quinidine sulfate oral tablet
quinidine sulfate er oral tablet er
TIKOSYN ORAL CAPSULE
Antilipemic Agents, Miscellaneous
LOVAZA ORAL CAPSULE
NIASPAN 1000 MG ORAL TABLET ER
NIASPAN 500 MG, 750 MG ORAL TABLET ER
Beta-Adrenergic Blocking Agents
acebutolol hcl oral capsule
atenolol oral tablet
atenolol-chlorthalidone oral tablet
betaxolol hcl 20 mg oral tablet
bisoprolol fumarate oral tablet
bisoprolol-hydrochlorothiazide oral tablet
carvedilol oral tablet
COREG CR ORAL CAPSULE ER 24 HOUR
labetalol hcl 100 mg, 200 mg, 300 mg oral tablet
labetalol hcl 5 mg/ml intravenous solution
metoprolol succinate er oral tablet er 24 hour
metoprolol tartrate 100 mg, 25 mg, 50 mg oral tablet
metoprolol tartrate 1 mg/ml intravenous solution
Drug Tier
1
1
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
2
1
1
1
3
3
2
2
1
1
1
1
1
1
1
3
1
1
1
1
1
Requirements/Limits
PA(*)
PA
QL(60 per 30 days)
QL(120 per 30 days)
PA(*)
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
22 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
metoprolol-hydrochlorothiazide oral tablet
nadolol oral tablet
nadolol-bendroflumethiazide oral tablet
pindolol oral tablet
propranolol hcl intravenous solution, oral tablet, oral solution
propranolol hcl er oral capsule er 24 hour
propranolol-hctz oral tablet
sotalol hcl 120 mg, 160 mg, 240 mg, 80 mg oral tablet
timolol maleate oral tablet
Bile Acid Sequestrants
cholestyramine light 4 gm oral packet
colestipol hcl 1 gm oral tablet, 5 gm oral granules
PREVALITE 4 GM/DOSE ORAL POWDER
WELCHOL ORAL PACKET, ORAL TABLET
Calcium-Channel Blocking Agents, Misc
dilt-cd 120 mg, 300 mg oral capsule er 24 hour
diltiazem hcl 120 mg, 30 mg, 60 mg, 90 mg oral tablet
diltiazem hcl 100 mg intravenous solution , 50 mg/10ml
intravenous solution
diltiazem hcl er 120 mg, 60 mg, 90 mg oral capsule er 12 hour
diltiazem hcl er beads 180 mg, 360 mg oral capsule er 24 hour
diltiazem hcl er coated beads 120 mg, 240 mg, 300 mg oral capsule
er 24 hour
dilt-xr 180 mg, 240 mg oral capsule er 24 hour
MATZIM LA ORAL TABLET ER 24 HOUR
TARKA ORAL TABLET ER
TAZTIA XT ORAL CAPSULE ER 24 HOUR
verapamil hcl 120 mg, 40 mg, 80 mg oral tablet
verapamil hcl 2.5 mg/ml intravenous solution
verapamil hcl er 100 mg oral capsule er 24 hour, 120 mg oral
capsule er 24 hour, 120 mg oral tablet er, 180 mg oral capsule er
24 hour, 180 mg oral tablet er, 200 mg oral capsule er 24 hour,
240 mg oral capsule er 24 hour, 240 mg oral tablet er, 300 mg oral
capsule er 24 hour
Cardiac Drugs, Miscellaneous
RANEXA ORAL TABLET ER 12 HOUR
Cardiotonic Agents
digoxin 0.05 mg/ml oral solution, 0.125 mg oral tablet, 0.25 mg
oral tablet
digoxin 0.25 mg/ml injection solution
LANOXIN 0.125 MG ORAL TABLET, 0.25 MG ORAL
Drug Tier
1
1
1
1
1
1
1
1
1
Requirements/Limits
1
1
1
3
2
1
1
1
1
1
2
2
3
1
1
1
PA(*)
PA(*)
1
3
PA
1
1
1
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
23 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
TABLET, 0.25 MG/ML INJECTION SOLUTION
LANOXIN 0.1 MG/ML INJECTION SOLUTION
Central Alpha-Agonists
clonidine hcl oral tablet, transdermal patch weekly
CLORPRES ORAL TABLET
guanfacine hcl oral tablet
methyldopa oral tablet
methyldopa-hydrochlorothiazide oral tablet
Cholesterol Absorption Inhibitors
ZETIA ORAL TABLET
Dihydropyridines
AFEDITAB CR ORAL TABLET ER 24 HOUR
amlodipine besy-benazepril hcl oral capsule
amlodipine besylate oral tablet
AZOR ORAL TABLET
DYNACIRC CR ORAL TABLET ER 24 HOUR
EXFORGE ORAL TABLET
EXFORGE HCT ORAL TABLET
felodipine er oral tablet er 24 hour
isradipine oral capsule
nicardipine hcl intravenous solution, oral capsule
NIFEDIAC CC 90 MG ORAL TABLET ER 24 HOUR
NIFEDICAL XL ORAL TABLET ER 24 HOUR
nifedipine oral capsule
nifedipine er osmotic oral tablet er 24 hour
nimodipine oral capsule
nisoldipine er oral tablet er 24 hour
TRIBENZOR ORAL TABLET
Direct Vasodilators
hydralazine hcl oral tablet, injection solution
minoxidil oral tablet
PROGLYCEM ORAL SUSPENSION
Fibric Acid Derivatives
fenofibrate 160 mg, 54 mg oral tablet
fenofibrate micronized oral capsule
gemfibrozil oral tablet
TRICOR ORAL TABLET
TRILIPIX ORAL CAPSULE DELAYED RELEASE
HMG-CoA Reductase Inhibitors
ALTOPREV ORAL TABLET ER 24 HOUR
atorvastatin calcium oral tablet
Drug Tier
1
Requirements/Limits
PA(*)
1
3
1
1
1
2
1
1
1
3
3
2
2
1
1
1
1
1
1
1
1
1
3
1
1
2
1
1
1
3
2
3
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
24 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
CRESTOR ORAL TABLET
lovastatin oral tablet
pravastatin sodium oral tablet
SIMCOR 1000-40 MG, 500-20 MG, 500-40 MG, 750-20 MG
ORAL TABLET ER 24 HOUR
simvastatin oral tablet
VYTORIN ORAL TABLET
Mineralocorticoid (Aldost) Recept Antag
ALDACTAZIDE ORAL TABLET
eplerenone oral tablet
spironolactone oral tablet
spironolactone-hctz oral tablet
Nitrates And Nitrites
ISORDIL TITRADOSE 40 MG ORAL TABLET
isosorbide dinitrate oral tablet, sublingual tablet sublingual
isosorbide dinitrate er oral tablet er
isosorbide mononitrate 20 mg oral tablet
isosorbide mononitrate er oral tablet er 24 hour
MINITRAN TRANSDERMAL PATCH 24 HOUR
NITRO-BID TRANSDERMAL OINTMENT
nitroglycerin 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
transdermal patch 24 hour
nitroglycerin 5 mg/ml intravenous solution
NITROLINGUAL TRANSLINGUAL SOLUTION
NITROSTAT SUBLINGUAL TABLET SUBLINGUAL
Peripheral Adrenergic Inhibitors
reserpine oral tablet
Phosphodiesterase Type 5 Inhibitors
ADCIRCA ORAL TABLET
REVATIO 20 MG ORAL TABLET
Renin Inhibitors
AMTURNIDE ORAL TABLET
TEKAMLO ORAL TABLET
TEKTURNA ORAL TABLET
TEKTURNA HCT ORAL TABLET
Vasodilating Agents, Miscellaneous
dipyridamole 25 mg, 50 mg, 75 mg oral tablet
LETAIRIS ORAL TABLET
TRACLEER ORAL TABLET
VENTAVIS 10 MCG/ML INHALATION SOLUTION
CENTRAL NERVOUS SYSTEM AGENTS
Drug Tier
2
1
1
Requirements/Limits
2
1
2
3
1
1
1
3
1
1
1
1
3
3
1
1
3
3
PA(*)
1
4
2
PA
PA
2
2
2
2
1
4
4
4
PA
LA
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
25 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
Adamantanes
amantadine hcl oral capsule, oral tablet, oral syrup
Amphetamines
amphetamine-dextroamphetamine oral tablet
dextroamphetamine sulfate oral tablet
dextroamphetamine sulfate er oral capsule er 24 hour
methamphetamine hcl oral tablet
VYVANSE ORAL CAPSULE
Anorexigenics & Resp & Cereb Stim, Misc
CONCERTA ORAL TABLET ER
dexmethylphenidate hcl oral tablet
METADATE CD 10 MG, 20 MG, 30 MG ORAL CAPSULE ER
methylphenidate hcl oral tablet, oral solution
methylphenidate hcl er 20 mg oral tablet er
methylphenidate hcl er (la) oral capsule er 24 hour
PROVIGIL ORAL TABLET
RITALIN LA ORAL CAPSULE ER 24 HOUR
Anticholinergic Agents
benztropine mesylate oral tablet, injection solution
trihexyphenidyl hcl oral elixir, oral tablet
Anticonvulsants, Miscellaneous
BANZEL ORAL TABLET, ORAL SUSPENSION
carbamazepine oral tablet chewable, oral suspension, oral tablet
carbamazepine er 100 mg, 200 mg, 300 mg oral capsule er 12 hour
divalproex sodium oral capsule sprinkle, oral tablet delayed
release
divalproex sodium er oral tablet er 24 hour
EPITOL ORAL TABLET
felbamate oral tablet, oral suspension
gabapentin oral capsule, oral solution, oral tablet
GABITRIL ORAL TABLET
HORIZANT ORAL TABLET ER 24 HOUR
lamotrigine oral tablet, oral tablet chewable
levetiracetam 100 mg/ml oral solution, 1000 mg oral tablet, 250
mg oral tablet, 500 mg oral tablet, 750 mg oral tablet
levetiracetam 500 mg/5ml intravenous solution
levetiracetam er oral tablet er 24 hour
LYRICA 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG,
50 MG, 75 MG ORAL CAPSULE
oxcarbazepine 150 mg, 300 mg, 600 mg oral tablet
POTIGA ORAL TABLET
Drug Tier
Requirements/Limits
1
1
1
1
1
3
PA
3
1
3
1
1
1
2
3
PA
PA
PA
PA
PA
PA
1
1
3
1
1
1
1
2
1
1
3
3
1
1
1
1
3
1
4
PA(*)
PA
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
26 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
Drug Tier
SABRIL ORAL PACKET, ORAL TABLET
4
TEGRETOL ORAL TABLET CHEWABLE, ORAL
SUSPENSION, ORAL TABLET
3
TEGRETOL XR ORAL TABLET ER 12 HOUR
3
topiramate oral tablet, oral capsule sprinkle
1
TRILEPTAL 300 MG/5ML ORAL SUSPENSION
3
valproate sodium 100 mg/ml intravenous solution
1
valproic acid 250 mg oral capsule, 250 mg/5ml oral syrup
1
VIMPAT 10 MG/ML ORAL SOLUTION, 100 MG ORAL
TABLET, 150 MG ORAL TABLET, 200 MG ORAL TABLET, 50
MG ORAL TABLET
3
VIMPAT 200 MG/20ML INTRAVENOUS SOLUTION
3
zonisamide oral capsule
1
Antidepressants
amitriptyline hcl oral tablet
1
amoxapine oral tablet
1
APLENZIN ORAL TABLET ER 24 HOUR
3
BUDEPRION SR ORAL TABLET ER 12 HOUR
1
BUDEPRION XL ORAL TABLET ER 24 HOUR
1
BUPROBAN ORAL TABLET ER 12 HOUR
1
bupropion hcl oral tablet
1
bupropion hcl er (sr) oral tablet er 12 hour
1
chlordiazepoxide-amitriptyline oral tablet
1
citalopram hydrobromide oral tablet, oral solution
1
clomipramine hcl oral capsule
1
CYMBALTA ORAL CAPSULE DELAYED RELEASE
PARTICLES
2
desipramine hcl oral tablet
1
doxepin hcl oral capsule, oral concentrate
1
escitalopram oxalate oral tablet, oral solution
1
fluoxetine hcl 10 mg oral capsule, 10 mg oral tablet, 20 mg oral
capsule, 20 mg oral tablet, 20 mg/5ml oral solution, 40 mg oral
capsule, 90 mg oral capsule delayed release
1
fluvoxamine maleate oral tablet
1
imipramine hcl oral tablet
1
imipramine pamoate oral capsule
1
LUVOX CR ORAL CAPSULE ER 24 HOUR
3
maprotiline hcl oral tablet
1
MARPLAN ORAL TABLET
3
mirtazapine oral tablet, oral tablet dispersible
1
nefazodone hcl oral tablet
1
Requirements/Limits
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
27 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
nortriptyline hcl 10 mg, 25 mg, 50 mg, 75 mg oral capsule
paroxetine hcl 10 mg, 20 mg, 30 mg, 40 mg oral tablet
paroxetine hcl er oral tablet er 24 hour
PAXIL 10 MG/5ML ORAL SUSPENSION
perphenazine-amitriptyline oral tablet
phenelzine sulfate oral tablet
PRISTIQ ORAL TABLET ER 24 HOUR
protriptyline hcl oral tablet
sertraline hcl oral tablet, oral concentrate
SYMBYAX ORAL CAPSULE
tranylcypromine sulfate oral tablet
trazodone hcl oral tablet
trimipramine maleate oral capsule
venlafaxine hcl oral tablet
venlafaxine hcl er 150 mg oral capsule er 24 hour, 150 mg oral
tablet er 24 hour, 37.5 mg oral capsule er 24 hour, 37.5 mg oral
tablet er 24 hour, 75 mg oral capsule er 24 hour, 75 mg oral tablet
er 24 hour
VIIBRYD ORAL TABLET, ORAL KIT
Antimanic Agents
lithium carbonate oral capsule, oral tablet
lithium carbonate er oral tablet er
lithium citrate oral solution
LITHOBID ORAL TABLET ER
Antimigraine Agents, Miscellaneous
MIGERGOT RECTAL SUPPOSITORY
Antipsychotics
ABILIFY ORAL SOLUTION, ORAL TABLET,
INTRAMUSCULAR SOLUTION
ABILIFY DISCMELT ORAL TABLET DISPERSIBLE
chlorpromazine hcl oral tablet, injection solution
clozapine 100 mg, 200 mg, 25 mg, 50 mg oral tablet
COMPRO RECTAL SUPPOSITORY
FANAPT ORAL TABLET
FANAPT TITRATION PACK ORAL TABLET
FAZACLO ORAL TABLET DISPERSIBLE
fluphenazine decanoate injection solution
fluphenazine hcl oral tablet, oral elixir, injection solution, oral
concentrate
GEODON 20 MG INTRAMUSCULAR SOLUTION
HALDOL INJECTION SOLUTION
Drug Tier
1
1
1
3
1
1
3
1
1
3
1
1
1
1
Requirements/Limits
1
3
1
1
1
3
3
2
2
1
1
1
3
3
3
1
1
3
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
28 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
haloperidol oral tablet
haloperidol decanoate intramuscular solution
haloperidol lactate 2 mg/ml oral concentrate
INVEGA ORAL TABLET ER 24 HOUR
INVEGA SUSTENNA 39 MG/0.25ML, 78 MG/0.5ML
INTRAMUSCULAR SUSPENSION
INVEGA SUSTENNA 117 MG/0.75ML, 156 MG/ML, 234
MG/1.5ML INTRAMUSCULAR SUSPENSION
LATUDA 20 MG, 40 MG, 80 MG ORAL TABLET
loxapine succinate oral capsule
olanzapine intramuscular solution , oral tablet, oral tablet
dispersible
ORAP ORAL TABLET
perphenazine oral tablet
prochlorperazine rectal suppository
prochlorperazine edisylate injection solution
prochlorperazine maleate oral tablet
quetiapine fumarate oral tablet
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION
risperidone oral tablet, oral tablet dispersible, oral solution
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL
SEROQUEL XR ORAL TABLET ER 24 HOUR
thioridazine hcl oral tablet
thiothixene oral capsule
trifluoperazine hcl oral tablet
ziprasidone hcl oral capsule
Anxiolytics, Sedatives, & Hypnotics Misc
buspirone hcl oral tablet
hydroxyzine hcl 10 mg oral tablet, 10 mg/5ml oral syrup, 25 mg
oral tablet, 50 mg oral tablet
hydroxyzine pamoate oral capsule
LUNESTA 2 MG, 3 MG ORAL TABLET
LUNESTA 1 MG ORAL TABLET
meprobamate oral tablet
zaleplon oral capsule
zolpidem tartrate 10 mg oral tablet
zolpidem tartrate 5 mg oral tablet
zolpidem tartrate er 12.5 mg oral tablet er
zolpidem tartrate er 6.25 mg oral tablet er
Barbiturates
phenobarbital 16.2 mg oral tablet, 20 mg/5ml oral elixir, 30 mg
Drug Tier
1
1
1
3
Requirements/Limits
3
4
3
1
1
3
1
1
1
1
1
3
1
3
2
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
PA
PA
QL(30 per 30 days)
QL(90 per 30 days)
1
PA
QL(60 per 30 days)
QL(30 per 30 days)
QL(60 per 30 days)
QL(30 per 30 days)
QL(60 per 30 days)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
29 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
oral tablet, 32.4 mg oral tablet, 64.8 mg oral tablet, 97.2 mg oral
tablet
primidone oral tablet
Benzodiazepines
clonazepam oral tablet dispersible, oral tablet
clorazepate dipotassium oral tablet
diazepam 10 mg, 2.5 mg, 20 mg rectal gel
diazepam 1 mg/ml oral solution, 10 mg oral tablet, 2 mg oral
tablet, 5 mg oral tablet
DIAZEPAM INTENSOL ORAL CONCENTRATE
ONFI ORAL TABLET
Central Nervous System Agents, Misc
CAMPRAL ORAL TABLET DELAYED RELEASE
INTUNIV ORAL TABLET ER 24 HOUR
NAMENDA ORAL TABLET, ORAL SOLUTION
NAMENDA TITRATION PAK ORAL TABLET
RILUTEK ORAL TABLET
STRATTERA ORAL CAPSULE
XENAZINE ORAL TABLET
XYREM ORAL SOLUTION
COMT Inhibitors
COMTAN ORAL TABLET
TASMAR ORAL TABLET
Dopamine Precursors
carbidopa-levodopa oral tablet, oral tablet dispersible
carbidopa-levodopa er oral tablet er
LODOSYN ORAL TABLET
STALEVO 100 ORAL TABLET
STALEVO 125 ORAL TABLET
STALEVO 150 ORAL TABLET
STALEVO 200 ORAL TABLET
STALEVO 50 ORAL TABLET
STALEVO 75 ORAL TABLET
Dopamine Receptor Agonists
APOKYN SUBCUTANEOUS SOLUTION
bromocriptine mesylate oral tablet, oral capsule
cabergoline oral tablet
MIRAPEX ER ORAL TABLET ER 24 HOUR
pramipexole dihydrochloride oral tablet
ropinirole hcl oral tablet
ropinirole hcl er oral tablet er 24 hour
Drug Tier
Requirements/Limits
1
1
1
1
PA
PA
1
3
3
PA
PA
PA
2
3
2
2
4
2
2
3
PA
PA
PA
PA, LA
2
3
1
1
3
2
2
2
2
2
2
4
1
1
3
1
1
1
PA
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
30 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
Hydantoins
DILANTIN ORAL CAPSULE, ORAL SUSPENSION
DILANTIN INFATABS ORAL TABLET CHEWABLE
fosphenytoin sodium 100 mg pe/2ml injection solution
PEGANONE ORAL TABLET
PHENYTEK ORAL CAPSULE
phenytoin 125 mg/5ml oral suspension
phenytoin sodium injection solution
phenytoin sodium extended oral capsule
Monoamine Oxidase B Inhibitors
AZILECT ORAL TABLET
EMSAM TRANSDERMAL PATCH 24 HOUR
selegiline hcl oral capsule, oral tablet
Nonsteroidal Anti-Inflammatory Agents
ARTHROTEC ORAL TABLET
CELEBREX ORAL CAPSULE
diclofenac potassium oral tablet
diclofenac sodium oral tablet delayed release
diclofenac sodium er oral tablet er 24 hour
diflunisal oral tablet
etodolac 200 mg oral capsule, 400 mg oral tablet, 500 mg oral
tablet
etodolac er oral tablet er 24 hour
flurbiprofen oral tablet
ibuprofen 100 mg/5ml oral suspension, 400 mg oral tablet, 600 mg
oral tablet, 800 mg oral tablet
INDOCIN 25 MG/5ML ORAL SUSPENSION
indomethacin oral capsule
indomethacin er oral capsule er
ketoprofen oral capsule
ketoprofen er oral capsule er 24 hour
ketorolac tromethamine 30 mg/ml injection solution
ketorolac tromethamine 10 mg oral tablet, 15 mg/ml injection
solution
meclofenamate sodium oral capsule
mefenamic acid oral capsule
meloxicam oral tablet, oral suspension
nabumetone oral tablet
NAPRELAN 375 MG, 750 MG ORAL TABLET ER 24 HOUR
naproxen oral suspension, oral tablet
naproxen dr oral tablet delayed release
Drug Tier
3
3
1
3
3
1
1
1
Requirements/Limits
PA(*)
PA(*)
2
3
1
3
2
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
3
1
1
PA, QL(10 per 5 days)
PA, QL(20 per 5 days)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
31 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
naproxen sodium 275 mg, 550 mg oral tablet
orphenadrine compound-ds oral tablet
orphenadrine-aspirin-caffeine 25-385-30 mg oral tablet
oxaprozin oral tablet
piroxicam oral capsule
sulindac oral tablet
tolmetin sodium oral tablet, oral capsule
Opiate Agonists
acetaminophen-codeine oral solution
acetaminophen-codeine #2 oral tablet
acetaminophen-codeine #3 oral tablet
acetaminophen-codeine #4 oral tablet
apap-caff-dihydrocodeine oral tablet
Drug Tier
1
1
1
1
1
1
1
Requirements/Limits
PA
PA
1
1
1
1
1
PA(*), QL(1800 per 30
days)
PA(*), QL(3600 per 30
days)
ASTRAMORPH 1 MG/ML INJECTION SOLUTION
3
ASTRAMORPH 0.5 MG/ML INJECTION SOLUTION
codeine sulfate 15 mg, 30 mg, 60 mg oral tablet
DEMEROL 50 MG/ML INJECTION SOLUTION
3
1
3
duramorph 1 mg/ml injection solution
2
duramorph 0.5 mg/ml injection solution
ENDOCET ORAL TABLET
fentanyl transdermal patch 72 hour
fentanyl citrate 200 mcg buccal lollipop
fentanyl citrate 1200 mcg, 1600 mcg, 400 mcg, 600 mcg, 800 mcg
buccal lollipop
2
2
1
3
FENTORA BUCCAL TABLET
hydrocodone-acetaminophen 10-325 mg oral tablet, 10-500 mg
oral tablet, 10-650 mg oral tablet, 10-660 mg oral tablet, 10-750
mg oral tablet, 2.5-500 mg oral tablet, 5-325 mg oral tablet, 5-500
mg oral tablet, 7.5-325 mg oral tablet, 7.5-325 mg/15ml oral
solution, 7.5-500 mg oral tablet, 7.5-500 mg/15ml oral solution,
7.5-650 mg oral tablet, 7.5-750 mg oral tablet
hydrocodone-ibuprofen 7.5-200 mg oral tablet
hydromorphone hcl 8 mg oral tablet
hydromorphone hcl 2 mg, 4 mg oral tablet
hydromorphone hcl pf 500 mg/50ml injection solution
KADIAN 100 MG, 200 MG ORAL CAPSULE ER 24 HOUR
4
QL(120 per 30 days)
PA, QL(240 per 30
days)
1
1
1
1
1
3
QL(60 per 30 days)
QL(120 per 30 days)
PA(*)
QL(30 per 30 days)
4
PA, QL(24 per 2 days)
PA(*), QL(1800 per 30
days)
PA(*), QL(3600 per 30
days)
PA, QL(20 per 30 days)
QL(120 per 30 days)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
32 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
KADIAN 10 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG ORAL
CAPSULE ER 24 HOUR
levorphanol tartrate oral tablet
morphine sulfate 15 mg, 30 mg oral tablet
morphine sulfate 20 mg/5ml oral solution
morphine sulfate 10 mg/5ml oral solution
morphine sulfate (concentrate) 20 mg/ml oral solution
morphine sulfate er 100 mg oral capsule er 24 hour, 200 mg oral
tablet er 12 hour, 80 mg oral capsule er 24 hour
morphine sulfate er 100 mg oral tablet er 12 hour, 15 mg oral
tablet er 12 hour, 20 mg oral capsule er 24 hour, 30 mg oral
capsule er 24 hour, 30 mg oral tablet er 12 hour, 50 mg oral
capsule er 24 hour, 60 mg oral capsule er 24 hour, 60 mg oral
tablet er 12 hour
oxycodone hcl 15 mg oral tablet, 30 mg oral tablet, 5 mg oral
capsule, 5 mg oral tablet
oxycodone hcl 20 mg/ml oral concentrate
oxycodone-acetaminophen oral tablet, oral capsule
oxycodone-aspirin 4.8355-325 mg oral tablet
oxycodone-ibuprofen oral tablet
OXYCONTIN ORAL TABLET ER 12 HOUR
oxymorphone hcl oral tablet
oxymorphone hcl er oral tablet er 12 hour
REPREXAIN 10-200 MG ORAL TABLET
REPREXAIN 2.5-200 MG ORAL TABLET
ROXICET 5-325 MG/5ML ORAL SOLUTION, 5-500 MG ORAL
TABLET
stagesic oral capsule
SYNALGOS-DC ORAL CAPSULE
tramadol hcl oral tablet
tramadol hcl er 100 mg, 200 mg oral tablet er 24 hour
tramadol-acetaminophen oral tablet
XODOL 10-300 MG, 7.5-300 MG ORAL TABLET
ZYDONE ORAL TABLET
Opiate Antagonists
naloxone hcl 1 mg/ml injection solution
naltrexone hcl oral tablet
Opiate Partial Agonists
buprenorphine hcl 2 mg, 8 mg sublingual tablet sublingual
butorphanol tartrate injection solution, nasal solution
Drug Tier
Requirements/Limits
3
1
1
1
1
1
QL(120 per 30 days)
QL(450 per 30 days)
QL(900 per 30 days)
QL(90 per 30 days)
1
QL(30 per 30 days)
1
QL(60 per 30 days)
1
1
1
1
1
3
1
1
1
3
QL(120 per 15 days)
QL(120 per 30 days)
3
3
3
1
1
1
3
3
1
1
QL(60 per 30 days)
PA, QL(60 per 30 days)
QL(120 per 15 days)
QL(30 per 30 days)
QL(80 per 10 days)
PA(*), QL(10 per 15
days)
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
33 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
pentazocine-acetaminophen oral tablet
pentazocine-naloxone hcl oral tablet
SUBOXONE 2-0.5 MG, 8-2 MG SUBLINGUAL FILM
SUBOXONE 2-0.5 MG, 8-2 MG SUBLINGUAL TABLET
SUBLINGUAL
TALWIN INJECTION SOLUTION
Selective Serotonin Agonists
AXERT ORAL TABLET
FROVA ORAL TABLET
MAXALT ORAL TABLET
MAXALT-MLT ORAL TABLET DISPERSIBLE
naratriptan hcl oral tablet
RELPAX ORAL TABLET
sumatriptan succinate 6 mg/0.5ml subcutaneous solution
sumatriptan succinate 100 mg, 25 mg, 50 mg oral tablet
ZOMIG ORAL TABLET, NASAL SOLUTION
ZOMIG ZMT ORAL TABLET DISPERSIBLE
Succinimides
CELONTIN ORAL CAPSULE
ethosuximide oral capsule, oral solution
DEVICES
Devices
gauze pads 2"x2" pad
insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml
miscellaneous
pen needles 5/16" 31g x 8 mm miscellaneous
alcohol preps
ELECTROLYTIC, CALORIC, AND WATER BALANCE
Ammonia Detoxicants
BUPHENYL ORAL TABLET
enulose oral solution
lactulose 10 gm/15ml oral solution
Caloric Agents
AMINOSYN II 8.5 % INTRAVENOUS SOLUTION
AMINOSYN II 10 %, 15 %, 7 % INTRAVENOUS SOLUTION
AMINOSYN II/ELECTROLYTES INTRAVENOUS SOLUTION
AMINOSYN M INTRAVENOUS SOLUTION
AMINOSYN/ELECTROLYTES 8.5 % INTRAVENOUS
SOLUTION
AMINOSYN-HBC INTRAVENOUS SOLUTION
AMINOSYN-PF INTRAVENOUS SOLUTION
Drug Tier
1
1
3
3
3
3
3
3
3
1
3
1
1
3
3
Requirements/Limits
QL(90 per 30 days)
QL(12 per 30 days)
QL(12 per 30 days)
QL(6 per 30 days)
QL(5 per 30 days)
QL(9 per 30 days)
QL(6 per 30 days)
QL(6 per 30 days)
3
1
1
1
1
1
4
1
1
1
3
3
3
PA(*)
PA(*)
PA(*)
PA(*)
3
3
3
PA(*)
PA(*)
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
34 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS
SOLUTION
CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION
CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS SOLUTION
CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION
CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION
dextrose 10 %, 5 % intravenous solution
FREAMINE III 8.5 % INTRAVENOUS SOLUTION
HEPATAMINE INTRAVENOUS SOLUTION
HEPATASOL INTRAVENOUS SOLUTION
INTRALIPID INTRAVENOUS EMULSION
LIPOSYN III 10 %, 20 % INTRAVENOUS EMULSION
NEPHRAMINE INTRAVENOUS SOLUTION
TRAVASOL INTRAVENOUS SOLUTION
TROPHAMINE INTRAVENOUS SOLUTION
Irrigating Solutions
lactated ringers
PHYSIOLYTE
PHYSIOSOL IRRIGATION
ringers irrigation
sodium chloride irrigation solution
sterile water for irrigation
Loop Diuretics
bumetanide injection solution, oral tablet
furosemide 10 mg/ml oral solution, 20 mg oral tablet, 40 mg oral
tablet, 8 mg/ml oral solution, 80 mg oral tablet
furosemide 10 mg/ml injection solution
torsemide 10 mg oral tablet, 100 mg oral tablet, 20 mg oral tablet,
20 mg/2ml intravenous solution, 5 mg oral tablet
Phosphate-Removing Agents
FOSRENOL ORAL TABLET CHEWABLE
RENAGEL ORAL TABLET
RENVELA ORAL PACKET, ORAL TABLET
Potassium-Removing Agents
sodium polystyrene sulfonate oral suspension
Potassium-Sparing Diuretics
amiloride hcl oral tablet
amiloride-hydrochlorothiazide oral tablet
triamterene-hctz oral capsule, oral tablet
Replacement Preparations
calcium acetate 667 mg oral capsule
Drug Tier
Requirements/Limits
1
1
1
1
1
1
1
1
3
3
3
3
1
1
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
1
1
1
1
1
1
PA(*)
PA(*)
PA(*)
PA(*)
1
1
1
PA(*)
1
2
3
2
1
1
1
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
35 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
dextrose in lactated ringers intravenous solution
dextrose-nacl 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5-0.45 %,
5-0.9 % intravenous solution
dextrose-nacl 10-0.2 %, 10-0.45 % intravenous solution
ELIPHOS ORAL TABLET
IONOSOL-B IN D5W
IONOSOL-MB IN D5W
ISOLYTE-H IN D5W
ISOLYTE-P IN D5W
ISOLYTE-S
ISOLYTE-S IN D5W
kcl-lactated ringers-d5w intravenous solution
KLOR-CON 8 MEQ ORAL TABLET ER
KLOR-CON 10 ORAL TABLET ER
KLOR-CON M15 ORAL TABLET ER
KLOR-CON M20 ORAL TABLET ER
NORMOSOL-R PH 7.4
PHOSLYRA ORAL SOLUTION
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN D5W
potassium chloride 0.4 meq/ml, 10 meq/100ml, 10 meq/50ml, 2
meq/ml, 30 meq/100ml intravenous solution
potassium chloride crys er oral tablet er
potassium chloride er 10 meq, 8 meq oral capsule er
ringers
sodium chloride 0.45 % intravenous solution, 0.9 % intravenous
solution, 2.5 meq/ml injection solution, 3 % intravenous solution, 5
% intravenous solution
Thiazide Diuretics
chlorothiazide oral tablet
chlorothiazide sodium intravenous solution
DIURIL ORAL SUSPENSION
hydrochlorothiazide oral capsule, oral tablet
methyclothiazide oral tablet
Thiazide-Like Diuretics
chlorthalidone 25 mg, 50 mg oral tablet
indapamide oral tablet
metolazone oral tablet
THALITONE ORAL TABLET
Uricosuric Agents
Drug Tier
1
Requirements/Limits
PA(*)
1
3
1
3
3
3
3
3
3
1
1
1
1
1
3
3
3
3
3
PA(*)
PA(*)
1
1
1
1
PA(*)
1
PA(*)
1
1
3
1
1
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
1
1
1
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
36 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
colchicine-probenecid oral tablet
probenecid oral tablet
ENZYMES
Enzymes
ADAGEN INTRAMUSCULAR SOLUTION
ALDURAZYME INTRAVENOUS SOLUTION
CEREZYME 200 UNIT INTRAVENOUS SOLUTION
ELAPRASE INTRAVENOUS SOLUTION
ELITEK 1.5 MG INTRAVENOUS SOLUTION
FABRAZYME 35 MG INTRAVENOUS SOLUTION
NAGLAZYME INTRAVENOUS SOLUTION
VPRIV INTRAVENOUS SOLUTION
EYE, EAR, NOSE & THROAT PREPARATIONS
Alpha-Adrenergic Agonists
ALPHAGAN P 0.1 % OPHTHALMIC SOLUTION
brimonidine tartrate ophthalmic solution
COMBIGAN OPHTHALMIC SOLUTION
Antiallergic Agents
ALOCRIL OPHTHALMIC SOLUTION
ALOMIDE OPHTHALMIC SOLUTION
ASTEPRO NASAL SOLUTION
azelastine hcl ophthalmic solution, nasal solution
cromolyn sodium 4 % ophthalmic solution
ELESTAT OPHTHALMIC SOLUTION
EMADINE OPHTHALMIC SOLUTION
PATADAY OPHTHALMIC SOLUTION
PATANASE NASAL SOLUTION
PATANOL OPHTHALMIC SOLUTION
Antibacterials
AZASITE OPHTHALMIC SOLUTION
bacitracin ophthalmic ointment
bacitracin-polymyxin b ophthalmic ointment
CILOXAN 0.3 % OPHTHALMIC OINTMENT
ciprofloxacin hcl 0.3 % ophthalmic solution
erythromycin ophthalmic ointment
GENTAK 0.3 % OPHTHALMIC OINTMENT
gentamicin sulfate 0.3 % ophthalmic solution
neomycin-bacitracin zn-polymyx ophthalmic ointment
neomycin-polymyxin-gramicidin
ofloxacin ophthalmic solution, otic solution
polymyxin b-trimethoprim ophthalmic solution
Drug Tier
1
1
4
4
4
4
4
4
4
4
Requirements/Limits
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
2
1
2
3
3
2
1
1
2
3
2
3
2
3
1
1
3
1
1
1
1
1
1
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
37 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
sulfacetamide sodium ophthalmic ointment, ophthalmic solution
TOBREX 0.3 % OPHTHALMIC OINTMENT
VIGAMOX OPHTHALMIC SOLUTION
ZYMAXID OPHTHALMIC SOLUTION
Antifungals
NATACYN OPHTHALMIC SUSPENSION
Antivirals
trifluridine ophthalmic solution
ZIRGAN OPHTHALMIC GEL
Beta-Adrenergic Blocking Agents
betaxolol hcl ophthalmic solution
BETIMOL OPHTHALMIC SOLUTION
BETOPTIC-S OPHTHALMIC SUSPENSION
carteolol hcl ophthalmic solution
levobunolol hcl 0.5 % ophthalmic solution
metipranolol ophthalmic solution
timolol maleate ophthalmic gel forming solution, ophthalmic
solution
Carbonic Anhydrase Inhibitors
acetazolamide oral tablet
acetazolamide er oral capsule er 12 hour
AZOPT OPHTHALMIC SUSPENSION
dorzolamide hcl ophthalmic solution
dorzolamide hcl-timolol mal ophthalmic solution
methazolamide oral tablet
Corticosteroids
ACETASOL HC OTIC SOLUTION
ALREX OPHTHALMIC SUSPENSION
bacitra-neomycin-polymyxin-hc ophthalmic ointment
BECONASE AQ NASAL SUSPENSION
BLEPHAMIDE OPHTHALMIC SUSPENSION
BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT
CIPRO HC OTIC SUSPENSION
CIPRODEX OTIC SUSPENSION
COLY-MYCIN S OTIC SUSPENSION
CORTISPORIN-TC OTIC SUSPENSION
dexamethasone sodium phosphate ophthalmic solution
FLAREX OPHTHALMIC SUSPENSION
flunisolide 0.025 % nasal solution
fluticasone propionate nasal suspension
FML OPHTHALMIC OINTMENT
Drug Tier
1
3
2
2
Requirements/Limits
2
1
3
1
3
3
1
1
1
1
1
1
2
1
1
1
2
3
1
3
3
3
3
2
3
3
1
3
1
1
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
38 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
FML FORTE OPHTHALMIC SUSPENSION
hydrocortisone-acetic acid otic solution
LOTEMAX OPHTHALMIC OINTMENT, OPHTHALMIC
SUSPENSION
MAXIDEX OPHTHALMIC SUSPENSION
NASACORT AQ NASAL AEROSOL SOLUTION
NASONEX NASAL SUSPENSION
neomycin-polymyxin-dexameth ophthalmic ointment, ophthalmic
suspension
neomycin-polymyxin-hc otic solution, ophthalmic suspension, otic
suspension
PRED MILD OPHTHALMIC SUSPENSION
PRED-G OPHTHALMIC SUSPENSION
prednisolone acetate ophthalmic suspension
prednisolone sodium phosphate ophthalmic solution
RHINOCORT AQUA NASAL SUSPENSION
sulfacetamide-prednisolone 10-0.23 % ophthalmic solution
TOBRADEX 0.3-0.1 % OPHTHALMIC OINTMENT
tobramycin-dexamethasone ophthalmic suspension
triamcinolone acetonide nasal inhaler
VERAMYST NASAL SUSPENSION
VEXOL OPHTHALMIC SUSPENSION
ZYLET OPHTHALMIC SUSPENSION
EENT Anti-Infectives, Miscellaneous
chlorhexidine gluconate mouth/throat solution
EENT Anti-Inflammatory Agents, Misc
RESTASIS OPHTHALMIC EMULSION
Eent Drugs, Miscellaneous
acetic acid otic solution
apraclonidine hcl ophthalmic solution
IOPIDINE 1 % OPHTHALMIC SOLUTION
Local Anesthetics
lidocaine viscous mouth/throat solution
proparacaine hcl ophthalmic solution
Miotics
PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION
PILOPINE HS OPHTHALMIC GEL
Mydriatics
tropicamide ophthalmic solution
Nonsteroidal Anti-Inflammatory Agents
diclofenac sodium ophthalmic solution
Drug Tier
3
1
Requirements/Limits
3
3
3
2
1
1
3
3
1
1
3
1
3
1
1
3
3
2
1
2
1
1
3
1
1
3
3
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
39 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
flurbiprofen sodium ophthalmic solution
ketorolac tromethamine ophthalmic solution
NEVANAC OPHTHALMIC SUSPENSION
Prostaglandin Analogs
latanoprost ophthalmic solution
LUMIGAN OPHTHALMIC SOLUTION
TRAVATAN Z OPHTHALMIC SOLUTION
XALATAN OPHTHALMIC SOLUTION
Vasoconstrictors
ak-con ophthalmic solution
TYZINE 0.1 % NASAL SOLUTION
GASTROINTESTINAL DRUGS
5-HT3 Receptor Antagonists
ALOXI INTRAVENOUS SOLUTION
ANZEMET ORAL TABLET, INTRAVENOUS SOLUTION
granisetron hcl 0.1 mg/ml intravenous solution, 1 mg oral tablet, 1
mg/ml intravenous solution
GRANISOL ORAL SOLUTION
ondansetron oral tablet dispersible
ondansetron hcl 24 mg oral tablet, 4 mg oral tablet, 4 mg/2ml
injection solution, 4 mg/5ml oral solution, 8 mg oral tablet
SANCUSO TRANSDERMAL PATCH
Antidiarrhea Agents
diphenoxylate-atropine 2.5-0.025 mg oral tablet
diphenoxylate-atropine 2.5-0.025 mg/5ml oral liquid
loperamide hcl 2 mg oral capsule
MOTOFEN ORAL TABLET
Antiemetics, Miscellaneous
dronabinol oral capsule
EMEND 125 MG, 40 MG, 80 MG, 80 & 125 MG ORAL
CAPSULE
Antihistamines
ANTIVERT 50 MG ORAL TABLET
meclizine hcl 12.5 mg, 25 mg oral tablet
trimethobenzamide hcl 300 mg oral capsule
Anti-Inflammatory Agents
APRISO ORAL CAPSULE ER 24 HOUR
ASACOL ORAL TABLET DELAYED RELEASE
ASACOL HD ORAL TABLET DELAYED RELEASE
balsalazide disodium oral capsule
CANASA RECTAL SUPPOSITORY
Drug Tier
1
1
2
Requirements/Limits
1
2
2
3
1
3
3
3
PA
1
1
1
PA
PA
PA
1
3
PA
PA
1
1
1
3
PA, QL(40 per 5 days)
PA, QL(200 per 5 days)
1
PA
2
PA
3
1
1
PA
3
2
2
1
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
40 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
DIPENTUM ORAL CAPSULE
LOTRONEX ORAL TABLET
mesalamine-cleanser rectal kit
PENTASA ORAL CAPSULE ER
Antiulcer Agents And Acid Suppressants,
HELIDAC
PYLERA ORAL CAPSULE
Cathartics And Laxatives
GAVILYTE-C ORAL SOLUTION
GAVILYTE-G ORAL SOLUTION
GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION
MOVIPREP ORAL SOLUTION
OSMOPREP ORAL TABLET
polyethylene glycol 3350
TRILYTE ORAL SOLUTION
Cholelitholytic Agents
ursodiol oral tablet, oral capsule
Digestants
CREON ORAL CAPSULE DELAYED RELEASE PARTICLES
PANCREAZE ORAL CAPSULE DELAYED RELEASE
PARTICLES
ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES
GI Drugs, Miscellaneous
AMITIZA ORAL CAPSULE
RELISTOR 12 MG/0.6ML SUBCUTANEOUS KIT
Histamine H2-Antagonists
cimetidine oral tablet
cimetidine hcl 300 mg/5ml oral solution
famotidine 20 mg oral tablet, 40 mg oral tablet, 40 mg/5ml oral
suspension
famotidine 10 mg/ml intravenous solution
famotidine premixed intravenous solution
nizatidine oral solution, oral capsule
ranitidine hcl 15 mg/ml oral syrup, 150 mg oral capsule, 150 mg
oral tablet, 300 mg oral capsule, 300 mg oral tablet
ranitidine hcl 150 mg/6ml injection solution
Prokinetic Agents
metoclopramide hcl 10 mg oral tablet, 5 mg oral tablet, 5 mg/5ml
oral solution
metoclopramide hcl 5 mg/ml injection solution
Prostaglandins
Drug Tier
2
2
1
3
Requirements/Limits
3
3
1
1
1
3
2
1
1
1
3
2
3
3
3
PA, QL(60 per 30 days)
PA
1
1
1
1
1
1
PA(*)
1
1
PA(*)
1
1
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
41 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
misoprostol 200 mcg oral tablet
Protectants
sucralfate 1 gm oral tablet
Proton-Pump Inhibitors
DEXILANT ORAL CAPSULE DELAYED RELEASE
lansoprazole 15 mg, 30 mg oral capsule delayed release
omeprazole 10 mg, 20 mg, 40 mg oral capsule delayed release
omeprazole-sodium bicarbonate oral capsule
pantoprazole sodium oral tablet delayed release
PREVPAC
PROTONIX 40 MG INTRAVENOUS SOLUTION
GOLD COMPOUNDS
Gold Compounds
RIDAURA ORAL CAPSULE
HEAVY METAL ANTAGONISTS
Heavy Metal Antagonists
DEPEN TITRATABS ORAL TABLET
EXJADE 125 MG ORAL TABLET SOLUBLE
EXJADE 250 MG, 500 MG ORAL TABLET SOLUBLE
FERRIPROX ORAL TABLET
SYPRINE ORAL CAPSULE
HORMONES AND SYNTHETIC SUBSTITUTES
Adrenals
ALVESCO INHALATION AEROSOL SOLUTION
ASMANEX 120 METERED DOSES INHALATION AEROSOL
POWDER BREATH ACTIVATED
ASMANEX 14 METERED DOSES INHALATION AEROSOL
POWDER BREATH ACTIVATED
ASMANEX 30 METERED DOSES 110 MCG/INH
INHALATION AEROSOL POWDER BREATH ACTIVATED
ASMANEX 30 METERED DOSES 220 MCG/INH
INHALATION AEROSOL POWDER BREATH ACTIVATED
ASMANEX 60 METERED DOSES INHALATION AEROSOL
POWDER BREATH ACTIVATED
budesonide inhalation suspension
budesonide er oral capsule er 24 hour
CELESTONE ORAL SOLUTION
cortisone acetate oral tablet
DEPO-MEDROL 20 MG/ML INJECTION SUSPENSION
dexamethasone 0.5 mg oral tablet, 0.5 mg/5ml oral elixir, 0.75 mg
oral tablet, 1 mg oral tablet, 1.5 mg oral tablet, 2 mg oral tablet, 4
Drug Tier
1
Requirements/Limits
1
3
1
1
1
1
3
3
PA(*)
3
2
3
4
3
3
3
QL(12.2 per 30 days)
2
QL(0.24 per 30 days)
2
QL(0.24 per 30 days)
2
QL(0.135 per 30 days)
2
QL(0.24 per 30 days)
2
1
1
3
1
3
QL(0.24 per 30 days)
PA(*)
PA(*)
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
42 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
mg oral tablet, 6 mg oral tablet
DEXAMETHASONE INTENSOL ORAL CONCENTRATE
dexamethasone sodium phosphate 4 mg/ml injection solution
FLOVENT DISKUS INHALATION AEROSOL POWDER
BREATH ACTIVATED
FLOVENT HFA 44 MCG/ACT INHALATION AEROSOL
FLOVENT HFA 110 MCG/ACT INHALATION AEROSOL
FLOVENT HFA 220 MCG/ACT INHALATION AEROSOL
fludrocortisone acetate oral tablet
hydrocortisone oral tablet
methylprednisolone oral tablet
methylprednisolone (pak) oral tablet
methylprednisolone acetate 40 mg/ml injection suspension
methylprednisolone acetate pf 80 mg/ml injection suspension
methylprednisolone sodium succ 1 gm injection solution
prednisolone sodium phosphate 15 mg/5ml, 6.7 (5 base) mg/5ml
oral solution
prednisone oral tablet, oral solution
PREDNISONE INTENSOL ORAL CONCENTRATE
PULMICORT 1 MG/2ML INHALATION SUSPENSION
PULMICORT FLEXHALER 180 MCG/ACT INHALATION
AEROSOL POWDER BREATH ACTIVATED
PULMICORT FLEXHALER 90 MCG/ACT INHALATION
AEROSOL POWDER BREATH ACTIVATED
QVAR INHALATION AEROSOL SOLUTION
SYMBICORT INHALATION AEROSOL
Alpha-Glucosidase Inhibitors
acarbose oral tablet
GLYSET ORAL TABLET
Amylinomimetics
SYMLINPEN 120 SUBCUTANEOUS SOLUTION
SYMLINPEN 60 SUBCUTANEOUS SOLUTION
Androgens
ANDROGEL 50 MG/5GM TRANSDERMAL GEL
ANDROXY ORAL TABLET
danazol oral capsule
oxandrolone oral tablet
STRIANT BUCCAL MISCELLANEOUS
TESTIM TRANSDERMAL GEL
testosterone cypionate intramuscular oil
TESTRED ORAL CAPSULE
Drug Tier
Requirements/Limits
1
1
3
3
3
3
1
1
1
1
1
1
1
QL(60 per 25 days)
QL(10.6 per 25 days)
QL(12 per 25 days)
QL(24 per 30 days)
PA(*)
PA(*)
1
1
1
3
PA(*)
2
QL(1 per 30 days)
2
2
2
QL(2 per 30 days)
1
3
2
2
QL(10.8 per 30 days)
QL(12 per 30 days)
2
3
1
1
3
3
1
3
PA
PA
PA
PA
PA
PA
PA
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
43 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
Antithyroid Agents
methimazole oral tablet
propylthiouracil oral tablet
Biguanides
metformin hcl oral tablet
metformin hcl er oral tablet er 24 hour
RIOMET ORAL SOLUTION
Contraceptives
APRI ORAL TABLET
ARANELLE ORAL TABLET
AVIANE ORAL TABLET
BALZIVA ORAL TABLET
BREVICON (28) ORAL TABLET
CAMILA ORAL TABLET
CRYSELLE-28 ORAL TABLET
CYCLAFEM 1/35 ORAL TABLET
CYCLAFEM 7/7/7 ORAL TABLET
ENPRESSE-28
ERRIN ORAL TABLET
GIANVI ORAL TABLET
JOLIVETTE ORAL TABLET
JUNEL 1.5/30 ORAL TABLET
JUNEL 1/20 ORAL TABLET
JUNEL FE 1.5/30 ORAL TABLET
JUNEL FE 1/20 ORAL TABLET
KARIVA ORAL TABLET
KELNOR 1/35 ORAL TABLET
LEENA ORAL TABLET
LESSINA-28 ORAL TABLET
LEVORA 0.15/30 (28) ORAL TABLET
LOW-OGESTREL ORAL TABLET
LUTERA ORAL TABLET
MICROGESTIN 1.5/30 ORAL TABLET
MICROGESTIN 1/20 ORAL TABLET
MICROGESTIN FE 1.5/30 ORAL TABLET
MICROGESTIN FE 1/20 ORAL TABLET
MONONESSA ORAL TABLET
NECON 0.5/35 (28) ORAL TABLET
NECON 1/35 (28) ORAL TABLET
NECON 10/11 (28) ORAL TABLET
NECON 7/7/7 ORAL TABLET
Drug Tier
Requirements/Limits
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
44 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
NORA-BE ORAL TABLET
NORTREL 0.5/35 (28) ORAL TABLET
NORTREL 1/35 (21) ORAL TABLET
NORTREL 1/35 (28) ORAL TABLET
NORTREL 7/7/7 ORAL TABLET
OCELLA ORAL TABLET
OGESTREL ORAL TABLET
ORTHO EVRA TRANSDERMAL PATCH WEEKLY
ORTHO TRI-CYCLEN LO ORAL TABLET
PORTIA-28 ORAL TABLET
PREVIFEM ORAL TABLET
QUASENSE ORAL TABLET
RECLIPSEN ORAL TABLET
SPRINTEC 28 ORAL TABLET
SRONYX ORAL TABLET
TRI-LEGEST FE ORAL TABLET
TRINESSA (28) ORAL TABLET
TRI-PREVIFEM ORAL TABLET
TRI-SPRINTEC ORAL TABLET
TRIVORA (28)
VELIVET
ZOVIA 1/35E (28) ORAL TABLET
ZOVIA 1/50E (28) ORAL TABLET
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor
JANUMET ORAL TABLET
JANUMET XR ORAL TABLET ER 24 HOUR
JANUVIA ORAL TABLET
JUVISYNC 100-10 MG, 100-20 MG, 100-40 MG ORAL
TABLET
KOMBIGLYZE XR ORAL TABLET ER 24 HOUR
ONGLYZA ORAL TABLET
Estrogen Agonist-Antagonists
EVISTA ORAL TABLET
Estrogens
ACTIVELLA ORAL TABLET
ALORA TRANSDERMAL PATCH BIWEEKLY
ANGELIQ 0.5-1 MG ORAL TABLET
CENESTIN ORAL TABLET
CLIMARA PRO TRANSDERMAL PATCH WEEKLY
COMBIPATCH TRANSDERMAL PATCH BIWEEKLY
DIVIGEL 1 MG/GM TRANSDERMAL GEL
Drug Tier
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
2
2
2
2
2
2
2
3
2
3
2
2
2
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
45 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
ELESTRIN TRANSDERMAL GEL
ENJUVIA ORAL TABLET
ESTRACE 0.1 MG/GM VAGINAL CREAM
estradiol transdermal patch weekly, oral tablet
estradiol valerate 20 mg/ml, 40 mg/ml intramuscular oil
estradiol-norethindrone acet 1-0.5 mg oral tablet
ESTRING VAGINAL RING
estropipate oral tablet
EVAMIST TRANSDERMAL SOLUTION
FEMHRT 1/5 ORAL TABLET
FEMHRT LOW DOSE ORAL TABLET
FEMRING VAGINAL RING
MENEST ORAL TABLET
MENOSTAR TRANSDERMAL PATCH WEEKLY
PREFEST ORAL TABLET
PREMARIN 0.3 MG ORAL TABLET, 0.45 MG ORAL TABLET,
0.625 MG ORAL TABLET, 0.625 MG/GM VAGINAL CREAM,
0.9 MG ORAL TABLET, 1.25 MG ORAL TABLET
PREMARIN 25 MG INJECTION SOLUTION
PREMPHASE ORAL TABLET
PREMPRO ORAL TABLET
VAGIFEM VAGINAL TABLET
VIVELLE-DOT TRANSDERMAL PATCH BIWEEKLY
Glycogenolytic Agents
GLUCAGEN HYPOKIT INJECTION SOLUTION
GLUCAGON EMERGENCY INJECTION KIT
Gonadotropins
chorionic gonadotropin intramuscular solution
SYNAREL NASAL SOLUTION
Incretin Mimetics
BYDUREON SUBCUTANEOUS SUSPENSION
BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION
BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION
VICTOZA SUBCUTANEOUS SOLUTION
Insulins
HUMALOG SUBCUTANEOUS SOLUTION
HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION
HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION
HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS
SUSPENSION
HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION
Drug Tier
3
3
3
1
1
1
3
1
3
3
3
3
3
3
3
2
2
2
2
3
2
Requirements/Limits
PA(*)
2
3
1
4
PA(*)
PA
3
3
3
2
QL(4 per 28 days)
QL(2.4 per 30 days)
QL(2.4 per 30 days)
2
2
2
2
2
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
46 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS
SUSPENSION
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION
HUMULIN 70/30 PEN SUBCUTANEOUS SUSPENSION
HUMULIN N SUBCUTANEOUS SUSPENSION
HUMULIN N PEN SUBCUTANEOUS SUSPENSION
HUMULIN R INJECTION SOLUTION
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS
SOLUTION
LANTUS SUBCUTANEOUS SOLUTION
LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION
LEVEMIR SUBCUTANEOUS SOLUTION
LEVEMIR FLEXPEN SUBCUTANEOUS SOLUTION
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION
NOVOLIN N SUBCUTANEOUS SUSPENSION
NOVOLIN R INJECTION SOLUTION
NOVOLOG SUBCUTANEOUS SOLUTION
NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION
NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION
NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS
SUSPENSION
Meglitinides
nateglinide oral tablet
PRANDIMET ORAL TABLET
PRANDIN ORAL TABLET
Parathyroid
calcitonin (salmon) nasal solution
FORTEO SUBCUTANEOUS SOLUTION
FORTICAL NASAL SOLUTION
MIACALCIN 200 UNIT/ML INJECTION SOLUTION
Pituitary
desmopressin ace spray refrig nasal solution
desmopressin acetate 0.1 mg, 0.2 mg oral tablet
desmopressin acetate 4 mcg/ml injection solution
STIMATE NASAL SOLUTION
Progestins
medroxyprogesterone acetate oral tablet, intramuscular suspension
MEGACE ES ORAL SUSPENSION
norethindrone acetate oral tablet
progesterone micronized oral capsule
Somatotropin Agonists
Drug Tier
Requirements/Limits
2
2
2
2
2
2
2
3
3
2
2
2
2
2
2
2
2
2
1
3
3
1
4
3
3
1
1
1
3
PA
PA(*)
PA(*)
1
3
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
47 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
EGRIFTA 1 MG SUBCUTANEOUS SOLUTION
GENOTROPIN SUBCUTANEOUS SOLUTION
HUMATROPE 6 MG INJECTION SOLUTION
HUMATROPE 12 MG, 24 MG INJECTION SOLUTION
INCRELEX SUBCUTANEOUS SOLUTION
NORDITROPIN FLEXPRO 5 MG/1.5ML SUBCUTANEOUS
SOLUTION
NORDITROPIN FLEXPRO 10 MG/1.5ML, 15 MG/1.5ML
SUBCUTANEOUS SOLUTION
NORDITROPIN NORDIFLEX PEN 30 MG/3ML
SUBCUTANEOUS SOLUTION
NUTROPIN SUBCUTANEOUS SOLUTION
NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION
NUTROPIN AQ PEN SUBCUTANEOUS SOLUTION
OMNITROPE 10 MG/1.5ML, 5 MG/1.5ML SUBCUTANEOUS
SOLUTION
OMNITROPE 5.8 MG SUBCUTANEOUS SOLUTION
SAIZEN 5 MG INJECTION SOLUTION
SAIZEN CLICK.EASY INJECTION SOLUTION
SEROSTIM SUBCUTANEOUS SOLUTION
TEV-TROPIN SUBCUTANEOUS SOLUTION
ZORBTIVE SUBCUTANEOUS SOLUTION
Somatotropin Antagonists
SOMAVERT SUBCUTANEOUS SOLUTION
Sulfonylureas
chlorpropamide oral tablet
glimepiride oral tablet
glipizide oral tablet
glipizide er oral tablet er 24 hour
glipizide-metformin hcl oral tablet
glyburide oral tablet
glyburide micronized oral tablet
glyburide-metformin oral tablet
tolazamide oral tablet
tolbutamide oral tablet
Thiazolidinediones
ACTOPLUS MET ORAL TABLET
ACTOPLUS MET XR ORAL TABLET ER 24 HOUR
ACTOS ORAL TABLET
AVANDAMET ORAL TABLET
AVANDARYL ORAL TABLET
Drug Tier
4
3
3
4
4
Requirements/Limits
PA
PA
PA
PA
PA
3
PA
4
PA
4
3
3
3
PA
PA
PA
PA
3
4
4
4
4
3
4
PA
PA
PA
PA
PA
PA
PA
4
PA
1
1
1
1
1
1
1
1
1
1
2
2
2
3
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
48 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
AVANDIA ORAL TABLET
DUETACT ORAL TABLET
Thyroid Agents
CYTOMEL ORAL TABLET
LEVOTHROID ORAL TABLET
levothyroxine sodium 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
oral tablet
LEVOXYL ORAL TABLET
liothyronine sodium intravenous solution, oral tablet
SYNTHROID ORAL TABLET
UNITHROID 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175
MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88
MCG ORAL TABLET
LOCAL ANESTHETICS
Local Anesthetics
lidocaine hcl 0.5 % injection solution
lidocaine hcl (pf) 1 % injection solution
MISCELLANEOUS THERAPEUTIC AGENTS
5-Alpha-Reductase Inhibitors
AVODART ORAL CAPSULE
finasteride oral tablet
JALYN ORAL CAPSULE
Alcohol Deterrents
disulfiram oral tablet
Antidotes
acetylcysteine 10 %, 20 % inhalation solution
fomepizole 1 gm/ml intravenous solution
FUSILEV INTRAVENOUS SOLUTION
leucovorin calcium 10 mg, 15 mg, 25 mg, 5 mg oral tablet
leucovorin calcium 100 mg, 350 mg injection solution
Antigout Agents
allopurinol oral tablet
COLCRYS ORAL TABLET
ULORIC ORAL TABLET
Biologic Response Modifiers
ACTIMMUNE SUBCUTANEOUS SOLUTION
AVONEX INTRAMUSCULAR KIT
AVONEX PREFILLED INTRAMUSCULAR KIT
BETASERON SUBCUTANEOUS SOLUTION
COPAXONE SUBCUTANEOUS KIT
Drug Tier
3
3
Requirements/Limits
3
1
1
1
1
2
2
1
1
PA(*)
PA(*)
3
1
3
1
1
1
3
1
1
PA(*)
PA(*)
PA(*)
1
3
2
4
4
4
4
4
PA
PA
PA
PA
PA
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
49 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
REBIF SUBCUTANEOUS SOLUTION
THALOMID ORAL CAPSULE
Bone Resorption Inhibitors
ACTONEL ORAL TABLET
alendronate sodium oral tablet
BONIVA 3 MG/3ML INTRAVENOUS SOLUTION
etidronate disodium oral tablet
FOSAMAX PLUS D ORAL TABLET
ibandronate sodium oral tablet
pamidronate disodium 30 mg/10ml, 6 mg/ml, 90 mg/10ml
intravenous solution
RECLAST INTRAVENOUS SOLUTION
ZOMETA INTRAVENOUS SOLUTION, INTRAVENOUS
CONCENTRATE
Disease-Modifying Antirheumatic Agents
CIMZIA SUBCUTANEOUS KIT
ENBREL SUBCUTANEOUS KIT, SUBCUTANEOUS
SOLUTION
HUMIRA SUBCUTANEOUS KIT
HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS KIT
KINERET SUBCUTANEOUS SOLUTION
leflunomide oral tablet
ORENCIA SUBCUTANEOUS SOLUTION, INTRAVENOUS
SOLUTION
REMICADE INTRAVENOUS SOLUTION
Immunosuppressive Agents
ATGAM INTRAVENOUS INJECTABLE
AZASAN ORAL TABLET
azathioprine oral tablet
BENLYSTA 120 MG INTRAVENOUS SOLUTION
CELLCEPT ORAL SUSPENSION , ORAL CAPSULE, ORAL
TABLET
cyclosporine 100 mg oral capsule, 25 mg oral capsule, 50 mg/ml
intravenous solution
cyclosporine modified 100 mg oral capsule, 100 mg/ml oral
solution, 50 mg oral capsule
GENGRAF ORAL CAPSULE, ORAL SOLUTION
mycophenolate mofetil oral capsule, oral tablet
MYFORTIC ORAL TABLET DELAYED RELEASE
NEORAL ORAL CAPSULE, ORAL SOLUTION
NULOJIX INTRAVENOUS SOLUTION
Drug Tier
4
4
Requirements/Limits
PA
3
1
3
1
3
1
QL(1 per 28 days)
1
3
PA(*)
PA(*)
4
PA(*)
4
PA
4
4
4
4
1
PA
PA
PA
PA
4
4
PA
PA(*)
2
2
1
4
PA
PA(*)
PA(*)
PA
3
PA(*)
1
PA(*)
1
3
1
3
3
4
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
50 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
PROGRAF ORAL CAPSULE, INTRAVENOUS SOLUTION
RAPAMUNE ORAL TABLET, ORAL SOLUTION
SANDIMMUNE ORAL CAPSULE, ORAL SOLUTION,
INTRAVENOUS SOLUTION
SIMULECT 20 MG INTRAVENOUS SOLUTION
tacrolimus oral capsule
ZORTRESS ORAL TABLET
Other Miscellaneous Therapeutic Agents
ARCALYST SUBCUTANEOUS SOLUTION
BOTOX 100 UNIT INJECTION SOLUTION
CYSTADANE
CYSTAGON ORAL CAPSULE
DEMSER ORAL CAPSULE
ELMIRON ORAL CAPSULE
KUVAN ORAL TABLET SOLUBLE
levocarnitine 1 gm/10ml oral solution, 330 mg oral tablet
octreotide acetate 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50
mcg/ml, 500 mcg/ml injection solution
ORFADIN ORAL CAPSULE
SENSIPAR ORAL TABLET
SOMATULINE DEPOT SUBCUTANEOUS SOLUTION
ZAVESCA ORAL CAPSULE
Protective Agents
amifostine intravenous solution
dexrazoxane 500 mg intravenous solution
MESNEX 400 MG ORAL TABLET
RESPIRATORY TRACT AGENTS
Leukotriene Modifiers
SINGULAIR ORAL TABLET, ORAL PACKET, ORAL TABLET
CHEWABLE
zafirlukast oral tablet
ZYFLO ORAL TABLET
ZYFLO CR ORAL TABLET ER 12 HOUR
Mast-Cell Stabilizers
cromolyn sodium 100 mg/5ml oral concentrate
cromolyn sodium 20 mg/2ml inhalation nebulization solution
Mucolytic Agents
PULMOZYME INHALATION SOLUTION
Respiratory Tract Agents, Miscellaneous
ARALAST NP 400 MG INTRAVENOUS SOLUTION
PROLASTIN-C INTRAVENOUS SOLUTION
Drug Tier
3
3
Requirements/Limits
PA(*)
PA(*)
3
2
1
3
PA(*)
4
3
3
3
3
3
3
1
PA(*)
PA
1
2
2
4
2
PA(*)
1
4
3
PA(*)
PA(*)
PA
PA(*)
PA(*)
PA
PA
3
1
3
3
1
1
PA(*)
4
PA(*)
3
3
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
51 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
XOLAIR SUBCUTANEOUS SOLUTION
ZEMAIRA INTRAVENOUS SOLUTION
SERUMS, TOXOIDS AND VACCINES
Serums
CARIMUNE NF 3 GM INTRAVENOUS SOLUTION
GAMMAGARD 2.5 GM/25ML INJECTION SOLUTION
GAMMAPLEX 10 GM/200ML INTRAVENOUS SOLUTION
GAMUNEX-C 1 GM/10ML INJECTION SOLUTION
HIZENTRA 20% 1 GM/5ML SUBCUTANEOUS SOLUTION
PRIVIGEN 20 GM/200ML INTRAVENOUS SOLUTION
Toxoids
ADACEL INTRAMUSCULAR SUSPENSION
BOOSTRIX INTRAMUSCULAR SUSPENSION
DAPTACEL INTRAMUSCULAR SUSPENSION
DECAVAC INTRAMUSCULAR INJECTABLE
INFANRIX INTRAMUSCULAR SUSPENSION
tetanus-diphtheria toxoids td intramuscular suspension
Vaccines
ACTHIB
CERVARIX
COMVAX INTRAMUSCULAR SUSPENSION
ENGERIX-B 10 MCG/0.5ML, 20 MCG/ML INJECTION
SUSPENSION
GARDASIL
HAVRIX INTRAMUSCULAR SUSPENSION
IPOL
IXIARO
MENACTRA
MENOMUNE
MENVEO
M-M-R II
PEDVAX HIB
PROQUAD
RABAVERT
RECOMBIVAX HB 10 MCG/ML, 40 MCG/ML INJECTION
SUSPENSION
ROTATEQ
TWINRIX INTRAMUSCULAR SUSPENSION
TYPHIM VI INTRAMUSCULAR SOLUTION
VAQTA 25 UNIT/0.5ML INTRAMUSCULAR SUSPENSION
VARIVAX SUBCUTANEOUS INJECTABLE
Drug Tier
4
3
4
4
4
4
3
4
3
3
3
3
3
3
3
3
2
Requirements/Limits
PA
PA(*)
PA
PA
PA
PA
PA(*)
PA
PA(*)
PA(*)
PA
3
3
2
3
3
3
2
3
3
3
3
3
PA(*)
PA
PA(*)
3
3
2
3
3
3
PA(*)
PA(*)
PA(*)
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
52 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
YF-VAX
ZOSTAVAX SUBCUTANEOUS SOLUTION
SKIN AND MUCOUS MEMBRANE PREPARATIONS
Antibacterials
BACTROBAN 2 % EXTERNAL CREAM
BACTROBAN NASAL NASAL OINTMENT
CLEOCIN 100 MG VAGINAL SUPPOSITORY
clindamycin phosphate external foam, external gel, external lotion,
external solution, external swab, vaginal cream
erythromycin 2 % external gel, 2 % external solution
gentamicin sulfate external cream, external ointment
METROGEL 1 % EXTERNAL GEL
metronidazole 0.75 % external cream, 0.75 % external gel, 0.75 %
external lotion
mupirocin external ointment
neomycin-polymyxin b gu irrigation solution
VANDAZOLE VAGINAL GEL
Antifungals
ciclopirox external gel, external shampoo, external solution
ciclopirox olamine external cream, external suspension
clotrimazole 1 % external cream, 1 % external solution, 10 mg
mouth/throat troche
clotrimazole-betamethasone external cream, external lotion
econazole nitrate external cream
EXELDERM EXTERNAL CREAM, EXTERNAL SOLUTION
ketoconazole 2 % external cream, 2 % external shampoo
miconazole 3 200 mg vaginal suppository
NAFTIN 1 % EXTERNAL CREAM, 1 % EXTERNAL GEL
NYAMYC EXTERNAL POWDER
nystatin 100000 unit/gm external cream, 100000 unit/gm external
ointment, 100000 unit/gm external powder
NYSTOP EXTERNAL POWDER
OXISTAT EXTERNAL CREAM, EXTERNAL LOTION
pedi-dri external powder
terconazole 0.4 % vaginal cream, 80 mg vaginal suppository
ZAZOLE 0.4 %, 0.8 % VAGINAL CREAM
Anti-Inflammatory Agents
ala cort external cream
ALA SCALP EXTERNAL LOTION
alclometasone dipropionate external cream, external ointment
amcinonide external cream, external lotion, external ointment
Drug Tier
3
3
Requirements/Limits
3
3
3
1
1
1
3
1
1
1
2
1
1
1
1
1
3
1
1
3
2
1
2
3
1
1
2
1
3
1
1
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
53 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
betamethasone dipropionate external cream, external lotion,
external ointment
betamethasone dipropionate aug 0.05 % external cream, 0.05 %
external lotion, 0.05 % external ointment
betamethasone valerate external cream, external lotion, external
ointment
CAPEX EXTERNAL SHAMPOO
clobetasol propionate 0.05 % external foam, 0.05 % external gel,
0.05 % external lotion, 0.05 % external ointment, 0.05 % external
shampoo, 0.05 % external solution
clobetasol propionate e external cream
CLOBEX SPRAY EXTERNAL LIQUID
CLODERM PUMP EXTERNAL CREAM
COLOCORT RECTAL ENEMA
CORDRAN EXTERNAL LOTION, EXTERNAL TAPE
CORTISPORIN EXTERNAL CREAM, EXTERNAL OINTMENT
DERMA-SMOOTHE/FS BODY EXTERNAL OIL
desonide external cream, external lotion, external ointment
desoximetasone 0.05 % external cream, 0.05 % external gel, 0.25
% external cream, 0.25 % external ointment
diflorasone diacetate external cream, external ointment
fluocinolone acetonide external cream, external solution, external
ointment
fluocinolone acetonide body external oil
fluocinonide 0.05 % external gel, 0.05 % external ointment, 0.05 %
external solution
fluocinonide-e external cream
fluticasone propionate external ointment, external cream, external
lotion
halobetasol propionate external cream, external ointment
HALOG EXTERNAL CREAM, EXTERNAL OINTMENT
hydrocortisone 1 % external cream, 1 % external ointment, 100
mg/60ml rectal enema, 2.5 % external cream, 2.5 % external
lotion, 2.5 % external ointment
hydrocortisone valerate external cream, external ointment
KENALOG
LUXIQ EXTERNAL FOAM
mometasone furoate external cream, external ointment, external
solution
nystatin-triamcinolone external cream, external ointment
PANDEL EXTERNAL CREAM
Drug Tier
Requirements/Limits
1
1
1
3
1
1
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
3
1
1
3
3
1
1
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
54 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
prednicarbate external cream, external ointment
PROCTOCREAM HC RECTAL CREAM
triamcinolone acetonide external cream, external lotion, external
ointment, mouth/throat paste
U-CORT EXTERNAL CREAM
VANOS EXTERNAL CREAM
Antipruritics And Local Anesthetics
lidocaine external ointment
lidocaine hcl 2 % external gel, 4 % external solution
lidocaine-prilocaine 2.5-2.5 % external cream
LIDODERM EXTERNAL PATCH
ZONALON EXTERNAL CREAM
Antivirals
DENAVIR EXTERNAL CREAM
ZOVIRAX EXTERNAL CREAM, EXTERNAL OINTMENT
Basic Lotions And Liniments
ammonium lactate 12 % external cream, 12 % external lotion
LACLOTION EXTERNAL LOTION
Cell Stimulants And Proliferants
ATRALIN EXTERNAL GEL
AVITA EXTERNAL CREAM, EXTERNAL GEL
KEPIVANCE INTRAVENOUS SOLUTION
tretinoin external gel, external cream
Local Anti-Infectives, Miscellaneous
selenium sulfide external lotion
silver sulfadiazine external cream
SSD EXTERNAL CREAM
SULFAMYLON EXTERNAL PACKET, EXTERNAL CREAM
THERMAZENE EXTERNAL CREAM
Pigmenting Agents
8-MOP ORAL CAPSULE
OXSORALEN ULTRA ORAL CAPSULE
UVADEX INJECTION SOLUTION
Scabicides And Pediculicides
EURAX EXTERNAL CREAM, EXTERNAL LOTION
lindane external lotion, external shampoo
malathion external lotion
permethrin 5 % external cream
Skin And Mucous Membrane Agents, Misc
adapalene external cream, external gel
ALDARA EXTERNAL CREAM
Drug Tier
1
3
Requirements/Limits
1
1
3
1
1
1
3
3
3
3
1
2
3
3
4
1
PA
PA
PA(*)
PA
1
1
1
3
1
3
2
3
PA(*)
3
1
1
1
1
3
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
55 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
AMEVIVE INTRAMUSCULAR SOLUTION
AMNESTEEM ORAL CAPSULE
AZELEX EXTERNAL CREAM
calcipotriene 0.005 % external ointment, 0.005 % external solution
CARAC EXTERNAL CREAM
CLARAVIS ORAL CAPSULE
CONDYLOX 0.5 % EXTERNAL GEL
DOVONEX EXTERNAL CREAM, EXTERNAL SOLUTION
ELIDEL EXTERNAL CREAM
FINACEA EXTERNAL GEL
FLECTOR TRANSDERMAL PATCH
FLUOROPLEX EXTERNAL CREAM
fluorouracil 5 % external cream
imiquimod external cream
minocycline hcl er oral tablet er 24 hour
PANRETIN EXTERNAL GEL
PICATO EXTERNAL GEL
podofilox external solution
PROTOPIC EXTERNAL OINTMENT
REGRANEX EXTERNAL GEL
SANTYL EXTERNAL OINTMENT
SOLARAZE TRANSDERMAL GEL
SORIATANE 10 MG, 17.5 MG, 25 MG ORAL CAPSULE
TARGRETIN EXTERNAL GEL
TAZORAC EXTERNAL CREAM, EXTERNAL GEL
VEREGEN EXTERNAL OINTMENT
SMOOTH MUSCLE RELAXANTS
Genitourinary Smooth Muscle Relaxants
DETROL ORAL TABLET
DETROL LA ORAL CAPSULE ER 24 HOUR
ENABLEX ORAL TABLET ER 24 HOUR
flavoxate hcl oral tablet
oxybutynin chloride oral tablet, oral syrup
oxybutynin chloride er oral tablet er 24 hour
OXYTROL TRANSDERMAL PATCH BIWEEKLY
SANCTURA XR ORAL CAPSULE ER 24 HOUR
TOVIAZ ORAL TABLET ER 24 HOUR
trospium chloride oral tablet
VESICARE ORAL TABLET
Respiratory Smooth Muscle Relaxants
aminophylline 25 mg/ml intravenous solution
Drug Tier
4
1
3
1
3
1
3
3
2
3
3
3
1
1
1
2
3
1
3
4
3
3
4
3
3
3
Requirements/Limits
PA
PA
PA
PA
PA
PA
3
2
2
1
1
1
3
3
3
1
3
1
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
56 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
Drug Name
ELIXOPHYLLIN ORAL ELIXIR
LUFYLLIN ORAL TABLET
theophylline 400 mg, 600 mg oral tablet er 24 hour
theophylline er oral tablet er 12 hour
VITAMINS
Multivitamins preparations
prenatal vitamin with minerals and folic acid greater than 0.8 mg
oral tablet
Vitamin B Complex
NIACOR ORAL TABLET
Vitamin D
calcitriol 0.25 mcg oral capsule, 0.5 mcg oral capsule, 1 mcg/ml
oral solution
calcitriol 1 mcg/ml intravenous solution
HECTOROL 0.5 MCG, 1 MCG, 2.5 MCG ORAL CAPSULE
HECTOROL 4 MCG/2ML INTRAVENOUS SOLUTION
ZEMPLAR 1 MCG, 2 MCG, 4 MCG ORAL CAPSULE
ZEMPLAR 2 MCG/ML, 5 MCG/ML INTRAVENOUS
SOLUTION
Drug Tier
2
3
1
1
Requirements/Limits
2
2
1
1
3
3
2
2
PA(*)
PA(*)
PA(*)
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
57 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
ALDURAZYME....................................................... 37
alendronate sodium ................................................... 50
8-MOP ...................................................................... 55
alfuzosin hcl er .......................................................... 18
A
ALIMTA ................................................................... 15
ALINIA ....................................................................... 9
ABELCET ................................................................ 13
allopurinol ................................................................. 49
ABILIFY .................................................................. 28
ALOCRIL ................................................................. 37
ABILIFY DISCMELT ............................................. 28
ALOMIDE ................................................................ 37
ABRAXANE ............................................................ 14
ALORA ..................................................................... 45
acarbose .................................................................... 43
ALOXI ...................................................................... 40
acebutolol hcl ............................................................ 22
ALPHAGAN P ......................................................... 37
acetaminophen-codeine ............................................ 32
ALREX ..................................................................... 38
acetaminophen-codeine #2 ....................................... 32
ALTOPREV .............................................................. 24
acetaminophen-codeine #3 ....................................... 32
ALVESCO ................................................................ 42
acetaminophen-codeine #4 ....................................... 32
amantadine hcl .......................................................... 26
ACETASOL HC ....................................................... 38
AMBISOME ............................................................. 13
acetazolamide ........................................................... 38
amcinonide ................................................................ 53
acetazolamide er ....................................................... 38
AMEVIVE ................................................................ 56
acetic acid ................................................................. 39
amifostine.................................................................. 51
acetylcysteine............................................................ 49
amiloride hcl ............................................................. 35
ACTHIB ................................................................... 52
amiloride-hydrochlorothiazide .................................. 35
ACTIMMUNE.......................................................... 49
aminophylline ........................................................... 56
ACTIVELLA ............................................................ 45
AMINOSYN II ......................................................... 34
ACTONEL................................................................ 50
AMINOSYN II/ELECTROLYTES .......................... 34
ACTOPLUS MET .................................................... 48
AMINOSYN M ........................................................ 34
ACTOPLUS MET XR.............................................. 48
AMINOSYN/ELECTROLYTES ............................. 34
ACTOS ..................................................................... 48
AMINOSYN-HBC ................................................... 34
acyclovir ................................................................... 12
AMINOSYN-PF ....................................................... 34
acyclovir sodium....................................................... 12
amiodarone hcl .......................................................... 22
ADACEL .................................................................. 52
AMITIZA .................................................................. 41
ADAGEN ................................................................. 37
amitriptyline hcl ........................................................ 27
adapalene .................................................................. 55
amlodipine besy-benazepril hcl ................................ 24
ADCIRCA ................................................................ 25
amlodipine besylate .................................................. 24
ADRIAMYCIN ........................................................ 14
ammonium lactate ..................................................... 55
ADVAIR DISKUS ................................................... 18
AMNESTEEM.......................................................... 56
ADVAIR HFA .......................................................... 18
amoxapine ................................................................. 27
AFEDITAB CR ........................................................ 24
amoxicillin ................................................................ 12
AFINITOR................................................................ 14
amoxicillin-pot clavulanate ....................................... 13
AGGRENOX ............................................................ 21
amoxicillin-pot clavulanate er................................... 13
ak-con ....................................................................... 40
amphetamine-dextroamphetamine ............................ 26
ala cort ...................................................................... 53
AMPHOTEC............................................................. 13
ALA SCALP............................................................. 53
amphotericin b .......................................................... 13
ALBENZA.................................................................. 8
ampicillin .................................................................. 13
albuterol sulfate ........................................................ 18
ampicillin sodium...................................................... 13
alclometasone dipropionate ...................................... 53
ampicillin-sulbactam sodium .................................... 13
alcohol preps ............................................................. 34
AMTURNIDE........................................................... 25
ALDACTAZIDE ...................................................... 25
anagrelide hcl ............................................................ 21
ALDARA.................................................................. 55
anastrozole ................................................................ 15
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
8
58 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
ANDROGEL ............................................................ 43
AZACTAM IN DEXTROSE .................................... 12
ANDROXY .............................................................. 43
AZASAN .................................................................. 50
ANGELIQ ................................................................ 45
AZASITE .................................................................. 37
ANTIVERT .............................................................. 40
azathioprine ............................................................... 50
ANZEMET ............................................................... 40
azelastine hcl ............................................................. 37
apap-caff-dihydrocodeine ......................................... 32
AZELEX ................................................................... 56
APLENZIN ............................................................... 27
AZILECT .................................................................. 31
APOKYN.................................................................. 30
azithromycin ............................................................. 11
apraclonidine hcl....................................................... 39
AZOPT ...................................................................... 38
APRI ......................................................................... 44
AZOR ........................................................................ 24
APRISO .................................................................... 40
B
APTIVUS ................................................................... 9
bacitracin ................................................................... 37
ARALAST NP .......................................................... 51
bacitracin-polymyxin b ............................................. 37
ARANELLE ............................................................. 44
bacitra-neomycin-polymyxin-hc ............................... 38
ARANESP (ALBUMIN FREE) ............................... 20
baclofen ..................................................................... 19
ARCALYST ............................................................. 51
BACTOCILL IN DEXTROSE ................................. 13
ARRANON .............................................................. 15
BACTROBAN .......................................................... 53
ARTHROTEC .......................................................... 31
BACTROBAN NASAL............................................ 53
ASACOL .................................................................. 40
balsalazide disodium ................................................. 40
ASACOL HD ........................................................... 40
BALZIVA ................................................................. 44
ASMANEX 120 METERED DOSES ...................... 42
BANZEL ................................................................... 26
ASMANEX 14 METERED DOSES ........................ 42
BARACLUDE .......................................................... 12
ASMANEX 30 METERED DOSES ........................ 42
BECONASE AQ ....................................................... 38
ASMANEX 60 METERED DOSES ........................ 42
benazepril hcl ............................................................ 21
ASTEPRO ................................................................ 37
benazepril-hydrochlorothiazide ................................ 21
ASTRAMORPH ....................................................... 32
BENICAR ................................................................. 21
ATACAND ............................................................... 21
BENICAR HCT ........................................................ 21
ATACAND HCT ...................................................... 21
BENLYSTA .............................................................. 50
atenolol ..................................................................... 22
BENTYL ................................................................... 18
atenolol-chlorthalidone ............................................. 22
benztropine mesylate ................................................ 26
ATGAM.................................................................... 50
betamethasone dipropionate...................................... 54
atorvastatin calcium .................................................. 24
betamethasone dipropionate aug ............................... 54
atovaquone-proguanil hcl ........................................... 8
betamethasone valerate ............................................. 54
ATRALIN ................................................................. 55
BETASERON ........................................................... 49
ATRIPLA ................................................................... 9
betaxolol hcl ........................................................ 22, 38
atropine sulfate ......................................................... 18
bethanechol chloride ................................................. 19
ATROVENT HFA .................................................... 18
BETIMOL ................................................................. 38
AVANDAMET ........................................................ 48
BETOPTIC-S ............................................................ 38
AVANDARYL ......................................................... 48
bicalutamide .............................................................. 15
AVANDIA................................................................ 49
BICILLIN C-R .......................................................... 13
AVASTIN ................................................................. 15
BICILLIN C-R 900/300 ............................................ 13
AVELOX .................................................................. 13
BICILLIN L-A .......................................................... 13
AVELOX ABC PACK ............................................. 13
BILTRICIDE .............................................................. 8
AVIANE ................................................................... 44
bisoprolol fumarate ................................................... 22
AVITA ...................................................................... 55
bisoprolol-hydrochlorothiazide ................................. 22
AVODART ............................................................... 49
bleomycin sulfate ...................................................... 15
AVONEX ................................................................. 49
BLEPHAMIDE ......................................................... 38
AVONEX PREFILLED ........................................... 49
BLEPHAMIDE S.O.P. ............................................. 38
AXERT ..................................................................... 34
BONIVA ................................................................... 50
AZACTAM .............................................................. 12
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
59 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
BOOSTRIX .............................................................. 52
BOTOX .................................................................... 51
BREVICON (28) ...................................................... 44
brimonidine tartrate .................................................. 37
bromocriptine mesylate ............................................ 30
BUDEPRION SR ..................................................... 27
BUDEPRION XL ..................................................... 27
budesonide ................................................................ 42
budesonide er ............................................................ 42
bumetanide................................................................ 35
BUPHENYL ............................................................. 34
buprenorphine hcl ..................................................... 33
BUPROBAN ............................................................ 27
bupropion hcl ............................................................ 27
bupropion hcl er (sr) ................................................. 27
buspirone hcl............................................................. 29
BUSULFEX.............................................................. 15
butorphanol tartrate................................................... 33
BYDUREON ............................................................ 46
BYETTA 10 MCG PEN ........................................... 46
BYETTA 5 MCG PEN ............................................. 46
C
carteolol hcl ............................................................... 38
carvedilol................................................................... 22
CEDAX ..................................................................... 10
CEENU ..................................................................... 15
cefaclor ...................................................................... 10
cefaclor er.................................................................. 10
cefadroxil .................................................................. 11
cefazolin sodium ....................................................... 11
cefdinir ...................................................................... 11
cefepime hcl .............................................................. 11
cefotaxime sodium .................................................... 11
cefoxitin sodium........................................................ 12
cefpodoxime proxetil ................................................ 11
cefprozil .................................................................... 11
ceftazidime ................................................................ 11
ceftazidime and dextrose........................................... 11
CEFTIN..................................................................... 11
ceftriaxone sodium .................................................... 11
cefuroxime axetil ...................................................... 11
cefuroxime sodium.................................................... 11
CELEBREX .............................................................. 31
CELESTONE ............................................................ 42
CELLCEPT ............................................................... 50
cabergoline................................................................ 30
CELONTIN............................................................... 34
calcipotriene.............................................................. 56
CENESTIN ............................................................... 45
calcitonin (salmon) ................................................... 47
cephalexin ................................................................. 11
calcitriol .................................................................... 57
CEREZYME ............................................................. 37
calcium acetate ......................................................... 35
CERVARIX .............................................................. 52
CAMILA .................................................................. 44
cetirizine hcl ................................................................ 7
CAMPATH ............................................................... 15
CHANTIX................................................................. 18
CAMPRAL ............................................................... 30
CHANTIX STARTING MONTH PAK ................... 18
CANASA .................................................................. 40
chlordiazepoxide-amitriptyline ................................. 27
CANCIDAS .............................................................. 11
chlorhexidine gluconate ............................................ 39
CANTIL.................................................................... 18
chloroquine phosphate ................................................ 8
CAPASTAT SULFATE ........................................... 10
chlorothiazide ............................................................ 36
CAPEX ..................................................................... 54
chlorothiazide sodium ............................................... 36
CAPRELSA .............................................................. 15
chlorpromazine hcl.................................................... 28
captopril .................................................................... 21
chlorpropamide ......................................................... 48
captopril-hydrochlorothiazide .................................. 21
chlorthalidone ........................................................... 36
CARAC .................................................................... 56
chlorzoxazone ........................................................... 19
carbamazepine .......................................................... 26
cholestyramine light .................................................. 23
carbamazepine er ...................................................... 26
chorionic gonadotropin ............................................. 46
carbidopa-levodopa .................................................. 30
ciclopirox .................................................................. 53
carbidopa-levodopa er .............................................. 30
ciclopirox olamine .................................................... 53
carbinoxamine maleate ............................................... 7
cilostazol ................................................................... 21
carboplatin ................................................................ 15
CILOXAN................................................................. 37
CARIMUNE NF ....................................................... 52
cimetidine .................................................................. 41
carisoprodol .............................................................. 19
cimetidine hcl ............................................................ 41
carisoprodol-aspirin .................................................. 19
CIMZIA .................................................................... 50
carisoprodol-aspirin-codeine .................................... 19
CIPRO HC ................................................................ 38
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
60 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
CIPRODEX .............................................................. 38
COPAXONE ............................................................. 49
ciprofloxacin ............................................................. 13
CORDRAN ............................................................... 54
ciprofloxacin hcl ................................................. 13, 37
COREG CR............................................................... 22
ciprofloxacin-ciproflox hcl er ................................... 13
cortisone acetate ........................................................ 42
citalopram hydrobromide ......................................... 27
CORTISPORIN ........................................................ 54
cladribine .................................................................. 15
CORTISPORIN-TC .................................................. 38
CLARAVIS .............................................................. 56
COSMEGEN............................................................. 15
clarithromycin ........................................................... 11
COUMADIN............................................................. 20
clarithromycin er....................................................... 11
CREON ..................................................................... 41
clemastine fumarate .................................................... 7
CRESTOR................................................................. 25
CLEOCIN ............................................................. 8, 53
CRIXIVAN ................................................................. 9
CLEOCIN IN D5W .................................................... 8
cromolyn sodium ................................................ 37, 51
CLIMARA PRO ....................................................... 45
CRYSELLE-28 ......................................................... 44
clindamycin hcl........................................................... 8
CUBICIN .................................................................... 8
clindamycin phosphate ............................................. 53
CYCLAFEM 1/35 ..................................................... 44
CLINIMIX E/DEXTROSE (4.25/25)....................... 35
CYCLAFEM 7/7/7.................................................... 44
CLINIMIX/DEXTROSE (4.25/10) .......................... 35
cyclobenzaprine hcl .................................................. 19
CLINIMIX/DEXTROSE (4.25/20) .......................... 35
cyclophosphamide..................................................... 15
CLINIMIX/DEXTROSE (4.25/25) .......................... 35
cyclosporine .............................................................. 50
CLINIMIX/DEXTROSE (4.25/5) ............................ 35
cyclosporine modified ............................................... 50
clobetasol propionate ................................................ 54
CYMBALTA ............................................................ 27
clobetasol propionate e ............................................. 54
cyproheptadine hcl ...................................................... 7
CLOBEX SPRAY .................................................... 54
CYSTADANE .......................................................... 51
CLODERM PUMP ................................................... 54
CYSTAGON ............................................................. 51
CLOLAR .................................................................. 15
CYTOMEL ............................................................... 49
clomipramine hcl ...................................................... 27
D
clonazepam ............................................................... 30
dacarbazine ............................................................... 15
clonidine hcl ............................................................. 24
DACOGEN ............................................................... 15
clopidogrel bisulfate ................................................. 21
danazol ...................................................................... 43
clorazepate dipotassium ............................................ 30
dantrolene sodium ..................................................... 19
CLORPRES .............................................................. 24
dapsone ....................................................................... 9
clotrimazole .............................................................. 53
DAPTACEL.............................................................. 52
clotrimazole-betamethasone ..................................... 53
DARAPRIM ............................................................... 8
clozapine ................................................................... 28
daunorubicin hcl........................................................ 15
codeine sulfate .......................................................... 32
DECAVAC ............................................................... 52
colchicine-probenecid ............................................... 37
demeclocycline hcl.................................................... 14
COLCRYS ................................................................ 49
DEMEROL ............................................................... 32
colestipol hcl ............................................................. 23
DEMSER .................................................................. 51
colistimethate sodium ................................................. 8
DENAVIR................................................................. 55
COLOCORT ............................................................. 54
DEPEN TITRATABS ............................................... 42
COLY-MYCIN S ..................................................... 38
DEPO-MEDROL ...................................................... 42
COMBIGAN ............................................................ 37
DERMA-SMOOTHE/FS BODY.............................. 54
COMBIPATCH ........................................................ 45
desipramine hcl ......................................................... 27
COMBIVENT .......................................................... 18
desmopressin ace spray refrig ................................... 47
COMPLERA .............................................................. 9
desmopressin acetate ................................................. 47
COMPRO ................................................................. 28
desonide .................................................................... 54
COMTAN ................................................................. 30
desoximetasone ......................................................... 54
COMVAX ................................................................ 52
DETROL ................................................................... 56
CONCERTA ............................................................. 26
DETROL LA ............................................................ 56
CONDYLOX ............................................................ 56
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
61 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
dexamethasone.......................................................... 42
doxazosin mesylate ................................................... 21
DEXAMETHASONE INTENSOL .......................... 43
doxepin hcl ................................................................ 27
dexamethasone sodium phosphate...................... 38, 43
DOXIL ...................................................................... 15
DEXILANT .............................................................. 42
doxorubicin hcl ......................................................... 15
dexmethylphenidate hcl ............................................ 26
doxycycline hyclate .................................................. 14
dexrazoxane .............................................................. 51
doxycycline monohydrate ......................................... 14
dextroamphetamine sulfate ....................................... 26
dronabinol ................................................................. 40
dextroamphetamine sulfate er ................................... 26
DROXIA ................................................................... 15
dextrose..................................................................... 35
DUETACT ................................................................ 49
dextrose in lactated ringers ....................................... 36
duramorph ................................................................. 32
dextrose-nacl ............................................................. 36
DYNACIRC CR ....................................................... 24
diazepam ................................................................... 30
E
DIAZEPAM INTENSOL ......................................... 30
E.E.S. 400 ................................................................. 12
diclofenac potassium ................................................ 31
econazole nitrate ....................................................... 53
diclofenac sodium ............................................... 31, 39
EDURANT ................................................................. 9
diclofenac sodium er ................................................. 31
EFFIENT................................................................... 21
dicloxacillin sodium ................................................. 13
EGRIFTA .................................................................. 48
dicyclomine hcl......................................................... 18
ELAPRASE .............................................................. 37
didanosine ................................................................... 9
ELESTAT ................................................................. 37
diflorasone diacetate ................................................. 54
ELESTRIN ................................................................ 46
diflunisal ................................................................... 31
ELIDEL..................................................................... 56
digoxin ...................................................................... 23
ELIGARD ................................................................. 15
dihydroergotamine mesylate..................................... 18
ELIPHOS .................................................................. 36
DILANTIN ............................................................... 31
ELITEK..................................................................... 37
DILANTIN INFATABS........................................... 31
ELIXOPHYLLIN ..................................................... 57
dilt-cd ........................................................................ 23
ELMIRON ................................................................ 51
diltiazem hcl ............................................................. 23
EMADINE ................................................................ 37
diltiazem hcl er ......................................................... 23
EMCYT..................................................................... 15
diltiazem hcl er beads ............................................... 23
EMEND .................................................................... 40
diltiazem hcl er coated beads .................................... 23
EMSAM .................................................................... 31
dilt-xr ........................................................................ 23
EMTRIVA .................................................................. 9
DIOVAN .................................................................. 21
ENABLEX ................................................................ 56
DIOVAN HCT ......................................................... 21
enalapril maleate ....................................................... 21
DIPENTUM.............................................................. 41
enalapril-hydrochlorothiazide ................................... 21
diphenhydramine hcl .................................................. 7
ENBREL ................................................................... 50
diphenoxylate-atropine ............................................. 40
ENDOCET ................................................................ 32
dipyridamole ............................................................. 25
ENGERIX-B ............................................................. 52
disopyramide phosphate ........................................... 22
ENJUVIA .................................................................. 46
disulfiram .................................................................. 49
enoxaparin sodium .................................................... 20
DIURIL..................................................................... 36
ENPRESSE-28.......................................................... 44
divalproex sodium .................................................... 26
enulose ...................................................................... 34
divalproex sodium er ................................................ 26
EPIPEN 2-PAK ......................................................... 17
DIVIGEL .................................................................. 45
EPIPEN JR 2-PAK ................................................... 17
DOCEFREZ.............................................................. 15
epirubicin hcl ............................................................ 15
docetaxel ................................................................... 15
EPITOL ..................................................................... 26
donepezil hcl ............................................................. 19
EPIVIR ........................................................................ 9
DORIBAX ................................................................ 12
EPIVIR HBV .............................................................. 9
dorzolamide hcl ........................................................ 38
eplerenone ................................................................. 25
dorzolamide hcl-timolol mal .................................... 38
EPOGEN ................................................................... 20
DOVONEX .............................................................. 56
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
62 | First+Plus – 2013 – Comprehensive Formulary
Y0031_FP_13_1085_03_I F&U
EPZICOM ................................................................... 9
ERBITUX ................................................................. 15
ergoloid mesylates .................................................... 18
ERIVEDGE .............................................................. 15
ERRIN ...................................................................... 44
ERYPED 400 ............................................................ 12
ERY-TAB ................................................................. 12
ERYTHROCIN STEARATE ................................... 12
erythromycin ....................................................... 37, 53
erythromycin base..................................................... 12
escitalopram oxalate ................................................. 27
ESTRACE ................................................................ 46
estradiol .................................................................... 46
estradiol valerate ....................................................... 46
estradiol-norethindrone acet ..................................... 46
ESTRING ................................................................. 46
estropipate ................................................................. 46
ethambutol hcl .......................................................... 10
ethosuximide ............................................................. 34
etidronate disodium .................................................. 50
etodolac ..................................................................... 31
etodolac er................................................................. 31
ETOPOPHOS ........................................................... 15
etoposide ................................................................... 15
EURAX .................................................................... 55
EVAMIST ................................................................ 46
EVISTA .................................................................... 45
EVOXAC.................................................................. 19
EXELDERM ............................................................ 53
EXELON .................................................................. 19
exemestane................................................................ 15
EXFORGE ................................................................ 24
EXFORGE HCT ....................................................... 24
EXJADE ................................................................... 42
F
fenofibrate ................................................................. 24
fenofibrate micronized .............................................. 24
fentanyl ..................................................................... 32
fentanyl citrate .......................................................... 32
FENTORA ................................................................ 32
FERRIPROX............................................................. 42
FINACEA ................................................................. 56
finasteride .................................................................. 49
FIRMAGON ............................................................. 15
FLAREX ................................................................... 38
flavoxate hcl .............................................................. 56
flecainide acetate ....................................................... 22
FLECTOR ................................................................. 56
FLOVENT DISKUS ................................................. 43
FLOVENT HFA ....................................................... 43
fluconazole ................................................................ 10
flucytosine ................................................................. 13
fludarabine phosphate ............................................... 15
fludrocortisone acetate .............................................. 43
flunisolide ................................................................. 38
fluocinolone acetonide .............................................. 54
fluocinolone acetonide body ..................................... 54
fluocinonide .............................................................. 54
fluocinonide-e ........................................................... 54
FLUOROPLEX......................................................... 56
fluorouracil .......................................................... 15, 56
fluoxetine hcl ............................................................ 27
fluphenazine decanoate ............................................. 28
fluphenazine hcl ........................................................ 28
flurbiprofen ............................................................... 31
flurbiprofen sodium .................................................. 40
flutamide ................................................................... 15
fluticasone propionate ......................................... 38, 54
fluvoxamine maleate ................................................. 27
FML .......................................................................... 38
FML FORTE ............................................................. 39
FABRAZYME.......................................................... 37
fomepizole................................................................. 49
famciclovir ................................................................ 12
fondaparinux sodium ................................................ 20
famotidine ................................................................. 41
FORADIL AEROLIZER .......................................... 18
famotidine premixed ................................................. 41
FORTEO ................................................................... 47
FANAPT ................................................................... 28
FORTICAL ............................................................... 47
FANAPT TITRATION PACK ................................. 28
FOSAMAX PLUS D ................................................ 50
FARESTON.............................................................. 15
foscarnet sodium ....................................................... 10
FASLODEX ............................................................. 15
fosinopril sodium ...................................................... 21
FAZACLO ................................................................ 28
fosinopril sodium-hctz .............................................. 21
felbamate .................................................................. 26
fosphenytoin sodium ................................................. 31
felodipine er .............................................................. 24
FOSRENOL .............................................................. 35
FEMHRT 1/5 ............................................................ 46
FRAGMIN ................................................................ 20
FEMHRT LOW DOSE ............................................ 46
FREAMINE III ......................................................... 35
FEMRING ................................................................ 46
FROVA ..................................................................... 34
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
63 | First+Plus – 2013 – Comprehensive Formulary
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FURADANTIN ........................................................ 14
furosemide ................................................................ 35
FUSILEV .................................................................. 49
FUZEON .................................................................... 9
G
gabapentin ................................................................. 26
GABITRIL................................................................ 26
galantamine hydrobromide ....................................... 19
galantamine hydrobromide er ................................... 19
GAMMAGARD ....................................................... 52
GAMMAPLEX ........................................................ 52
GAMUNEX-C .......................................................... 52
ganciclovir sodium ................................................... 12
GARDASIL .............................................................. 52
gauze pads................................................................. 34
GAVILYTE-C .......................................................... 41
GAVILYTE-G .......................................................... 41
GAVILYTE-N WITH FLAVOR PACK .................. 41
gemcitabine hcl ......................................................... 15
gemfibrozil................................................................ 24
GEMZAR ................................................................. 15
GENGRAF ............................................................... 50
GENOTROPIN ......................................................... 48
GENTAK .................................................................. 37
gentamicin in saline .................................................... 8
gentamicin sulfate ........................................... 8, 37, 53
GEODON ................................................................. 28
GIANVI .................................................................... 44
GLEEVEC ................................................................ 15
glimepiride ................................................................ 48
glipizide .................................................................... 48
glipizide er ................................................................ 48
glipizide-metformin hcl ............................................ 48
GLUCAGEN HYPOKIT .......................................... 46
GLUCAGON EMERGENCY .................................. 46
glyburide ................................................................... 48
glyburide micronized ................................................ 48
glyburide-metformin ................................................. 48
glycopyrrolate ........................................................... 18
GLYSET ................................................................... 43
granisetron hcl .......................................................... 40
GRANISOL .............................................................. 40
griseofulvin microsize ................................................ 8
GRIS-PEG .................................................................. 8
guanfacine hcl ........................................................... 24
H
halobetasol propionate .............................................. 54
HALOG..................................................................... 54
haloperidol ................................................................ 29
haloperidol decanoate ............................................... 29
haloperidol lactate ..................................................... 29
HAVRIX ................................................................... 52
HECTOROL ............................................................. 57
HELIDAC ................................................................. 41
heparin (porcine) in nacl ........................................... 20
heparin sodium (porcine) .......................................... 20
HEPATAMINE......................................................... 35
HEPATASOL ........................................................... 35
HEPSERA ................................................................. 12
HERCEPTIN............................................................. 16
HEXALEN ................................................................ 16
HIZENTRA 20% ...................................................... 52
HORIZANT .............................................................. 26
HUMALOG .............................................................. 46
HUMALOG KWIKPEN ........................................... 46
HUMALOG MIX 50/50 ........................................... 46
HUMALOG MIX 50/50 KWIKPEN ........................ 46
HUMALOG MIX 75/25 ........................................... 46
HUMALOG MIX 75/25 KWIKPEN ........................ 47
HUMATROPE .......................................................... 48
HUMIRA .................................................................. 50
HUMIRA PEN-CROHNS STARTER ..................... 50
HUMULIN 70/30...................................................... 47
HUMULIN 70/30 PEN ............................................. 47
HUMULIN N ............................................................ 47
HUMULIN N PEN ................................................... 47
HUMULIN R ............................................................ 47
HUMULIN R U-500 (CONCENTRATED) ............. 47
HYCAMTIN ............................................................. 16
hydralazine hcl .......................................................... 24
hydrochlorothiazide .................................................. 36
hydrocodone-acetaminophen .................................... 32
hydrocodone-ibuprofen ............................................. 32
hydrocortisone..................................................... 43, 54
hydrocortisone valerate ............................................. 54
hydrocortisone-acetic acid ........................................ 39
hydromorphone hcl ................................................... 32
hydromorphone hcl pf ............................................... 32
hydroxychloroquine sulfate ........................................ 9
hydroxyurea .............................................................. 16
hydroxyzine hcl ......................................................... 29
hydroxyzine pamoate ................................................ 29
I
HALAVEN ............................................................... 15
HALDOL .................................................................. 28
ibandronate sodium ................................................... 50
ibuprofen ................................................................... 31
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
64 | First+Plus – 2013 – Comprehensive Formulary
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idarubicin hcl ............................................................ 16
imipenem-cilastatin .................................................. 12
imipramine hcl .......................................................... 27
imipramine pamoate ................................................. 27
imiquimod................................................................. 56
INCIVEK .................................................................. 11
INCRELEX .............................................................. 48
indapamide................................................................ 36
INDOCIN ................................................................. 31
indomethacin ............................................................ 31
indomethacin er ........................................................ 31
INFANRIX ............................................................... 52
INFERGEN .............................................................. 11
INLYTA ................................................................... 16
insulin syringe........................................................... 34
INTELENCE .............................................................. 9
INTRALIPID ............................................................ 35
INTRON-A ............................................................... 16
INTUNIV.................................................................. 30
INVANZ ................................................................... 12
INVEGA ................................................................... 29
INVEGA SUSTENNA ............................................. 29
INVIRASE.................................................................. 9
IONOSOL-B IN D5W .............................................. 36
IONOSOL-MB IN D5W .......................................... 36
IOPIDINE ................................................................. 39
IPOL ......................................................................... 52
ipratropium bromide ................................................. 18
ipratropium-albuterol ................................................ 18
irbesartan .................................................................. 21
irbesartan-hydrochlorothiazide ................................. 21
irinotecan hcl ............................................................ 16
ISENTRESS ............................................................... 9
ISOLYTE-H IN D5W .............................................. 36
ISOLYTE-P IN D5W ............................................... 36
ISOLYTE-S .............................................................. 36
ISOLYTE-S IN D5W ............................................... 36
isoniazid .................................................................... 10
ISORDIL TITRADOSE ........................................... 25
isosorbide dinitrate ................................................... 25
isosorbide dinitrate er ............................................... 25
isosorbide mononitrate ............................................. 25
isosorbide mononitrate er ......................................... 25
isradipine .................................................................. 24
itraconazole ............................................................... 10
IXEMPRA KIT......................................................... 16
IXIARO .................................................................... 52
J
JALYN ...................................................................... 49
JANTOVEN.............................................................. 20
JANUMET ................................................................ 45
JANUMET XR ......................................................... 45
JANUVIA ................................................................. 45
JEVTANA................................................................. 16
JOLIVETTE .............................................................. 44
JUNEL 1.5/30 ........................................................... 44
JUNEL 1/20 .............................................................. 44
JUNEL FE 1.5/30...................................................... 44
JUNEL FE 1/20......................................................... 44
JUVISYNC ............................................................... 45
K
KADIAN ............................................................. 32, 33
KALETRA .................................................................. 9
KARIVA ................................................................... 44
kcl-lactated ringers-d5w............................................ 36
KELNOR 1/35 .......................................................... 44
KENALOG ............................................................... 54
KEPIVANCE ............................................................ 55
ketoconazole ....................................................... 10, 53
ketoprofen ................................................................. 31
ketoprofen er ............................................................. 31
ketorolac tromethamine ...................................... 31, 40
KINERET ................................................................. 50
KLOR-CON .............................................................. 36
KLOR-CON 10 ......................................................... 36
KLOR-CON M15 ..................................................... 36
KLOR-CON M20 ..................................................... 36
KOMBIGLYZE XR.................................................. 45
KUVAN .................................................................... 51
L
labetalol hcl ............................................................... 22
LACLOTION ............................................................ 55
lactated ringers .......................................................... 35
lactulose .................................................................... 34
LAMISIL .................................................................... 7
lamivudine................................................................... 9
lamivudine-zidovudine ............................................... 9
lamotrigine ................................................................ 26
LANOXIN .......................................................... 23, 24
lansoprazole .............................................................. 42
LANTUS ................................................................... 47
LANTUS SOLOSTAR ............................................. 47
latanoprost ................................................................. 40
LATUDA .................................................................. 29
LEENA ..................................................................... 44
leflunomide ............................................................... 50
JAKAFI .................................................................... 16
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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LESSINA-28 ............................................................ 44
LUNESTA ................................................................ 29
LETAIRIS ................................................................ 25
LUPRON DEPOT ..................................................... 16
letrozole .................................................................... 16
LUPRON DEPOT-PED ............................................ 16
leucovorin calcium ................................................... 49
LUTERA ................................................................... 44
LEUKERAN ............................................................. 16
LUVOX CR .............................................................. 27
LEUKINE ................................................................. 20
LUXIQ ...................................................................... 54
leuprolide acetate ...................................................... 16
LYRICA .................................................................... 26
levalbuterol hcl ......................................................... 18
LYSODREN ............................................................. 16
LEVEMIR ................................................................ 47
M
LEVEMIR FLEXPEN .............................................. 47
MACRODANTIN..................................................... 14
levetiracetam ............................................................. 26
MALARONE .............................................................. 9
levetiracetam er......................................................... 26
malathion................................................................... 55
levobunolol hcl ......................................................... 38
maprotiline hcl .......................................................... 27
levocarnitine ............................................................. 51
MARPLAN ............................................................... 27
levocetirizine dihydrochloride .................................... 7
MATULANE ............................................................ 16
levofloxacin .............................................................. 14
MATZIM LA ............................................................ 23
levofloxacin in d5w .................................................. 14
MAXAIR AUTOHALER ......................................... 18
LEVORA 0.15/30 (28) ............................................. 44
MAXALT ................................................................. 34
levorphanol tartrate ................................................... 33
MAXALT-MLT ........................................................ 34
LEVOTHROID ........................................................ 49
MAXIDEX ................................................................ 39
levothyroxine sodium ............................................... 49
meclizine hcl ............................................................. 40
LEVOXYL ............................................................... 49
meclofenamate sodium ............................................. 31
LEXIVA ..................................................................... 9
medroxyprogesterone acetate.................................... 47
lidocaine.................................................................... 55
mefenamic acid ......................................................... 31
lidocaine hcl ........................................................ 49, 55
mefloquine hcl ............................................................ 9
lidocaine hcl (pf) ....................................................... 49
MEGACE ES ............................................................ 47
lidocaine viscous....................................................... 39
megestrol acetate ....................................................... 16
lidocaine-prilocaine .................................................. 55
meloxicam ................................................................. 31
LIDODERM ............................................................. 55
melphalan hcl ............................................................ 16
lindane ...................................................................... 55
MENACTRA ............................................................ 52
liothyronine sodium .................................................. 49
MENEST................................................................... 46
LIPOSYN III ............................................................ 35
MENOMUNE ........................................................... 52
lisinopril .................................................................... 21
MENOSTAR............................................................. 46
lisinopril-hydrochlorothiazide .................................. 21
MENVEO ................................................................. 52
lithium carbonate ...................................................... 28
meprobamate ............................................................. 29
lithium carbonate er .................................................. 28
MEPRON .................................................................... 9
lithium citrate ............................................................ 28
mercaptopurine ......................................................... 16
LITHOBID ............................................................... 28
meropenem ................................................................ 12
LODOSYN ............................................................... 30
mesalamine-cleanser ................................................. 41
loperamide hcl .......................................................... 40
MESNEX .................................................................. 51
losartan potassium .................................................... 21
MESTINON .............................................................. 19
losartan potassium-hctz ............................................ 21
METADATE CD ...................................................... 26
LOTEMAX ............................................................... 39
metaproterenol sulfate ............................................... 18
LOTRONEX ............................................................. 41
metformin hcl ............................................................ 44
lovastatin ................................................................... 25
metformin hcl er ........................................................ 44
LOVAZA .................................................................. 22
methamphetamine hcl ............................................... 26
LOW-OGESTREL ................................................... 44
methazolamide .......................................................... 38
loxapine succinate..................................................... 29
methenamine hippurate ............................................. 14
LUFYLLIN ............................................................... 57
methimazole .............................................................. 44
LUMIGAN ............................................................... 40
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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methocarbamol ......................................................... 19
MONUROL .............................................................. 14
methotrexate ............................................................. 16
morphine sulfate........................................................ 33
methotrexate sodium................................................. 16
morphine sulfate (concentrate) ................................. 33
methotrexate sodium (pf).......................................... 16
morphine sulfate er ................................................... 33
methscopolamine bromide ........................................ 18
MOTOFEN ............................................................... 40
methyclothiazide ....................................................... 36
MOVIPREP .............................................................. 41
methyldopa ............................................................... 24
MOZOBIL ................................................................ 20
methyldopa-hydrochlorothiazide .............................. 24
MULTAQ ................................................................. 22
methylphenidate hcl .................................................. 26
mupirocin .................................................................. 53
methylphenidate hcl er.............................................. 26
MYCAMINE ............................................................ 11
methylphenidate hcl er (la) ....................................... 26
MYCOBUTIN .......................................................... 10
methylprednisolone .................................................. 43
mycophenolate mofetil.............................................. 50
methylprednisolone (pak) ......................................... 43
MYFORTIC .............................................................. 50
methylprednisolone acetate ...................................... 43
MYTELASE ............................................................. 19
methylprednisolone acetate pf .................................. 43
N
methylprednisolone sodium succ.............................. 43
nabumetone ............................................................... 31
metipranolol .............................................................. 38
nadolol....................................................................... 23
metoclopramide hcl .................................................. 41
nadolol-bendroflumethiazide .................................... 23
metolazone ................................................................ 36
nafcillin sodium ........................................................ 13
metoprolol succinate er ............................................. 22
NAFTIN .................................................................... 53
metoprolol tartrate .................................................... 22
NAGLAZYME ......................................................... 37
metoprolol-hydrochlorothiazide ............................... 23
NALLPEN IN DEXTROSE ..................................... 13
METROGEL ............................................................ 53
naloxone hcl .............................................................. 33
metronidazole ....................................................... 9, 53
naltrexone hcl ............................................................ 33
mexiletine hcl ........................................................... 22
NAMENDA .............................................................. 30
MIACALCIN............................................................ 47
NAMENDA TITRATION PAK ............................... 30
MICARDIS ............................................................... 21
NAPRELAN ............................................................. 31
MICARDIS HCT ...................................................... 21
naproxen .................................................................... 31
miconazole 3 ............................................................. 53
naproxen dr ............................................................... 31
MICROGESTIN 1.5/30 ............................................ 44
naproxen sodium ....................................................... 32
MICROGESTIN 1/20 ............................................... 44
naratriptan hcl ........................................................... 34
MICROGESTIN FE 1.5/30 ...................................... 44
NASACORT AQ ...................................................... 39
MICROGESTIN FE 1/20 ......................................... 44
NASONEX ............................................................... 39
midodrine hcl ............................................................ 17
NATACYN ............................................................... 38
MIGERGOT ............................................................. 28
nateglinide ................................................................. 47
MIGRANAL ............................................................. 18
NEBUPENT ................................................................ 9
MINITRAN .............................................................. 25
NECON 0.5/35 (28) .................................................. 44
minocycline hcl......................................................... 14
NECON 1/35 (28) ..................................................... 44
minocycline hcl er .................................................... 56
NECON 10/11 (28) ................................................... 44
minoxidil................................................................... 24
NECON 7/7/7............................................................ 44
MIRAPEX ER .......................................................... 30
nefazodone hcl .......................................................... 27
mirtazapine ............................................................... 27
neomycin sulfate ......................................................... 8
misoprostol ............................................................... 42
neomycin-bacitracin zn-polymyx ............................. 37
mitomycin ................................................................. 16
neomycin-polymyxin b gu ........................................ 53
mitoxantrone hcl ....................................................... 16
neomycin-polymyxin-dexameth ............................... 39
M-M-R II .................................................................. 52
neomycin-polymyxin-gramicidin ............................. 37
moexipril hcl ............................................................. 22
neomycin-polymyxin-hc ........................................... 39
moexipril-hydrochlorothiazide ................................. 22
NEORAL .................................................................. 50
mometasone furoate .................................................. 54
NEPHRAMINE ........................................................ 35
MONONESSA ......................................................... 44
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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NEULASTA ............................................................. 20
nystatin ................................................................ 13, 53
NEUMEGA .............................................................. 20
nystatin-triamcinolone .............................................. 54
NEUPOGEN ............................................................. 20
NYSTOP ................................................................... 53
NEVANAC ............................................................... 40
O
nevirapine ................................................................... 9
OCELLA ................................................................... 45
NEXAVAR ............................................................... 16
octreotide acetate ...................................................... 51
NIACOR ................................................................... 57
ofloxacin ............................................................. 14, 37
NIASPAN ................................................................. 22
OGESTREL .............................................................. 45
nicardipine hcl .......................................................... 24
olanzapine ................................................................. 29
NICOTROL NS ........................................................ 18
omeprazole ................................................................ 42
NIFEDIAC CC ......................................................... 24
omeprazole-sodium bicarbonate ............................... 42
NIFEDICAL XL ....................................................... 24
OMNITROPE ........................................................... 48
nifedipine .................................................................. 24
ondansetron ............................................................... 40
nifedipine er osmotic ................................................ 24
ondansetron hcl ......................................................... 40
NILANDRON .......................................................... 16
ONFI ......................................................................... 30
nimodipine ................................................................ 24
ONGLYZA ............................................................... 45
nisoldipine er ............................................................ 24
ONTAK..................................................................... 16
NITRO-BID .............................................................. 25
ORAP ........................................................................ 29
nitrofurantoin ............................................................ 14
ORENCIA ................................................................. 50
nitrofurantoin macrocrystal ...................................... 14
ORFADIN ................................................................. 51
nitrofurantoin monohyd macro ................................. 14
orphenadrine citrate er .............................................. 20
nitroglycerin.............................................................. 25
orphenadrine compound-ds ....................................... 32
NITROLINGUAL .................................................... 25
orphenadrine-aspirin-caffeine ................................... 32
NITROSTAT ............................................................ 25
ORTHO EVRA ......................................................... 45
nizatidine .................................................................. 41
ORTHO TRI-CYCLEN LO ...................................... 45
NORA-BE ................................................................ 45
OSMOPREP ............................................................. 41
NORDITROPIN FLEXPRO .................................... 48
oxacillin sodium ........................................................ 13
NORDITROPIN NORDIFLEX PEN ....................... 48
oxaliplatin ................................................................. 16
norethindrone acetate ................................................ 47
oxandrolone............................................................... 43
NORMOSOL-R PH 7.4............................................ 36
oxaprozin................................................................... 32
NORPACE CR ......................................................... 22
oxcarbazepine ........................................................... 26
NORTREL 0.5/35 (28) ............................................. 45
OXISTAT ................................................................. 53
NORTREL 1/35 (21) ................................................ 45
OXSORALEN ULTRA ............................................ 55
NORTREL 1/35 (28) ................................................ 45
oxybutynin chloride .................................................. 56
NORTREL 7/7/7....................................................... 45
oxybutynin chloride er .............................................. 56
nortriptyline hcl ........................................................ 28
oxycodone hcl ........................................................... 33
NORVIR ..................................................................... 9
oxycodone-acetaminophen ....................................... 33
NOVOLIN 70/30 ...................................................... 47
oxycodone-aspirin ..................................................... 33
NOVOLIN N ............................................................ 47
oxycodone-ibuprofen ................................................ 33
NOVOLIN R ............................................................ 47
OXYCONTIN ........................................................... 33
NOVOLOG .............................................................. 47
oxymorphone hcl ...................................................... 33
NOVOLOG FLEXPEN ............................................ 47
oxymorphone hcl er .................................................. 33
NOVOLOG MIX 70/30............................................ 47
OXYTROL ............................................................... 56
NOVOLOG MIX 70/30 FLEXPEN ......................... 47
P
NOXAFIL ................................................................. 10
NULOJIX ................................................................. 50
PACERONE ............................................................. 22
NUTROPIN .............................................................. 48
paclitaxel ................................................................... 16
NUTROPIN AQ NUSPIN 5 ..................................... 48
pamidronate disodium ............................................... 50
NUTROPIN AQ PEN ............................................... 48
PANCREAZE ........................................................... 41
NYAMYC ................................................................ 53
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
68 | First+Plus – 2013 – Comprehensive Formulary
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PANDEL .................................................................. 54
piroxicam .................................................................. 32
PANRETIN .............................................................. 56
PLASMA-LYTE 148 ................................................ 36
pantoprazole sodium ................................................. 42
PLASMA-LYTE A ................................................... 36
paromomycin sulfate .................................................. 7
PLASMA-LYTE-56 IN D5W................................... 36
paroxetine hcl ........................................................... 28
podofilox ................................................................... 56
paroxetine hcl er ....................................................... 28
polyethylene glycol 3350 .......................................... 41
PASER ...................................................................... 10
polymyxin b sulfate..................................................... 8
PATADAY ............................................................... 37
polymyxin b-trimethoprim ........................................ 37
PATANASE ............................................................. 37
PORTIA-28 ............................................................... 45
PATANOL................................................................ 37
potassium chloride .................................................... 36
PAXIL ...................................................................... 28
potassium chloride crys er ........................................ 36
PCE ........................................................................... 12
potassium chloride er ................................................ 36
pedi-dri...................................................................... 53
POTIGA .................................................................... 26
PEDVAX HIB .......................................................... 52
PRADAXA ............................................................... 20
PEGANONE ............................................................. 31
pramipexole dihydrochloride .................................... 30
PEGASYS ................................................................ 11
PRANDIMET ........................................................... 47
PEGASYS PROCLICK ............................................ 11
PRANDIN ................................................................. 47
PEG-INTRON .......................................................... 11
pravastatin sodium .................................................... 25
PEG-INTRON REDIPEN ........................................ 11
prazosin hcl ............................................................... 21
pen needles 5/16 ....................................................... 34
PRED MILD ............................................................. 39
penicillin g pot in dextrose ....................................... 13
PRED-G .................................................................... 39
penicillin g potassium ............................................... 13
prednicarbate ............................................................. 55
penicillin g procaine ................................................. 13
prednisolone acetate .................................................. 39
penicillin v potassium ............................................... 13
prednisolone sodium phosphate .......................... 39, 43
PENTASA ................................................................ 41
prednisone ................................................................. 43
pentazocine-acetaminophen...................................... 34
PREDNISONE INTENSOL ..................................... 43
pentazocine-naloxone hcl ......................................... 34
PREFEST .................................................................. 46
pentoxifylline er ........................................................ 21
PREMARIN .............................................................. 46
PERFOROMIST ....................................................... 19
PREMPHASE ........................................................... 46
perindopril erbumine ................................................ 22
PREMPRO ................................................................ 46
permethrin ................................................................. 55
prenatal vitamins ....................................................... 57
perphenazine ............................................................. 29
PREVALITE ............................................................. 23
perphenazine-amitriptyline ....................................... 28
PREVIFEM ............................................................... 45
PFIZERPEN-G ......................................................... 13
PREVPAC................................................................. 42
PHENADOZ ............................................................... 7
PREZISTA .................................................................. 9
phenelzine sulfate ..................................................... 28
PRIFTIN ................................................................... 10
phenobarbital ............................................................ 29
primaquine phosphate ................................................. 9
PHENYTEK ............................................................. 31
primidone .................................................................. 30
phenytoin .................................................................. 31
PRIMSOL ................................................................. 14
phenytoin sodium ..................................................... 31
PRISTIQ ................................................................... 28
phenytoin sodium extended ...................................... 31
PRIVIGEN ................................................................ 52
PHOSLYRA ............................................................. 36
PROAIR HFA ........................................................... 19
PHOSPHOLINE IODIDE ........................................ 39
probenecid ................................................................. 37
PHYSIOLYTE.......................................................... 35
prochlorperazine ....................................................... 29
PHYSIOSOL IRRIGATION .................................... 35
prochlorperazine edisylate ........................................ 29
PICATO .................................................................... 56
prochlorperazine maleate .......................................... 29
pilocarpine hcl .......................................................... 19
PROCRIT .................................................................. 20
PILOPINE HS .......................................................... 39
PROCTOCREAM HC .............................................. 55
pindolol ..................................................................... 23
progesterone micronized ........................................... 47
piperacillin sod-tazobactam so ................................. 13
PROGLYCEM .......................................................... 24
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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PROGRAF ................................................................ 51
PROLASTIN-C ........................................................ 51
PROLEUKIN............................................................ 16
PROMACTA ............................................................ 20
promethazine hcl......................................................... 7
PROMETHEGAN ...................................................... 7
propafenone hcl ........................................................ 22
propafenone hcl er .................................................... 22
proparacaine hcl ........................................................ 39
propranolol hcl .......................................................... 23
propranolol hcl er...................................................... 23
propranolol-hctz........................................................ 23
propylthiouracil ........................................................ 44
PROQUAD ............................................................... 52
PROTONIX .............................................................. 42
PROTOPIC ............................................................... 56
protriptyline hcl ........................................................ 28
PROVENTIL HFA ................................................... 19
PROVIGIL................................................................ 26
PULMICORT ........................................................... 43
PULMICORT FLEXHALER ................................... 43
PULMOZYME ......................................................... 51
PYLERA ................................................................... 41
pyridostigmine bromide ............................................ 19
Q
QUASENSE ............................................................. 45
quetiapine fumarate .................................................. 29
quinapril hcl .............................................................. 22
quinapril-hydrochlorothiazide .................................. 22
quinidine gluconate................................................... 22
quinidine gluconate er .............................................. 22
quinidine sulfate ....................................................... 22
quinidine sulfate er ................................................... 22
QVAR ....................................................................... 43
R
RABAVERT ............................................................. 52
ramipril ..................................................................... 22
RANEXA.................................................................. 23
ranitidine hcl ............................................................. 41
RAPAFLO ................................................................ 18
RAPAMUNE ............................................................ 51
REBETOL ................................................................ 12
REBIF ....................................................................... 50
RECLAST ................................................................ 50
RECLIPSEN ............................................................. 45
RECOMBIVAX HB ................................................. 52
REGONOL ............................................................... 19
REGRANEX ............................................................ 56
RELENZA DISKHALER ......................................... 12
RELISTOR ............................................................... 41
RELPAX ................................................................... 34
REMICADE .............................................................. 50
RENAGEL ................................................................ 35
RENVELA ................................................................ 35
REPREXAIN ............................................................ 33
RESCRIPTOR ............................................................ 9
reserpine .................................................................... 25
RESTASIS ................................................................ 39
RETROVIR................................................................. 9
REVATIO ................................................................. 25
REVLIMID ............................................................... 16
REYATAZ ............................................................ 9, 10
RHEUMATREX ....................................................... 16
RHINOCORT AQUA ............................................... 39
RIBAPAK ................................................................. 12
RIBASPHERE .......................................................... 12
ribavirin ..................................................................... 12
RIDAURA ................................................................ 42
RIFADIN .................................................................. 10
rifampin ..................................................................... 10
RIFATER .................................................................. 10
RILUTEK ................................................................. 30
rimantadine hcl............................................................ 7
ringers ....................................................................... 36
ringers irrigation........................................................ 35
RIOMET ................................................................... 44
RISPERDAL CONSTA ............................................ 29
risperidone................................................................. 29
RITALIN LA ............................................................ 26
RITUXAN................................................................. 16
rivastigmine tartrate .................................................. 20
ropinirole hcl ............................................................. 30
ropinirole hcl er ......................................................... 30
ROTATEQ ................................................................ 52
ROXICET ................................................................. 33
S
SABRIL .................................................................... 27
SAIZEN .................................................................... 48
SAIZEN CLICK.EASY ............................................ 48
SANCTURA XR ...................................................... 56
SANCUSO ................................................................ 40
SANDIMMUNE ....................................................... 51
SANTYL ................................................................... 56
SAPHRIS .................................................................. 29
selegiline hcl ............................................................. 31
selenium sulfide ........................................................ 55
SELZENTRY ............................................................ 10
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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SENSIPAR ............................................................... 51
sulindac ..................................................................... 32
SEREVENT DISKUS .............................................. 19
sumatriptan succinate ................................................ 34
SEROMYCIN ........................................................... 10
SUPRAX ................................................................... 11
SEROQUEL XR ....................................................... 29
SUSTIVA .................................................................. 10
SEROSTIM .............................................................. 48
SUTENT ................................................................... 17
sertraline hcl ............................................................. 28
SYLATRON ............................................................. 17
silver sulfadiazine ..................................................... 55
SYMBICORT ........................................................... 43
SIMCOR ................................................................... 25
SYMBYAX............................................................... 28
SIMULECT .............................................................. 51
SYMLINPEN 120 ..................................................... 43
simvastatin ................................................................ 25
SYMLINPEN 60 ....................................................... 43
SINGULAIR ............................................................. 51
SYNAGIS ................................................................. 12
sodium chloride .................................................. 35, 36
SYNALGOS-DC ...................................................... 33
sodium polystyrene sulfonate ................................... 35
SYNAREL ................................................................ 46
SOLARAZE ............................................................. 56
SYNERCID................................................................. 8
SOMATULINE DEPOT .......................................... 51
SYNTHROID ........................................................... 49
SOMAVERT ............................................................ 48
SYPRINE .................................................................. 42
SORIATANE............................................................ 56
T
sotalol hcl .................................................................. 23
TABLOID ................................................................. 17
SPIRIVA HANDIHALER ....................................... 18
tacrolimus .................................................................. 51
spironolactone ........................................................... 25
TALWIN ................................................................... 34
spironolactone-hctz ................................................... 25
TAMIFLU ................................................................. 12
SPORANOX............................................................. 10
tamoxifen citrate ....................................................... 17
SPRINTEC 28 .......................................................... 45
tamsulosin hcl ........................................................... 18
SPRYCEL................................................................. 16
TARCEVA ................................................................ 17
SRONYX .................................................................. 45
TARGRETIN ...................................................... 17, 56
SSD ........................................................................... 55
TARKA ..................................................................... 23
stagesic...................................................................... 33
TASIGNA ................................................................. 17
STALEVO 100 ......................................................... 30
TASMAR .................................................................. 30
STALEVO 125 ......................................................... 30
TAZORAC ................................................................ 56
STALEVO 150 ......................................................... 30
TAZTIA XT .............................................................. 23
STALEVO 200 ......................................................... 30
TEGRETOL .............................................................. 27
STALEVO 50 ........................................................... 30
TEGRETOL XR ....................................................... 27
STALEVO 75 ........................................................... 30
TEKAMLO ............................................................... 25
stavudine ................................................................... 10
TEKTURNA ............................................................. 25
sterile water for irrigation ......................................... 35
TEKTURNA HCT .................................................... 25
STIMATE ................................................................. 47
terazosin hcl .............................................................. 21
STRATTERA ........................................................... 30
terbinafine hcl ............................................................. 7
streptomycin sulfate .................................................... 8
terbutaline sulfate ...................................................... 19
STRIANT ................................................................. 43
terconazole ................................................................ 53
STROMECTOL.......................................................... 8
TESTIM .................................................................... 43
SUBOXONE ............................................................ 34
testosterone cypionate ............................................... 43
sucralfate ................................................................... 42
TESTRED ................................................................. 43
sulfacetamide sodium ............................................... 38
tetanus-diphtheria toxoids td ..................................... 52
sulfacetamide-prednisolone ...................................... 39
tetracycline hcl .......................................................... 14
sulfadiazine ............................................................... 14
TEV-TROPIN ........................................................... 48
sulfamethoxazole-tmp ds .......................................... 14
THALITONE ............................................................ 36
sulfamethoxazole-trimethoprim................................ 14
THALOMID ............................................................. 50
SULFAMYLON ....................................................... 55
theophylline............................................................... 57
sulfasalazine.............................................................. 14
theophylline er .......................................................... 57
SULFAZINE EC ...................................................... 14
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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THERMAZENE ....................................................... 55
TRILIPIX .................................................................. 24
thioridazine hcl ......................................................... 29
TRILYTE .................................................................. 41
thiotepa ..................................................................... 17
trimethobenzamide hcl .............................................. 40
thiothixene ................................................................ 29
trimethoprim ............................................................. 14
ticlopidine hcl ........................................................... 21
trimipramine maleate ................................................ 28
TIKOSYN ................................................................. 22
TRINESSA (28) ........................................................ 45
TIMENTIN ............................................................... 13
TRI-PREVIFEM ....................................................... 45
timolol maleate ................................................... 23, 38
TRISENOX ............................................................... 17
tizanidine hcl............................................................. 19
TRI-SPRINTEC ........................................................ 45
TOBI ........................................................................... 8
TRIVORA (28) ......................................................... 45
TOBRADEX ............................................................ 39
TRIZIVIR ................................................................. 10
tobramycin sulfate ...................................................... 8
TROPHAMINE ........................................................ 35
tobramycin sulfate in saline ........................................ 8
tropicamide ............................................................... 39
tobramycin-dexamethasone ...................................... 39
trospium chloride ...................................................... 56
TOBREX .................................................................. 38
TRUVADA ............................................................... 10
tolazamide ................................................................. 48
TWINRIX ................................................................. 52
tolbutamide ............................................................... 48
TYGACIL ................................................................. 14
tolmetin sodium ........................................................ 32
TYKERB................................................................... 17
topiramate ................................................................. 27
TYPHIM VI .............................................................. 52
TOPOSAR ................................................................ 17
TYZEKA................................................................... 12
topotecan hcl ............................................................. 17
TYZINE .................................................................... 40
TORISEL .................................................................. 17
U
torsemide .................................................................. 35
U-CORT .................................................................... 55
TOVIAZ ................................................................... 56
ULORIC .................................................................... 49
TRACLEER.............................................................. 25
UNITHROID ............................................................ 49
tramadol hcl .............................................................. 33
ursodiol ..................................................................... 41
tramadol hcl er .......................................................... 33
UVADEX .................................................................. 55
tramadol-acetaminophen .......................................... 33
V
trandolapril................................................................ 22
tranexamic acid ......................................................... 21
VAGIFEM ................................................................ 46
tranylcypromine sulfate ............................................ 28
valacyclovir hcl ......................................................... 12
TRAVASOL ............................................................. 35
VALCYTE ................................................................ 12
TRAVATAN Z ......................................................... 40
valproate sodium ....................................................... 27
trazodone hcl............................................................. 28
valproic acid .............................................................. 27
TREANDA ............................................................... 17
VANCOCIN HCL ...................................................... 8
TRECATOR ............................................................. 10
vancomycin hcl ........................................................... 8
TRELSTAR DEPOT MIXJECT .............................. 17
VANDAZOLE .......................................................... 53
TRELSTAR LA MIXJECT ...................................... 17
VANOS ..................................................................... 55
TRELSTAR MIXJECT ............................................ 17
VAQTA..................................................................... 52
tretinoin ............................................................... 17, 55
VARIVAX ................................................................ 52
TREXALL ................................................................ 17
VECTIBIX ................................................................ 17
triamcinolone acetonide ...................................... 39, 55
VELCADE ................................................................ 17
triamterene-hctz ........................................................ 35
VELIVET .................................................................. 45
TRIBENZOR ............................................................ 24
venlafaxine hcl .......................................................... 28
TRICOR.................................................................... 24
venlafaxine hcl er ...................................................... 28
trifluoperazine hcl ..................................................... 29
VENTAVIS............................................................... 25
trifluridine ................................................................. 38
VENTOLIN HFA ..................................................... 19
trihexyphenidyl hcl ................................................... 26
VERAMYST............................................................. 39
TRI-LEGEST FE ...................................................... 45
verapamil hcl ............................................................. 23
TRILEPTAL ............................................................. 27
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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verapamil hcl er ........................................................ 23
VEREGEN................................................................ 56
VESICARE ............................................................... 56
VEXOL ..................................................................... 39
VFEND ..................................................................... 10
VFEND IV ................................................................ 10
VIBRAMYCIN ........................................................ 14
VICTOZA ................................................................. 46
VICTRELIS .............................................................. 11
VIDAZA ................................................................... 17
VIDEX ...................................................................... 10
VIGAMOX ............................................................... 38
VIIBRYD.................................................................. 28
VIMPAT ................................................................... 27
vinblastine sulfate ..................................................... 17
VINCASAR PFS ...................................................... 17
vincristine sulfate ...................................................... 17
vinorelbine tartrate .................................................... 17
VIRACEPT ............................................................... 10
VIRAMUNE ............................................................. 10
VIRAMUNE XR ...................................................... 10
VIREAD ................................................................... 10
VISTIDE ................................................................... 12
VIVELLE-DOT ........................................................ 46
VOTRIENT .............................................................. 17
VPRIV ...................................................................... 37
VYTORIN ................................................................ 25
VYVANSE ............................................................... 26
W
warfarin sodium ........................................................ 20
WELCHOL ............................................................... 23
X
XALATAN ............................................................... 40
XALKORI ................................................................ 17
XENAZINE .............................................................. 30
XIFAXAN .................................................................. 8
XODOL .................................................................... 33
XOLAIR ................................................................... 52
XOPENEX HFA....................................................... 19
XYREM .................................................................... 30
Y
YERVOY .................................................................. 17
YF-VAX ................................................................... 53
Z
zafirlukast .................................................................. 51
zaleplon ..................................................................... 29
ZANOSAR ................................................................ 17
ZAVESCA ................................................................ 51
ZAZOLE ................................................................... 53
ZELBORAF .............................................................. 17
ZEMAIRA ................................................................ 52
ZEMPLAR ................................................................ 57
ZENPEP .................................................................... 41
ZERIT ....................................................................... 10
ZETIA ....................................................................... 24
ZIAGEN .................................................................... 10
zidovudine ................................................................. 10
ziprasidone hcl .......................................................... 29
ZIRGAN ................................................................... 38
ZOLINZA ................................................................. 17
zolpidem tartrate ....................................................... 29
zolpidem tartrate er ................................................... 29
ZOMETA .................................................................. 50
ZOMIG ..................................................................... 34
ZOMIG ZMT ............................................................ 34
ZONALON ............................................................... 55
zonisamide ................................................................ 27
ZORBTIVE ............................................................... 48
ZORTRESS............................................................... 51
ZOSTAVAX ............................................................. 53
ZOVIA 1/35E (28) .................................................... 45
ZOVIA 1/50E (28) .................................................... 45
ZOVIRAX................................................................. 55
ZYDONE .................................................................. 33
ZYFLO ...................................................................... 51
ZYFLO CR ............................................................... 51
ZYLET ...................................................................... 39
ZYMAXID ................................................................ 38
ZYTIGA .................................................................... 17
ZYVOX....................................................................... 8
PA=Prior Authorization; PA(*)=Part B vs D Prior Authorization; QL=Quantity Limit; ST=Step Therapy;
LA=Limited Access (This prescription may be available only at certain pharmacies)
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