Preferred (PPO) - Geisinger Health Plan

HEALTH CARE BENEFITS YOU CAN COUNT ON 2013 

Geisinger Gold 

Preferred (PPO)

Thank you for your interest in Geisinger Gold, 

the #1 ranked Medicare Advantage plan in Pennsylvania and 6th in the nation!* 

Dear Prospective Member: 

You have an important decision to make when choosing your health coverage for 2013. Geisinger Gold offers 

quality, affordable coverage to more than 57,000 Pennsylvania residents. Just a few of the advantages include: 

Benefits: Easy to use, comprehensive benefits, including worldwide emergency coverage! 

Quality: Gold is the #1 ranked Medicare Advantage plan in Pennsylvania and 6th in the nation.* 

Extra Care: In addition to your doctor, you’ll have a nurse to help you manage a chronic illness, a newly 

diagnosed condition or care after a hospital stay. 

Safety and Security: The Geisinger name represents a rich heritage in providing quality health care and an 

ongoing commitment to the communities we serve. We’ve offered quality coverage to Medicare 

beneficiaries since 1994. 

To help with your decision, this booklet includes the following information: 

A Summary of Benefits for the plan in which you expressed interest. This Summary of Benefits 

includes information on medical and prescription drug benefits and costs. 

A Geisinger Gold Formulary (List of Covered Drugs). Please consult this Formulary for information 

on the prescription drugs we cover, including most generics for a $3 copay. 

An Accessories Brochure, which includes information on special discounts for Gold members 

Information about the SilverSneakers ® Fitness Program 

An Enrollment Application and business reply envelope (in the back pocket) 

Information on our plan’s quality ratings from the Centers for Medicare and Medicaid Services (CMS) 

A Geisinger Gold Provider List. These lists include information on primary care providers, specialists, 

hospitals, pharmacies and dentists in the Geisinger Gold network. 

Call us today for more information! Our Geisinger Gold Sales Counselors are available every step of the 

way. We’ll work with you to find a plan that fits your needs and budget. 

For your convenience, additional information and an online application are available at 

www.GeisingerGold.com, any time of the day or night! 

We hope you find the enclosed information helpful in making a decision regarding your health care 

coverage. We look forward to serving you and your health care coverage needs. 

Sincerely, 

Dudley F. Gerow 

Chief Government Programs Officer 

100 North Academy Avenue ● Danville, PA 17822-3220 

(800) 514-0138 (TDD 711) ● Seven days a week, 8 a.m. to 8 p.m. 

HPM50 Y0032 12256_16 File and Use 9/17/12 Classic Preferred Secure 3 Letter

*NCQA’s Medicare Health Insurance Plan Rankings 2012-2013 

In addition to the plan detailed in the enclosed Summary of Benefits, there may be other plans available to 

you, based on your county of residence. If you would like to discuss other plan options, or have any 

questions about this packet or the coverage offered by Geisinger Gold, please call (800) 514-0138, seven 

days a week from 8 a.m. to 8 p.m. (TDD 711) for more information. 

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, 

Medicare could pay for up to one-hundred (100) percent of drug costs including monthly prescription drug 

premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the 

coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t know it. For 

more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE 

(1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048. You can also 

call 1-800-MEDICARE or visit www.medicare.gov for more information about Medicare. 

Geisinger Gold Medicare Advantage plans are offered by Geisinger Health Plan/Geisinger Indemnity 

Insurance Company, health plans with a Medicare contract. 

The benefit information provided is a brief summary, not a complete description of benefits. For more 

information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, 

pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. You 

must continue to pay your Medicare Part B premium.

Summary of Benefi ts

Th ank you for your interest in Geisinger Gold Preferred 

(PPO). Our plan is off ered by GEISINGER INDEM- 

NITY INSURANCE COMPANY/Geisinger Gold, a 

Medicare Advantage Preferred (PPO) Provider Organization 

(PPO) that contracts with the Federal government. 

Th is Summary of Benefi ts tells you some features of our 

plan. It doesn’t list every service that we cover or list every 

limitation or exclusion. To get a complete list of our 

benefi ts, please call Geisinger Gold Preferred (PPO) and 

ask for the “Evidence of Coverage”. 

YOU HAVE CHOICES IN YOUR HEALTH CARE 

As a Medicare benefi ciary, you can choose from diff erent 

Medicare options. One option is the Original (fee-forservice) 

Medicare Plan. Another option is a Medicare 

health plan, like Geisinger Gold Preferred (PPO). You 

may have other options too. You make the choice. No 

matter what you decide, you are still in the Medicare 

Program. 

You may be able to join or leave a plan only at certain 

times. Please call Geisinger Gold Preferred (PPO) at 

the number listed at the end of this introduction or 

1-800-MEDICARE (1-800-633-4227) for more information. 

TTY/TDD users should call 1-877-486-2048. 

You can call this number 24 hours a day, 7 days a week. 

HOW CAN I COMPARE MY OPTIONS? 

You can compare Geisinger Gold Preferred (PPO) and 

the Original Medicare Plan using this Summary of 

Benefi ts. Th e charts in this booklet list some important 

health benefi ts. For each benefi t, you can see what our 

plan covers and what the Original Medicare Plan covers. 

Our members receive all of the benefi ts that the Original 

Medicare Plan off ers. We also off er more benefi ts, which 

may change from year to year. 

WHERE IS GEISINGER GOLD Preferred (PPO) 

AVAILABLE? 

Th ere is more than one plan listed in this Summary of 

Benefi ts. Please refer to the chart in the back of this 

Summary for plan availability. If you move out of the 

state or county where you currently live, you must call 

Customer Service to update your information. If you 

don’t, you may be disenrolled from Geisinger Gold. 

Please call Customer Service to fi nd out if Geisinger 

Gold has a plan in your new state or county. 

H3924 12256_2 File and Use 9/17/12 

WHO IS ELIGIBLE TO JOIN GEISINGER GOLD 

PREFERRED (PPO)? 

You can join Geisinger Gold Preferred (PPO) if you are 

entitled to Medicare Part A and enrolled in Medicare 

Part B and live in the service area. However, individuals 

with End-Stage Renal Disease are generally not eligible 

to enroll in Geisinger Gold Preferred (PPO) unless they 

are members of our organization and have been since 

their dialysis began. 

CAN I CHOOSE MY DOCTORS? 

Geisinger Gold Preferred (PPO) has formed a network 

of doctors, specialists, and hospitals. You can use any 

doctor who is part of our network. You may also go to 

doctors outside of our network. Th e health providers in 

our network can change at any time. 

You can ask for a current provider directory. For an 

updated list, visit us at www.GeisingerGold.com. Our 

customer service number is listed at the end of this 

introduction. 

WHAT HAPPENS IF I GO TO A DOCTOR WHO’S 

NOT IN YOUR NETWORK? 

You can go to doctors, specialists, or hospitals in or out 

of network. You may have to pay more for the services 

you receive outside the network, and you may have to 

follow special rules prior to getting services in and/or out 

of network. For more information, please call the customer 

service number at the end of this introduction. 

WHERE CAN I GET MY PRESCRIPTIONS IF I 

JOIN THIS PLAN? 

Geisinger Gold Preferred (PPO) has formed a network 

of pharmacies. You must use a network pharmacy to 

receive plan benefi ts. We may not pay for your prescriptions 

if you use an out-of-network pharmacy, except in 

certain cases. Th e pharmacies in our network can change 

at any time. You can ask for a pharmacy directory or visit 

us at www.GeisingerGold.com. Our customer service 

number is listed at the end of this introduction. 

DOES MY PLAN COVER MEDICARE PART B OR 

PART D DRUGS? 

Geisinger Gold Preferred 1, Preferred 2 and Preferred 3 

do cover Medicare Part B prescription drugs. Geisinger 

Gold Preferred 1, Preferred 2 and Preferred 3 do NOT 

cover Medicare Part D prescription drugs. Geisinger 

Gold Preferred 1 $0 Deductible Rx, Preferred 2 $0 Deductible 

Rx and Preferred 3 $0 Deductible Rx do cover 

both Part B and Part D drugs.

WHAT IS A PRESCRIPTION 

DRUG FORMULARY? 

Geisinger Gold Preferred (PPO) uses a formulary. A 

formulary is a list of drugs covered by your plan to meet 

patient needs. We may periodically add, remove, or 

make changes to coverage limitations on certain drugs 

or change how much you pay for a drug. If we make any 

formulary change that limits our members’ ability to fi ll 

their prescriptions, we will notify the aff ected members 

before the change is made. We will send a formulary 

to you and you can see our complete formulary on our 

Web site at https://www.thehealthplan.com/Gold/Landing_Pages/Formulary/. 

If you are currently taking a drug that is not on our formulary 

or subject to additional requirements or limits, 

you may be able to get a temporary supply of the drug. 

You can contact us to request an exception or switch to 

an alternative drug listed on our formulary with your 

physician’s help. Call us to see if you can get a temporary 

supply of the drug or for more details about our drug 

transition policy. 

HOW CAN I GET EXTRA HELP WITH MY PRE- 

SCRIPTION DRUG PLAN COSTS OR GET EXTRA 

HELP WITH OTHER MEDICARE COSTS? 

You may be able to get extra help to pay for your prescription 

drug premiums and costs as well as get help 

with other Medicare costs. To see if you qualify for getting 

extra help, call: 

•1-800-MEDICARE (1-800-633-4227). TTY/TDD 

users should call 1-877-486-2048, 24 hours a day/7 

days a week and see www.medicare.gov ‘Programs for 

People with Limited Income and Resources’ in the 

publication Medicare You. 

•Th e Social Security Administration at 1-800-772-1213 

between 7 a.m. and 7 p.m., Monday through Friday. 

TTY/TDD users should call 1-800-325-0778 or 

•Your State Medicaid Offi ce. 

WHAT ARE MY PROTECTIONS IN THIS PLAN? 

All Medicare Advantage Plans agree to stay in the program 

for a full calendar year at a time. Plan benefi ts and 

cost-sharing may change from calendar year to calendar 

year. Each year, plans can decide whether to continue to 

participate with Medicare Advantage. A plan may continue 

in their entire service area (geographic area where 

the plan accepts members) or choose to continue only in 

certain areas. Also, Medicare may decide to end a contract 

with a plan. Even if your Medicare Advantage Plan 

leaves the program, you will not lose Medicare coverage. 

If a plan decides not to continue for an additional calen- 

dar year, it must send you a letter at least 90 days before 

your coverage will end. Th e letter will explain your options 

for Medicare coverage in your area. 

As a member of Geisinger Gold Preferred (PPO), you 

have the right to request an organization determination, 

which includes the right to fi le an appeal if we deny 

coverage for an item or service, and the right to fi le a 

grievance. You have the right to request an organization 

determination if you want us to provide or pay for an 

item or service that you believe should be covered. If we 

deny coverage for your requested item or service, you 

have the right to appeal and ask us to review our decision. 

You may ask us for an expedited (fast) coverage 

determination or appeal if you believe that waiting for a 

decision could seriously put your life or health at risk, or 

aff ect your ability to regain maximum function. If your 

doctor makes or supports the expedited request, we must 

expedite our decision. Finally, you have the right to fi le 

a grievance with us if you have any type of problem with 

us or one of our network providers that does not involve 

coverage for an item or service. If your problem involves 

quality of care, you also have the right to fi le a grievance 

with the Quality Improvement Organization (QIO) 

for your state. Please refer to the Evidence of Coverage 

(EOC) for the QIO contact information. 

As a member of Geisinger Gold Preferred (PPO), you 

have the right to request a coverage determination, 

which includes the right to request an exception, the 

right to fi le an appeal if we deny coverage for a prescription 

drug, and the right to fi le a grievance. You have the 

right to request a coverage determination if you want us 

to cover a Part D drug that you believe should be covered. 

An exception is a type of coverage determination. 

You may ask us for an exception if you believe you need 

a drug that is not on our list of covered drugs or believe 

you should get a non-Preferred (PPO) drug at a lower 

out-of-pocket cost. You can also ask for an exception to 

cost utilization rules, such as a limit on the quantity of 

a drug. If you think you need an exception, you should 

contact us before you try to fi ll your prescription at a 

pharmacy. Your doctor must provide a statement to 

support your exception request. If we deny coverage for 

your prescription drug(s), you have the right to appeal 

and ask us to review our decision. Finally, you have the 

right to fi le a grievance if you have any type of problem 

with us or one of our network pharmacies that does not 

involve coverage for a prescription drug. If your problem 

involves quality of care, you also have the right to fi le a 

grievance with the Quality Improvement Organization 

(QIO) for your state. Please refer to the Evidence of

Coverage (EOC) for the QIO contact information. 

WHAT IS A MEDICATION THERAPY MANAGE- 

MENT (MTM) PROGRAM? 

A Medication Th erapy Management (MTM) Program 

is a free service we off er. You may be invited to participate 

in a program designed for your specifi c health and 

pharmacy needs. You may decide not to participate but 

it is recommended that you take full advantage of this 

covered service if you are selected. Contact Geisinger 

Gold Preferred (PPO) for more details. 

WHAT TYPES OF DRUGS MAY BE COVERED 

UNDER MEDICARE PART B? 

Some outpatient prescription drugs may be covered 

under Medicare Part B. Th ese may include, but are not 

limited to, the following types of drugs. Contact Geisinger 

Gold Preferred (PPO) for more details. 

-- Some Antigens: If they are prepared by a doctor and 

administered by a properly instructed person (who could 

be the patient) under doctor supervision. 

-- Osteoporosis Drugs: Injectable osteoporosis drugs for 

some women. 

-- Erythropoietin (Epoetin Alfa or Epogen®): By injection 

if you have end-stage renal disease (permanent kidney 

failure requiring either dialysis or transplantation) 

and need this drug to treat anemia. 

-- Hemophilia Clotting Factors: Self-administered clotting 

factors if you have hemophilia. 

-- Injectable Drugs: Most injectable drugs administered 

incident to a physician’s service. 

-- Immunosuppressive Drugs: Immunosuppressive drug 

therapy for transplant patients if the transplant took 

place in a Medicare-certifi ed facility and was paid for by 

Medicare or by a private insurance company that was the 

primary payer for Medicare Part A coverage. 

-- Some Oral Cancer Drugs: If the same drug is available 

in injectable form. 

-- Oral Anti-Nausea Drugs: If you are part of an anticancer 

chemotherapeutic regimen. 

-- Inhalation and Infusion Drugs administered through 

Durable Medical Equipment. 

WHERE CAN I FIND INFORMATION ON PLAN 

RATINGS? 

Th e Medicare program rates how well plans perform in 

diff erent categories (for example, detecting and preventing 

illness, ratings from patients and customer service). 

If you have access to the web, you may use the web 

tools on www.medicare.gov and select “Health and 

Drug Plans” then “Compare Drug and Health Plans” 

to compare the plan ratings for Medicare plans in your 

area. You can also call us directly to obtain a copy of the 

plan ratings for this plan. Our customer service number 

is listed below. 

Please call Geisinger Gold for more information 

about Geisinger Gold Preferred (PPO). 

Visit us at www.GeisingerGold.com or, call us: 

Customer Service Hours for October 1 – February 

14: 

Sunday, Monday, Tuesday, Wednesday, Th ursday , 

Friday, Saturday, 8:00 a.m. - 8:00 p.m. Eastern 

Customer Service Hours for February 15 – September 

30: 

For information related to the Medicare Advantage 

Program, current members should call: 

• Toll Free: (800)-498-9731 

• Locally: (570)-271-8771 

• TTY/TDD 711 

For information related to the Medicare Part D Prescription 

Drug Program, current members should call: 

• Toll Free: (800)-988-4861 

• Locally: (570)-271-8771 


For information related to the Medicare Advantage 

Program or Medicare Part D Prescription Drug Program, 

prospective members should call: 

• Toll Free: (800)-514-0138 


For more information about Medicare, please call 

Medicare at 1-800-MEDICARE (1-800-633-4227). 

TTY users should call 1-877-486-2048. You can call 

24 hours a day, 7 days a week. 

Or, visit www.medicare.gov on the web. 

Th is document may be available in other formats such 

as Braille, large print or other alternate formats. 

Th is document may be available in a non-English language. 

For additional information, call customer service 

at the phone number listed above.

IMPORTANT 

INFORMATION 

Benefi t Original 

Medicare 

1 - Premium and Other 

Important Information 

Summary of Benefi ts 

• In 2012 the monthly Part 

B Premium was $99.90 

and may change for 2013 

and the annual Part B deductible 

amount was $140 

and may change for 2013. 

• If a doctor or supplier 

does not accept assignment, 

their costs are often 

higher, which means you 

pay more. 

• Most people will pay the 

standard monthly Part 

B premium. However, 

some people will pay a 

higher premium because 

of their yearly income 

(over $85,000 for singles, 

$170,000 for married couples). 

For more information 

about Part B premiums 

based on income, call 

Medicare at 1-800-MEDI- 

CARE (1-800-633-4227). 

TTY users should call 

1-877-486-2048. You may 

also call Social Security at 

1-800-772-1213. TTY users 

should call 1-800-325- 

0778. 

6 

Preferred 1 

(PPO) 

General 

• Premiums range from 

$33 to $98 per month. 

Please refer to the Premium 

Table located after this section 

to fi nd out what the 

premium is in your area. 

• You also must continue to 

pay your monthly Medicare 

Part B premium. 


standard monthly Part B 

premium in addition to 

their MA plan premium. 

However, some people 

will pay higher Part B and 

Part D premiums because 



$170,000 for married 

couples). For more information 

about Part B and 

Part D premiums based 

on income, call Medicare 

at 1-800-MEDICARE (1- 

800-633-4227). TTY users 


2048. You may also call Social 

Security at 1-800-772- 

1213. TTY users should 

call 1-800-325-0778. 

Some physicians, providers 

and suppliers that are out 

of a plan’s network (i.e., 

Out-of-Network) accept 

“assignment” from Medicare 

and will only charge 

up to a Medicare-approved 

amount. If you choose to 


$0 Deductible Rx 


General 

























800-633-4227). TTY users 





call 1-800-325-0778. 








amount. If you choose to

If you have any questions about this plan’s benefi ts or costs, please contact Geisinger Gold for details. 



General 

























800-633-4227). TTY users 





call 1-800-325-0778. 












General 

























800-633-4227). TTY users 





call 1-800-325-0778. 









7 



General 

• $96 monthly plan premium 

in addition to your 

monthly Medicare Part B 

premium. 
















800-633-4227). TTY users 





call 1-800-325-0778. 









see an Out-of-Network 

physician who does NOT 

accept Medicare “assignment,” 

your coinsurance 

can be based on the Medi- 




General 

• $148 monthly plan premium 

in addition to your 

monthly Medicare Part B 

premium. 
















800-633-4227). TTY users 





call 1-800-325-0778. 













can be based on the Medi- 



Medicare 


8 







can be based on the Medicare-approved 

amount plus 

an additional amount up to 

a higher Medicare “limiting 

charge.” If you are a member 

of a plan that charges a 

copay for Out-of-Network 

physician services, the 

higher Medicare “limiting 

charge” does not apply. See 

the publications Medicare 

You or Your Medicare 

Benefi ts available on www. 

medicare.gov for a full listing 

of benefi ts under Original 

Medicare, as well as for 

explanations of the rules 

related to “assignment” and 

“limiting charges” that apply 

by benefi t type. 

• To fi nd out if physicians 

and DME suppliers accept 

assignment or participate 

in Medicare, visit www. 

medicare.gov/physician 

or www.medicare.gov/ 

supplier. You can also call 

1-800-MEDICARE, or ask 

your physician, provider, 

or supplier if they accept 

assignment. 

In-Network 

• $3,400 out-of-pocket 

limit for Medicare-covered 

services and select Non- 

Medicare Supplemental 

Services. Contact plan for 

details regarding Non- 









amount plus 





























assignment. 

In-Network 






details regarding Non-








amount plus 





























assignment. 

In-Network 















amount plus 





























assignment. 

In-Network 







9 



care-approved amount plus 





























assignment. 

In-Network 








Services covered under this 

limit. 




care-approved amount plus 





























assignment. 

In-Network 









limit. 



Medicare 

2 - Doctor and 

Hospital Choice 

(For more 

information, see Emergency 

Care - #15 and Urgently 

Needed Care - #16.) 

INPATIENT CARE 

3 - Inpatient 

Hospital Care 

(includes Substance Abuse 

and 

Rehabilitation 

Services) 


• You may go to any doctor, 

specialist or hospital 

that accepts Medicare. 

• In 2012 the amounts for 

each benefi t period were: 

• Days 1 - 60: $1156 deductible 

• Days 61 - 90: $289 per 

day 

• Days 91 - 150: $578 per 

10 





limit. 

In and Out-of-Network 

• $195 annual deductible. 

Contact the plan for 

services that apply. 

• Any annual service 

category deductible may 

count towards the plan 

level deductible, if there is 

one. 









limit. 

In-Network 

• No referral required for 

network doctors, specialists, 

and hospitals. 


• You can go to doctors, 

specialists, and hospitals in 

or out of the network. It 

will cost more to get out of 

network benefi ts. 

In-Network 

• No limit to the number 

of days covered by the plan 

each hospital stay. 

• $295 copay for each 

Medicare-covered hospital 

stay 






limit. 









one. 









limit. 

In-Network 










In-Network 






stay





limit. 









one. 









limit. 

In-Network 










In-Network 




• For Medicare-covered 

hospital stays: 

• Days 1 - 5: $225 copay 






limit. 









one. 









limit. 

In-Network 










In-Network 






• Days 1 - 5: $225 copay 

11 





Contact the plan for services 

that apply. 





one. 









limit. 

In-Network 










In-Network 






stay 






Contact the plan for services 

that apply. 





one. 









limit. 

In-Network 










In-Network 






stay 



Medicare 

4 - Inpatient Mental 

Health Care 


lifetime reserve day 

•Th ese amounts may 

change for 2013. 

• Call 1-800-MEDICARE 

(1-800-633-4227) for 

information about lifetime 

reserve days. 

• Lifetime reserve days can 

only be used once. 

• A “benefi t period” starts 

the day you go into a 

hospital or skilled nursing 

facility. It ends when you 

go for 60 days in a row 

without hospital or skilled 

nursing care. If you go 

into the hospital after one 

benefi t period has ended, a 

new benefi t period begins. 

You must pay the inpatient 

hospital deductible for each 

benefi t period. Th ere is no 

limit to the number of benefi 

t periods you can have. 


each benefi t period were: 

• Days 1 - 60: $1156 deductible 

• Days 61 - 90: $289 per 

day 

• Days 91 - 150: $578 per 

lifetime reserve day 



You get up to 190 days of 

inpatient psychiatric hospital 

care in a lifetime. Inpatient 

psychiatric hospital 

services count toward the 

190-day lifetime limitation 

only if certain conditions 

are met. Th is limitation 

12 



• $0 copay for additional 

hospital days 

• Except in an emergency, 

your doctor must tell the 

plan that you are going to 

be admitted to the hospital. 

Out-of-Network 

• 20% of the cost for each 

hospital stay. 

In-Network 









does not apply to inpatient 

psychiatric services 

furnished in a General 

hospital. 



stay. 






hospital days 








In-Network 












hospital. 



stay. 

• Except in an emergency,



per day 

• Days 6 - 90: $0 copay 

per day 


hospital days 








In-Network 












hospital. 



• Days 1 - 5: $225 copay 

per day 




per day 

• Days 6 - 90: $0 copay 

per day 


hospital days 








In-Network 












hospital. 



• Days 1 - 5: $225 copay 

per day 

13 




hospital days 








In-Network 












hospital. 



stay. 






hospital days 








In-Network 












hospital. 



stay. 




Medicare 

5 - Skilled Nursing Facility 

(SNF) 

(in a Medicare-certifi ed 

skilled nursing facility) 

6 - Home Health Care 

(includes medically necessary 

intermittent skilled 

nursing care, home health 

aide services, and rehabilitation 

services, etc.) 





hospital. 


each benefi t period after at 

least a 3-day covered hospital 

stay were: 

• Days 1 - 20: $0 per day 

• Days 21 - 100: $144.50 

per day 



• A “benefi t period” starts 

the day you go into a hospital 

or SNF. It ends when 

you go for 60 days in a row 

without hospital or skilled 

nursing care. If you go 

into the hospital after one 

benefi t period has ended, a 

new benefi t period begins. 

You must pay the inpatient 

hospital deductible for each 

benefi t period. Th ere is no 

limit to the number of benefi 

t periods you can have. 

• $0 copay. 

14 









General 

• Authorization rules may 

apply. 

In-Network 

• Plan covers up to 100 

days each benefi t period 

• No prior hospital stay is 

required. 

• For SNF stays: 

• Days 1 - 8: $0 copay 

per day 

• Days 9 - 42: $65 copay 

per day 

• Days 43 - 100: $0 

copay per day 



SNF stay. 

General 


apply. 

In-Network 

• $0 copay for Medicarecovered 

home health visits 


• 20% of the cost for 










General 


apply. 

In-Network 




required. 


• Days 1 - 8: $0 copay 

per day 

• Days 9 - 42: $65 copay 

per day 

• Days 43 - 100: $0 

copay per day 



SNF stay. 

General 


apply. 

In-Network 




• 20% of the cost for



• Days 6 - 90: $0 copay 

per day 








General 


apply. 

In-Network 




required. 


• Days 1 - 3: $0 copay 

per day 

• Days 4 - 45: $65 copay 

per day 

• Days 46 - 100: $0 

copay per day 



SNF stay. 

General 


apply. 

In-Network 








• Days 6 - 90: $0 copay 

per day 








General 


apply. 

In-Network 




required. 


• Days 1 - 3: $0 copay 

per day 

• Days 4 - 45: $65 copay 

per day 

• Days 46 - 100: $0 

copay per day 



SNF stay. 

General 


apply. 

In-Network 





15 









General 


apply. 

In-Network 




required. 


• Days 1 - 8: $0 copay 

per day 

• Days 9 - 42: $65 copay 

per day 

• Days 43 - 100: $0 

copay per day 



SNF stay. 

General 


apply. 

In-Network 














General 


apply. 

In-Network 




required. 


• Days 1 - 8: $0 copay 

per day 

• Days 9 - 42: $65 copay 

per day 

• Days 43 - 100: $0 

copay per day 



SNF stay. 

General 


apply. 

In-Network 






7 - Hospice 


Medicare 

OUTPATIENT CARE 

8 - Doctor Offi ce Visits 

9 - Chiropractic Services 


• You pay part of the cost 

for outpatient drugs and 

inpatient respite care. 

• You must get care from a 

Medicare-certifi ed hospice. 

• 20% coinsurance 

• Supplemental routine 

care not covered 

• 20% coinsurance for 

manual manipulation of 

the spine to correct subluxation 

(a displacement 

or misalignment of a joint 

or body part) if you get 

it from a chiropractor or 

other qualifi ed providers. 

16 



Medicare-covered home 

health visits 

General 



Your plan will pay for a 

consultative visit before 

you select hospice. 

In-Network 


Medicare-covered primary 

care doctor visit. 


Medicare-covered specialist 

visit. 




care doctor visit 



visit 

In-Network 


Medicare-covered chiropractic 

visit 

• Medicare-covered chiropractic 

visits are for manual 

manipulation of the spine 

to correct subluxation (a 

displacement or misalignment 

of a joint or body 

part) if you get it from a 

chiropractor. 



chiropractic visits. 





health visits 

General 






In-Network 






visit. 







visit 

In-Network 



visit 








chiropractor. 



chiropractic visits.




health visits 

General 






In-Network 






visit. 







visit 

In-Network 



visit 








chiropractor. 








health visits 

General 






In-Network 






visit. 







visit 

In-Network 



visit 








chiropractor. 




17 




health visits 

General 






In-Network 






visit. 







visit 

In-Network 



visit 








chiropractor. 








health visits 

General 






In-Network 






visit. 







visit 

In-Network 



visit 








chiropractor. 





10 - Podiatry 

Services 


Medicare 

11 - Outpatient Mental 

Health Care 



care not covered. 


medically necessary foot 

care, including care for 

medical conditions aff ecting 

the lower limbs. 


most outpatient mental 

health services 

• Specifi ed copayment for 

outpatient partial hospitalization 

program services 

furnished by a hospital or 

community mental health 

center (CMHC). Copay 

cannot exceed the Part A 

inpatient hospital deductible. 

• “Partial hospitalization 

program” is a structured 

program of active outpatient 

psychiatric treatment 

that is more intense than 

the care received in your 

doctor’s or therapist’s offi ce 

and is an alternative to 

inpatient hospitalization. 

18 



In-Network 


Medicare-covered podiatry 

visit 

• $0 copay for up to 4 supplemental 

routine podiatry 

visit(s) every year 

• Medicare-covered podiatry 

visits are for medicallynecessary 

foot care. 



podiatry visits 

• $35 copay for supplemental 

routine podiatry visits 

General 


apply. 

In-Network 


Medicare-covered individual 

therapy visit 


Medicare-covered group 

therapy visit 



therapy visit with a 

psychiatrist 

• $10 copay for each Medicare-covered 

group therapy 

visit with a psychiatrist 


partial hospitalization 



• 20% of the cost for Medicare-covered 

Mental Health 

visits with a psychiatrist 





In-Network 



visit 






foot care. 






General 


apply. 

In-Network 



therapy visit 



therapy visit 




psychiatrist 


group therapy 









• 20% of the cost for



In-Network 

• up to 4 supplemental routine 

podiatry visit(s) every 

year 



visit 



foot care. 






General 


apply. 

In-Network 



therapy visit 



therapy visit 




psychiatrist 


group therapy 



Medicare-covered partial 

hospitalization program 

services 








In-Network 

• up to 4 supplemental routine 

podiatry visit(s) every 

year 



visit 



foot care. 






General 


apply. 

In-Network 



therapy visit 



therapy visit 




psychiatrist 


group therapy 





services 





19 



In-Network 



visit 






foot care. 






General 


apply. 

In-Network 


individual 

therapy visit 



therapy visit 




psychiatrist 


group therapy 













In-Network 



visit 






foot care. 






General 


apply. 

In-Network 


individual 

therapy visit 



therapy visit 




psychiatrist 


group therapy 












Medicare 

12 - Outpatient 

Substance Abuse Care 

13 - Outpatient Services 





Medicare-covered Mental 

Health visits 




services 

General 


apply. 

In-Network 


individual substance 

abuse outpatient 

treatment visits 


group substance 

abuse outpatient treatment 

visits 


• 20% of the cost Medicare-covered 

substance 


visits 

• 20% coinsurance for the General 

doctor’s services 


• Specifi ed copayment for apply. 

outpatient hospital facil- In-Network 

ity services Copay cannot • $250 copay for each 

exceed the Part A inpatient Medicare-covered ambula- 

hospital deductible. tory surgical center visit 

• 20% coinsurance for • $250 copay for each 

ambulatory surgical center Medicare-covered outpa- 

facility services 

tient hospital facility visit 



Medicare-covered outpatient 

hospital facility visits 


Medicare-covered ambulatory 

surgical center visits 

20 









services 

General 


apply. 

In-Network 








visits 



substance 


visits 

General 


apply. 

In-Network 



surgical center visit 



hospital facility visit 







surgical center visits









services 

General 


apply. 

In-Network 








visits 



substance 


visits 

General 


apply. 

In-Network 























services 

General 


apply. 

In-Network 








visits 



substance 


visits 








services 

General 


apply. 

In-Network 








visits 



substance 


visits 

General 

General 

• Authorization rules may • Authorization rules may 

apply. 

apply. 

In-Network 

In-Network 

• $375 copay for each • $125 copay for each 

Medicare-covered ambula- Medicare-covered ambulatory 

surgical center visit tory surgical center visit 

• $375 copay for each • $125 copay for each 

Medicare-covered outpa- Medicare-covered outpatient 

hospital facility visit tient hospital facility visit 



• 25% of the cost for • 20% of the cost for 

Medicare-covered outpa- Medicare-covered outpatient 

hospital facility visits tient hospital facility visits 

• 25% of the cost for • 20% of the cost for 

Medicare-covered ambula- Medicare-covered ambulatory 

surgical center visits tory surgical center visits 

21 









services 

General 


apply. 

In-Network 








visits 



substance 


visits 

General 


apply. 

In-Network 
















Medicare 

14 - Ambulance Services 

(medically necessary ambulance 

services) 

15 - Emergency Care 

(You may go to any emergency 

room if you reasonably 

believe you need 

emergency care.) 

16 - Urgently 

Needed Care 

(Th is is NOT emergency 

care, and in most cases, is 

out of the service area.) 



• 20% coinsurance for the 

doctor’s services 

• Specifi ed copayment for 

outpatient hospital facility 

emergency services. 

• Emergency services copay 

cannot exceed Part A inpatient 

hospital deductible 

for each service provided 

by the hospital. 

• You don’t have to pay the 

emergency room copay if 

you are admitted to the 

hospital as an inpatient for 

the same condition within 

3 days of the emergency 

room visit. 

• Not covered outside the 

U.S. except under limited 

circumstances. 



In-Network 


ambulance benefi 

ts. 

• If you are admitted to the 

hospital, you pay $0 for 

Medicare-covered ambulance 

benefi ts. 




benefi ts. 

General 


emergency room 

visits 

Th is amount applies toward 

your In-Network plan 

deductible. 


your Out-of-Network 

plan deductible. 

• Worldwide coverage. 


hospital within 3-day(s) for 

the same condition, you 

pay $0 for the emergency 

room visit. 

• 20% coinsurance, or a set General 

copay 

• $25 copay for Medicare- 

• NOT covered outside the coveredurgently-needed- U.S. except under limited care visits 

circumstances. 




pay $0 for the urgentlyneeded-care 

visit. 

22 




In-Network 



ts. 




benefi ts. 




benefi ts. 

General 



visits 



deductible. 









room visit. 

General 

• $25 copay for Medicarecoveredurgently-neededcare 

visits 





visit.



In-Network 



ts. 




benefi ts. 




benefi ts. 

General 



visits 






room visit. 

General 


visits 





visit. 




In-Network 



ts. 




benefi ts. 




benefi ts. 

General 



visits 






room visit. 



In-Network 



ts. 




benefi ts. 




benefi ts. 

General 



visits 



deductible. 









room visit. 

General 

General 

• $35 copay for Medicare- • $25 copay for Medicarecoveredurgently-neededcoveredurgently-neededcare 

visits 

care visits 

• If you are admitted to the • If you are admitted to the 

hospital within 3-day(s) for hospital within 3-day(s) for 

the same condition, you the same condition, you 

pay $0 for the urgently- pay $0 for the urgentlyneeded-care 

visit. needed-care visit. 

23 




In-Network 



ts. 




benefi ts. 




benefi ts. 

General 



visits 



deductible. 









room visit. 

General 


visits 





visit. 



Medicare 


Rehabilitation 

Services 

(Occupational Th erapy, 

Physical Th erapy, Speech 

and Language Th erapy) 

OUTPATIENT 

MEDICAL SERVICES 

AND SUPPLIES 

18 - Durable Medical 

Equipment 

(includes wheelchairs, 

oxygen, etc.) 




24 



General 


apply. 

In-Network 


Occupational 

Th erapy visits 


Physical Th erapy 

and/or Speech and Language 

Pathology visits 



Medicare-covered Physical 

Th erapy and/or Speech and 

Language Pathology visits 


Medicare-covered Occupational 

Th erapy visits. 

General 


apply. 

In-Network 


Medicare-covered durable 

medical equipment 








General 


apply. 

In-Network 


Occupational 














General 


apply. 

In-Network 







medical equipment



General 


apply. 

In-Network 


Occupational 














General 


apply. 

In-Network 











General 


apply. 

In-Network 


Occupational 














General 


apply. 

In-Network 








25 



General 


apply. 

In-Network 


Occupational 














General 


apply. 

In-Network 











General 


apply. 

In-Network 


Occupational 














General 


apply. 

In-Network 










Medicare 

19 - Prosthetic 

Devices 

(includes braces, artifi cial 

limbs and eyes, etc.) 

20 - Diabetes 

Programs and 

Supplies 




diabetes self-management 

training 


diabetes supplies 


diabetic therapeutic shoes 

or inserts 

26 



General 


apply. 

In-Network 


Medicare-covered prosthetic 

devices 




devices. 

General 


apply. 

In-Network 


Diabetes self-management 

training 

• 0% to 20% of the cost for 

Medicare-covered Diabetes 

monitoring supplies 


Medicare-covered Th erapeutic 

shoes or inserts 




self-management training 










General 


apply. 

In-Network 



devices 




devices. 

General 


apply. 

In-Network 



training 
















shoes or inserts



General 


apply. 

In-Network 



devices 




devices. 

General 


apply. 

In-Network 



training 




• Diabetic Supplies and 

Services are limited to 

specifi c manufacturers, 

products and/or brands. 

Contact the plan for a list 

of covered supplies. 

















General 


apply. 

In-Network 



devices 




devices. 

General 


apply. 

In-Network 



training 




• Diabetic Supplies and 

Services are limited to 

specifi c manufacturers, 

products and/or brands. 

Contact the plan for a list 

of covered supplies. 














27 



General 


apply. 

In-Network 



devices 




devices. 

General 


apply. 

In-Network 



training 




















General 


apply. 

In-Network 



devices 




devices. 

General 


apply. 

In-Network 



training 



















Medicare 

21 - Diagnostic Tests, X- 

Rays, Lab 

Services, and 

Radiology Services 

22 - Cardiac and Pulmonary 

Rehabilitation Services 


• 20% coinsurance for diagnostic 

tests and x-rays 


lab services 

• Lab Services: Medicare 

covers medically necessary 

diagnostic lab services 

that are ordered by your 

treating doctor when they 

are provided by a Clinical 

Laboratory Improvement 

Amendments (CLIA) 

certifi ed laboratory that 

participates in Medicare. 

Diagnostic lab services are 

done to help your doctor 

diagnose or rule out a suspected 

illness or condition. 

Medicare does not cover 

most supplemental routine 

screening tests, like checking 

your cholesterol. 

• 20% coinsurance for Cardiac 

Rehabilitation services 


Pulmonary Rehabilitation 

services 


Intensive Cardiac Rehabilitation 

services 

28 



General 


apply. 

In-Network 


lab services 


diagnostic procedures 

and tests 


X-rays 

• $45 to $125 copay for 

Medicare-covered diagnostic 

radiology services (not 

including X-rays) 


therapeutic radiology 

services 



Medicare-covered therapeutic 

radiology services 



X-rays 






procedures, tests, and 

lab services 

General 


apply. 

In-Network 


Cardiac Rehabilitation 

Services 





General 


apply. 

In-Network 


lab services 



and tests 


X-rays 







services 







X-rays 







lab services 

General 


apply. 

In-Network 



Services 

• $10 copay for Medicare-



General 


apply. 

In-Network 

• 0% to 20% of the cost 

for Medicare-covered lab 

services 



procedures and tests 


X-rays 














X-rays 







lab services 

In-Network 



Services 


Intensive Cardiac 






General 


apply. 

In-Network 

• 0% to 20% of the cost 

for Medicare-covered lab 

services 



procedures and tests 


X-rays 














X-rays 







lab services 

In-Network 



Services 


Intensive Cardiac 



29 



General 


apply. 

In-Network 


lab services 



and tests 


X-rays 







services 



therapeutic 




X-rays 







lab services 

General 


apply. 

In-Network 



Services 





General 


apply. 

In-Network 


lab services 



and tests 


X-rays 







services 



therapeutic 




X-rays 







lab services 

General 


apply. 

In-Network 



Services 




Medicare 

PREVENTIVE 

SERVICES, 

WELLNESS/ 

EDUCATION AND 

OTHER 

SUPPLEMENTAL BEN- 

EFIT 

PROGRAMS 

23 -Preventive Services, 

Wellness/Education and 

other Supplemental Benefi 

t Programs 


•Th is applies to program 

services provided in a doctor’s 

offi ce. Specifi ed cost 

sharing for program services 

provided by hospital 

outpatient departments. 

• No coinsurance, copayment 

or deductible for the 

following: 

• - Abdominal Aortic Aneurysm 

Screening 

• - Bone Mass Measurement. 

Covered once every 

24 months (more often 

if medically necessary) if 

you meet certain medical 

conditions. 

• - Cardiovascular Screening 

• Cervical and Vaginal 

Cancer Screening. Covered 

once every 2 years. Covered 

30 



covered Intensive Cardiac 




Services 



Medicare-covered Cardiac 



Medicare-covered Intensive 


Services 


Pulmonary 


General 

• $0 copay for all preventive 

services covered under 

Original Medicare at zero 

cost sharing. 

• Any additional preventive 

services approved by 

Medicare mid-year will be 

covered by the plan or by 

Original Medicare. 

In-Network 

• $10 copay for an annual 

physical exam 

•Th e plan covers the following 

supplemental education/wellness 

programs: 








Services 








Services 


Pulmonary 


General 




cost sharing. 






In-Network 


physical exam 



programs:



covered Pulmonary Rehabilitation 

Services 








Services 


Pulmonary 


General 




cost sharing. 






In-Network 


physical exam 



programs: 




covered Pulmonary Rehabilitation 

Services 








Services 


Pulmonary 


General 




cost sharing. 






In-Network 


physical exam 



programs: 

31 







Services 








Services 


Pulmonary 


General 




cost sharing. 






In-Network 


physical exam 

• Th e plan covers the following 


programs: 








Services 








Services 


Pulmonary 


General 




cost sharing. 






In-Network 


physical exam 

• Th e plan covers the following 


programs: 



Medicare 


once a year for women 

with Medicare at high risk. 

• Colorectal Cancer Screening 

• Diabetes Screening 

•Infl uenza Vaccine 

• Hepatitis B Vaccine for 

people with Medicare who 

are at risk 

HIV Screening. $0 copay 

for the HIV screening, but 

you Generally pay 20% 

of the Medicare-approved 

amount for the doctor’s 

visit. HIV screening is 

covered for people with 

Medicare who are pregnant 

and people at increased risk 

for the infection, including 

anyone who asks for the 

test. Medicare covers this 

test once every 12 months 

or up to three times during 

a pregnancy. 

• Breast Cancer Screening 

(Mammogram). Medicare 

covers screening mammograms 

once every 12 

months for all women 

with Medicare age 40 and 

older. Medicare covers one 

baseline mammogram for 

women between ages 35- 

39. 

• Medical Nutrition 

Th erapy Services Nutrition 

therapy is for people who 

have diabetes or kidney 

disease (but aren’t on dialysis 

or haven’t had a kidney 

transplant) when referred 

by a doctor. Th ese services 

32 



• Health Club Membership/Fitness 

Classes 

• Nursing Hotline 

• $0 copay for Enhanced 

Preventive Health Services. 

• Contact plan for details. 



physical exam 


preventive services 


Preventive Health Services 


supplemental education/ 

wellness programs 

• 20% of the cost for Enhanced 

Preventive Health 

Services 





Classes 







physical exam 










Services



• Health Education 


Classes 







physical exam 











• Health Education 


Classes 







physical exam 








33 




Classes 







physical exam 










Services 





Classes 







physical exam 










Services 



Medicare 


can be given by a registered 

dietitian and may include 

a nutritional assessment 

and counseling to help you 

manage your diabetes or 

kidney disease 

• Personalized Prevention 

Plan 

• Services (Annual Wellness 

Visits) 

• Pneumococcal Vaccine. 

You may only need the 

Pneumonia vaccine once 

in your lifetime. Call your 

doctor for more information. 

• Prostate Cancer Screening 

• Prostate Specifi c Antigen 

(PSA) test only. Covered 

once a year for all men 

with Medicare over age 50. 

• Smoking and Tobacco 

Use Cessation (counseling 

to stop smoking and 

tobacco use). Covered if 

ordered by your doctor. 

Includes two counseling attempts 

within a 12-month 

period. Each counseling 

attempt includes up to four 

face-to-face visits. 

• Screening and behavioral 

counseling interventions 

in primary care to reduce 

alcohol misuse 

• Screening for depression 

in adults 

• Screening for sexually 

transmitted infections 

(STI) and high-intensity 

behavioral counseling to 

prevent STIs 

34 





(PPO)






35 








Medicare 

24 - Kidney Disease and 

Conditions 


• Intensive behavioral 

counseling for Cardiovascular 

Disease (bi-annual) 

• Intensive behavioral 

therapy for obesity 

• Welcome to Medicare 

Preventive Visits (initial 

preventive physical exam) 

When you join Medicare 

Part B, then you are eligible 

as follows. During the fi rst 

12 months of your new 

Part B coverage, you can 

get either a Welcome to 

Medicare Preventive Visits 

or an Annual Wellness 

Visit. After your fi rst 12 

months, you can get one 

• Annual Wellness Visit 

every 12 months. 


renal dialysis 


kidney disease education 

services 

36 



General 


apply. 

In-Network 


Medicare-covered renal 

dialysis 



education services 



Medicare-covered kidney 

disease education services 



dialysis 




General 


apply. 

In-Network 



dialysis 










dialysis



In-Network 



dialysis 










dialysis 




In-Network 



dialysis 










dialysis 

37 



General 


apply. 

In-Network 















General 


apply. 

In-Network 














Medicare 

PRESCRIPTION DRUG 

BENEFITS 


Prescription Drugs 


• Most drugs are not 

covered under Original 

Medicare. You can add prescription 

drug coverage to 

Original Medicare by joining 

a Medicare Prescription 

Drug Plan, or you can get 

all your Medicare coverage, 

including prescription 

drug coverage, by joining a 

Medicare Advantage Plan 

or a Medicare Cost Plan 

that off ers prescription 

drug coverage. 

38 



Drugs covered under Medicare 

Part B 

General 

• Most drugs not covered. 

• 20% of the cost for Medicare 

Part B chemotherapy 

drugs and other Part B 

drugs. 


Part B drugs Out-of- 

Network. 


Part D 

General 

•Th is plan does not off er 

prescription drug coverage. 





Part B 

General 




drugs. 


Part B drugs out-ofnetwork. 


Part D 

General 

•Th is plan uses a formulary. 

Th e plan will send 

you the formulary. You can 

also see the formulary at 

https://www.thehealthplan. 

com/Gold/Landing_Pages/ 

Formulary/ on the web. 

•Diff erent out-of-pocket 

costs may apply for people 

who 

• have limited incomes, 

• live in long term care 

facilities, or 

• have access to Indian/ 

Tribal/Urban (Indian 

Health Service) providers. 

•Th e plan off ers national 

in-network prescription 

coverage (i.e., this would 

include 50 states and the 

District of Columbia). 

Th is means that you will 

pay the same cost-sharing 

amount for your prescription 

drugs if you get them




Part B 

General 





drugs. 



Network. 


Part D 

General 







Part B 

General 




drugs. 


Part B drugs out-ofnetwork. 


Part D 

General 










who 















drugs if you get them 

39 




Part B 

General 





drugs. 



Network. 


Part D 

General 







Part B 

General 




drugs. 



Network. 


Part D 

General 










who 















drugs if you get them 



Medicare 


40 






at an in-network pharmacy 

outside of the plan’s service 

area (for instance when you 

travel). 

• Total yearly drug costs are 

the total drug costs paid 

by both you and a Part D 

plan. 

•Th e plan may require you 

to fi rst try one drug to treat 

your condition before it 

will cover another drug for 

that condition. 

• Some drugs have quantity 

limits. 

• Your provider must get 

prior authorization from 

Geisinger Gold Preferred 1 

$0 Deductible Rx (PPO) 

for certain drugs. 

• You must go to certain 

pharmacies for a very 

limited number of drugs, 

due to special handling, 

provider coordination, or 

patient education requirements 

that cannot be met 

by most pharmacies in your 

network. Th ese drugs are 

listed on the plan’s website, 

formulary, printed materials, 

as well as on the Medicare 

Prescription Drug Plan 

Finder on Medicare.gov. 

If the actual cost of a drug 

is less than the normal 

cost-sharing amount for 

that drug, you will pay the 

actual cost, not the higher 

cost-sharing amount. 

• If you request a formulary 

exception for a drug and









travel). 




plan. 







limits. 



























exception for a drug and 

41 









travel). 




plan. 







limits. 



























exception for a drug and 



Medicare 


42 








approves the exception, you 

will pay Tier 4: Non-Preferred 

Brand cost sharing 

for that drug. 

In-Network 

• $0 deductible. 

Initial Coverage 

• You pay the following 

until total yearly drug costs 

reach $2,970: 

Retail Pharmacy 

• Tier 1: Preferred Generic 

• - $3 copay for a onemonth 

(34-day) supply 

of drugs in this tier 

• $9 copay for a threemonth 



• Not all drugs on this tier 

are available at this extended 

day supply. Please 

contact the plan for more 

information. 

• Tier 2: Non-Preferred 

Generic 

• $7 copay for a onemonth 










information. 

• Tier 3: Preferred Brand 



of drugs in this tier












In-Network 





reach $2,970: 













information. 


Generic 











information. 





43 












In-Network 





reach $2,970: 













information. 


Generic 











information. 







Medicare 


44 













information. 


Brand 











information. 

• Tier 5: Specialty Tier 


a one-month (34-day) 

supply of drugs in this 

tier 

Long Term Care Pharmacy 






Generic 









Brand













information. 


Brand 











information. 





tier 







Generic 









Brand 

45 













information. 


Brand 











information. 





tier 







Generic 









Brand 



Medicare 


46 













tier 

• Please note that brand 

drugs must be dispensed 

incrementally in long-term 

care facilities. Generic 

drugs may be dispensed incrementally. 

Contact your 

plan about cost-sharing 

billing/collection when less 

than a one-month supply is 

dispensed. 

Mail Order 









information. 

Tier 2: Non-Preferred 

Generic 




Not all drugs on this tier 




information. 

Tier 3: Preferred Brand 



of drugs in this tier













tier 






Contact your 




dispensed. 

Mail Order 









information. 


Generic 








information. 





47 













tier 






Contact your 




dispensed. 

Mail Order 









information. 


Generic 








information. 







Medicare 


48 










information. 


Brand 








information. 

Coverage Gap 

• After your total yearly 

drug costs reach $2,970, 

you receive limited coverage 

by the plan on certain 

drugs. You will also receive 

a discount on brand name 

drugs and generally pay no 

more than 47.5% for the 

plan’s costs for brand drugs 

and 79% of the plan’s costs 

for generic drugs until your 

yearly out-of-pocket drug 

costs reach $4,750. 

Additional Coverage Gap 

•Th e plan covers few formulary 

generics (less than 

10% of formulary generic 

drugs) through the coverage 

gap. 

•Th e plan off ers additional 

coverage in the gap for the 

following tiers. 

• You pay the following: 



• $3 copay for a one-










information. 


Brand 








information. 

Coverage Gap 



















gap. 







• $3 copay for a one- 

49 










information. 


Brand 








information. 

Coverage Gap 



















gap. 










Medicare 


50 






month (34-day) supply 

of all drugs covered in 

this tier 




this tier 





information. 






this tier 

• Mail Order 





this tier 





information. 

Catastrophic Coverage 

• After your yearly out-ofpocket 

drug costs reach 

$4,750, you pay the greater 

of: 

• -5% coinsurance, or 

• $2.65 copay for generic 

(including brand 

drugs treated as generic) 

and a $6.60 copay for 

all other drugs. 


• Plan drugs may be








this tier 




this tier 





information. 






this tier 






this tier 





information. 





of: 








• Plan drugs may be 

51 








this tier 




this tier 





information. 






this tier 






this tier 





information. 





of: 








• Plan drugs may be 



Medicare 


52 






covered in special circumstances, 

for instance, illness 

while traveling outside 

of the plan’s service area 

where there is no network 

pharmacy. You may have to 

pay more than your normal 

cost-sharing amount 

if you get your drugs at an 

out-of-network pharmacy. 

In addition, you will likely 

have to pay the pharmacy’s 

full charge for the drug 

and submit documentation 

to receive reimbursement 

from Geisinger Gold 

Preferred 1 $0 Deductible 

Rx (PPO). 

Out-of-Network Initial 

Coverage 

• You will be reimbursed 

up to the plan’s cost of the 

drug minus the following 

for drugs purchased out-ofnetwork 

until total yearly 

drug costs reach $2,970: 






Generic 









Brand 

• $69 copay for a one-

























Coverage 












Generic 









Brand 


53 

























Coverage 












Generic 









Brand 




Medicare 


54 












tier 

Out-of-Network Coverage 

Gap 


up to 21% of the plan 

allowable cost for generic 

drugs purchased out-ofnetwork 


out-of-pocket drug costs 

reach $4,750. Please note 

that the plan allowable cost 

may be less than the outof-network 

pharmacy price 

paid for your drug(s). 


up to 52.5% of the plan 

allowable cost for brand 

name drugs purchased outof-network 

until your total 


costs reach $4,750. Please 

note that the plan allowable 

cost may be less than 

the out-of-network pharmacy 

price paid for your 

drug(s). 

Additional Out-of-Network 

Coverage Gap 





gap. 


for these drugs purchased 

out-of-network up to the












tier 


Gap 























drug(s). 


Coverage Gap 





gap. 



out-of-network up to the 

55 












tier 


Gap 























drug(s). 


Coverage Gap 





gap. 






Medicare 


56 






plan’s cost of the drug minus 

the following: 

Tier 1: Preferred Generic 




this tier 

Out-of-Network Catastrophic 

Coverage 



$4,750, you will be reimbursed 

for drugs purchased 



your cost share, which 

is the greater of: 

• 5% coinsurance, or 





all other drugs.












this tier 


Coverage 















57 












this tier 


Coverage 
















OUTPATIENT 

MEDICAL 

SERVICES AND 

SUPPLIES 


Medicare 

26 - Dental Services 

27 - Hearing 

Services 


• Preventive dental services 

(such as cleaning) not 

covered. 


hearing exams and hearing 

aids not covered. 

• 20% coinsurance for diagnostic 

hearing exams. 

58 



General 


apply. 

In-Network 


dental benefi ts 

• $20 copay for a visit that 

includes: 

• up to 1 oral exam(s) 

every six months 

• up to 1 cleaning(s) 


• $20 to $30 copay for up 

to 1 dental x-ray(s) every 

year 



comprehensive 



supplemental preventive 


In-Network 


diagnostic hearing 

exams 

• $25 copay for up to 1 

supplemental routine hearing 

exam(s) every year 

• $0 copay for up to 1 hearing 

aid fi tting-evaluation(s) 

every three years 


aid(s) every three years 





General 


apply. 

In-Network 




includes: 







year 



comprehensive 





In-Network 



exams 









Out-of-Network



General 


apply. 

In-Network 


Medicare-covered dental 

benefi ts 


includes: 







year 



comprehensive 





In-Network 



exams 













General 


apply. 

In-Network 


Medicare-covered dental 

benefi ts 


includes: 







year 



comprehensive 





In-Network 



exams 










59 



General 


apply. 

In-Network 




includes: 







year 



comprehensive 





In-Network 



exams 













General 


apply. 

In-Network 




includes: 







year 



comprehensive 





In-Network 



exams 











28 - Vision Services 


Medicare 



diagnosis and treatment of 

diseases and conditions of 

the eye. 


eye exams and glasses not 

covered. 

• Medicare pays for one 

pair of eyeglasses or contact 

lenses after cataract surgery. 

• Annual glaucoma screenings 

covered for people at 

risk. 

60 





exams. 




hearing aids. 

•Th e plan will pay up to 

$800 for all of the following 

services combined: 

• Supplemental 

• Hearing Aids 


$800 plan coverage limit 

for supplemental routine 

hearing aids every three 

years. Th is limit applies to 

both In-Network and outof-network 

benefi ts. 

In-Network 

• $0 copay for one pair of 

Medicare-covered eyeglasses 

or contact lenses after 

cataract surgery. 


Medicare-covered exams to 

diagnose and treat diseases 

and conditions of the eye. 


supplemental routine eye 


• $0 copay for glasses 

• $0 copay for contacts 

• $0 copay for lenses 

• $0 copay for frames 



eye exams 


eye exams 







exams. 




hearing aids. 












benefi ts. 

In-Network 


















eye exams 


eye exams 

• $0 copay for Medicare-





exams. 




hearing aids. 












benefi ts. 

In-Network 




cataract surgery 














eye exams 


eye exams 







exams. 




hearing aids. 












benefi ts. 

In-Network 




cataract surgery 














eye exams 


eye exams 


61 





exams. 




hearing aids. 

• Th e plan will pay up to 











benefi ts. 

In-Network 


















eye exams 


eye exams 







exams. 




hearing aids. 












benefi ts. 

In-Network 


















eye exams 


eye exams 




Medicare 

Over-the-Counter Items 

Transportation 

(Routine) 

Acupuncture 


• Not covered. 



62 



covered eye wear 


eye wear 




• Medicare-covered 

• Eye Wear 


• Eye Wear 



for eye wear every two 



benefi ts. 

General 

•Th e plan does not cover 

Over-the-Counter items. 

In-Network 

•Th is plan does not cover 

supplemental routine transportation. 

In-Network 


Acupuncture. 






eye wear 





• Eye Wear 


• Eye Wear 






benefi ts. 

General 



In-Network 



In-Network 


Acupuncture.





eye wear 





• Eye Wear 


• Eye Wear 






benefi ts. 

General 



In-Network 



In-Network 


Acupuncture. 






eye wear 





• Eye Wear 


• Eye Wear 






benefi ts. 

General 



In-Network 



In-Network 


Acupuncture. 

63 





eye wear 





• Eye Wear 


• Eye Wear 






benefi ts. 

General 

• Th e plan does not cover 


• In-Network 

• Th is plan does not cover 


In-Network 


Acupuncture. 






eye wear 





• Eye Wear 


• Eye Wear 






benefi ts. 

General 

• Th e plan does not cover 


• In-Network 



In-Network 


Acupuncture. 


2013 Monthly Premiums by County of Residence 

Please locate your county in the list below for plan availability and monthly premium. 

Preferred 1 (PPO) Preferred 1 Preferred 2 (PPO) 


Adams $33 $74 $25 

Berks $33 $74 $25 

Blair $98 $150 $25 

Cambria $98 $150 $25 

Cameron $98 $150 $25 

Carbon NA NA $26 

Centre $98 $150 $20 

Clearfi eld $98 $150 $20 

Clinton $98 $150 $20 

Columbia $98 $150 $20 

Cumberland $98 $150 $20 

Dauphin $33 $74 $20 

Fulton $98 $150 $20 

Huntingdon $98 $150 $20 

Jeff erson $98 $150 $25 

Juniata $98 $150 $25 

Lackawanna $98 $150 $20 

Lancaster $33 $74 $20 

Lebanon $33 $74 $20 

Lehigh NA NA $26 

Luzerne $98 $150 $20 

Lycoming $98 $150 $20 

Miffl in $98 $150 $25 

Monroe $98 $150 $25 

Montour $98 $150 $20 

Northampton NA NA $26 

Northumberland $98 $150 $20 

Perry $98 $150 $25 

Pike $98 $150 $25 

Potter $98 $150 $25 

Schuylkill $98 $150 $25 

Snyder $98 $150 $20 

Somerset $98 $150 $25 

Sullivan $98 $150 $20 

Susquehanna $98 $150 $25 

Tioga $98 $150 $20 

Union $98 $150 $20 

Wayne $98 $150 $25 

Wyoming $98 $150 $20 

York $33 $74 $20

Preferred 2 Preferred 3 (PPO) Preferred 3 

$0 Deductible Rx (PPO) $0 Deductible Rx (PPO) 

$60 NA NA 

$60 NA NA 

$60 NA NA 

$60 NA NA 

$60 NA NA 

$61 $96 $148 

$55 NA NA 

$55 NA NA 

$55 NA NA 

$55 NA NA 

$55 NA NA 

$55 NA NA 

$55 NA NA 

$55 NA NA 

$60 NA NA 

$60 NA NA 

$55 NA NA 

$55 NA NA 

$55 NA NA 

$61 $96 $148 

$55 NA NA 

$55 NA NA 

$60 NA NA 

$60 NA NA 

$55 NA NA 

$61 $96 $148 

$55 NA NA 

$60 NA NA 

$60 NA NA 

$60 NA NA 

$60 NA NA 

$55 NA NA 

$60 NA NA 

$55 NA NA 

$60 NA NA 

$55 NA NA 

$55 NA NA 

$60 NA NA 

$55 NA NA 

$55 NA NA

Notes

Notes

Formulary 

(List of Covered Drugs)

Geisinger Gold $0 Deductible RX 

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, 2014. 

Geisinger Gold is offered by Geisinger Health Plan, a health plan with a Medicare contract. 

This document is available in alternate formats, please call (800) 988-4861; 8 a.m. to 8 p.m. (7 days a week, 

Oct. – Feb.) or 8 a.m. to 8 p.m. (Mon. – Fri., March – Sept). TTY/TDD users should call 711. 

Y0032 12230_3 File and Use 8/22/12 Last Updated: August 21, 2012 

Version Number: 7 Effective: January 1, 2013 

1 

Formulary

What is the Geisinger Gold $0 Deductible RX Formulary? 

A formulary is a list of covered drugs selected by Geisinger Gold $0 Deductible RX 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. Geisinger Gold $0 Deductible RX will generally cover the drugs listed in our 

formulary as long as the drug is medically necessary, the prescription is filled at a Geisinger Gold $0 

Deductible RX 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 2013 formulary that was covered at the beginning of the year, we 

will not discontinue or reduce coverage of the drug during the 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 Januar 1, 2013. To get updated information 

about the drugs covered by Geisinger Gold $0 Deductible RX , please visit our Web site at 

www.thehealthplan.com/Gold/Landing_Pages/Formulary/ or call Member Services at (800) 988-4861, 

8 a.m. to 8 p.m. (7 days a week, Oct. – Feb.) or 8 a.m. to 8 p.m. (Mon. – Fri., March – Sept) . TTY/TDD 

users should call 711. If non-maintenance changes are made to the formulary during the plan year, Geisinger 

Gold $0 Deductible RX communicates changes to the formulary in the member newsletter and on the 

monthly explanation of benefits (EOB). 

How do I use the Formulary? 

There are two ways to find your drug within the formulary: 

Medical Condition 

The formulary begins on page 13. 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 under the category, “Cardiac Drugs”. If you know what your drug is used for, look 

for the category name in the list that begins 13. Then look under the category name for your drug. 

2

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 I-1. 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? 

Geisinger Gold $0 Deductible RX 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: Geisinger Gold $0 Deductible RX requires you or your physician to get prior 

authorization for certain drugs. This means that you will need to get approval from Geisinger Gold 

$0 Deductible RX before you fill your prescriptions. If you don’t get approval, Geisinger Gold $0 

Deductible RX may not cover the drug. 

Quantity Limits: For certain drugs, Geisinger Gold $0 Deductible RX limits the amount of the drug 

that Geisinger Gold $0 Deductible RX will cover. For example, Geisinger Gold $0 Deductible RX 

provides six (6) tablets per prescription for Axert. This may be in addition to a standard one month 

or three month supply. 

Step Therapy: In some cases, Geisinger Gold $0 Deductible RX 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, Geisinger Gold $0 Deductible RX 

may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Geisinger Gold 

$0 Deductible RX 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 13. You can also get more information about the restrictions applied to specific covered 

drugs by visiting our Web site at www.thehealthplan.com/Gold/Landing_Pages/Formulary/. 

You can ask Geisinger Gold $0 Deductible RX to make an exception to these restrictions or limits. See the 

section, “How do I request an exception to the Geisinger Gold $0 Deductible RX’s formulary?” on page 5 

for information about how to request an exception. 

3 

Formulary

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 Geisinger Gold $0 Deductible RX does not cover your drug, you 

have two options: 

You can ask Member Services for a list of similar drugs that are covered by Geisinger Gold $0 

Deductible RX. When you receive the list, show it to your doctor and ask him or her to prescribe a 

similar drug that is covered by Geisinger Gold $0 Deductible RX. 

You can ask Geisinger Gold $0 Deductible RX 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 Geisinger Gold $0 Deductible RX’s Formulary? 

You can ask Geisinger Gold $0 Deductible RX 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, 

Geisinger Gold $0 Deductible RX 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 

non-preferred brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in 

the preferred brand 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 specialty tier. 

Generally, Geisinger Gold $0 Deductible RX 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. 

4

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 34-day supply (unless you have a prescription written for fewer days) when you go to a 

network pharmacy. After your first 34-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 93-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 34-day 

emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary 

exception. 

For members who experience a level of care change such as changing from one treatment setting to another 

(e.g. hospital to long-term care facility), being admitted to or discharged from a long-term care facility, or 

reverting from hospice status back to standard Medicare Part A and B benefits, an exception for a one-time 

temporary fill will be granted even if the member is past the first 90 days of membership in our plan. Early 

refill edits will not be applied when a level of care change exists. 

For more information 

For more detailed information about your Geisinger Gold $0 Deductible RX prescription drug coverage, 

please review your Evidence of Coverage and other plan materials. 

If you have questions about Geisinger Gold $0 Deductible RX, please call Member Services at (800) 988- 

4861, 8 a.m. to 8 p.m. (7 days a week, Oct. – Feb.) or 8 a.m. to 8 p.m. (Mon. – Fri., March – Sept). 

TTY/TDD users should call 711. Or visit www.thehealthplan.com/Gold/Landing_Pages/Formulary/. 

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. 

5 

Formulary

Geisinger Gold $0 Deductible RX Formulary 

The formulary that begins on page 13 provides coverage information about some of the drugs covered by 

Geisinger Gold $0 Deductible RX. If you have trouble finding your drug in the list, turn to the Index that 

begins on page I-1. 

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BYETTA and 

generic drugs are listed in lower-case italics (e.g., simvastatin). 

The information in the Requirements/Limits column tells you if Geisinger Gold $0 Deductible RX has any 

special requirements for coverage of your drug. 

6

The following abbreviations may be found within the body of this document 

COVERAGE NOTES ABBREVIATIONS 

ABBREVIATION DESCRIPTION EXPLANATION 

generic (BRAND) 

General 

The reference brand name in parenthesis is provided 

for information only to assist in identifying the generic 

medication and does NOT indicate formulary status or 

coverage. 

Utilization Management Restrictions 

You (or your physician) are required to get prior 

PA 

Prior Authorization 

Restriction 

authorization from Geisinger Gold $0 Deductible RX 

before you fill your prescription for this drug. Without 

prior approval, Geisinger Gold $0 Deductible RX may 

not cover this drug. 

Geisinger Gold $0 Deductible RX limits the amount of 

QL Quantity Limit Restriction this drug that is covered per prescription, or within a 

specific time frame. 

Before Geisinger Gold $0 Deductible RX will provide 

coverage for this drug, you must first try another 

ST Step Therapy Restriction drug(s) to treat your medical condition. This drug may 

only be covered if the other drug(s) does not work for 

you. 

Other Special Requirements for Coverage 

This prescription may be available only at certain 

pharmacies. For more information consult your 

LA Limited Access Drug 

Pharmacy Directory or call Member Services at (800) 

988-4861, 8 a.m. to 8 p.m. (7 days a week, Oct. – Feb.) 

or 8 a.m. to 8 p.m. (Mon. – Fri., March – Sept). 

TTY/TDD users should call 711. 

We provide coverage of this prescription drug in the 

GC Gap Coverage coverage gap. Please refer to our Evidence of 

Coverage for more information about this coverage. 

You may be able to receive greater than a 1-month 

supply of most of the drugs on your formulary via mail 

NM Non-Mail Order Drug order at a reduced cost share. Drugs not available via 

your mail order benefit are noted with “NM” in the 

notes column of your formulary. 

7 

Formulary

STRENGTH AND DOSAGE FORM ABBREVIATIONS 

ABBREVIATION DESCRIPTION 

adh. patch adhesive patch 

aer br act aerosol, breath activated 

aer pow aerosol, powder 

aer pow ba aerosol powder, breath activated 

aer refill aerosol refill 

aer w/adap aerosol with adapter 

ampul ampule 

blkbaginj bulk bag injection 

cap dr mp capsule, delayed release multiphasic 

cap ds pk capsule, dose pack 

cap er 12h capsule, 12 hour extended release 

cap er 24h capsule, 24 hour extended release 

cap er deg capsule, extended release degradable 

cap er pel capsule, extended release pellets 

cap mphase capsule, multiphasic 

cap.sa 24h capsule, 24 hour sustained action 

cap.sr 12h capsule, 12 hour sustained release 

cap.sr 24h capsule, 24 hour sustained release 

cap24h pct capsule, 24 hour controlled-onset pellets 

cap24h pel capsule, 24 hour sustained release pellets 

cap sprink capsule, sprinkle 

cap sr pel capsule sustained release pellets 

cap w/dev capsule with device 

capsule dr capsule, delayed release 

capsule er capsule, extended release 

capsule sa capsule, sustained action 

cmb cappad combination: capsule, pad 

cmb ont fm combination: ointment, foam 

cmb ont lt combination: ointment, lotion 

cmb tabpad combination: tablet, pad 

combo. pkg combination package 

cpmp 12hr capsule, 12 hour multiphasic 

cpmp 24hr capsule, 24 hour multiphasic 

cpmp 30-70 capsule, multiphasic, 30%-70% 

cpmp 50-50 capsule, multiphasic, 50%-50% 

cream(g), cream(gm) cream (grams) 

cream(ml) cream (milliliters) 

cream/appl cream with applicator 

cream, er (g) cream, extended release (grams) 

cream pack cream, package 

dehp fr bg di(2-ethylhexyl)phthalate free bag 

dis needle disposable needle 

disk w/dev disk with inhalation device 

8


disp syrin disposable syringe 

drops susp drops, suspension 

drps hpvis drops, hyperviscous 

emul adhes emulsion adhesive 

emul packt emulsion packet 

emulsn(g) emulsion (grams) 

foam/appl. foam with applicator 

froz.piggy frozen piggyback 

g gram 

gel/pf app gel with prefilled applicator 

gel (gm) gel (grams) 

gel (ml) gel (milliliters) 

gel md pmp gel in metered dose pump 

gel w/appl gel with applicator 

gel w/pump gel with pump 

gran pack granule pack 

hfa aer ad hfa aerosol adapter 

infus. btl infusion bottle 

insuln pen insulin pen 

ip soln intraperitoneal solution 

irrig soln irrigating solution 

iv soln. intravenous solution 

jel jelly 

jelly/app jelly with applicator 

jel/pf app jelly with pre-filled applicator 

kit cl&crm kit: cleasner and cream 

kt crm le kit: cream, lotion emollient 

kt lotn ce kit: lotion, cream emollient 

kt oint le kit: ointment, lotion emollient 

lotion, er lotion, extended release 

lozenge hd lozenge handle 

m.ht patch medicated heated patch 

ma buc tab mucoadhesive buccal tablet 

mcg microgram 

med. pad medicated pad 

med. swab medicated swab 

med. tape medicated tape 

mg milligram 

ml milliliter 

muc er 12h mucoadhesive system, 12 hour extended release 

ndl fr inj needle for injection 

nl fm susp nail film suspension 

oint. (g), oint.(gm) ointment (grams) 

9 

Formulary


oral conc oral concentrate 

oral susp oral suspension 

paste (g) paste (grams) 

patch td24 patch, 24 hour transdermal 

patch td72 patch, 72 hour transdermal 

patch tdsw patch, biweekly transdermal 

patch tdwk patch, weekly transdermal 

pca syring patient-controlled analgesic syringe 

pca vial patient-controlled analgesic vial 

pellet(ea) pellet (each) 

pen ij kit pen injector kit 

pen injctr pen injector 

pggybk btl piggyback bottle 

plast. bag plastic bag 

powd pack powder pack 

sol md pmp solution with multi-dose pump 

sol w/appl solution with applicator 

sol/pf app solution with pre-filled applicator 

sol-gel solution, gel-forming 

soln recon solution, reconstituted 

soln(gram) solution (grams) 

spray susp spray, suspension 

spray/pump spray with pump 

stick(ea) stick (each) 

supp.rect suppository, rectal 

supp.vag suppository, vaginal 

suppos. suppository 

sus er 24h suspension, 24 hour extended release 

sus er rec suspension, extended release reconstituted 

sus mc rec suspension, microcapsule reconstituted 

suspdr pkt suspension, delayed release packet 

susp recon suspension, reconstituted 

syringekit syringe kit 

tab chew tablet, chewable 

tab er 12h tablet, 12 hour extended release 

tab er 24h tablet, 24 hour extended release 

tab er prt tablet, extended release particles 

tab er seq tablet, extended release sequels 

tab disper tablet, dispersable 

tab ds pk tablet, dose pack 

tab er 24 tablet, 24 hour extended release 

tab mphase tablet, multiphasic 

tab part tablet, particles 

10


tab rap dr tablet, rapid disintegrating delayed release 

tab rapdis tablet, rapid disintegrating 

tab subl tablet, sublingual 

tab.sr 12h tablet, 12 hour sustained release 

tab.sr 24h tablet, 24 hour sustained release 

tabergr24hr tablet, 24 hour gradual extended release 

tablet dr tablet, delayed release 

tablet, er tablet, extended release 

tablet eff tablet, effervescent 

tablet sa tablet, sustained action 

tablet sol tablet, soluble 

tb er dspk tablet, extended release dosepack 

tb mp dspk tablet, multiphasic dosepack 

tb rd dspk tablet, rapid disintegrating dosepack 

tbdspk 3mo tablet, 3-month dosepack 

tbmp 12hr tablet, 12 hour multiphasic 

tbmp 24hr tablet, 24 hour multiphasic 

u unit 

vag ring vaginal ring 

11 

Formulary

Every medication on the Geisinger Gold $0 Deductible RX formulary is in one of five (5) cost-sharing tiers. 

In general, the higher the cost-sharing tier number, the higher your cost for the medication: As shown in the 

table below, the amount of the copayment or coinsurance depends on which cost-sharing tier your 

medication is in. Please note: what you pay for your medication depends on which “drug payment stage” you 

are in when you get the medication, and where you get the medication filled. 

Your share of the cost when you get a one-month supply (or less) of a covered Part D prescription drug 

prior to entering the coverage gap: 

Tier 1 (preferred generic) $3 

Tier 2 (non-preferred generic) $7 

Tier 3 (preferred brand) $39 

Tier 4 (non-preferred brand) $69 

Tier 5 (specialty tier) 33% coinsurance 

12

Drug Name 

Drug 

Tier Requirements/Limits 

Adrenals 

Adrenals 

ADVAIR DISKUS 3 

ADVAIR HFA 3 

ASMANEX 4 aer pow ba: 

110mcg(30), 

220mcg(14), 

220mcg(30), 

220mcg(60), 

220mcg120 

ASMANEX 4 aer pow ba: 

110mcg(7) 

betamet acet/betamet na 

ph 

(Celestone) 2 NM, PA 

budesonide (Entocort EC) 2 

cortisone acetate (Cortisone Acetate) 2 PA 

DEXAMETHASONE 

INTENSOL 

4 

dexamethasone sod 

phosphate 

(Dexamethasone Sod Phosphate) 2 NM, PA vial: 10mg/ml 


phosphate 

(Dexamethasone Sod Phosphate) 2 NM, PA vial: 4mg/ml 

dexamethasone (Dexamethasone) 2 PA 

DULERA 3 

FLOVENT DISKUS 4 

FLOVENT HFA 3 

fludrocortisone acetate (Fludrocortisone Acetate) 2 

hydrocortisone sod 

succinate 

(Hydrocortisone Sod Succinate) 2 NM, PA 

hydrocortisone (Cortef) 2 PA 

methylprednisolone 

acetate 

(Depo-medrol) 2 NM, PA 

methylprednisolone sod 

succ 

(Solu-medrol) 2 NM, PA vial: 1000mg 

methylprednisolone sod 

succ 

(Solu-medrol) 2 NM, PA vial: 125mg/2ml 

methylprednisolone (Medrol) 2 PA 

prednisolone acetate (Prednisolone Acetate) 2 NM, PA 

prednisolone sod 

phosphate 

(Orapred) 2 PA 

13 

Geisinger Gold $0 Deductible Rx 2013 Part D Formulary Effective: January 01, 2013 

Formulary ID: 13099.000, Version: 7 

Formulary

Drug Name 

Drug 


prednisolone (Prednisolone) 2 PA 

prednisone (Prednisone) 2 tab ds pk 

prednisone (Prednisone) 2 PA solution, tablet 

PULMICORT 

FLEXHALER 

3 

QVAR 3 

SOLU-MEDROL (PF) 4 NM, PA vial: 40mg/ml 

SYMBICORT 3 

VERIPRED 20 2 PA 

Alpha-Adrenergic Blocking Agents 


doxazosin mesylate (Cardura) 2 

prazosin hcl (Minipress) 2 

terazosin hcl 

Ammonia Detoxicants 

(Hytrin) 2 

Ammonia Detoxicants 

BUPHENYL 3 tablet 

BUPHENYL 4 powder 

lactulose (Lactulose) 2 solution 

lactulose (Lactulose) 2 syrup 

Analgesics and Antipyretics 

Analgesics And Antipyretics, Miscellaneous 

acetaminophen/phenyltolx (Staflex) 2 QL: 180 tablet: 650mg-50mg 

cit 

in 30 

days 

acetaminophen/phenyltolx (Staflex) 2 QL: 240 tablet: 500mg-50mg 

cit 

in 30 

days 

sal-amide/acetamin/p-tlox/ (Durabac) 2 QL: 360 

caff 

in 30 

days 

sal-amide/acetaminophn/ (Asp) 2 QL: 390 capsule 

p-tlox 

in 30 

days 

Nonsteroidal Anti-inflammatory Agents 

CELEBREX 3 

choline sal/mag salicylate (Choline Sal/mag Salicylate) 2 

diclofenac potassium (Cataflam) 2 

diclofenac sodium (Voltaren) 2 

diclofenac sodium (Voltaren) 2 (oral products only) 

14 


Formulary ID: 13099.000, Version: 7

Drug Name 

Drug 


diflunisal (Diflunisal) 2 

etodolac (Etodolac) 2 capsule: 200mg; tab 

er 24h, tablet 

etodolac (Etodolac) 2 capsule: 300mg 

fenoprofen calcium (Fenoprofen Calcium) 2 

flurbiprofen (Ansaid) 2 

ibuprofen (Motrin) 2 

ketoprofen (Ketoprofen) 2 

magnesium salicylate (Magnesium Salicylate) 2 

meclofenamate sodium (Meclofenamate Sodium) 2 

mefenamic acid (Ponstel) 2 

meloxicam (Mobic) 2 

methyl salicylate (Methyl Salicylate) 2 

nabumetone (Relafen) 2 

naproxen sodium (Anaprox) 2 

naproxen (Naprosyn) 2 

oxaprozin (Oxaprozin) 2 

phenylbutazone (Phenylbutazone) 2 

piroxicam (Feldene) 2 

salsalate (Salflex) 2 

SOLARAZE 4 (oral products only) 

sulindac (Clinoril) 2 

tolmetin sodium (Tolmetin Sodium) 2 

Opiate Agonists 

acetaminophen with 

codeine 


codeine 


codeine 


codeine 

(Tylenol-codeine No.3) 2 NM, QL: 

360 in 30 

15 



days 

(Tylenol-codeine No.3) 2 NM, QL: 

390 in 30 

days 

(Tylenol-codeine No.3) 2 QL: 180 

in 30 

days 

(Tylenol-codeine No.3) 2 QL: 180 

in 30 

days 

AVINZA 3 NM, QL: 

30 in 30 

days 

tablet: 300mg-30mg 



tablet: 650mg- 

30mg, 650mg-60mg 

cpmp 24hr: 30mg, 

45mg, 60mg 

Formulary

Drug Name 

AVINZA 3 NM, QL: 

60 in 30 

codeine phos/ 

acetaminophen 

Drug 


16 



days 

(Codeine Phos/acetaminophen) 2 NM, QL: 

5000 in 

30 days 

codeine sulfate (Codeine Sulfate) 2 NM, QL: 

180 in 30 

codeine/butalbit/acetamin/ 

caff 

codeine/butalbital/asa/ 

caffein 

dhcodeine bt/ 

acetaminophn/caff 

dhcodeine bt/ 

acetaminophn/caff 

days 

(Fioricet with Codeine) 2 NM, QL: 

180 in 30 

days 

(Fiorinal with Codeine #3) 2 NM, QL: 

180 in 30 

(Dhcodeine Bt/acetaminophn/ 

caff) 

days 

2 QL: 330 

in 30 

days 

(Panlor SS) 2 NM, QL: 

150 in 30 

days 

fentanyl citrate (Actiq) 2 NM, PA, 

QL: 120 

in 30 

days 

fentanyl (Duragesic) 2 NM, QL: 

10 in 30 

days 

fentanyl (Duragesic) 2 NM, QL: 

20 in 30 

hydrocodone bit/ 

acetaminophen 


acetaminophen 


acetaminophen 

days 

(Hycet) 2 NM, QL: 

2700 in 

30 days 

(Hycet) 2 QL: 2025 

in 30 

days 

(Hycet) 2 QL: 2700 

in 30 

days 

cpmp 24hr: 75mg, 

90mg, 120mg 

capsule 

tablet 

patch td72: 12mcg/ 

hr, 25mcg/hr, 

50mcg/hr 

patch td72: 75mcg/ 

hr, 100mcg/hr 

solution: 7.5-500/15 

solution: 10-300/15 

solution: 5-163/7.5


acetaminophen 


acetaminophen 


acetaminophen 


acetaminophen 


acetaminophen 


acetaminophen 


acetaminophen 

Drug Name 

Drug 


(Hycet) 2 QL: 2700 solution: 7.5-325/15 

in 30 

days 

(Vicodin) 2 tablet: 2.5-325mg 

(Vicodin) 2 NM, QL: 

150 in 30 

17 



days 


180 in 30 

days 


240 in 30 

days 


360 in 30 

days 


390 in 30 

days 

hydrocodone/ibuprofen (Vicoprofen) 2 NM, QL: 

150 in 30 

days 

tablet: 7.5-750mg, 

10-750mg 


10-660mg, 10mg- 

650mg 

capsule, tablet: 2.5- 

500mg, 5mg- 

500mg, 7.5-500mg, 

10mg-500mg 

tablet: 5mg-325mg, 

7.5-325mg, 10mg- 

325mg 

tablet: 5mg-300mg, 

7.5-300mg, 10mg- 

300mg 

hydromorphone hcl (Dilaudid) 2 vial 

hydromorphone hcl (Dilaudid) 2 NM, QL: 

180 in 30 

days 

tablet: 2mg, 4mg 

hydromorphone hcl (Dilaudid) 2 NM, QL: 

240 in 30 

days 

tablet: 8mg 

hydromorphone hcl/pf (Dilaudid) 2 NM ampul 

hydromorphone hcl/pf (Hydromorphone HCl/PF) 2 disp syrin 

hydromorphone hcl/pf (Hydromorphone HCl/PF) 2 NM vial 

ibuprofen/oxycodone hcl (Combunox) 2 NM, QL: 

28 in 30 

days 

levorphanol tartrate (Levo-dromoran) 2 NM, QL: 

180 in 30 

days 

Formulary

Drug Name 

methadone hcl (Methadone HCl) 2 NM, QL: 

1800 in 

Drug 


oral conc, solution 

methadone hcl (Methadone HCl) 2 

30 days 

NM vial 

methadone hcl (Methadose) 2 NM, QL: 

360 in 30 

days 

tablet 

methadone hcl (Methadose) 2 QL: 90 in tablet sol 

30 days 

morphine sulfate (Kadian) 2 QL: 120 cap er pel: 20mg, 

in 30 

days 

60mg, 80mg 

morphine sulfate (Kadian) 2 QL: 90 in cap er pel: 30mg, 

30 days 50mg, 100mg 

morphine sulfate (Morphine Sulfate) 2 supp.rect, vial: 

10mg/ml 

morphine sulfate (Morphine Sulfate) 2 NM, QL: 

180 in 30 

days 

tablet 

morphine sulfate (Morphine Sulfate) 2 NM disp syrin, pen 

injctr, vial: 50mg/ml 

morphine sulfate (MS Contin) 2 NM, QL: tablet er: 60mg, 

120 in 30 200mg 

days 

morphine sulfate (MS Contin) 2 NM, QL: tablet er: 15mg, 

90 in 30 

days 

30mg, 100mg 

morphine sulfate (MSIR) 2 NM, QL: solution: 100mg/ 

200 in 30 5ml 

days 

morphine sulfate (MSIR) 2 NM, QL: 

300 in 30 

days 

solution: 20mg/5ml 

morphine sulfate (MSIR) 2 NM, QL: 

700 in 30 

days 

solution: 10mg/5ml 

morphine sulfate/pf (Morphine Sulfate/PF) 2 pca vial: 150mg/ 

30ml 

morphine sulfate/pf (Morphine Sulfate/PF) 2 NM pca vial: 30mg/ 

30ml; vial: 25mg/ml 

morphine sulfate/pf (Morphine Sulfate/PF) 2 NM vial: 1mg/ml 

18 



Drug Name 

oxycodone hcl (Oxycodone HCl) 2 NM, QL: 

1300 in 

Drug 


30 days 

oxycodone hcl (Roxicodone) 2 NM, QL: 

180 in 30 

solution 

19 



days 

oxycodone hcl (Roxicodone) 2 NM, QL: 

180 in 30 

oxycodone hcl/ 

acetaminophen 


acetaminophen 


acetaminophen 


acetaminophen 

(Oxycodone HCl/ 

acetaminophen) 

days 

2 NM, QL: 

1830 in 

30 days 

(Percocet) 2 NM, QL: 

180 in 30 

days 


240 in 30 

days 


360 in 30 

days 

oxycodone hcl/aspirin (Percodan) 2 NM, QL: 

360 in 30 

days 

OXYCONTIN 4 NM, ST, 

QL: 120 

in 30 

days 

OXYCONTIN 4 NM, ST, 

QL: 90 in 

30 days 

oxymorphone hcl (Opana) 2 NM, QL: 

180 in 30 

days 

tramadol hcl (Tramadol HCl) 2 QL: 60 in 

30 days 

tramadol hcl (Ultram ER) 2 QL: 30 in 

30 days 

tramadol hcl (Ultram ER) 2 QL: 90 in 

30 days 

capsule, oral conc, 

tablet: 5mg, 15mg, 

30mg 


solution 


capsule, tablet: 

5mg-500mg, 7.5- 

500mg 


5mg-325mg, 7.5- 

325mg, 10mg- 

325mg 

tab er 12h: 60mg, 

80mg 


15mg, 20mg, 30mg, 

40mg 

tablet 

cpmp 25-75 


300mg 

tab er 24h: 100mg 

Formulary

Drug Name 

tramadol hcl (Ultram) 2 QL: 240 

in 30 

Drug 


20 



days 

tablet 

tramadol hcl/ 

(Ultracet) 2 QL: 240 

acetaminophen 

in 30 

days 

Opiate Partial Agonists 

buprenorphine hcl (Buprenorphine HCl) 2 NM disp syrin, (oral 

buprenorphine hcl (Subutex) 2 NM, QL: 

20 in 30 

days 

buprenorphine hcl (Subutex) 2 NM, QL: 

5 in 30 

days 

butorphanol tartrate (Butorphanol Tartrate) 2 NM 

BUTRANS 4 PA, QL: 

4 in 28 

days 

nalbuphine hcl (Nalbuphine HCl) 2 NM 

SUBOXONE 4 NM, QL: 

360 in 30 

days 

SUBOXONE 4 NM, QL: 

90 in 30 

days 

Androgens 

Androgens 

ANADROL-50 3 NM 

ANDRODERM 3 

ANDROGEL 4 

danazol (Danocrine) 2 

fluoxymesterone (Fluoxymesterone) 2 

oxandrolone (Oxandrin) 2 NM 

STRIANT 4 

testosterone cypionate (Depo-testosterone) 2 NM 

testosterone enanthate (Delatestryl) 2 NM 

products only) 

tab subl: 2mg, (oral 


tab subl: 8mg, (oral 


tab subl: 2mg- 

0.5mg 

tab subl: 8mg-2mg

Drug Name 

Drug 


Anorexigenics, Respiratory, Cerebral Stimulants 

Amphetamines 

amphet asp/amphet/damphet 

(Adderall XR) 2 cap er 24h 

amphet asp/amphet/damphet 

(Adderall) 2 NM tablet 

dextroamphetamine 

sulfate 

(Dexedrine) 2 NM 

methamphetamine hcl (Desoxyn) 2 NM 

Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous 

caffeine citrated (Cafcit) 2 solution 

caffeine citrated (Cafcit) 2 NM vial 

caffeine/sodium benzoate (Caffeine/sodium Benzoate) 2 NM 

dexmethylphenidate hcl (Focalin) 2 NM 

METADATE CD 3 NM 

METHYLIN 2 NM tab chew, (oral 


methylphenidate hcl (Concerta) 2 tab er 24, (oral 


methylphenidate hcl (Ritalin LA) 2 cpmp 50-50, tablet 

er, (oral products 

only) 

methylphenidate hcl (Ritalin) 2 cpmp 50-50, tablet 

er 

methylphenidate hcl (Ritalin) 2 NM solution, tablet, 

(oral products only) 

modafinil (Provigil) 2 

NUVIGIL 4 PA 

PROVIGIL 

Anthelmintics 

Anthelmintics 

3 PA 

ALBENZA 3 

BILTRICIDE 4 

STROMECTOL 

Antiallergic Agents 

4 

Antiallergic Agents 

ALOMIDE 4 

azelastine hcl (Astelin) 2 

epinastine hcl (Elestat) 2 

PATADAY 3 

21 



Formulary

Drug Name 

Drug 


Antibacterials 

Aminoglycosides 

amikacin sulfate (Amikacin Sulfate) 2 vial: 1000mg/4ml 

amikacin sulfate (Amikacin Sulfate) 2 NM vial: 100mg/2ml 

gentamicin in nacl, isoosm 

(Gentamicin In Nacl, Iso-osm) 2 piggyback: 80mg/ 

100ml, 80mg/50ml, 

100mg/0.1l 

(Gentamicin In Nacl, Iso-osm) 2 NM piggyback: 100mg/ 

gentamicin in nacl, isoosm 

50ml 

gentamicin in nacl, iso- (Gentamicin In Nacl, Iso-osm) 2 NM piggyback: 60mg/ 

osm 

50ml, 70mg/50ml, 

90mg/100ml 

gentamicin sulfate (Garamycin) 2 NM 

gentamicin sulfate/pf (Gentamicin Sulfate/PF) 2 NM 

kanamycin sulfate (Kanamycin Sulfate) 2 NM vial: 1g/3ml 

kanamycin sulfate (Kanamycin Sulfate) 2 NM vial: 500mg/2ml 

neomycin sulfate (Neomycin Sulfate) 2 solution 

neomycin sulfate (Neomycin Sulfate) 2 tablet 

streptomycin sulfate (Streptomycin Sulfate) 2 NM 

TOBI 4 PA 

tobramycin sulfate (Nebcin) 2 NM 

tobramycin/sodium 

chloride 

(Tobramycin/sodium Chloride) 2 NM 

Antibacterials, Miscellaneous 

bacitracin (Bacitracin) 2 NM 

chloramphenicol na succ (Chloramphenicol Na Succ) 2 NM 

clindamycin hcl (Cleocin HCl) 2 capsule: 150mg, 

300mg 

clindamycin hcl (Cleocin HCl) 2 capsule: 75mg 

clindamycin palmitate hcl (Cleocin Palmitate) 2 

clindamycin phosphate (Cleocin Phosphate) 2 NM 

colistin (colistimethate na) (Coly-mycin M Parenteral) 2 NM 

CUBICIN 5 NM, PA 

LINCOCIN 4 NM 

polymyxin b sulfate (Polymyxin B Sulfate) 2 NM 

vancomycin hcl (Vancocin HCl) 2 capsule 

vancomycin hcl (Vancomycin HCl) 2 NM, PA vial: 10g 

vancomycin hcl (Vancomycin HCl) 2 PA vial: 1g 

vancomycin hcl/d5w (Vancomycin HCl/D5W) 2 NM 

ZYVOX 5 NM, PA 

22 



Drug Name 

Cephalosporins 

cefaclor (Ceclor) 2 

cefadroxil hydrate (Cefadroxil Hydrate) 2 

Drug 


cefazolin sodium (Ancef) 2 NM 

cefazolin sodium/ 

dextrose,iso 

(Cefazolin Sodium/dextrose, Iso) 2 froz.piggy 

cefdinir (Omnicef) 2 

cefditoren pivoxil (Spectracef) 2 

cefepime hcl (Maxipime) 2 NM 

cefotaxime sodium (Claforan) 2 NM vial: 1g, 2g, 10g 

cefotaxime sodium (Claforan) 2 NM vial: 500mg 

cefpodoxime proxetil (Vantin) 2 

cefprozil (Cefzil) 2 

ceftazidime pentahydrate (Fortaz) 2 vial: 500mg 

ceftazidime pentahydrate (Fortaz) 2 NM vial: 1g; vial port: 

1g 

ceftazidime pentahydrate (Fortaz) 2 NM vial: 2g, 6g 

CEFTAZIDIME 2 

ceftriaxone na/ 

dextrose,iso 

(Ceftriaxone Na/dextrose, Iso) 2 NM froz.piggy: 1g/50ml 

ceftriaxone sodium (Rocephin) 2 NM vial 

cefuroxime axetil (Ceftin) 2 

cefuroxime sodium (Zinacef) 2 vial: 7.5g 

cefuroxime sodium (Zinacef) 2 NM vial: 1.5g, 750mg 

cefuroxime sodium/ (Cefuroxime Sodium/dextrose, 2 NM 

dextrose,iso 

Iso) 

cephalexin (Keflex) 2 

SUPRAX 

Macrolides 

4 tablet 

azithromycin (Zithromax) 2 NM vial 

azithromycin (Zithromax) 2 PA packet 

azithromycin (Zithromax) 2 PA susp recon, tablet 

clarithromycin (Biaxin) 2 PA 

ery e-succ/sulfisoxazole (Pediazole) 2 PA 

ERY-TAB 2 PA 

ERYTHROCIN 

LACTOBIONATE 

3 vial port: 500mg 

erythromycin base (Eryc) 2 PA capsule dr 

erythromycin base (Erythromycin Base) 2 PA tablet, tablet dr 

23 



Formulary

Drug Name 

Drug 


erythromycin 

(Erythromycin Ethylsuccinate) 2 PA oral susp: 200mg/ 

ethylsuccinate 

5ml 

erythromycin 

ethylsuccinate 

(Erythromycin Ethylsuccinate) 2 PA tablet 

erythromycin stearate (Erythromycin Stearate) 2 PA 

KETEK 4 PA 

PCE 4 PA 

Miscellaneous B-lactam Antibiotics 

aztreonam (Azactam) 2 NM 

cefotetan disod/ 

dextrose,iso 

(Cefotetan Disod/dextrose, Iso) 2 NM 

cefotetan disodium (Cefotetan Disodium) 2 NM 

cefoxitin sodium (Mefoxin) 2 NM 

cefoxitin sodium/ 

dextrose,iso 

(Cefoxitin Sodium/dextrose, Iso) 2 NM 

imipenem/cilastatin 

sodium 

(Primaxin) 2 

meropenem (Merrem) 2 NM 

PRIMAXIN I.M. 3 NM 

PRIMAXIN 

Penicillins 

3 NM 

amoxicillin (Amoxil) 2 

amoxicillin/potassium clav (Augmentin) 2 

ampicillin sodium (Totacillin-N) 2 vial: 2g 

ampicillin sodium (Totacillin-N) 2 NM vial port 

ampicillin sodium (Totacillin-N) 2 NM vial: 10g, 125mg 

ampicillin sodium/ 

sulbactam na 

(Unasyn) 2 vial port 


sulbactam na 

(Unasyn) 2 vial: 3g 


sulbactam na 

(Unasyn) 2 NM vial: 15g 

ampicillin trihydrate (Ampicillin Trihydrate) 2 

dicloxacillin sodium (Dicloxacillin Sodium) 2 

nafcillin sodium (Unipen) 2 NM vial 

nafcillin sodium (Unipen) 2 NM vial port 

NALLPEN-ISO- 

OSMOTIC DEXTROSE 

2 NM 

oxacillin sodium (Oxacillin Sodium) 2 vial: 2g 

oxacillin sodium (Oxacillin Sodium) 2 NM vial: 10g 

24 



Drug Name 

Drug 


oxacillin sodium/ 

dextrose,iso 

(Oxacillin Sodium/dextrose, Iso) 2 NM 

pen g pot/dextrose-water (Pen G Pot/dextrose-water) 2 NM froz.piggy: 1mm/ 

50ml 

pen g pot/dextrose-water (Pen G Pot/dextrose-water) 2 NM froz.piggy: 2mm/ 

50ml, 3mm/50ml 

penicillin g potassium (Penicillin G Potassium) 2 NM 

penicillin g potassium/d5w (Penicillin G Potassium/D5W) 2 NM 

penicillin g procaine (Penicillin G Procaine) 2 NM disp syrin: 1.2mm/ 

2ml 

penicillin g procaine (Penicillin G Procaine) 2 NM disp syrin: 600000/ 

ml 

penicillin v potassium (Veetids 500) 2 

piperacillin sodium/ 

tazobactam 

(Zosyn) 2 

TIMENTIN 

Quinolones 

3 NM 

AVELOX ABC PACK 3 

AVELOX 3 

ciprofloxacin hcl (Cipro) 2 

ciprofloxacin lactate/d5w (Cipro I.V.) 2 

ciprofloxacin/ciprofloxa 

hcl 

(Cipro XR) 2 

LEVAQUIN 3 piggyback 

levofloxacin (Levaquin) 2 

levofloxacin/d5w (Levaquin) 2 

nalidixic acid (Nalidixic Acid) 2 

ofloxacin (Floxin) 2 

Sulfonamides (Systemic) 

sulfadiazine (Sulfadiazine) 2 

sulfamethoxazole/ 

trimethoprim 

(Septra) 2 oral susp, tablet 

sulfamethoxazole/ (Sulfamethoxazole/ 

2 NM vial 

trimethoprim 

trimethoprim) 

sulfasalazine 

Tetracyclines 

(Azulfidine) 2 

ALODOX 3 

demeclocycline hcl (Declomycin) 2 

doxycycline hyclate (Doxycycline Hyclate) 2 NM vial 

doxycycline hyclate (Vibramycin) 2 capsule, tablet dr 

25 



Formulary

Drug Name 

Drug 


doxycycline hyclate (Vibra-tabs) 2 capsule dr, tablet 

doxycycline monohydrate (Adoxa) 2 capsule: 75mg; 

tablet 

doxycycline monohydrate (Monodox) 2 capsule: 150mg 

minocycline hcl (Dynacin) 2 

tetracycline hcl (Ala-tet) 2 capsule 

tetracycline hcl (Tetracycline HCl) 2 oral susp 

TYGACIL 4 NM 

Anticholinergic Agents 

Antimuscarinics/Antispasmodics 

atropine sulfate (Atropine Sulfate) 2 NM disp syrin 

atropine sulfate (Atropine Sulfate) 2 NM vial 

ATROVENT HFA 3 

dicyclomine hcl (Bentyl) 2 

glycopyrrolate (Robinul) 2 tablet 

glycopyrrolate (Robinul) 2 NM vial 

hyoscyamine sulfate (Symax-sl) 2 drops, elixir, tab 

rapdis: 0.125mg, 

0.25mg; tab subl, 

tablet 

hyoscyamine (Cystospaz) 2 

isopropamide/ 

prochlorperazine 

(Isopropamide/prochlorperazine) 2 

methscopolamine bromide (Pamine) 2 

propantheline/ 

phenobarbital 

(Propantheline/phenobarbital) 2 

SPIRIVA 

Anticonvulsants 

3 

Anticonvulsants, Miscellaneous 

BANZEL 4 

carbamazepine (Tegretol XR) 2 tab er 12h 

carbamazepine (Tegretol) 2 cpmp 12hr, oral 

susp, tab chew, 

tablet 

divalproex sodium (Depakote ER) 2 

felbamate (Felbatol) 2 

gabapentin (Neurontin) 2 

GABITRIL 3 

LAMICTAL (BLUE) 4 

LAMICTAL (GREEN) 4 

26 



Drug Name 

Drug 


LAMICTAL (ORANGE) 4 

LAMICTAL ODT 

(BLUE) 

4 

LAMICTAL ODT 

(GREEN) 

4 

LAMICTAL ODT 

(ORANGE) 

4 

LAMICTAL ODT 4 

LAMICTAL XR (BLUE) 4 

LAMICTAL XR 

(GREEN) 

4 

LAMICTAL XR 

(ORANGE) 

4 

LAMICTAL XR 4 tab er 24: 25mg, 

50mg, 100mg, 

200mg, 250mg 

LAMICTAL XR 4 tab er 24: 300mg 

lamotrigine (Lamictal (green)) 2 tab ds pk 

lamotrigine (Lamictal) 2 tablet, tb chw dsp 

levetiracetam in nacl (isoos) 

(Levetiracetam In Nacl (iso-os)) 2 

levetiracetam (Keppra) 2 solution, tab er 24h, 

tablet 

levetiracetam (Keppra) 2 NM vial 

LYRICA 3 

magnesium chloride (Magnesium Chloride) 2 

magnesium sulfate (Magnesium Sulfate) 2 NM disp syrin 

magnesium sulfate (Magnesium Sulfate) 2 NM infus. btl, 

piggyback, vial 

magnesium sulfate/d5w (Magnesium Sulfate/D5W) 2 NM 

oxcarbazepine (Trileptal) 2 oral susp 

oxcarbazepine (Trileptal) 2 tablet 

POTIGA 4 

SABRIL 3 PA 

STAVZOR 4 

TEGRETOL XR 3 tab er 12h: 100mg 

topiramate (Topamax) 2 

TRILEPTAL 4 oral susp 

valproate sodium (Depacon) 2 NM vial 

valproate sodium (Depakene) 2 solution 

27 



Formulary

Drug Name 

Drug 


valproic acid (Depakene) 2 

VIMPAT 4 NM, PA vial 

VIMPAT 4 PA solution, tablet 

zonisamide (Zonegran) 2 

Hydantoins 

DILANTIN 3 tab chew 

DILANTIN 4 capsule 

fosphenytoin sodium (Cerebyx) 2 NM 

PEGANONE 3 

PHENYTEK 4 

phenytoin sodium 

extended 

(Dilantin) 2 

phenytoin sodium (Phenytoin Sodium) 2 ampul 

phenytoin sodium (Phenytoin Sodium) 2 disp syrin 

phenytoin 

Succinimides 

(Dilantin-125) 2 

CELONTIN 4 

ethosuximide 

Antidiabetic Agents 

(Zarontin) 2 

Antidiabetic Agents, Miscellaneous 

acarbose (Precose) 1 GC 

BYETTA 3 

GLYSET 4 

JANUMET 3 QL: 60 in 

30 days 

JANUVIA 3 

KORLYM 5 NM, LA, 

QL: 120 

in 30 

days 

metformin hcl (Fortamet) 2 QL: 60 in tab er 24 

30 days 

metformin hcl (Glucophage XR) 2 QL: 120 

in 30 

days 

tab er 24h: 500mg 

metformin hcl (Glucophage XR) 2 QL: 60 in tab er 24h: 750mg 

30 days 

metformin hcl (Glucophage) 1 GC, QL: 

150 in 30 

days 

tablet: 500mg 

28 



Drug Name 


75 in 30 

Drug 


29 



days 


90 in 30 

days 

nateglinide (Starlix) 2 

PRANDIN 3 

SYMLIN 3 NM, PA 

SYMLINPEN 120 3 PA 

SYMLINPEN 60 

Insulins 

3 PA 

LANTUS SOLOSTAR 3 

LANTUS 3 

LEVEMIR 3 

NOVOLIN 70-30 

3 

INNOLET 

tablet: 1000mg 

tablet: 850mg 

NOVOLIN 70-30 3 

NOVOLIN N INNOLET 3 

NOVOLIN N 3 

NOVOLIN R 3 insuln pen 

NOVOLIN R 3 vial 

NOVOLOG MIX 70-30 3 

NOVOLOG 

Sulfonylureas 

3 

chlorpropamide (Diabinese) 2 QL: 225 

in 30 

days 

tablet: 100mg 

chlorpropamide (Diabinese) 2 QL: 90 in tablet: 250mg 

30 days 

glimepiride (Amaryl) 1 GC, QL: 

120 in 30 

days 


240 in 30 

days 


60 in 30 

days 

tablet: 2mg 

tablet: 1mg 

tablet: 4mg 

Formulary

Drug Name 

glipizide (Glucotrol XL) 1 GC, QL: 

60 in 30 

Drug 


30 



days 

glipizide (Glucotrol) 1 GC, QL: 

120 in 30 

days 

glipizide (Glucotrol) 1 GC, QL: 

240 in 30 

days 

glipizide/metformin hcl (Metaglip) 1 GC, QL: 

120 in 30 

days 

glipizide/metformin hcl (Metaglip) 1 GC, QL: 

240 in 30 

days 

glyburide (Micronase) 2 QL: 120 

in 30 

days 


in 30 

days 


in 30 

days 

glyburide,micronized (Glynase) 2 QL: 120 

in 30 

days 

glyburide,micronized (Glynase) 2 QL: 240 

in 30 

days 

glyburide,micronized (Glynase) 2 QL: 60 in 

30 days 

glyburide/metformin hcl (Glucovance) 2 QL: 120 

in 30 

days 

glyburide/metformin hcl (Glucovance) 2 QL: 240 

in 30 

days 

tolazamide (Tolazamide) 1 GC, QL: 

120 in 30 

days 

tab er 24: 10mg 

tab er 24: 5mg; 

tablet: 10mg 

tab er 24: 2.5mg; 

tablet: 5mg 


5mg-500mg 

tablet: 2.5-250mg 

tablet: 5mg 

tablet: 2.5mg 

tablet: 1.25mg 

tablet: 3mg 

tablet: 1.5mg 

tablet: 6mg 


5mg-500mg 

tablet: 1.25-250mg 

tablet: 250mg

Drug Name 

tolazamide (Tolazamide) 1 GC, QL: 

60 in 30 

Drug 


31 



days 

tolbutamide 

Thiazolidinediones 

(Tolbutamide) 1 GC, QL: 

180 in 30 

days 

ACTOPLUS MET XR 3 QL: 30 in 

30 days 

ACTOPLUS MET XR 3 QL: 60 in 

30 days 

ACTOPLUS MET 3 QL: 90 in 

30 days 

ACTOS 3 QL: 30 in 

tablet: 500mg 

tbmp 24hr: 30- 

1000mg 

tbmp 24hr: 15- 

1000mg 


ACTOS 

Antidiarrhea Agents 

3 

30 days 

QL: 90 in tablet: 15mg 

30 days 

Antidiarrhea Agents 

diphenoxylate hcl/atropine (Lomotil) 2 NM, PA liquid 

diphenoxylate hcl/atropine (Lomotil) 2 PA tablet 

loperamide hcl (Loperamide HCl) 2 

opium tincture 

Antiemetics 

(Opium Tincture) 2 

5-ht3 Receptor Antagonists 

ANZEMET 4 PA tablet 

granisetron hcl (Kytril) 2 vial 

granisetron hcl (Kytril) 2 PA solution, tablet 

granisetron hcl/pf (Kytril) 2 NM 

ondansetron hcl (Zofran) 2 NM vial 

ondansetron hcl (Zofran) 2 PA solution, tablet 

ondansetron in 0.9 % 

nacl/pf 

(Ondansetron In 0.9 % Nacl/PF) 2 NM 

ondansetron (Zofran Odt) 2 PA 

Antiemetics, Miscellaneous 

dronabinol (Marinol) 2 NM 

EMEND 4 PA cap ds pk, capsule 

Antihistamines (GI Drugs) 

dimenhydrinate (Dimenhydrinate) 2 NM 

meclizine hcl (Antivert) 2 

Formulary

Drug Name 

prochlorperazine edisylate (Compazine) 2 NM 

prochlorperazine maleate (Compazine) 2 

Antifungal (Systemic) 

Antifungals, Miscellaneous 

ABELCET 5 NM, PA 

AMBISOME 5 NM, PA 

amphotericin b (Amphotericin B) 2 NM, PA 

ANCOBON 5 NM 

flucytosine (Ancobon) 2 

griseofulvin,microsize (Grifulvin V) 2 

GRIS-PEG 3 

nystatin (Mycostatin) 2 

terbinafine hcl (Lamisil) 2 

triacetin (Triacetin) 2 

Azoles 

fluconazole in nacl,iso- 

osm 

(Fluconazole In Nacl,iso-osm) 2 

Drug 


fluconazole (Diflucan) 2 

itraconazole (Sporanox) 2 PA 

ketoconazole (Nizoral) 2 

voriconazole (Vfend IV) 2 vial 

voriconazole 

Echinocandins 

(Vfend) 2 tablet 

CANCIDAS 4 NM 

ERAXIS (WATER 

4 

DILUENT) 

Antiglaucoma Agents 

Antiglaucoma Agents 

acetazolamide sodium (Acetazolamide Sodium) 2 NM 

acetazolamide (Acetazolamide) 2 

ALPHAGAN P 3 drops: 0.1% 

AZOPT 4 

betaxolol hcl (Betaxolol HCl) 2 

BETOPTIC S 4 

brimonidine tartrate (Alphagan P) 2 

dorzolamide hcl (Trusopt) 2 

dorzolamide hcl/timolol (Cosopt) 2 

maleat 

latanoprost (Xalatan) 2 

levobunolol hcl (Betagan) 2 drops: 0.25% 

32 



Drug Name 

Drug 


levobunolol hcl (Betagan) 2 drops: 0.5% 

LUMIGAN 4 

methazolamide (Neptazane) 2 

metipranolol (Optipranolol) 2 

PHOSPHOLINE IODIDE 4 

pilocarpine hcl (Isopto Carpine) 2 

PILOPINE HS 3 

timolol maleate (Timoptic) 2 

TRAVATAN Z 3 

Antihistamines 

Antihistamines 

carbinoxamine maleate (Palgic) 2 liquid: 4mg/5ml; 

tablet: 4mg 

cetirizine hcl (Cetirizine HCl) 2 

chlorpheniramine maleate (Chlorpheniramine Maleate) 2 

clemastine fumarate (Clemastine Fumarate) 2 tablet 

clemastine fumarate (Tavist) 2 syrup 

cyproheptadine hcl (Cyproheptadine HCl) 2 

desloratadine (Clarinex) 2 

diphenhydramine hcl (Benadryl) 2 NM vial 

diphenhydramine hcl (Diphenhydramine HCl) 2 capsule: 25mg 

diphenhydramine hcl (Diphenhydramine HCl) 2 capsule: 50mg 

doxylamine succinate (Doxylamine Succinate) 2 

fexofenadine hcl (Allegra) 2 

fexofenadine/ 

pseudoephedrine 

(Fexofenadine/pseudoephedrine) 2 

levocetirizine 

dihydrochloride 

(Xyzal) 2 

p-epd tan/chlor-tan (P-epd Tan/chlor-tan) 2 

phenylephrine hcl/prometh (Phenylephrine HCl/prometh 2 

hcl 

HCl) 

promethazine hcl (Promethazine HCl) 2 supp.rect, syrup, 

tablet 

promethazine hcl (Promethazine HCl) 2 NM ampul, vial 

tripelennamine hcl (Tripelennamine HCl) 2 

Anti-infectives (EENT) 

Anti-infectives (EENT) 

acetic acid (Vosol) 2 

acetic acid/hydrocortisone (Vosol HC) 2 

AZASITE 4 

33 



Formulary

Drug Name 

Drug 


bacitracin (Bacitracin) 2 

bacitracin/polymyxin b 

sulfate 

(Polycin-b) 2 

BESIVANCE 4 

BLEPHAMIDE S.O.P. 3 

BLEPHAMIDE 4 

chlorhexidine gluconate (Peridex) 2 

CILOXAN 3 oint. (g) 

CIPRODEX 3 

ciprofloxacin hcl (Ciloxan) 2 

cresyl ace/ben alc/ 

butanol/ipa 

(Cresyl Ace/ben Alc/butanol/ipa) 2 

doxycycline hyclate (Periostat) 2 

erythromycin base (Romycin) 2 

gentamicin sulfate (Garamycin) 2 

levofloxacin (Quixin) 2 

neo/polymyx b sulf/ 

dexameth 

(Maxitrol) 2 

neomy sulf/bacitra/ 

polymyxin b 

(Neo-polycin) 2 oint. (g) 

neomy sulf/bacitrac zn/ 

poly/hc 

(Triple Antibiotic HC) 2 

neomycin sulfate/dex na 

ph 

(Neomycin Sulfate/dex Na Ph) 2 

neomycin/polymyxin b 

sulf/hc 

(Oticin HC) 2 

neomycin/polymyxn b/ 

gramicidin 

(Neosporin) 2 

ofloxacin (Floxin) 2 

polymyxin b sulfate/tmp (Polytrim) 2 

PRED-G 4 drops susp 

sulfacetamide sodium (Sulfac) 2 

sulfacetamide/ 

prednisolone sp 

(Sulfacetamide/prednisolone Sp) 2 

TOBRADEX ST 4 

TOBRADEX 3 oint. (g) 

tobramycin sulf/ 

dexamethasone 

(Tobradex) 2 

tobramycin sulfate (Tobrex) 2 

trifluridine (Viroptic) 2 

34 



Drug Name 

Drug 


VIGAMOX 4 

ZIRGAN 4 

ZYMAXID 3 

Anti-infectives (Skin and Mucous Membrane) 

Antibacterials (Skin and Mucous Membrane) 

BACTROBAN 3 cream (g) 

clindamycin phos/benzoyl 

perox 

(Benzaclin) 2 gel (gram) 


perox 

(Duac) 2 gel er (g) 

clindamycin phosphate (Cleocin T) 2 

CLINDESSE 3 

erythromycin base/ethanol (Emgel) 2 

erythromycin/benzoyl 

peroxide 

(Benzamycin) 2 

gentamicin sulfate (Gentamicin Sulfate) 2 

METROGEL 3 

metronidazole (Vitazol) 2 

mupirocin (Centany) 2 

neomy sulf/polymyxin b 

sulfate 

(Neosporin G.U. Irrigant) 2 

Antifungals (Skin and Mucous Membrane) 

ciclopirox olamine (Loprox) 2 

ciclopirox (Penlac) 2 

clotrimazole (Lotrimin) 2 cream (g), solution, 

troche 

clotrimazole/ 

betamethasone dip 

(Lotrisone) 2 

econazole nitrate (Spectazole) 2 

ketoconazole (Kuric) 2 

miconazole nitrate (Monistat 3) 2 

NAFTIN 3 cream (g): 1%; gel 

(gram) 

NAFTIN 3 cream (g): 2% 

nystatin (Mycostatin) 2 cream (g), oint. (g), 

powder 

nystatin (Nystatin) 2 tablet 

nystatin/triamcin (Mycogen II) 2 

sod propionate/inosi/aa14/ 

urea 

(Sod Propionate/inosi/aa14/urea) 2 

35 



Formulary

Drug Name 

sodium thiosulfate/sal acid (Sodium Thiosulfate/sal Acid) 2 

terconazole (Terazol 7) 2 

Antivirals (Skin and Mucous Membrane) 

DENAVIR 4 

ZOVIRAX 4 

Drug 


Local Anti-infectives, Miscellaneous 

acetic ac/ricinoleic/ 

oxyquinol 

(Acetic Ac/ricinoleic/oxyquinol) 2 

alcohol antiseptic pads (Alcohol Antiseptic Pads) 3 

PHISOHEX 4 

selenium sulfide (Selenium Sulfide) 2 suspension 

selenium sulfide (Selseb) 2 shampoo 

silver nitrate (Silver Nitrate) 2 

silver sulfadiazine (Silvadene) 2 

sulfacetamide sodium (Klaron) 2 suspension 

THERMAZENE 2 

Scabicides and Pediculicides 

lindane (Lindane) 2 

malathion (Ovide) 2 

permethrin (Elimite) 2 

Anti-inflammatory Agents (EENT) 

Anti-inflammatory Agents (EENT) 

ALREX 4 

bromfenac sodium (Bromfenac Sodium) 2 


phosphate 

(Ak-dex) 2 

diclofenac sodium (Voltaren) 2 (oral products only) 

FLAREX 4 

flunisolide (Nasarel) 2 

fluocinolone acetonide oil (Dermotic) 2 

fluorometholone (Fluorometholone) 2 

flurbiprofen sodium (Ocufen) 2 

fluticasone propionate (Flonase) 2 

FML FORTE 4 

FML S.O.P. 4 

FML 4 

ketorolac tromethamine (Acular LS) 2 

LOTEMAX 4 drops susp 

MAXIDEX 4 

NASONEX 3 

36 



Drug Name 

Drug 


prednisolone acetate (Pred Forte) 2 

prednisolone sod 

phosphate 

(Prednisol) 2 

RESTASIS 4 

RHINOCORT AQUA 4 

triamcinolone acetonide (Nasacort Aq) 2 

Anti-inflammatory Agents (GI Drugs) 

Anti-inflammatory Agents (GI Drugs) 

ASACOL HD 3 

ASACOL 3 

balsalazide disodium (Colazal) 2 

CANASA 4 

mesalamine w/cleansing 

wipes 

(Rowasa) 2 

Anti-inflammatory Agents (Respiratory) 

Anti-inflammatory Agents (Respiratory) 

ALOCRIL 4 

cromolyn sodium (Cromolyn Sodium) 2 drops, solution 

cromolyn sodium (Intal) 2 PA ampul-neb 

SINGULAIR 3 

zafirlukast (Accolate) 2 

ZYFLO CR 4 

Anti-inflammatory Agents (Skin and Mucous) 

Anti-inflammatory Agents (Skin and Mucous) 

alclometasone 

dipropionate 

(Aclovate) 2 

amcinonide (Amcinonide) 2 

betamet diprop/prop gly (Diprolene AF) 2 

betamethasone 

dipropionate 

(Betamethasone Dipropionate) 2 gel (gram) 

betamethasone 

(Del-beta) 2 cream (g), lotion, 

dipropionate 

oint. (g) 

betamethasone valerate (Betamethasone Valerate) 2 

clobetasol propionate (Temovate) 2 

desonide (Desowen) 2 

desoximetasone (Topicort) 2 cream (g), gel 

(gram), oint. (g): 

0.25% 

desoximetasone (Topicort) 2 oint. (g): 0.05% 

diflorasone diacetate (Psorcon) 2 

37 



Formulary

Drug Name 

fluocinolone acetonide (Fluocinolone Acetonide) 2 

fluocinolone/shower cap (Derma-smoothe-fs) 2 

fluocinonide (Fluocinonide) 2 

fluticasone propionate (Cutivate) 2 

halobetasol propionate (Ultravate) 2 

Drug 


hydrocortisone acetate (Hydrocortisone Acetate) 2 suppos. 

hydrocortisone acetate/ 

aloe v 

(Nuzon) 2 gel (gram) 

hydrocortisone acetate/ 

urea 

(Carmol HC) 2 

hydrocortisone butyrate (Locoid) 2 

hydrocortisone valerate (Hydrocortisone Valerate) 2 

hydrocortisone (Proctocort) 2 

mometasone furoate (Elocon) 2 

prednicarbate (Dermatop) 2 

triamcinolone acetonide (Triamcinolone Acetonide) 2 cream 

triamcinolone acetonide 

Antilipemic Agents 

(Triamcinolone Acetonide) 2 cream (g), lotion, 

oint. (g), paste (g) 

Antilipemic Agents, Miscellaneous 

LOVAZA 3 

niacin (Niacin) 2 tablet: 500mg 

NIASPAN 3 

ZETIA 3 

Bile Acid Sequestrants 

cholestyramine (with 

sugar) 

(Questran) 2 

cholestyramine/aspartame (Questran Light) 2 

colestipol hcl (Colestid) 2 

WELCHOL 3 

Fibric Acid Derivatives 

fenofibrate (Lofibra) 2 PA 

fenofibrate,micronized (Lofibra) 2 PA 

fenofibric acid (Fibricor) 2 PA 

gemfibrozil (Lopid) 2 PA 

TRICOR 3 PA 

TRILIPIX 3 PA 

HMG-CoA Reductase Inhibitors 

amlodipine/atorvastatin (Caduet) 2 

atorvastatin calcium (Lipitor) 2 

38 



Drug Name 

Drug 


CRESTOR 3 

fluvastatin sodium (Lescol) 2 

lovastatin (Mevacor) 2 

pravastatin sodium (Pravachol) 2 

simvastatin (Zocor) 2 tablet: 5mg, 10mg, 

20mg 

simvastatin (Zocor) 2 PA tablet: 40mg, 80mg 

Antimigraine Agents 

Selective Serotonin Agonists 

AXERT 3 NM, QL: 

6 in 14 

days 

MAXALT MLT 3 NM, QL: 

12 in 14 

days 

MAXALT 3 NM, QL: 

12 in 14 

tablet: 5mg 

MAXALT 3 

days 

QL: 12 in tablet: 10mg 

14 days 

naratriptan hcl (Amerge) 2 QL: 9 in 

14 days 

sumatriptan succinate (Imitrex) 2 NM, QL: 

2 in 14 

days 

cartridge, vial 

sumatriptan succinate (Imitrex) 2 NM, QL: 

9 in 14 

days 

tablet 

sumatriptan succinate (Imitrex) 2 QL: 2 in 

14 days 

pen injctr 

sumatriptan 

Antimycobacterials 

(Imitrex) 2 QL: 4 in 

14 days 

Antimycobacterials 

CAPASTAT SULFATE 4 NM 

dapsone (Dapsone) 2 

ethambutol hcl (Myambutol) 2 

isoniazid (Isoniazid) 2 syrup, tablet 

isoniazid (Isoniazid) 2 NM vial 

MYCOBUTIN 3 

39 



Formulary

Drug Name 

Drug 


PASER 4 

PRIFTIN 3 

pyrazinamide (Pyrazinamide) 2 

rifampin (Rifadin) 2 capsule 

rifampin (Rifadin) 2 NM vial 

rifampin/isoniazid (Rifamate) 2 

SEROMYCIN 4 

TRECATOR 4 

Antineoplastic Agents 

Antineoplastic Agents 

ABRAXANE 4 NM 

ADCETRIS 5 NM, PA 

AFINITOR 4 NM, PA tablet: 2.5mg, 5mg, 

10mg 

AFINITOR 4 PA tablet: 7.5mg 

ALIMTA 4 NM 

anastrozole (Arimidex) 2 

ARRANON 4 NM 

ARZERRA 4 NM 

AVASTIN 4 NM 

bicalutamide (Casodex) 2 NM 

BICNU 4 NM 

bleomycin sulfate (Bleomycin Sulfate) 2 NM, PA 

BUSULFEX 4 NM 

CAMPATH 3 NM 

CAPRELSA 4 PA 

carboplatin (Paraplatin) 2 

CEENU 3 NM 

cisplatin (Cisplatin) 2 NM 

cladribine (Leustatin) 2 NM, PA 

CLOLAR 4 NM 

cyclophosphamide (Cyclophosphamide) 2 NM tablet 

cyclophosphamide (Cytoxan) 2 PA vial 

cytarabine/pf (Cytarabine/PF) 2 NM, PA 

dacarbazine (Dtic-Dome IV) 2 NM 

DACOGEN 4 NM 

dactinomycin (Cosmegen) 2 NM 

daunorubicin hcl (Cerubidine) 2 

DAUNOXOME 4 NM 

DEPOCYT 4 NM, PA 

40 



Drug Name 

Drug 


DOCEFREZ 4 

docetaxel (Taxotere) 2 vial: fnl20mg/2 

docetaxel (Taxotere) 2 NM vial: 20mg/2ml, 

20mg/ml(1) 

DOXIL 4 NM, PA 

doxorubicin hcl liposomal (Doxil) 2 PA 

doxorubicin hcl (Adriamycin RDF) 2 PA vial: 50mg 

DROXIA 4 

ELIGARD 4 NM 

ELOXATIN 4 NM 

ELSPAR 4 NM 

EMCYT 3 NM 

epirubicin hcl (Ellence) 2 

ERBITUX 4 NM 

ERIVEDGE 5 NM, LA, 

PA, QL: 

30 in 30 

days 

ERWINAZE 4 PA 

ETOPOPHOS 4 NM 

etoposide (Etoposide) 2 NM 

exemestane (Aromasin) 2 

FARESTON 4 

FASLODEX 4 NM 

FIRMAGON 4 NM 

floxuridine (FUDR) 2 NM, PA 

fludarabine phosphate (Fludara) 2 NM 

fluorouracil (Fluorouracil) 2 PA 

flutamide (Flutamide) 2 NM 

FOLOTYN 4 NM 

gemcitabine hcl (Gemzar) 2 NM 

GLEEVEC 3 NM 

HALAVEN 4 NM 

HERCEPTIN 4 NM, PA 

HEXALEN 4 NM 

hydroxyurea (Hydrea) 2 

idarubicin hcl (Idamycin Pfs) 2 

ifosfamide (Ifex) 2 NM, PA 

ifosfamide/mesna (Ifex-mesnex) 2 NM, PA 

41 



Formulary

Drug Name 

Drug 


INLYTA 5 NM, LA, 

PA 

irinotecan hcl (Camptosar) 2 NM 

ISTODAX 4 NM 

IXEMPRA 4 NM 

JAKAFI 5 NM, LA, 

PA, QL: 

60 in 30 

days 

JEVTANA 4 NM 

letrozole (Femara) 2 

LEUKERAN 3 NM 

leuprolide acetate (Lupron) 2 NM 

LUPRON DEPOT 5 NM 

LUPRON DEPOT-PED 5 NM kit: 7.5mg 

LYSODREN 3 NM 

MATULANE 5 NM 

MEGACE ES 4 

megestrol acetate (Megace) 2 

melphalan hcl (Alkeran) 2 NM 

mercaptopurine (Purinethol) 2 

methotrexate sodium (Methotrexate Sodium) 2 tablet 

methotrexate sodium (Methotrexate Sodium) 2 NM, PA vial 

methotrexate sodium/pf (Methotrexate Sodium/PF) 2 NM, PA 

MITHRACIN 4 NM 

mitomycin (Mitomycin) 2 PA 

mitoxantrone hcl (Novantrone) 2 

MUSTARGEN 4 NM 

NEXAVAR 4 NM, PA 

NILANDRON 3 NM 

ONCASPAR 4 NM 

ONTAK 5 NM 

oxaliplatin (Oxaliplatin) 2 

paclitaxel (Taxol) 2 

pentostatin (Nipent) 2 NM 

PHOTOFRIN 4 NM 

PROLEUKIN 3 NM 

REVLIMID 5 NM, LA, 

PA 

RITUXAN 3 NM 

42 



Drug Name 

Drug 


SPRYCEL 4 NM, PA 

SUTENT 4 NM, PA 

TABLOID 3 NM 

tamoxifen citrate (Nolvadex) 2 

TARCEVA 5 NM, PA 

TARGRETIN 4 NM 

TASIGNA 5 NM, PA 

TAXOTERE 4 NM vial: fnl20mg/2 

thiotepa (Thiotepa) 2 

topotecan hcl (Hycamtin) 2 NM 

TORISEL 4 NM 

TREANDA 4 

TRELSTAR 4 NM 

tretinoin (Tretinoin) 2 NM 

TRISENOX 3 NM 

TYKERB 5 NM, PA 

VALSTAR 4 NM 

VANDETANIB 4 PA 

VECTIBIX 5 NM, PA 

VELCADE 5 NM 

VIDAZA 4 NM 

vinblastine sulfate (Vinblastine Sulfate) 2 NM, PA 

vincristine sulfate (Vincristine Sulfate) 2 NM, PA 

vinorelbine tartrate (Navelbine) 2 

VOTRIENT 3 NM, PA 

VUMON 4 NM 

XALKORI 5 NM, LA, 

PA, QL: 

60 in 30 

days 

YERVOY 5 NM, PA 

ZANOSAR 4 NM 

ZELBORAF 5 NM, LA, 

PA, QL: 

240 in 30 

days 

ZOLADEX 4 NM 

ZOLINZA 5 NM 

43 



Formulary

Drug Name 

Drug 


ZYTIGA 5 NM, LA, 

PA, QL: 

120 in 30 

days 

Antiparkinsonian Agents 

Antiparkinsonian Agents 

amantadine hcl (Amantadine HCl) 2 

APOKYN 5 NM 

AZILECT 4 

benztropine mesylate (Benztropine Mesylate) 2 tablet 

benztropine mesylate (Cogentin) 2 NM ampul 

bromocriptine mesylate (Parlodel) 2 

cabergoline (Cabergoline) 2 

carbidopa/levodopa (Sinemet 25-100) 2 

carbidopa/levodopa/ 

entacapone 

(Stalevo 50) 2 

COMTAN 3 

pramipexole di-hcl (Mirapex) 2 

ropinirole hcl (Requip) 2 

selegiline hcl (Eldepryl) 2 

STALEVO 100 3 

STALEVO 125 3 

STALEVO 150 3 

STALEVO 200 3 

STALEVO 50 3 

STALEVO 75 3 

TASMAR 3 

trihexyphenidyl hcl 

Antiprotozoal Agents 

(Trihexyphenidyl HCl) 2 

Antiprotozoal Agents 

ALINIA 4 PA 

atovaquone/proguanil hcl (Malarone) 2 tablet: 250-100mg 

atovaquone/proguanil hcl (Malarone) 2 tablet: 62.5-25mg 

chloroquine phosphate (Aralen Phosphate) 2 

DARAPRIM 3 

hydroxychloroquine 

sulfate 

(Plaquenil) 2 

mefloquine hcl (Lariam) 2 

MEPRON 3 

metronidazole (Flagyl) 2 

44 



Drug Name 

Drug 


metronidazole/sodium 

chloride 

(Metro IV) 2 NM 

paromomycin sulfate (Paromomycin Sulfate) 2 

PENTAM 300 4 NM 

pentamidine isethionate (Pentam 300) 2 NM 

PRIMAQUINE 2 

tinidazole (Tindamax) 2 

Antipruritics and Local Anesthetics 

Antipruritics and Local Anesthetics 

lidocaine (Lidocaine) 2 PA 

lidocaine/prilocaine (EMLA) 2 PA 

LIDODERM 4 PA 

phenazopyridine hcl (Urodol) 2 

ZONALON 

Antiulcer Agents 

Antiulcer Agents 

3 

CARAFATE 4 oral susp 

cimetidine hcl (Cimetidine HCl) 2 solution 

cimetidine hcl (Cimetidine HCl) 2 NM vial 

cimetidine in 0.9 % nacl (Cimetidine In 0.9 % NaCl) 2 NM 

cimetidine (Tagamet) 2 

famotidine in nacl,isoosm/pf 

(Famotidine In Nacl,iso-osm/PF) 2 NM 

famotidine (Pepcid) 1 GC, NM vial 

famotidine (Pepcid) 1 GC oral susp, tablet 

lansoprazole (Prevacid) 2 capsule dr 

lansoprazole (Prevacid) 2 tab rap dr 

misoprostol (Cytotec) 2 tablet: 100mcg 

misoprostol (Cytotec) 2 tablet: 200mcg 

NEXIUM 4 ST capsule dr, suspdr 

pkt: 20mg, 40mg 

nizatidine (Axid) 2 

omeprazole (Prilosec) 2 

omeprazole/sodium 

bicarbonate 

(Zegerid) 2 

pantoprazole sodium (Protonix) 2 

PROTONIX IV 4 NM 

ranitidine hcl (Zantac) 1 GC capsule, syrup, 

tablet 

sucralfate (Carafate) 2 tablet 

45 



Formulary

Drug Name 

Drug 


sucralfate (Sucralfate) 2 oral susp 

Antivirals (Systemic) 

Antiretrovirals 

abacavir sulfate (Ziagen) 2 

APTIVUS 4 capsule 

APTIVUS 4 solution 

ATRIPLA 5 NM 

COMPLERA 4 

CRIXIVAN 3 

didanosine (Videx EC) 2 

EDURANT 4 

EMTRIVA 3 

EPIVIR HBV 3 tablet 

EPIVIR 3 solution 

EPZICOM 3 

FUZEON 5 NM 

INTELENCE 4 tablet: 200mg 

INTELENCE 4 tablet: 25mg 

INTELENCE 5 NM tablet: 100mg 

INVIRASE 4 

ISENTRESS 5 NM 

KALETRA 4 

lamivudine (Epivir) 2 

lamivudine/zidovudine (Combivir) 2 

LEXIVA 4 

nevirapine (Viramune) 2 oral susp 

nevirapine (Viramune) 2 tablet 

NORVIR 3 

PREZISTA 4 

RESCRIPTOR 3 

RETROVIR 4 NM vial 

REYATAZ 4 

SELZENTRY 5 NM 

stavudine (Zerit) 2 capsule 

stavudine (Zerit) 2 soln recon 

SUSTIVA 3 capsule: 100mg 

SUSTIVA 3 capsule: 50mg, 

200mg; tablet 

TRIZIVIR 4 

TRUVADA 5 NM 

46 



Drug Name 

Drug 


VIDEX 3 

VIRACEPT 3 

VIRAMUNE XR 4 

VIRAMUNE 3 oral susp 

VIREAD 3 tablet 

VIREAD 4 powder 

ZERIT 4 soln recon 

ZIAGEN 3 

zidovudine (Retrovir) 2 

Antivirals, Miscellaneous 

foscarnet sodium (Foscavir) 2 NM, PA 

RELENZA 3 

rimantadine hcl (Flumadine) 2 

TAMIFLU 3 NM capsule 

Hcv Protease Inhibitors 

INCIVEK 5 NM, PA 

VICTRELIS 5 NM, PA 

Interferons 

INTRON A 4 vial: 10mm/ml 

INTRON A 4 vial: 18mmunit 

INTRON A 4 NM pen ij kit, vial: 

6mmunit/ml 

INTRON A 4 NM vial: 50mmunit 

PEGASYS PROCLICK 5 NM 

PEGASYS 5 NM 

PEGINTRON REDIPEN 5 NM 

PEGINTRON 5 NM kit: 50mcg/0.5 

PEGINTRON 5 NM kit: 80mcg/0.5, 

120mcg/0.5 

SYLATRON 4 NM, PA 

Nucleosides and Nucleotides 

acyclovir sodium (Acyclovir Sodium) 2 NM, PA 

acyclovir (Zovirax) 2 

BARACLUDE 3 

famciclovir (Famvir) 2 

ganciclovir sodium (Cytovene) 2 NM, PA 

ganciclovir (Cytovene) 2 

HEPSERA 5 NM 

REBETOL 4 solution 

47 



Formulary

Drug Name 

Drug 


RIBATAB 2 tab ds pk: 600- 

600mg 

ribavirin (Copegus) 2 capsule, tab ds pk: 

400-400mg, 600- 

400mg; tablet 

ribavirin (Ribatab) 2 tab ds pk: 200- 

400mg 

TYZEKA 4 

valacyclovir hcl (Valtrex) 2 

VALCYTE 5 NM tablet 

VISTIDE 3 NM 

Anxiolytics, Sedatives and Hypnotics 

Anxiolytics, Sedatives and Hypnotics, Miscellaneous 

buspirone hcl (Buspar) 2 

chloral hydrate (Chloral Hydrate) 2 

droperidol (Inapsine) 2 NM 

glutethimide (Glutethimide) 2 

hydroxyzine hcl (Hydroxyzine HCl) 2 syrup, tablet 

hydroxyzine hcl (Hydroxyzine HCl) 2 NM vial 

hydroxyzine pamoate (Vistaril) 2 

meprobamate (Miltown) 2 

zaleplon (Sonata) 2 NM, PA, 

QL: 14 in 

30 days 

zolpidem tartrate (Ambien) 2 NM, PA, 

QL: 14 in 

30 days 

Astringents 

Astringents 

aluminum chloride (Drysol) 2 

Benzodiazepines 

Benzodiazepines 

ALPRAZOLAM 

INTENSOL 

alprazolam (Xanax) 2 

clonazepam (Klonopin) 2 

clorazepate dipotassium (Tranxene T-tab) 2 

diazepam (Diastat) 2 QL: 5 in 

30 days 

48 



3 

kit

Drug Name 

Drug 


diazepam (Valium) 2 oral conc, solution, 

tablet 

estazolam (Prosom) 2 

LORAZEPAM 

INTENSOL 

2 

lorazepam (Ativan) 2 disp syrin, vial 

lorazepam (Ativan) 2 tablet 

ONFI 4 PA 

oxazepam (Oxazepam) 2 

temazepam (Restoril) 2 

Beta-Adrenergic Blocking Agents 

Beta-Adrenergic Blocking Agents 

acebutolol hcl (Sectral) 2 

atenolol (Tenormin) 1 GC 

atenolol/chlorthalidone (Tenoretic 100) 1 GC 

betaxolol hcl (Kerlone) 1 GC 

bisoprolol fumarate (Zebeta) 1 GC 

bisoprolol fumarate/hctz (Ziac) 1 GC 

carvedilol (Coreg) 1 GC 

esmolol hcl (Brevibloc) 2 PA 

INNOPRAN XL 3 

labetalol hcl (Trandate) 2 disp syrin 

labetalol hcl (Trandate) 2 tablet 

labetalol hcl (Trandate) 2 NM vial 

metoprolol succinate (Toprol XL) 1 GC 

metoprolol tartrate (Lopressor) 1 GC 

metoprolol/ 

hydrochlorothiazide 

(Lopressor HCT) 1 GC 

nadolol (Corgard) 1 GC 

nadolol/ 

bendroflumethiazide 

(Corzide) 2 

pindolol (Pindolol) 1 GC 

propranolol hcl (Propranolol HCl) 1 GC, NM vial 

propranolol hcl (Propranolol HCl) 1 GC cap sa 24h, solution, 

tablet 

propranolol/ 

hydrochlorothiazid 

(Propranolol/hydrochlorothiazid) 1 GC 

sotalol hcl (Betapace) 2 

timolol maleate (Timolol Maleate) 1 GC 

49 



Formulary

Drug Name 

Drug 


Blood Derivatives 

Blood Derivatives 

ALBUMIN (HUMAN) 4 NM 

ALBUMINAR-25 4 NM 

ALBUMINAR-5 4 NM 

ALBURX 4 NM 

ALBUTEIN 4 NM 

Calcium-Channel Blocking Agents 

Calcium-Channel Blocking Agents, Miscellaneous 

diltiazem hcl (Cardizem CD) 2 various dosage and/ 

or strengths are 

available 

diltiazem hcl (Diltiazem HCl) 2 NM disp syrin, vial port 

diltiazem hcl (Tiazac) 2 capsule er: 420mg 

verapamil hcl (Calan) 2 cap24h pct, cap24h 

pel: 120mg, 180mg, 

240mg; tablet, tablet 

er 

verapamil hcl (Verapamil HCl) 2 NM vial 

verapamil hcl (Verelan) 2 cap24h pel: 360mg; 

disp syrin 

Dihydropyridines 

amlodipine besylate (Norvasc) 2 

amlodipine besylate/ 

benazepril 

(Lotrel) 2 

felodipine (Plendil) 2 

isradipine (Dynacirc) 2 

nicardipine hcl (Nicardipine HCl) 2 capsule 

nicardipine hcl (Nicardipine HCl) 2 NM vial 

nifedipine (Procardia XL) 2 

nimodipine (Nimotop) 2 

nisoldipine 

Caloric Agents 

Caloric Agents 

(Sular) 2 

AMINOSYN II 4 NM, PA iv soln: 10% 



AMINOSYN II 4 NM, PA iv soln: 8.5% 

AMINOSYN M 4 NM, PA 

50 



Drug Name 

Drug 


AMINOSYN with 

ELECTROLYTES 

4 NM, PA 

AMINOSYN 4 NM, PA iv soln: 10% 

AMINOSYN 4 NM, PA iv soln: 3.5% 

AMINOSYN 4 NM, PA iv soln: 7% 

AMINOSYN 4 NM, PA iv soln: 8.5% 

AMINOSYN-HBC 4 NM, PA 

AMINOSYN-PF 4 NM, PA iv soln: 10% 

AMINOSYN-PF 4 NM, PA iv soln: 7% 

AMINOSYN-RF 4 NM, PA 

CLINISOL 4 NM, PA 

cysteine hcl (Cysteine HCl) 2 NM, PA vial 

cysteine hcl (Cysteine HCl) 2 PA disp syrin 

dextrose 10 % and 0.225 (Dextrose 10 % and 0.225 % 2 iv soln 

% nacl 

NaCl) 

dextrose 10 % and 0.225 (Dextrose 10 % and 0.225 % 2 NM dehp fr bg 

% nacl 

NaCl) 

dextrose 10 % and 0.9 % 

nacl 

(Dextrose 10 % and 0.9 % NaCl) 2 NM 

dextrose 10%-0.5 normal (Dextrose 10%-0.5 Normal 2 NM 

saline 

Saline) 

dextrose 10%-water (Dextrose 10%-water) 2 NM, PA 

dextrose 2.5 %-water (Dextrose 2.5 %-water) 2 NM, PA 

dextrose 2.5%-0.5normal (Dextrose 2.5%-0.5 Normal 2 NM 

saline 

Saline) 

dextrose 20 % in water (Dextrose 20 % in Water) 2 PA 





nacl 



nacl 


dextrose 5 %-0.225 % 

nacl 

(Dextrose 5 %-0.225 % NaCl) 2 NM 

dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 % NaCl) 2 NM 

dextrose 5 %-water (Dextrose 5 %-water) 2 NM 

dextrose 50 % in water (Dextrose 50 % in Water) 2 NM, PA disp syrin 

dextrose 50 % in water (Dextrose 50 % in Water) 2 PA vial 

dextrose 60 % in water (Dextrose 60 % in Water) 2 NM, PA 

51 



Formulary

Drug Name 

Drug 


dextrose 70 % in water (Dextrose 70 % in Water) 2 PA 

FREAMINE III 4 NM, PA iv soln: 8.5% 

fructose 10% (Fructose 10%) 2 NM, PA 

INTRALIPID 3 NM, PA emulsion: 20% 



LIPOSYN II 4 NM, PA 

LIPOSYN III 4 NM, PA emulsion: 10%, 

20% 

LIPOSYN III 4 NM, PA emulsion: 30% 

NOVAMINE 4 NM, PA 

PREMASOL 4 NM, PA iv soln: 10% 

PREMASOL 4 NM, PA iv soln: 6% 

PROSOL 4 NM, PA 

TRAVAMULSION 4 NM, PA 

TRAVASOL W/ 

DEXTROSE 

4 PA 

TRAVASOL W/ 

ELECTROLYTES 

4 NM, PA iv soln.: 5.5% 

TRAVASOL W/ 

ELECTROLYTES 

4 NM, PA iv soln.: 8.5% 

TRAVASOL with 

DEXTROSE 

4 NM, PA iv soln: 8.5% 

TRAVASOL with 

ELECTROLYTES 

4 NM, PA 

TRAVASOL 4 NM, PA iv soln: 10% 

TRAVASOL 4 NM, PA iv soln: 8.5% 

TRAVASOL 4 PA iv soln: 5.5% 

TRAVERT IN NORMAL 

SALINE 

4 NM, PA 

TRAVERT 4 NM, PA iv soln: 10% 

TRAVERT 4 NM, PA iv soln: 5% 

TROPHAMINE 

Cardiac Drugs 

3 NM, PA iv soln: 10% 

Antiarrhythmic Agents 

amiodarone hcl (Amiodarone HCl) 2 NM disp syrin 

amiodarone hcl (Amiodarone HCl) 2 NM vial 

amiodarone hcl (Cordarone) 2 tablet 

disopyramide phosphate (Norpace) 2 

flecainide acetate (Tambocor) 2 

52 



Drug Name 

Drug 


lidocaine hcl (Lidocaine HCl) 2 NM 

lidocaine hcl/d5w/pf (Lidocaine HCl/d5w/PF) 2 NM iv soln: 2mg/ml, 

8mg/ml 

lidocaine hcl/d7.5w/pf (Lidocaine HCl/d7.5w/PF) 2 NM 

lidocaine hcl/pf (Lidocaine HCl/PF) 2 disp syrin: 50mg/ 

5ml 

lidocaine hcl/pf (Lidocaine HCl/PF) 2 NM disp syrin: 100mg/ 

5ml; vial 

mexiletine hcl (Mexitil) 2 

MULTAQ 3 

procainamide hcl (Procainamide HCl) 2 capsule, tablet sa 

procainamide hcl (Procainamide HCl) 2 NM vial 

propafenone hcl (Rythmol) 2 

quinidine gluconate (Quinidine Gluconate) 2 tablet er 

quinidine gluconate (Quinidine Gluconate) 2 NM vial 

quinidine sulfate (Quinidine Sulfate) 2 

TIKOSYN 3 

Cardiac Drugs, Miscellaneous 

digoxin (Lanoxin) 1 GC, NM ampul 

digoxin (Lanoxin) 1 GC tablet 

DIGOXIN 1 GC 

LANOXIN 4 tablet 

milrinone lactate (Milrinone Lactate) 2 NM, PA 

milrinone lactate/d5w (Primacor in 5% Dextrose) 2 NM, PA 

RANEXA 4 

Cathartics and Laxatives 

Cathartics and Laxatives 

AMITIZA 3 QL: 60 in 

30 days 

GOLYTELY 4 powd pack 

MOVIPREP 4 

OSMOPREP 4 

peg 3350/na sulf,bicarb,cl/ 

kcl 

(Colyte with Flavor Packets) 2 

polyethylene glycol 3350 (Polyethylene Glycol 3350) 2 

sodium chloride/nahco3/ 

kcl/peg 

(Nulytely) 2 

Cell Stimulants and Proliferants 

Cell Stimulants and Proliferants 

KEPIVANCE 5 NM, PA 

53 



Formulary

Drug Name 

Drug 


RETIN-A MICRO 4 

tretinoin (Retin-A) 2 

Central Nervous System Agents, Miscellaneous 

Central Nervous System Agents, Miscellaneous 

BUTISOL SODIUM 3 PA elixir: 30mg/5ml; 


CAMPRAL 4 

flumazenil (Romazicon) 2 

INTUNIV 4 PA 

lithium carbonate (Eskalith) 2 

lithium citrate (Lithium Citrate) 2 

NAMENDA 3 solution, tablet 

NAMENDA 4 tab ds pk 

phenobarbital sodium (Phenobarbital Sodium) 2 PA vial: 65mg/ml, 

130mg/ml 

phenobarbital (Phenobarbital) 2 PA elixir: 20mg/5ml; 

tablet: 16.2mg, 

30mg, 32.4mg, 

64.8mg, 97.2mg 

phenobarbital (Phenobarbital) 2 PA tablet: 15mg, 60mg, 

100mg 

primidone (Mysoline) 2 

RILUTEK 3 

SAVELLA 3 

STRATTERA 4 NM, PA 

XENAZINE 5 NM, LA 

XYREM 5 NM, LA 

Contraceptives 

Contraceptives 

desogestrel-ethinyl 

(Desogen) 2 

estradiol 

desog-et estra/ethin estra (Mircette) 2 

ethinyl estradiol/ 

drospirenone 

(Yaz) 2 

ethynodiol d-ethinyl 

estradiol 

(Demulen 1-50-21) 2 

levonorgestrel (Plan B) 2 

levonorgestrel-eth 

estradiol 

(Lybrel) 2 

54 



Drug Name 

Drug 


l-norgest-eth estr/ethin (Seasonique) 2 tbdspk 3mo: 100estra 

20(84) 

l-norgest-eth estr/ethin (Seasonique) 2 tbdspk 3mo: 150estra 

30(84) 

noreth a-et estra/fe 

fumarate 

(Loestrin Fe) 2 

noreth-ethinyl estradiol/ 

iron 

(Femcon Fe) 2 

norethindrone a-e 

estradiol 

(Loestrin) 2 

norethindrone (Nor-Q-D) 2 

norethindrone-ethinyl 

estrad 

(Ovcon-35) 2 

norethindrone-mestranol (Ortho-novum) 2 

norgestimate-ethinyl 

estradiol 

(Ortho Tri-cyclen) 2 

norgestrel-ethinyl 

estradiol 

(Lo-ovral-28) 2 

NUVARING 

Devices 

Devices 

3 

needles, insulin disp., 

safety 

(Needles, Insulin Disp., Safety) 3 

needles, insulin disposable (Needles, Insulin Disposable) 3 

syring wndl,disp,insul,0.3ml 

(Syring W-ndl,disp,insul,0.3ml) 3 

syring wndl,disp,insul,0.5ml 

(Syring W-ndl,disp,insul,0.5ml) 3 

syringe & needle,insulin,1 

ml 

Diuretics 

(Syringe & Needle,insulin,1 Ml) 3 

Diuretics, Miscellaneous 

chlorothiazide sodium (Diuril Sodium) 2 NM 

chlorothiazide (Chlorothiazide) 1 GC 

chlorthalidone (Chlorthalidone) 1 GC 

hydrochlorothiazide (Hydrochlorothiazide) 1 GC 

indapamide (Lozol) 1 GC 

methyclothiazide (Methyclothiazide) 2 

metolazone (Zaroxolyn) 1 GC 

55 



Formulary

Drug Name 

Drug 


Loop Diuretics 

bumetanide (Bumetanide) 1 GC, NM vial 

bumetanide (Bumex) 1 GC tablet 

furosemide (Furosemide) 1 GC, NM disp syrin 

furosemide (Furosemide) 1 GC, NM vial 

furosemide (Lasix) 1 GC solution, tablet 

torsemide (Demadex) 1 GC tablet 

torsemide (Torsemide) 2 NM vial 

Potassium-sparing Diuretics 

amiloride hcl (Midamor) 1 GC 

amiloride/ 


(Amiloride/hydrochlorothiazide) 2 

triamterene/ 


(Maxzide-25mg) 1 GC 

EENT Drugs, Miscellaneous 

EENT Drugs, Miscellaneous 

apraclonidine hcl (Iopidine) 2 

atropine sulfate (Isopto Atropine) 2 

carteolol hcl (Carteolol HCl) 2 

CYCLOGYL 4 drops: 2% 

cyclopentolate hcl (Cyclogyl) 2 

homatropine hbr (Isopto Homatropine) 2 

ipratropium bromide (Atrovent) 2 

naphazoline hcl (Albalon) 2 

naphazoline hcl/antazoline (Naphazoline HCl/antazoline) 2 

PENTOLAIR 2 

phenylephrine hcl (Mydfrin) 2 

tropicamide (Mydral) 2 

TYZINE 3 drops: 0.1% 

TYZINE 

Enzymes 

Enzymes 

4 spray 

ADAGEN 4 NM 

ALDURAZYME 5 NM, PA 

CEREDASE 3 NM 

CEREZYME 5 NM, PA 

ELAPRASE 5 NM, PA 

ELITEK 4 NM 

FABRAZYME 5 NM, PA 

MYOZYME 5 NM 

56 



Drug Name 

Drug 


NAGLAZYME 5 NM 

PULMOZYME 4 NM, PA 

Estrogens and Antiestrogens 

Estrogens and Antiestrogens 

CENESTIN 3 

ESTRACE 4 cream/appl 

estradiol valerate (Delestrogen) 2 NM 

estradiol (Estrace) 2 

estradiol/noreth ac (Activella) 2 tablet: 0.5-0.1mg 

estradiol/noreth ac (Activella) 2 tablet: 1-0.5mg 

estropipate (Ogen) 2 

EVISTA 3 

MENEST 4 

norethind ac/ethinyl 

estradiol 

(Femhrt) 2 

PREMARIN 3 cream/appl, tablet 

PREMARIN 3 NM vial 

PREMPHASE 3 

PREMPRO 3 

VAGIFEM 4 

VIVELLE-DOT 3 

Genitourinary Smooth Muscle Relaxants 

Genitourinary Smooth Muscle Relaxants 

DETROL LA 3 

DETROL 3 

flavoxate hcl (Urispas) 2 

oxybutynin chloride (Ditropan) 2 (oral products only) 

tolterodine tartrate (Detrol) 2 

trospium chloride (Sanctura) 2 

VESICARE 3 

GI Drugs, Miscellaneous 

GI Drugs, Miscellaneous 

CIMZIA 5 NM, PA, 

QL: 3 in 

28 days 

CREON 3 

lipase/protease/amylase (Zenpep) 2 

LOTRONEX 3 

metoclopramide hcl (Metoclopramide HCl) 2 disp syrin: 10mg/ 

2ml 

57 



Formulary

Drug Name 

Drug 


metoclopramide hcl (Reglan) 2 tablet 

metoclopramide hcl (Reglan) 2 NM vial 

RELISTOR 4 PA, QL: 

12 in 30 

days 

disp syrin 

RELISTOR 4 PA, QL: 

18 in 30 

days 

vial 

ULTRASE MT 12 3 



ULTRASE 4 

ursodiol (Actigall) 2 

ZENPEP 3 capsule dr: 3k-10k- 

16k, 10-34-55k, 15- 

51-82k, 20-68-109k, 

25-85-136k 

Heavy Metal Antagonists 

Heavy Metal Antagonists 

CUPRIMINE 4 

deferoxamine mesylate (Desferal) 2 PA 

edetate disodium (Edetate Disodium) 2 

EXJADE 4 

FERRIPROX 5 NM, LA, 

PA 

na nitrite/na thiosul/amyl 

nit 

(Na Nitrite/na Thiosul/amyl Nit) 2 NM 

sodium thiosulfate 

Hematologic Agents 

Anticoagulants 

(Sodium Thiosulfate) 2 NM 

citrate-phos-dex solution (Citrate-phos-dex Solution) 2 NM 

COUMADIN 4 tablet 

enoxaparin sodium (Lovenox) 2 NM, QL: disp syrin: 40mg/ 

11.2 in 

14 days 

0.4ml 

enoxaparin sodium (Lovenox) 2 NM, QL: disp syrin: 60mg/ 

16.8 in 

14 days 

0.6ml 

58 



Drug Name 

enoxaparin sodium (Lovenox) 2 NM, QL: 

22.4 in 

Drug 


14 days 


28 in 14 

disp syrin: 80mg/ 

0.8ml, 120mg/.8ml 

59 



days 


8.4 in 14 

days 

fondaparinux sodium (Arixtra) 2 QL: 11.2 

in 14 

days 


in 14 

days 

fondaparinux sodium (Arixtra) 2 QL: 7 in 

14 days 


in 14 

days 

heparin sodium,porcine (Hep-lock) 2 NM, PA 

heparin sodium,porcine/ 

d5w 

(Heparin Sodium, porcine/D5W) 2 NM, PA 

heparin sodium,porcine/ (Heparin Sodium, porcine/ns/PF) 2 NM, PA 

ns/pf 


ml, 150mg/ml 


0.3ml 


0.8ml 


0.4ml 

disp syrin: 2.5mg/ 

0.5 

disp syrin: 7.5mg/ 

0.6 

heparin sodium,porcine/pf (Hep-lock) 2 NM, PA vial 

heparin sodium,porcine/pf (Hep-lock) 2 NM, PA vial port 

heparin sodium,porcine/pf (Monoject Prefill Advanced) 2 PA disp syrin 

LOVENOX 4 NM vial 

PRADAXA 4 

REFLUDAN 4 NM, PA 

warfarin sodium (Coumadin) 2 

XARELTO 4 tablet: 15mg, 20mg 

XARELTO 4 QL: 34 tablet: 10mg 

per fill 

Hematologic Agents, Miscellaneous 

aminocaproic acid (Amicar) 2 tablet: 1000mg 

aminocaproic acid (Amicar) 2 NM solution, tablet: 

500mg; vial 

anagrelide hcl (Agrylin) 2 NM 

pentoxifylline (Trental) 2 

Formulary

Drug Name 

Drug 


protamine sulfate (Protamine Sulfate) 2 NM, PA 

tranexamic acid (Tranexamic Acid) 2 

Platelet-aggregation Inhibitors 

cilostazol (Pletal) 2 

clopidogrel bisulfate (Plavix) 2 tablet: 75mg 

EFFIENT 4 

ticlopidine hcl (Ticlid) 2 

Hematopoietic Agents 

Hematopoietic Agents 

ARANESP 4 NM, PA various dosage and/ 

or strengths are 

available 

ARANESP 4 PA vial: 200mcg/ml 

ARANESP 5 NM, PA disp syrin: 200mcg/ 

0.4, 300mcg/0.6, 

500mcg/ml 

EPOGEN 4 NM, PA 

LEUKINE 5 NM 

NEULASTA 5 NM, PA 

NEUMEGA 5 NM, PA 

NEUPOGEN 5 NM, PA 

PROCRIT 3 NM, PA 

PROMACTA 5 NM, PA 

Hypotensive Agents 

Hypotensive Agents, Miscellaneous 

ALDOMET 4 

ALDORIL-D50 4 

clonidine hcl (Catapres) 2 

clonidine hcl/ 

chlorthalidone 

(Clonidine HCl/chlorthalidone) 2 

clonidine (Catapres-TTS 3) 2 

fenoldopam mesylate (Corlopam) 2 NM, PA 

guanfacine hcl (Tenex) 2 

hydralazine hcl (Apresoline) 1 GC tablet 

hydralazine hcl (Hydralazine HCl) 2 NM vial 

hydralazine/ 

(Hydralazine/ 

2 

hydrochlorothiazid hydrochlorothiazid) 

hydralazine/reserpin/hctz (Hydralazine/reserpin/hctz) 2 

methyldopa (Aldomet) 2 

60 



Drug Name 

Drug 


methyldopa/ 

(Methyldopa/ 

2 

hydrochlorothiazide hydrochlorothiazide) 

methyldopate hcl (Methyldopate HCl) 2 NM 

minoxidil (Minoxidil) 2 

PROGLYCEM 3 

reserpine (Reserpine) 2 

reserpine/ 


Ion-Removing Agents 

(Reserpine/hydrochlorothiazide) 2 

Ion-Removing Agents 

calcium acetate (Phoslo) 2 

calcium carbonate/mag (Calcium Carbonate/mag Carb/ 2 

carb/fa 

fa) 

FOSRENOL 3 

KAYEXALATE 3 

RENAGEL 3 

RENVELA 4 

sodium polystyrene 

sulfonate 

Irrigating Solutions 

(Sodium Polystyrene Sulfonate) 2 

Irrigating Solutions 

acetic acid (Acetic Acid) 2 

LACTATED RINGERS 2 

mannitol/sorbitol solution (Mannitol/sorbitol Solution) 2 

ringers solution (Tis-u-sol) 2 

sodium chloride irrig 

solution 

(Sodium Chloride Irrig Solution) 2 

sorbitol solution (Sorbitol Solution) 2 

UROLOGIC SOLUTION 

G 

2 

water for irrigation,sterile (Water for Irrigation, Sterile) 

Keratolytic Agents 

Keratolytic Agents 

2 

benzoyl peroxide&skin 

cleansr5 

(Brevoxyl-4) 2 

benzoyl peroxide (Acne Medication-5) 2 cleanser: 3%, 4%, 

5%, 6%, 7%, 8%, 

9%, 10%; gel 

(gram), kit: 4%-5%; 

med. pad 

61 



Formulary

Drug Name 

Drug 


potassium hydroxide (Potassium Hydroxide) 2 

salicylic acid (Salacyn) 2 cream (g), foam, gel 

(gram), lotion, 

shampoo 

salicylic acid/ammon lact/ 

aloe 

(Salkera) 2 

salicylic acid/ceramide (Salex) 2 combo. pkg, kit 

cmb #1 

clcmer: 6% 

urea (Uramaxin) 2 cream (g): 40%, 

50%; foam: 35%; 

gel (ml), lotion: 

40%; nl fm susp, 

sol/pf app 

urea/lactic ac/zn 

undecylenate 

(Kerol) 2 emulsn(g): 50% 

urea/lactic acid/salicyl 

acid 

Keratoplastic Agents 

(Kerol) 2 

Keratoplastic Agents 

sulfacetamide sodium/urea (Rosula Ns) 

Local Anesthetics 

Local Anesthetics 

2 

aa/antipyrn/bcaine/ 

polico#1/al 

(Auralgan) 2 

AKTEN 4 

antipyrine/benzocaine/ 

glycerin 

(Otra Nr) 2 

chloroprocaine hcl/pf (Nesacaine-MPF) 2 NM 

cocaine hcl (Cocaine HCl) 2 

lidocaine hcl (Xylocaine) 2 jel (ml), jel/pf app, 

solution 

lidocaine hcl (Xylocaine) 2 NM, PA vial 

lidocaine hcl/pf (Xylocaine-MPF) 2 NM, PA ampul, ampul luer 

mepivacaine hcl/pf (Mepivacaine HCl/PF) 2 NM 

proparacaine hcl (Ophthetic) 2 

proparacaine/fluorescein 

sod 

(Proparacaine/fluorescein Sod) 2 

tetracaine hcl/pf (Pontocaine) 2 NM ampul 

tetracaine hcl/pf (Tetracaine HCl/PF) 2 drops 

XYLOCAINE 2 vial: 20mg/ml 

62 



Drug Name 

Miscellaneous Therapeutic Agents 

Miscellaneous Therapeutic Agents 

ACTEMRA 5 NM, QL: 

40 in 30 

days 

ACTIMMUNE 5 NM, LA 

ACTONEL 3 

alendronate sodium (Fosamax) 1 GC 

allopurinol (Zyloprim) 1 GC 

amifostine crystalline (Ethyol) 2 NM 

ammonium chloride (Ammonium Chloride) 2 NM 

AMPYRA 5 NM, PA, 

QL: 60 in 

30 days 

ARAVA 4 

ARCALYST 4 NM 

ATGAM 4 NM 

Drug 


AVODART 3 

AVONEX 

ADMINISTRATION 

PACK 

5 NM, ST 

AVONEX 5 NM, ST 

AZASAN 4 PA 

azathioprine sodium (Azathioprine Sodium) 2 NM, PA 

azathioprine (Imuran) 2 PA 

BETASERON 5 NM 

BONIVA 3 NM disp syrin 

CELLCEPT 4 NM, PA vial 

CELLCEPT 4 PA susp recon 

CINRYZE 5 NM, LA 

citric acid/sodium citrate (Bicitra) 2 

colchicine/probenecid (Colchicine/probenecid) 2 

COLCRYS 3 QL: 60 in 

30 days 

COPAXONE 5 NM 

cyclosporine (Cyclosporine) 2 NM, PA vial 

cyclosporine (Sandimmune) 2 PA capsule 

cyclosporine, modified (Neoral) 2 PA 

CYSTAGON 4 LA, NM 

dexrazoxane (Totect) 2 NM 

63 



Formulary

Drug Name 

disulfiram (Antabuse) 2 

ELMIRON 3 

ENBREL 5 NM, PA, 

QL: 4 in 

Drug 


14 days 

ENBREL 5 NM, PA, 

QL: 8 in 

14 days 

ergoloid mesylates (Ergoloid Mesylates) 2 tab subl 

ergoloid mesylates (Ergoloid Mesylates) 2 tablet 

etidronate disodium (Didronel) 2 

finasteride (Proscar) 2 

FLUORITAB 2 

FLURA-DROPS 2 

fomepizole (Antizol) 2 NM 

FOSAMAX PLUS D 3 

FOSAMAX 3 solution 

FUSILEV 4 NM 

gauze bandage (Gauze Bandage) 3 

GLUCAGEN 3 

GLUCAGON 

3 NM 

EMERGENCY KIT 

HUMIRA 5 NM, PA, 

QL: 4 in 

28 days 

HUMIRA 5 NM, PA, 

QL: 6 in 

28 days 

disp syrin, pen injctr 

64 



kit 

pen ij kit: 40mg/ 

0.8ml 

pen ij kit: 40mg/ 

0.8ml, (Starter Kit) 

ibandronate sodium (Boniva) 2 

KINERET 5 NM, PA 

KUVAN 5 NM, PA 

leflunomide (Arava) 2 

leucovorin calcium (Leucovorin Calcium) 2 tablet, vial: 10mg/ 

ml 

leucovorin calcium (Leucovorin Calcium) 2 NM vial: 350mg 

levocarnitine (with sugar) (Carnitor) 2 PA 

levocarnitine (Carnitor) 2 NM, PA vial 

levocarnitine (Carnitor) 2 PA tablet 

mesna (Mesnex) 2 NM 

MESNEX 4 tablet

Drug Name 

Drug 


methylene blue (Methylene Blue) 2 NM 

methylergonovine maleate (Methergine) 2 tablet 

methylergonovine maleate (Methylergonovine Maleate) 2 NM vial 

mycophenolate mofetil (Cellcept) 2 PA 

MYFORTIC 4 PA 

NPLATE 5 NM, LA, 

PA 

NULOJIX 5 NM, PA 

octreotide acetate (Sandostatin) 2 NM 

ORFADIN 3 

pamidronate disodium (Aredia) 2 NM vial: 60mg/10ml 

pamidronate disodium (Aredia) 2 PA vial: 30mg/10ml, 

90mg/10ml 

phosphorus #1 (K-phos Neutral) 2 

potassium citrate (Urocit-K) 2 

potassium citrate/citric (Polycitra-k) 2 packet: 3300-1002; 

acid 

solution 

probenecid (Probenecid) 2 

PROGRAF 3 NM, PA ampul 

RAPAMUNE 4 PA 

REMICADE 5 NM, PA 

REVLIMID 5 NM, LA, 

PA 

RIDAURA 3 

SENSIPAR 3 

SIMPONI 5 NM, PA, 

QL: 0.5 

in 28 

days 

SIMULECT 4 NM, PA 

sod/pot/k cit/sod cit/cit 

acid 

(Polycitra-lc) 2 

sodium bicarbonate (Sodium Bicarbonate) 2 disp syrin: 1meq/ml 

sodium bicarbonate (Sodium Bicarbonate) 2 NM disp syrin: 0.5meq/ 

ml, 0.9meq/ml; iv 

soln., vial 

sodium fluoride (Prevident 5000 Plus) 2 

sodium lactate (Sodium Lactate) 2 NM vial 

SOMATULINE DEPOT 4 NM, PA disp syrin: 120mg/ 

0.5 

65 



Formulary

Drug Name 

Drug 


stannous fluoride (Gel-kam) 2 soln(gram) 

STELARA 5 NM 

SUPPRELIN LA 4 NM 

SUPPRELIN 4 NM 

SYNAREL 4 

tacrolimus (Prograf) 2 PA 

THALOMID 5 NM capsule: 50mg, 

100mg, 200mg 

THYMOGLOBULIN 3 NM 

TYSABRI 5 NM, LA, 

PA 

ULORIC 4 ST 

VANTAS 4 NM 

VORAXAZE 5 NM, LA, 

PA, QL: 

6 per fill 

ZAVESCA 5 NM, PA 

ZOMETA 4 NM vial 

ZORTRESS 4 PA 

Opiate Antagonists 

Opiate Antagonists 

naloxone hcl (Naloxone HCl) 2 NM ampul, disp syrin: 

0.4mg/ml 

naloxone hcl (Naloxone HCl) 2 NM disp syrin: 1mg/ml 

naltrexone hcl (Revia) 2 

Parasympathomimetics (Cholinergic Agents) 

Parasympathomimetics (Cholinergic Agents) 

ARICEPT 4 tablet: 23mg 

bethanechol chloride (Urecholine) 2 

CHANTIX 4 tab ds pk 

CHANTIX 4 NM, QL: 

60 in 30 

days 

tablet 

donepezil hcl (Aricept) 2 

galantamine hbr (Razadyne ER) 2 

neostigmine methylsulfate (Neostigmine Methylsulfate) 2 NM 

nicotine (Nicotine) 2 

NICOTROL NS 4 

physostigmine salicylate (Physostigmine Salicylate) 2 NM 

pilocarpine hcl (Salagen) 2 

66 



Drug Name 

Drug 


pyridostigmine bromide (Mestinon) 2 

rivastigmine tartrate (Exelon) 2 (oral products only) 

Parathyroid 

Parathyroid 

calcitonin,salmon,syntheti 

c 

(Miacalcin) 2 

FORTEO 5 NM, PA 

FORTICAL 2 

MIACALCIN 

Pituitary 

Pituitary 

3 NM, PA vial 

CHORIONIC 

2 

GONADOTROPIN 

desmopressin acetate (DDAVP) 2 spray/pump, tablet 

desmopressin acetate (DDAVP) 2 NM ampul 

desmopressin acetate (Desmopressin Acetate) 2 solution 

GENOTROPIN 4 NM, PA disp syrin 

GENOTROPIN 5 NM, PA cartridge 

NORDITROPIN 

FLEXPRO 

4 PA 

NORDITROPIN 

4 NM, PA 

NORDIFLEX 

NUTROPIN AQ NUSPIN 5 NM, PA cartridge: 10mg/2ml 

NUTROPIN AQ NUSPIN 5 NM, PA cartridge: 5mg/2ml 

NUTROPIN AQ 5 NM, PA 

NUTROPIN 5 NM, PA 

OMNITROPE 5 NM, PA vial 

SEROSTIM 5 NM 

vasopressin (Pitressin) 2 NM 

ZORBTIVE 

Progestins 

Progestins 

5 NM, PA 

CRINONE 4 gel/pf app: 4% 

medroxyprogesterone 

acetate 

(Depo-provera) 2 disp syrin 


acetate 

(Depo-provera) 2 NM vial 


acetate 

(Provera) 2 tablet 

norethindrone acetate (Aygestin) 2 

67 



Formulary

Drug Name 

progesterone (Progesterone In Oil) 2 NM 

progesterone,micronized (Prometrium) 2 

Psychotherapeutic Agents 

Antidepressants 

amitrip hcl/ 

Drug 


(Limbitrol) 2 tablet: 12.5mg-5mg 

chlordiazepoxide 

amitrip hcl/ 

chlordiazepoxide 

(Limbitrol) 2 NM tablet: 25mg-10mg 

amitriptyline hcl (Amitriptyline HCl) 2 PA 

amoxapine (Amoxapine) 2 PA 

APLENZIN 4 PA, QL: 

30 in 30 

days 

bupropion hcl (Wellbutrin SR) 2 

citalopram hydrobromide (Celexa) 1 GC 

clomipramine hcl (Anafranil) 2 

CYMBALTA 3 

desipramine hcl (Norpramin) 2 

doxepin hcl (Doxepin HCl) 2 

EMSAM 4 

escitalopram oxalate (Lexapro) 2 

fluoxetine hcl (Prozac) 2 capsule, capsule dr, 

solution, tablet: 

10mg, 20mg 

fluoxetine hcl (Rapiflux) 2 tablet: 60mg 

fluvoxamine maleate (Fluvoxamine Maleate) 2 

imipramine hcl (Tofranil) 2 PA 

imipramine pamoate (Tofranil-PM) 2 PA 

LUVOX CR 4 

maprotiline hcl (Maprotiline HCl) 2 

MARPLAN 3 

mirtazapine (Remeron) 2 

NARDIL 4 

nefazodone hcl (Nefazodone HCl) 2 

nortriptyline hcl (Pamelor) 2 

olanzapine/fluoxetine hcl (Symbyax) 2 

OLEPTRO ER 4 PA 

paroxetine hcl (Paxil CR) 2 tab er 24h 

paroxetine hcl (Paxil) 1 GC tablet 

PAXIL 4 oral susp 

68 



Drug Name 

Drug 


perphenazine/ 

(Perphenazine/amitriptyline 2 

amitriptyline hcl HCl) 

PEXEVA 4 

phenelzine sulfate (Nardil) 2 

PRISTIQ ER 4 ST 

protriptyline hcl (Vivactil) 2 

sertraline hcl (Zoloft) 1 GC 

SYMBYAX 4 

tranylcypromine sulfate (Parnate) 2 

trazodone hcl (Trazodone HCl) 1 GC tablet: 50mg, 

100mg, 150mg 

trimipramine maleate (Surmontil) 2 PA 

VENLAFAXINE HCL 

ER 

2 

venlafaxine hcl (Effexor XR) 2 

VIIBRYD 4 tab ds pk 

VIIBRYD 4 PA tablet 

Antipsychotic Agents 

ABILIFY DISCMELT 3 

ABILIFY 3 solution, tablet 

ABILIFY 3 NM vial 

chlorpromazine hcl (Chlorpromazine HCl) 2 oral conc. 

chlorpromazine hcl (Chlorpromazine HCl) 2 tablet 

chlorpromazine hcl (Chlorpromazine HCl) 2 NM ampul 

clozapine (Clozaril) 2 

FANAPT 3 

FAZACLO 3 tab rapdis: 25mg, 

100mg 

FAZACLO 4 tab rapdis: 12.5mg, 

150mg, 200mg 

fluphenazine decanoate (Fluphenazine Decanoate) 2 NM 

fluphenazine hcl (Fluphenazine HCl) 2 elixir, oral conc, 

tablet 

fluphenazine hcl (Fluphenazine HCl) 2 NM vial 

GEODON 3 NM vial 

HALDOL DECANOATE 

100 

4 NM 


50 

4 NM 

HALDOL 4 NM 

69 



Formulary

Drug Name 

Drug 


haloperidol decanoate (Haloperidol Decanoate) 2 vial: 50mg/ml 

haloperidol decanoate (Haloperidol Decanoate) 2 NM vial: 100mg/ml 

haloperidol lactate (Haloperidol Lactate) 2 oral conc 

haloperidol lactate (Haloperidol Lactate) 2 NM vial 

haloperidol (Haloperidol) 2 

INVEGA SUSTENNA 3 NM 

INVEGA 3 

LATUDA 4 

loxapine succinate (Loxitane) 2 

MOBAN 4 

olanzapine (Zyprexa) 2 

ORAP 3 

perphenazine (Perphenazine) 2 

quetiapine fumarate (Seroquel) 2 

RISPERDAL CONSTA 3 NM 

risperidone (Risperdal) 2 

SAPHRIS 3 PA 

SEROQUEL XR 3 

thioridazine hcl (Thioridazine HCl) 2 oral conc. 

thioridazine hcl (Thioridazine HCl) 2 tablet 

thiothixene (Navane) 2 

trifluoperazine hcl (Trifluoperazine HCl) 2 

ziprasidone hcl (Geodon) 2 

ZYPREXA RELPREVV 4 NM 

Renin-Angiotensin-Aldosterone System Inhibitors 

Angiotensin II Receptor Antagonists 

BENICAR HCT 4 

BENICAR 4 

EDARBI 4 

EDARBYCLOR 4 

eprosartan mesylate (Teveten) 2 

irbesartan (Avapro) 2 

irbesartan/ 


(Avalide) 2 

losartan potassium (Cozaar) 1 GC 

losartan/ 


(Hyzaar) 1 GC 

MICARDIS HCT 4 

MICARDIS 4 

TEVETEN HCT 4 

70 



Drug Name 

Drug 


TEVETEN 4 tablet: 400mg 

Angiotensin-Converting Enzyme Inhibitors 

benazepril hcl (Lotensin) 1 GC 

benazepril/ 


(Lotensin HCT) 1 GC 

captopril (Capoten) 1 GC 

captopril/ 


(Capozide) 1 GC 

enalapril maleate (Vasotec) 1 GC 

enalapril/ 


(Vaseretic) 1 GC 

enalaprilat dihydrate (Enalaprilat Dihydrate) 2 NM 

fosinopril sodium (Monopril) 1 GC 

fosinopril/ 


(Monopril HCT) 1 GC 

lisinopril (Zestril) 1 GC 

lisinopril/ 


(Prinzide) 1 GC 

moexipril hcl (Univasc) 1 GC 

moexipril/ 


(Uniretic) 1 GC 

perindopril erbumine (Aceon) 2 

quinapril hcl (Accupril) 1 GC 

quinapril/ 


(Accuretic) 1 GC 

ramipril (Altace) 1 GC 

trandolapril (Mavik) 1 GC 

Renin-Angiotensin-Aldosterone System Inhibitors 

ALDACTAZIDE 4 tablet: 50mg-50mg 

eplerenone (Inspra) 1 GC 

spironolact/ 


(Aldactazide) 1 GC 

spironolactone (Aldactone) 1 GC 

TEKTURNA HCT 4 

TEKTURNA 4 

Replacement Preparations 

Replacement Preparations 

0.9 % sodium chloride (0.9 % Sodium Chloride) 2 NM 

calcium chloride (Calcium Chloride) 2 NM 

calcium gluconate (Calcium Gluconate) 2 PA 

71 



Formulary

Drug Name 

Drug 


dex 2.5%-half str 

lact.ringers 

(Dex 2.5%-half Str Lact.ringers) 2 NM 

dextrose 2.5% in half 

ringers 

(Dextrose 2.5% In Half Ringers) 2 NM 

dextrose 5% in ringers (Dextrose 5% In Ringers) 2 NM 

dextrose 5%-lactated 

ringers 

(Dextrose 5%-Lactated Ringers) 2 

electrolyte-48 solution/ 

d5w 

(Electrolyte-48 Solution/D5W) 2 NM 

electrolyte-48/fructose 

10% 

(Electrolyte-48/fructose 10%) 2 NM 

electrolyte-48/fructose 5% (Electrolyte-48/fructose 5%) 2 NM 

electrolyte-75 solution/ 

d5w 

(Electrolyte-75 Solution/D5W) 2 NM 

electrolyte-75/fructose 5% (Electrolyte-75/fructose 5%) 2 NM 

electrolyte-r solution/d5w (Normosol-r and Dextrose) 2 NM 

pot chloride/pot bicarb/cit 

ac 

(K-lyte-cl) 2 

potassium acetate (Potassium Acetate) 2 NM 

potassium bicarbonate/cit 

ac 

(K-lyte) 2 

potassium chlorid/d10- (Potassium Chlorid/d10- 

2 NM 

0.2%nacl 

0.2%NaCl) 


2 iv soln: 30meq/l, 

0.225nacl 

0.225NaCl) 

40meq/l 


2 NM iv soln: 10meq/l 

0.225nacl 

0.225NaCl) 


2 NM iv soln: 20meq/l 

0.225nacl 

0.225NaCl) 

potassium chloride in (Potassium Chloride In 

2 NM 

0.9%nacl 

0.9%NaCl) 

potassium chloride (Kaochlor) 2 liquid, packet, tablet 

sa 

potassium chloride (K-dur) 2 capsule er, tab er 

prt, tablet er, vial 

potassium chloride (Potassium Chloride) 2 NM piggyback 

potassium chloride/d5- (Potassium Chloride/D5-0.25 2 NM 

0.25ns 

NS) 

potassium chloride/d5- (Potassium Chloride/d5- 

2 NM 

0.33nacl 

0.33NaCl) 

72 



Drug Name 

Drug 



2 NM 

0.45nacl 

0.45NaCl) 


2 NM 

0.9%nacl 

0.9%NaCl) 

potassium chloride/d5lr (Potassium Chloride/D5 LR) 2 NM 

potassium chloride/d5w (Potassium Chloride/D5W) 2 NM iv soln: 10meq/l 

potassium chloride/d5w (Potassium Chloride/D5W) 2 NM iv soln: 20meq/l, 

30meq/l, 40meq/l 

potassium chloride-0.45% (Potassium Chloride-0.45% 2 NM 

nacl 

NaCl) 

potassium gluconate (Potassium Gluconate) 2 

potassium phos,m-basic-d- (Potassium Phos,m-basic-d- 2 NM 

basicbasic) 

ringers solution (Ringers Solution) 2 NM 

sodium acetate (Sodium Acetate) 2 NM 

sodium chloride 0.45 % (Sodium Chloride 0.45 %) 2 NM 

sodium chloride 3% (Sodium Chloride 3%) 2 NM 

sodium chloride 5% (Sodium Chloride 5%) 2 NM 

sodium chloride (Sodium Chloride) 2 NM iv soln 

sodium chloride (Sodium Chloride) 2 NM vial 

sodium phos,m-basic-dbasic 

(Sodium Phos,m-basic-d-basic) 2 NM 

TPN ELECTROLYTES 2 NM 

Respiratory Tract Agents, Miscellaneous 

Respiratory Tract Agents, Miscellaneous 

acetylcysteine (Acetylcysteine) 2 

aminophylline (Aminophylline) 2 liquid, tablet 

aminophylline (Aminophylline) 2 NM vial 

ARALAST 5 NM 

DALIRESP 4 PA 

guaifen/theop anhyd/pephed 

(Guaifen/theop Anhyd/p-ephed) 2 

PROLASTIN 5 NM 

theophylline anhydrous (Theochron) 2 elixir, tab er 12h: 

100mg, 300mg, 

450mg; tablet er 

theophylline anhydrous (Theochron) 2 solution, tab er 12h: 

200mg 

theophylline/d5w (Theophylline/D5W) 2 NM 

XOLAIR 5 NM, PA 

73 



Formulary

Drug Name 

Sclerosing Agents 

Sclerosing Agents 

ethanolamine oleate (Ethanolamine Oleate) 2 NM 

SCLEROSOL 4 

sodium morrhuate (Sodium Morrhuate) 2 NM 

sodium tetradecyl sulfate (Sodium Tetradecyl Sulfate) 2 NM 

talc (Talc) 2 NM 

Serums 

Serums 

ANTIVENIN 

LATRODECTUS 

Drug 


4 NM 

MACTANS 

ANTIVENIN 

MICRURUS FULVIUS 

4 NM 

CARIMUNE NF 

NANOFILTERED 

5 NM, PA 

FLEBOGAMMA DIF 4 NM, PA 

FLEBOGAMMA 4 NM, PA 

GAMMAGARD LIQUID 5 NM, PA 

GAMUNEX-C 5 NM, PA 

HIZENTRA 5 NM, PA 

PRIVIGEN 5 NM, PA 

VIVAGLOBIN 5 NM, PA 

Skeletal Muscle Relaxants 

Skeletal Muscle Relaxants 

baclofen (Baclofen) 2 

carisoprodol (Soma) 2 PA tablet: 250mg 

carisoprodol (Soma) 2 PA tablet: 350mg 

carisoprodol/aspirin (Soma Compound) 2 PA 

chlorzoxazone (Parafon Forte DSC) 2 PA 

codeine phos/ 

carisoprodol/asa 

(Soma Compound with Codeine) 2 NM, PA 

cyclobenzaprine hcl (Flexeril) 2 PA tablet: 5mg, 10mg 

dantrolene sodium (Dantrium) 2 capsule 

dantrolene sodium (Dantrium) 2 NM vial 

metaxalone (Skelaxin) 2 PA 

methocarbamol (Robaxin-750) 2 PA 

orphenadrine citrate (Norflex) 2 NM, PA ampul 

orphenadrine citrate (Norflex) 2 PA tablet er 

74 



Drug Name 

Drug 


orphenadrine/aspirin/ 

caffeine 

(Norgesic Forte) 2 PA 

tizanidine hcl (Zanaflex) 2 

Skin and Mucous Membrane Agents, Miscellaneous 

Skin and Mucous Membrane Agents, Miscellaneous 

8-MOP 4 

adapalene (Differin) 2 

ammonium lactate (Lac-hydrin) 2 

calcipotriene (Calcipotriene) 2 

calcitriol (Vectical) 2 

CARAC 4 

CONDYLOX 3 gel (gram) 

DOVONEX 4 

ELIDEL 4 PA 

FLUOROPLEX 3 

fluorouracil (Efudex) 2 cream (g) 

fluorouracil (Efudex) 2 solution 

imiquimod (Aldara) 2 

isotretinoin (Accutane) 2 

LEVULAN 4 

METVIXIA 4 

OXSORALEN 4 

OXSORALEN-ULTRA 4 

PANRETIN 3 

podofilox (Condylox) 2 

podophyllum resin (Pododerm) 2 

REGRANEX 5 NM 

SANTYL 3 

STELARA 5 NM 

TARGRETIN 4 

TAZORAC 4 

UVADEX 4 NM 

VECTICAL 3 

ZYCLARA 4 

Somatotropin Agonists and Antagonists 

Somatotropin Agonists and Antagonists 

INCRELEX 4 NM 

SOMAVERT 5 NM, LA 

75 



Formulary

Drug Name 

Sympatholytic Adrenergic Blocking Agents 


alfuzosin hcl (Uroxatral) 2 

Drug 


CAFERGOT 3 

dihydroergotamine 

mesylate 

(D.H.E. 45) 2 NM 

ergotamine tartrate/ 

caffeine 

(Ergotamine Tartrate/caffeine) 2 

phentolamine mesylate (Phentolamine Mesylate) 2 NM 

tamsulosin hcl (Flomax) 2 

Sympathomimetic (Adrenergic) Agents 

Sympathomimetic (Adrenergic) Agents 

albuterol sulfate (Accuneb) 2 PA solution, vial-neb 

albuterol sulfate (Proventil) 2 syrup, tab er 12h, 

tablet 

albuterol (Ventolin) 2 

COMBIVENT 

RESPIMAT 

4 

COMBIVENT 4 

dobutamine hcl (Dobutamine HCl) 2 NM, PA 

dobutamine hcl/d5w (Dobutamine HCl/D5W) 2 NM, PA 

dopamine hcl (Dopamine HCl) 2 NM, PA disp syrin, vial: 

800mg/5ml 

dopamine hcl (Dopamine HCl) 2 PA vial: 200mg/5ml, 

800mg/10ml 

dopamine hcl/d5w (Dopamine HCl/D5W) 2 NM, PA infus. btl: 400mg/ 

0.5l, 800mg/.25l; 

plast. bag 

dopamine hcl/d5w (Dopamine HCl/D5W) 2 PA infus. btl: 800mg/ 

0.5l 

ephedrine sulfate (Ephedrine Sulfate) 2 NM 

epinephrine (Epinephrine) 2 NM 

epinephrine/pf (Epinephrine/PF) 2 NM 

EPIPEN 3 NM 

FORADIL 3 

ipratropium/albuterol 

sulfate 

(Duoneb) 2 PA 

metaproterenol sulfate (Metaproterenol Sulfate) 2 

midodrine hcl (Proamatine) 2 

norepinephrine bitartrate (Norepinephrine Bitartrate) 2 NM, PA 

76 



Drug Name 

Drug 


phenylephrine hcl (Phenylephrine HCl) 2 NM 

SEREVENT DISKUS 3 disk w/dev: 50mcg 

terbutaline sulfate (Brethine) 2 tablet 

terbutaline sulfate (Terbutaline Sulfate) 2 NM vial 

TWINJECT 4 NM, QL: 

2 in 15 

days 

VENTOLIN HFA 2 hfa aer ad: 90mcg 

Thyroid and Antithyroid Agents 

Thyroid and Antithyroid Agents 

ARMOUR THYROID 4 

LEVOTHROID 4 

levothyroxine sodium (Levothyroxine Sodium) 2 vial: 100mcg 

levothyroxine sodium (Levothyroxine Sodium) 2 NM vial: 200mcg 

levothyroxine sodium (Synthroid) 2 tablet 

LEVOXYL 4 

liothyronine sodium (Cytomel) 2 tablet 

liothyronine sodium (Triostat) 2 NM vial 

methimazole (Tapazole) 2 tablet: 20mg 

methimazole (Tapazole) 2 tablet: 5mg, 10mg 

propylthiouracil (Propylthiouracil) 2 

SYNTHROID 4 

UNITHROID 4 

Toxoids 

Toxoids 

ADACEL 3 disp syrin 

ADACEL 3 NM vial 

BOOSTRIX 3 NM 

DAPTACEL 3 NM 

DIPHTHERIA- 

TETANUS TOXOID 

3 NM 

INFANRIX PF 3 

INFANRIX 3 NM 

TE ANATOXAL BERNA 3 NM, PA 

TETANUS DIPHTHERIA 

TOXOIDS 

2 NM 

TETANUS-DIPHTERIA- 

DECAVAC 

3 NM 

TRIHIBIT 3 NM 

TRIPEDIA 3 NM 

77 



Formulary

Drug Name 

Drug 


Urinary Anti-infectives 

Urinary Anti-infectives 

methen/m-blue/sal/na (Methen/m-blue/sal/na Phos/ 2 tablet 

phos/hyos 

hyos) 

methenamine mandelate (Mandelamine) 2 tablet: 1g 

methenamine mandelate (Mandelamine) 2 tablet: 500mg 

nitrofurantoin 

macrocrystal 

(Macrodantin) 2 PA 

trimethoprim 

Vaccines 

Vaccines 

(Trimethoprim) 2 

ACTHIB 3 NM 

BCG VACCINE (TICE 

STRAIN) 

4 NM, PA 

CERVARIX 3 NM 

COMVAX 3 NM 

ENGERIX-B 3 NM, PA disp syrin: 20mcg/ 

ml 

ENGERIX-B 3 PA disp syrin: 10mcg/ 

0.5; vial 

GARDASIL 3 NM vial 

HAVRIX 3 NM, PA vial 

HAVRIX 3 PA disp syrin 

IPOL 3 NM 

IXIARO 3 NM 

JE-VAX 3 NM 

MENACTRA 3 NM 

MENOMUNE-A-C-Y-W- 

135 

3 NM 

MENVEO A-C-Y-W-135- 

DIP 

3 NM 

M-M-R II VACCINE 3 NM 

PEDVAXHIB 3 NM 

PROQUAD 3 NM 

RABAVERT 3 NM, PA 

RECOMBIVAX HB 3 NM, PA vial: 40mcg/ml 

RECOMBIVAX HB 3 PA vial: 10mcg/ml 

ROTATEQ 3 NM 

THERACYS 4 NM, PA 

TWINRIX 3 NM vial 

78 



Drug Name 

Drug 


TYPHIM VI 3 NM 

VAQTA 4 disp syrin 

VAQTA 4 PA vial 

VARIVAX VACCINE 3 NM 

VIVOTIF BERNA 4 NM 

YF-VAX 3 NM 

ZOSTAVAX 3 NM 

Vasodilating Agents 

Vasodilating Agents 

AGGRENOX 3 

alprostadil (Alprostadil) 2 

amyl nitrite (Amyl Nitrite) 2 

dipyridamole (Persantine) 2 

epoprostenol sodium 

(glycine) 

(Flolan) 2 NM, PA 

isosorbide dinitrate (Isordil) 1 GC tab subl, tablet 

isosorbide dinitrate (Isordil) 2 tablet er 

isosorbide mononitrate (Imdur) 2 tab er 24h, tablet: 

20mg 

isosorbide mononitrate (Ismo) 2 tablet: 10mg 

LETAIRIS 4 LA, PA 

nitroglycerin (Nitro-dur) 2 patch td24 

nitroglycerin (Nitroglycerin) 2 NM vial 

nitroglycerin (Nitrolingual) 2 spray 

nitroglycerin/d5w (Nitroglycerin/D5W) 2 NM 

NITROSTAT 3 

nylidrin hcl (Nylidrin HCl) 2 

papaverine hcl (Papaverine HCl) 2 capsule er, tablet 

papaverine hcl (Papaverine HCl) 2 NM vial 

REVATIO 3 PA tablet 

REVATIO 5 NM, PA vial 

TRACLEER 5 NM, LA, 

PA 

VENTAVIS 5 NM, PA 

Vitamins and Minerals 

Vitamins and Minerals 

calcitriol (Calcijex) 2 NM, PA ampul 

calcitriol (Rocaltrol) 2 PA capsule, solution 

FLUOR-A-DAY 2 

fluoride/iron/vit a,c&d (Fluoride/iron/vit A,c&d) 2 

79 



Formulary

Drug Name 

Drug 


FLURA 2 

HECTOROL 3 NM, PA vial 

HECTOROL 3 PA capsule 

iron,carbonyl/vit c/vit b12/ 

fa 

(Iron,carbonyl/vit C/vit B12/fa) 2 

LOZI-FLUR 2 

multivitamins with 

fluoride 

(Multivitamins with Fluoride) 2 

MVC-FLUORIDE 2 

ped mv a,c,d3 #21 wfluoride 

(Ped Mv A,c,d3 #21 W-fluoride) 2 

pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/fa) 2 

sodium fluoride (Luride) 2 drops 

sodium fluoride (Luride) 2 tab chew 

ZEMPLAR 3 NM, PA vial 

ZEMPLAR 3 PA capsule 

80 



0.9 % sodium chloride ....... 71 

8-MOP................................ 75 

aa/antipyrn/bcaine/polico#1/ 

al .................................... 62 

abacavir sulfate .................. 46 

ABELCET.......................... 32 

ABILIFY ............................ 69 

ABILIFY DISCMELT ....... 69 

ABRAXANE ..................... 40 

acarbose ............................. 28 

acebutolol hcl ..................... 49 

acetaminophen with codeine 

........................................ 15 

acetaminophen/phenyltolx cit 

........................................ 14 

acetazolamide .................... 32 

acetazolamide sodium ........ 32 

acetic ac/ricinoleic/oxyquinol 

........................................ 36 

acetic acid .................... 33, 61 

acetic acid/hydrocortisone . 33 

acetylcysteine ..................... 73 

ACTEMRA ........................ 63 

ACTHIB ............................. 78 

ACTIMMUNE ................... 63 

ACTONEL ......................... 63 

ACTOPLUS MET ............. 31 

ACTOPLUS MET XR ....... 31 

ACTOS .............................. 31 

acyclovir ............................. 47 

acyclovir sodium ................ 47 

ADACEL ........................... 77 

ADAGEN ........................... 56 

adapalene ........................... 75 

ADCETRIS ........................ 40 

ADVAIR DISKUS............. 13 

ADVAIR HFA ................... 13 

AFINITOR ......................... 40 

AGGRENOX ..................... 79 

AKTEN .............................. 62 

ALBENZA ......................... 21 

INDEX 

ALBUMIN HUMAN ......... 50 

ALBUMINAR-25 .............. 50 

ALBUMINAR-5 ................ 50 

ALBURX ........................... 50 

ALBUTEIN ........................ 50 

albuterol ............................. 76 

albuterol sulfate.................. 76 

alclometasone dipropionate 

........................................ 37 

alcohol antiseptic pads ....... 36 

ALDACTAZIDE ................ 71 

ALDOMET ........................ 60 

ALDORIL-D50 .................. 60 

ALDURAZYME ................ 56 

alendronate sodium ............ 63 

alfuzosin hcl........................ 76 

ALIMTA ............................ 40 

ALINIA .............................. 44 

allopurinol .......................... 63 

ALOCRIL........................... 37 

ALODOX ........................... 25 

ALOMIDE ......................... 21 

ALPHAGAN P ................... 32 

alprazolam .......................... 48 

ALPRAZOLAM INTENSOL 

........................................ 48 

alprostadil .......................... 79 

ALREX............................... 36 

aluminum chloride.............. 48 

amantadine hcl ................... 44 

AMBISOME ...................... 32 

amcinonide ......................... 37 

amifostine crystalline ......... 63 

amikacin sulfate .................. 22 

amiloride hcl ...................... 56 

amiloride/ 

hydrochlorothiazide ....... 56 

aminocaproic acid .............. 59 

aminophylline ..................... 73 

AMINOSYN ...................... 51 

AMINOSYN II ................... 50 

AMINOSYN M ................. 50 

AMINOSYN with 

ELECTROLYTES ......... 51 

AMINOSYN-HBC ............ 51 

AMINOSYN-PF ................ 51 

AMINOSYN-RF ............... 51 

amiodarone hcl .................. 52 

AMITIZA .......................... 53 

amitrip hcl/chlordiazepoxide 

....................................... 68 

amitriptyline hcl ................. 68 

amlodipine besylate ........... 50 

amlodipine besylate/ 

benazepril ...................... 50 

amlodipine/atorvastatin ..... 38 

ammonium chloride ........... 63 

ammonium lactate.............. 75 

amoxapine .......................... 68 

amoxicillin ......................... 24 

amoxicillin/potassium clav 24 

amphet asp/amphet/d-amphet 

....................................... 21 

amphotericin b ................... 32 

ampicillin sodium .............. 24 

ampicillin sodium/sulbactam 

na ................................... 24 

ampicillin trihydrate .......... 24 

AMPYRA .......................... 63 

amyl nitrite ......................... 79 

ANADROL-50 .................. 20 

anagrelide hcl .................... 59 

anastrozole......................... 40 

ANCOBON ....................... 32 

ANDRODERM ................. 20 

ANDROGEL ..................... 20 

antipyrine/benzocaine/ 

glycerin .......................... 62 

ANTIVENIN 

LATRODECTUS 

MACTANS .................... 74 

I-1 



Formulary

ANTIVENIN MICRURUS 

FULVIUS ....................... 74 

ANZEMET ........................ 31 

APLENZIN ........................ 68 

APOKYN ........................... 44 

apraclonidine hcl ............... 56 

APTIVUS ........................... 46 

ARALAST ......................... 73 

ARANESP ......................... 60 

ARAVA ............................. 63 

ARCALYST ...................... 63 

ARICEPT ........................... 66 

ARMOUR THYROID ....... 77 

ARRANON ........................ 40 

ARZERRA ......................... 40 

ASACOL............................ 37 

ASACOL HD ..................... 37 

ASMANEX ........................ 13 

atenolol .............................. 49 

atenolol/chlorthalidone ...... 49 

ATGAM ............................. 63 

atorvastatin calcium........... 38 

atovaquone/proguanil hcl .. 44 

ATRIPLA ........................... 46 

atropine sulfate ............ 26, 56 

ATROVENT HFA ............. 26 

AVASTIN .......................... 40 

AVELOX ........................... 25 

AVELOX ABC PACK ...... 25 

AVINZA ...................... 15, 16 

AVODART ........................ 63 

AVONEX ........................... 63 

AVONEX 

ADMINISTRATION 

PACK ............................. 63 

AXERT .............................. 39 

AZASAN ........................... 63 

AZASITE ........................... 33 

azathioprine ....................... 63 

azathioprine sodium ........... 63 

azelastine hcl ...................... 21 

AZILECT ........................... 44 

azithromycin ....................... 23 

AZOPT ............................... 32 

aztreonam ........................... 24 

bacitracin ..................... 22, 34 

bacitracin/polymyxin b sulfate 

........................................ 34 

baclofen .............................. 74 

BACTROBAN ................... 35 

balsalazide disodium .......... 37 

BANZEL ............................ 26 

BARACLUDE ................... 47 

BCG VACCINE TICE 

STRAIN ......................... 78 

benazepril hcl ..................... 71 

benazepril/ 


BENICAR .......................... 70 

BENICAR HCT ................. 70 

benzoyl peroxide ................. 61 

benzoyl peroxide&skin 

cleansr5 .......................... 61 

benztropine mesylate .......... 44 

BESIVANCE ..................... 34 

betamet acet/betamet na ph 13 

betamet diprop/prop gly ..... 37 

betamethasone dipropionate 

........................................ 37 

betamethasone valerate ...... 37 

BETASERON .................... 63 

betaxolol hcl ................. 32, 49 

bethanechol chloride .......... 66 

BETOPTIC S...................... 32 

bicalutamide ....................... 40 

BICNU ............................... 40 

BILTRICIDE ...................... 21 

bisoprolol fumarate ............ 49 

bisoprolol fumarate/hctz .... 49 

bleomycin sulfate ................ 40 

BLEPHAMIDE .................. 34 

BLEPHAMIDE S.O.P. ....... 34 

BONIVA ............................ 63 

BOOSTRIX ........................ 77 

brimonidine tartrate ........... 32 

bromfenac sodium .............. 36 

bromocriptine mesylate ...... 44 

budesonide .......................... 13 

bumetanide......................... 56 

BUPHENYL ...................... 14 

buprenorphine hcl.............. 20 

bupropion hcl ..................... 68 

buspirone hcl ..................... 48 

BUSULFEX....................... 40 

BUTISOL SODIUM ......... 54 

butorphanol tartrate .......... 20 

BUTRANS......................... 20 

BYETTA ........................... 28 

cabergoline ........................ 44 

CAFERGOT ...................... 76 

caffeine citrated ................. 21 

caffeine/sodium benzoate ... 21 

calcipotriene ...................... 75 

calcitonin,salmon,synthetic 67 

calcitriol....................... 75, 79 

calcium acetate .................. 61 

calcium carbonate/mag carb/ 

fa .................................... 61 

calcium chloride ................ 71 

calcium gluconate .............. 71 

CAMPATH ........................ 40 

CAMPRAL ........................ 54 

CANASA ........................... 37 

CANCIDAS ....................... 32 

CAPASTAT SULFATE .... 39 

CAPRELSA ....................... 40 

captopril............................. 71 

captopril/hydrochlorothiazide 

....................................... 71 

CARAC ............................. 75 

CARAFATE ...................... 45 

carbamazepine ................... 26 

carbidopa/levodopa ........... 44 

carbidopa/levodopa/ 

entacapone ..................... 44 

carbinoxamine maleate...... 33 

carboplatin......................... 40 

CARIMUNE NF 

NANOFILTERED ......... 74 

carisoprodol ...................... 74 

carisoprodol/aspirin .......... 74 

carteolol hcl ....................... 56 

I-2 



carvedilol ........................... 49 

CEENU .............................. 40 

cefaclor .............................. 23 

cefadroxil hydrate .............. 23 

cefazolin sodium................. 23 

cefazolin sodium/dextrose,iso 

........................................ 23 

cefdinir ............................... 23 

cefditoren pivoxil ............... 23 

cefepime hcl ....................... 23 

cefotaxime sodium .............. 23 

cefotetan disod/dextrose,iso24 

cefotetan disodium ............. 24 

cefoxitin sodium ................. 24 

cefoxitin sodium/dextrose,iso 

........................................ 24 

cefpodoxime proxetil .......... 23 

cefprozil.............................. 23 

CEFTAZIDIME ................. 23 

ceftazidime pentahydrate ... 23 

ceftriaxone na/dextrose,iso 23 

ceftriaxone sodium ............. 23 

cefuroxime axetil ................ 23 

cefuroxime sodium ............. 23 

cefuroxime sodium/ 

dextrose,iso .................... 23 

CELEBREX ....................... 14 

CELLCEPT ........................ 63 

CELONTIN........................ 28 

CENESTIN ........................ 57 

cephalexin .......................... 23 

CEREDASE ....................... 56 

CEREZYME ...................... 56 

CERVARIX ....................... 78 

cetirizine hcl ....................... 33 

CHANTIX.......................... 66 

chloral hydrate ................... 48 

chloramphenicol na succ ... 22 

chlorhexidine gluconate ..... 34 

chloroprocaine hcl/pf ......... 62 

chloroquine phosphate ....... 44 

chlorothiazide .................... 55 

chlorothiazide sodium ........ 55 

chlorpheniramine maleate . 33 

chlorpromazine hcl ............. 69 

chlorpropamide .................. 29 

chlorthalidone .................... 55 

chlorzoxazone ..................... 74 

cholestyramine (with sugar) 

........................................ 38 

cholestyramine/aspartame . 38 

choline sal/mag salicylate .. 14 

CHORIONIC 

GONADOTROPIN ........ 67 

ciclopirox ............................ 35 

ciclopirox olamine .............. 35 

cilostazol............................. 60 

CILOXAN .......................... 34 

cimetidine ........................... 45 

cimetidine hcl ..................... 45 

cimetidine in 0.9 % nacl ..... 45 

CIMZIA .............................. 57 

CINRYZE........................... 63 

CIPRODEX ........................ 34 

ciprofloxacin hcl ........... 25, 34 

ciprofloxacin lactate/d5w ... 25 

ciprofloxacin/ciprofloxa hcl 

........................................ 25 

cisplatin .............................. 40 

citalopram hydrobromide ... 68 

citrate-phos-dex solution .... 58 

citric acid/sodium citrate ... 63 

cladribine ........................... 40 

clarithromycin .................... 23 

clemastine fumarate ........... 33 

clindamycin hcl .................. 22 

clindamycin palmitate hcl .. 22 


perox ............................... 35 

clindamycin phosphate . 22, 35 

CLINDESSE ...................... 35 

CLINISOL .......................... 51 

clobetasol propionate ......... 37 

CLOLAR ............................ 40 

clomipramine hcl ................ 68 

clonazepam ......................... 48 

clonidine ............................. 60 

clonidine hcl ....................... 60 

clonidine hcl/chlorthalidone 

....................................... 60 

clopidogrel bisulfate .......... 60 

clorazepate dipotassium .... 48 

clotrimazole ....................... 35 

clotrimazole/betamethasone 

dip .................................. 35 

clozapine ............................ 69 

cocaine hcl ......................... 62 

codeine phos/acetaminophen 

....................................... 16 

codeine phos/carisoprodol/ 

asa .................................. 74 

codeine sulfate ................... 16 

codeine/butalbit/acetamin/ 

caff ................................. 16 

codeine/butalbital/asa/caffein 

....................................... 16 

colchicine/probenecid ........ 63 

COLCRYS ......................... 63 

colestipol hcl ...................... 38 

colistin (colistimethate na) 22 

COMBIVENT ................... 76 

COMBIVENT RESPIMAT76 

COMPLERA ..................... 46 

COMTAN .......................... 44 

COMVAX ......................... 78 

CONDYLOX ..................... 75 

COPAXONE ..................... 63 

cortisone acetate ................ 13 

COUMADIN ..................... 58 

CREON .............................. 57 

CRESTOR ......................... 39 

cresyl ace/ben alc/butanol/ipa 

....................................... 34 

CRINONE ......................... 67 

CRIXIVAN ........................ 46 

cromolyn sodium................ 37 

CUBICIN ........................... 22 

CUPRIMINE ..................... 58 

cyclobenzaprine hcl ........... 74 

CYCLOGYL ..................... 56 

cyclopentolate hcl .............. 56 

cyclophosphamide ............. 40 

I-3 



Formulary

cyclosporine ....................... 63 

cyclosporine, modified ....... 63 

CYMBALTA ..................... 68 

cyproheptadine hcl ............. 33 

CYSTAGON ...................... 63 

cysteine hcl ......................... 51 

cytarabine/pf ...................... 40 

dacarbazine ........................ 40 

DACOGEN ........................ 40 

dactinomycin ...................... 40 

DALIRESP ........................ 73 

danazol ............................... 20 

dantrolene sodium .............. 74 

dapsone .............................. 39 

DAPTACEL ....................... 77 

DARAPRIM ...................... 44 

daunorubicin hcl ................ 40 

DAUNOXOME ................. 40 

deferoxamine mesylate ....... 58 

demeclocycline hcl ............. 25 

DENAVIR.......................... 36 

DEPOCYT ......................... 40 

desipramine hcl .................. 68 

desloratadine...................... 33 

desmopressin acetate ......... 67 

desogestrel-ethinyl estradiol 

........................................ 54 

desog-et estra/ethin estra ... 54 

desonide ............................. 37 

desoximetasone .................. 37 

DETROL ............................ 57 

DETROL LA ..................... 57 

dex 2.5%-half str lact.ringers 

........................................ 72 

dexamethasone ................... 13 

DEXAMETHASONE 

INTENSOL .................... 13 

dexamethasone sod phosphate 

.................................. 13, 36 

dexmethylphenidate hcl ...... 21 

dexrazoxane ....................... 63 

dextroamphetamine sulfate 21 


nacl ................................. 51 

dextrose 10 % and 0.9 % nacl 

........................................ 51 

dextrose 10%-0.5 normal 

saline .............................. 51 

dextrose 10%-water............ 51 

dextrose 2.5 %-water.......... 51 

dextrose 2.5% in half ringers 

........................................ 72 

dextrose 2.5%-0.5normal 

saline .............................. 51 

dextrose 20 % in water ....... 51 





........................................ 51 


........................................ 51 

dextrose 5 %-0.225 % nacl 51 

dextrose 5 %-0.45 % nacl .. 51 

dextrose 5 %-water............. 51 

dextrose 5% in ringers ....... 72 

dextrose 5%-lactated ringers 

........................................ 72 




dhcodeine bt/acetaminophn/ 

caff .................................. 16 

diazepam....................... 48, 49 

diclofenac potassium .......... 14 

diclofenac sodium ......... 14, 36 

dicloxacillin sodium ........... 24 

dicyclomine hcl ................... 26 

didanosine .......................... 46 

diflorasone diacetate .......... 37 

diflunisal ............................. 15 

digoxin ................................ 53 

DIGOXIN ........................... 53 

dihydroergotamine mesylate 

........................................ 76 

DILANTIN ......................... 28 

diltiazem hcl ....................... 50 

dimenhydrinate ................... 31 

diphenhydramine hcl ......... 33 

diphenoxylate hcl/atropine 31 

DIPHTHERIA-TETANUS 

TOXOID ........................ 77 

dipyridamole ...................... 79 

disopyramide phosphate .... 52 

disulfiram ........................... 64 

divalproex sodium.............. 26 

dobutamine hcl .................. 76 

dobutamine hcl/d5w ........... 76 

DOCEFREZ....................... 41 

docetaxel ............................ 41 

donepezil hcl ...................... 66 

dopamine hcl...................... 76 

dopamine hcl/d5w .............. 76 

dorzolamide hcl ................. 32 

dorzolamide hcl/timolol 

maleat ............................ 32 

DOVONEX ....................... 75 

doxazosin mesylate ............ 14 

doxepin hcl ......................... 68 

DOXIL ............................... 41 

doxorubicin hcl .................. 41 

doxorubicin hcl liposomal . 41 

doxycycline hyclate 25, 26, 34 

doxycycline monohydrate .. 26 

doxylamine succinate ......... 33 

dronabinol ......................... 31 

droperidol .......................... 48 

DROXIA ............................ 41 

DULERA ........................... 13 

econazole nitrate................ 35 

EDARBI ............................ 70 

EDARBYCLOR ................ 70 

edetate disodium ................ 58 

EDURANT ........................ 46 

EFFIENT ........................... 60 

ELAPRASE ....................... 56 

electrolyte-48 solution/d5w 72 

electrolyte-48/fructose 10%72 

electrolyte-48/fructose 5% . 72 

electrolyte-75 solution/d5w 72 

electrolyte-75/fructose 5% . 72 

electrolyte-r solution/d5w .. 72 

I-4 



ELIDEL.............................. 75 

ELIGARD .......................... 41 

ELITEK.............................. 56 

ELMIRON ......................... 64 

ELOXATIN ....................... 41 

ELSPAR ............................. 41 

EMCYT.............................. 41 

EMEND ............................. 31 

EMSAM ............................. 68 

EMTRIVA ......................... 46 

enalapril maleate ............... 71 

enalapril/hydrochlorothiazide 

........................................ 71 

enalaprilat dihydrate ......... 71 

ENBREL ............................ 64 

ENGERIX-B ...................... 78 

enoxaparin sodium ....... 58, 59 

ephedrine sulfate ................ 76 

epinastine hcl ..................... 21 

epinephrine ........................ 76 

epinephrine/pf .................... 76 

EPIPEN .............................. 76 

epirubicin hcl ..................... 41 

EPIVIR ............................... 46 

EPIVIR HBV ..................... 46 

eplerenone .......................... 71 

EPOGEN ............................ 60 

epoprostenol sodium (glycine) 

........................................ 79 

eprosartan mesylate ........... 70 

EPZICOM .......................... 46 

ERAXIS WATER DILUENT 

........................................ 32 

ERBITUX .......................... 41 

ergoloid mesylates ............. 64 

ergotamine tartrate/caffeine 

........................................ 76 

ERIVEDGE........................ 41 

ERWINAZE ....................... 41 

ery e-succ/sulfisoxazole ..... 23 

ERY-TAB .......................... 23 

ERYTHROCIN 

LACTOBIONATE ......... 23 

erythromycin base ........ 23, 34 

erythromycin base/ethanol . 35 

erythromycin ethylsuccinate 

........................................ 24 

erythromycin stearate ......... 24 

erythromycin/benzoyl 

peroxide .......................... 35 

escitalopram oxalate .......... 68 

esmolol hcl .......................... 49 

estazolam ............................ 49 

ESTRACE .......................... 57 

estradiol .............................. 57 

estradiol valerate ................ 57 

estradiol/noreth ac ............. 57 

estropipate .......................... 57 

ethambutol hcl .................... 39 

ethanolamine oleate ........... 74 

ethinyl estradiol/drospirenone 

........................................ 54 

ethosuximide ....................... 28 

ethynodiol d-ethinyl estradiol 

........................................ 54 

etidronate disodium ............ 64 

etodolac .............................. 15 

ETOPOPHOS ..................... 41 

etoposide ............................. 41 

EVISTA .............................. 57 

exemestane ......................... 41 

EXJADE ............................. 58 

FABRAZYME ................... 56 

famciclovir .......................... 47 

famotidine ........................... 45 

famotidine in nacl,iso-osm/pf 

........................................ 45 

FANAPT ............................ 69 

FARESTON ....................... 41 

FASLODEX ....................... 41 

FAZACLO ......................... 69 

felbamate ............................ 26 

felodipine ............................ 50 

fenofibrate .......................... 38 

fenofibrate,micronized........ 38 

fenofibric acid .................... 38 

fenoldopam mesylate .......... 60 

fenoprofen calcium ............. 15 

fentanyl .............................. 16 

fentanyl citrate ................... 16 

FERRIPROX ..................... 58 

fexofenadine hcl ................. 33 

fexofenadine/ 

pseudoephedrine ............ 33 

finasteride .......................... 64 

FIRMAGON ...................... 41 

FLAREX ............................ 36 

flavoxate hcl ....................... 57 

FLEBOGAMMA ............... 74 

FLEBOGAMMA DIF ....... 74 

flecainide acetate ............... 52 

FLOVENT DISKUS.......... 13 

FLOVENT HFA ................ 13 

floxuridine .......................... 41 

fluconazole ......................... 32 

fluconazole in nacl,iso-osm 32 

flucytosine .......................... 32 

fludarabine phosphate ....... 41 

fludrocortisone acetate ...... 13 

flumazenil........................... 54 

flunisolide .......................... 36 

fluocinolone acetonide ....... 38 

fluocinolone acetonide oil . 36 

fluocinolone/shower cap .... 38 

fluocinonide ....................... 38 

FLUOR-A-DAY ................ 79 

fluoride/iron/vit a,c&d ....... 79 

FLUORITAB ..................... 64 

fluorometholone ................. 36 

FLUOROPLEX ................. 75 

fluorouracil .................. 41, 75 

fluoxetine hcl...................... 68 

fluoxymesterone ................. 20 

fluphenazine decanoate ..... 69 

fluphenazine hcl ................. 69 

FLURA .............................. 80 

FLURA-DROPS ................ 64 

flurbiprofen ........................ 15 

flurbiprofen sodium ........... 36 

flutamide ............................ 41 

fluticasone propionate . 36, 38 

fluvastatin sodium .............. 39 

I-5 



Formulary

fluvoxamine maleate .......... 68 

FML ................................... 36 

FML FORTE ...................... 36 

FML S.O.P. ........................ 36 

FOLOTYN ......................... 41 

fomepizole .......................... 64 

fondaparinux sodium ......... 59 

FORADIL .......................... 76 

FORTEO ............................ 67 

FORTICAL ........................ 67 

FOSAMAX ........................ 64 

FOSAMAX PLUS D ......... 64 

foscarnet sodium ................ 47 

fosinopril sodium ............... 71 

fosinopril/ 


fosphenytoin sodium........... 28 

FOSRENOL ....................... 61 

FREAMINE III .................. 52 

fructose 10% ...................... 52 

furosemide .......................... 56 

FUSILEV ........................... 64 

FUZEON ............................ 46 

gabapentin.......................... 26 

GABITRIL ......................... 26 

galantamine hbr ................. 66 

GAMMAGARD LIQUID .. 74 

GAMUNEX-C ................... 74 

ganciclovir ......................... 47 

ganciclovir sodium ............. 47 

GARDASIL ....................... 78 

gauze bandage ................... 64 

gemcitabine hcl .................. 41 

gemfibrozil ......................... 38 

GENOTROPIN .................. 67 

gentamicin in nacl, iso-osm 22 

gentamicin sulfate .. 22, 34, 35 

gentamicin sulfate/pf .......... 22 

GEODON ........................... 69 

GLEEVEC ......................... 41 

glimepiride ......................... 29 

glipizide .............................. 30 

glipizide/metformin hcl ...... 30 

GLUCAGEN ...................... 64 

GLUCAGON EMERGENCY 

KIT ................................. 64 

glutethimide ........................ 48 

glyburide ............................. 30 

glyburide,micronized .......... 30 

glyburide/metformin hcl ..... 30 

glycopyrrolate .................... 26 

GLYSET............................. 28 

GOLYTELY ....................... 53 

granisetron hcl ................... 31 

granisetron hcl/pf ............... 31 

griseofulvin,microsize ........ 32 

GRIS-PEG .......................... 32 

guaifen/theop anhyd/p-ephed 

........................................ 73 

guanfacine hcl .................... 60 

HALAVEN ......................... 41 

HALDOL ........................... 69 


100 .................................. 69 

HALDOL DECANOATE 50 

........................................ 69 

halobetasol propionate ....... 38 

haloperidol ......................... 70 

haloperidol decanoate ........ 70 

haloperidol lactate ............. 70 

HAVRIX ............................ 78 

HECTOROL ....................... 80 

heparin sodium,porcine ...... 59 

heparin sodium,porcine/d5w 

........................................ 59 

heparin sodium,porcine/ns/pf 

........................................ 59 

heparin sodium,porcine/pf . 59 

HEPSERA .......................... 47 

HERCEPTIN ...................... 41 

HEXALEN ......................... 41 

HIZENTRA ........................ 74 

homatropine hbr ................. 56 

HUMIRA ............................ 64 

hydralazine hcl ................... 60 

hydralazine/ 

hydrochlorothiazid ......... 60 

hydralazine/reserpin/hctz ... 60 

hydrochlorothiazide ........... 55 


acetaminophen ......... 16, 17 

hydrocodone/ibuprofen ...... 17 

hydrocortisone ............. 13, 38 

hydrocortisone acetate ...... 38 

hydrocortisone acetate/aloe v 

....................................... 38 

hydrocortisone acetate/urea 

....................................... 38 

hydrocortisone butyrate ..... 38 

hydrocortisone sod succinate 

....................................... 13 

hydrocortisone valerate ..... 38 

hydromorphone hcl ............ 17 

hydromorphone hcl/pf........ 17 

hydroxychloroquine sulfate 44 

hydroxyurea ....................... 41 

hydroxyzine hcl .................. 48 

hydroxyzine pamoate ......... 48 

hyoscyamine....................... 26 

hyoscyamine sulfate ........... 26 

ibandronate sodium ........... 64 

ibuprofen ............................ 15 

ibuprofen/oxycodone hcl.... 17 

idarubicin hcl ..................... 41 

ifosfamide........................... 41 

ifosfamide/mesna ............... 41 

imipenem/cilastatin sodium 24 

imipramine hcl ................... 68 

imipramine pamoate .......... 68 

imiquimod .......................... 75 

INCIVEK ........................... 47 

INCRELEX ....................... 75 

indapamide ........................ 55 

INFANRIX ........................ 77 

INFANRIX PF ................... 77 

INLYTA ............................ 42 

INNOPRAN XL ................ 49 

INTELENCE ..................... 46 

INTRALIPID ..................... 52 

INTRON A ........................ 47 

INTUNIV........................... 54 

INVEGA ............................ 70 

I-6 



INVEGA SUSTENNA ...... 70 

INVIRASE ......................... 46 

IPOL ................................... 78 

ipratropium bromide .......... 56 

ipratropium/albuterol sulfate 

........................................ 76 

irbesartan ........................... 70 

irbesartan/ 


irinotecan hcl ..................... 42 

iron,carbonyl/vit c/vit b12/fa 

........................................ 80 

ISENTRESS ....................... 46 

isoniazid ............................. 39 

isopropamide/ 

prochlorperazine ............ 26 

isosorbide dinitrate ............ 79 

isosorbide mononitrate ...... 79 

isotretinoin ......................... 75 

isradipine ........................... 50 

ISTODAX .......................... 42 

itraconazole........................ 32 

IXEMPRA.......................... 42 

IXIARO.............................. 78 

JAKAFI .............................. 42 

JANUMET ......................... 28 

JANUVIA .......................... 28 

JE-VAX.............................. 78 

JEVTANA.......................... 42 

KALETRA ......................... 46 

kanamycin sulfate ............... 22 

KAYEXALATE ................ 61 

KEPIVANCE ..................... 53 

KETEK .............................. 24 

ketoconazole ................. 32, 35 

ketoprofen .......................... 15 

ketorolac tromethamine ..... 36 

KINERET .......................... 64 

KORLYM .......................... 28 

KUVAN ............................. 64 

labetalol hcl ....................... 49 

LACTATED RINGERS .... 61 

lactulose ............................. 14 

LAMICTAL BLUE ........... 26 

LAMICTAL GREEN ......... 26 

LAMICTAL ODT .............. 27 

LAMICTAL ODT BLUE... 27 

LAMICTAL ODT GREEN 27 

LAMICTAL ODT ORANGE 

........................................ 27 

LAMICTAL ORANGE ...... 27 

LAMICTAL XR ................. 27 

LAMICTAL XR BLUE ..... 27 

LAMICTAL XR GREEN .. 27 

LAMICTAL XR ORANGE 

........................................ 27 

lamivudine .......................... 46 

lamivudine/zidovudine ........ 46 

lamotrigine ......................... 27 

LANOXIN .......................... 53 

lansoprazole ....................... 45 

LANTUS ............................ 29 

LANTUS SOLOSTAR ...... 29 

latanoprost ......................... 32 

LATUDA ........................... 70 

leflunomide ......................... 64 

LETAIRIS .......................... 79 

letrozole .............................. 42 

leucovorin calcium ............. 64 

LEUKERAN ...................... 42 

LEUKINE ........................... 60 

leuprolide acetate ............... 42 

LEVAQUIN ....................... 25 

LEVEMIR .......................... 29 

levetiracetam ...................... 27 

levetiracetam in nacl (iso-os) 

........................................ 27 

levobunolol hcl ............. 32, 33 

levocarnitine ....................... 64 

levocarnitine (with sugar) .. 64 

levocetirizine dihydrochloride 

........................................ 33 

levofloxacin .................. 25, 34 

levofloxacin/d5w ................. 25 

levonorgestrel ..................... 54 

levonorgestrel-eth estradiol54 

levorphanol tartrate ........... 17 

LEVOTHROID .................. 77 

levothyroxine sodium ......... 77 

LEVOXYL ........................ 77 

LEVULAN ........................ 75 

LEXIVA ............................ 46 

lidocaine ............................ 45 

lidocaine hcl ................ 53, 62 

lidocaine hcl/d5w/pf .......... 53 

lidocaine hcl/d7.5w/pf ....... 53 

lidocaine hcl/pf ............ 53, 62 

lidocaine/prilocaine ........... 45 

LIDODERM ...................... 45 

LINCOCIN ........................ 22 

lindane ............................... 36 

liothyronine sodium ........... 77 

lipase/protease/amylase..... 57 

LIPOSYN II ....................... 52 

LIPOSYN III ..................... 52 

lisinopril............................. 71 

lisinopril/hydrochlorothiazide 

....................................... 71 

lithium carbonate ............... 54 

lithium citrate .................... 54 

l-norgest-eth estr/ethin estra 

....................................... 55 

loperamide hcl ................... 31 

lorazepam .......................... 49 

LORAZEPAM INTENSOL 

....................................... 49 

losartan potassium ............. 70 

losartan/hydrochlorothiazide 

....................................... 70 

LOTEMAX ........................ 36 

LOTRONEX ...................... 57 

lovastatin ........................... 39 

LOVAZA ........................... 38 

LOVENOX ........................ 59 

loxapine succinate ............. 70 

LOZI-FLUR....................... 80 

LUMIGAN ........................ 33 

LUPRON DEPOT ............. 42 

LUPRON DEPOT-PED .... 42 

LUVOX CR ....................... 68 

LYRICA ............................ 27 

LYSODREN ...................... 42 

I-7 



Formulary

magnesium chloride ........... 27 

magnesium salicylate ......... 15 

magnesium sulfate .............. 27 

magnesium sulfate/d5w ...... 27 

malathion ........................... 36 

mannitol/sorbitol solution .. 61 

maprotiline hcl ................... 68 

MARPLAN ........................ 68 

MATULANE ..................... 42 

MAXALT .......................... 39 

MAXALT MLT ................. 39 

MAXIDEX ......................... 36 

meclizine hcl....................... 31 

meclofenamate sodium ....... 15 

medroxyprogesterone acetate 

........................................ 67 

mefenamic acid .................. 15 

mefloquine hcl .................... 44 

MEGACE ES ..................... 42 

megestrol acetate ............... 42 

meloxicam .......................... 15 

melphalan hcl ..................... 42 

MENACTRA ..................... 78 

MENEST............................ 57 

MENOMUNE-A-C-Y-W-135 

........................................ 78 

MENVEO A-C-Y-W-135- 

DIP ................................. 78 

mepivacaine hcl/pf ............. 62 

meprobamate...................... 48 

MEPRON ........................... 44 

mercaptopurine .................. 42 

meropenem ......................... 24 

mesalamine w/cleansing 

wipes .............................. 37 

mesna ................................. 64 

MESNEX ........................... 64 

METADATE CD ............... 21 

metaproterenol sulfate ....... 76 

metaxalone ......................... 74 

metformin hcl ............... 28, 29 

methadone hcl .................... 18 

methamphetamine hcl ........ 21 

methazolamide ................... 33 

methen/m-blue/sal/na phos/ 

hyos................................. 78 

methenamine mandelate ..... 78 

methimazole ........................ 77 

methocarbamol ................... 74 

methotrexate sodium .......... 42 

methotrexate sodium/pf ...... 42 

methscopolamine bromide.. 26 

methyclothiazide ................. 55 

methyl salicylate ................. 15 

methyldopa ......................... 60 

methyldopa/ 


methyldopate hcl ................ 61 

methylene blue .................... 65 

methylergonovine maleate .. 65 

METHYLIN ....................... 21 

methylphenidate hcl ............ 21 

methylprednisolone ............ 13 

methylprednisolone acetate 13 

methylprednisolone sod succ 

........................................ 13 

metipranolol ....................... 33 

metoclopramide hcl ...... 57, 58 

metolazone .......................... 55 

metoprolol succinate .......... 49 

metoprolol tartrate ............. 49 

metoprolol/ 


METROGEL ...................... 35 

metronidazole ............... 35, 44 

metronidazole/sodium 

chloride ........................... 45 

METVIXIA ........................ 75 

mexiletine hcl ...................... 53 

MIACALCIN ..................... 67 

MICARDIS ........................ 70 

MICARDIS HCT ............... 70 

miconazole nitrate .............. 35 

midodrine hcl ...................... 76 

milrinone lactate ................ 53 

milrinone lactate/d5w ......... 53 

minocycline hcl ................... 26 

minoxidil ............................. 61 

mirtazapine ........................ 68 

misoprostol ........................ 45 

MITHRACIN..................... 42 

mitomycin........................... 42 

mitoxantrone hcl ................ 42 

M-M-R II VACCINE ........ 78 

MOBAN ............................ 70 

modafinil ............................ 21 

moexipril hcl ...................... 71 

moexipril/ 


mometasone furoate ........... 38 

morphine sulfate ................ 18 

morphine sulfate/pf ............ 18 

MOVIPREP ....................... 53 

MULTAQ .......................... 53 

multivitamins with fluoride 80 

mupirocin ........................... 35 

MUSTARGEN .................. 42 

MVC-FLUORIDE ............. 80 

MYCOBUTIN ................... 39 

mycophenolate mofetil ....... 65 

MYFORTIC....................... 65 

MYOZYME....................... 56 

na nitrite/na thiosul/amyl nit 

....................................... 58 

nabumetone ........................ 15 

nadolol ............................... 49 

nadolol/bendroflumethiazide 

....................................... 49 

nafcillin sodium ................. 24 

NAFTIN............................. 35 

NAGLAZYME .................. 57 

nalbuphine hcl ................... 20 

nalidixic acid ..................... 25 

NALLPEN-ISO-OSMOTIC 

DEXTROSE .................. 24 

naloxone hcl ....................... 66 

naltrexone hcl .................... 66 

NAMENDA ....................... 54 

naphazoline hcl .................. 56 

naphazoline hcl/antazoline 56 

naproxen ............................ 15 

naproxen sodium................ 15 

I-8 



naratriptan hcl ................... 39 

NARDIL ............................ 68 

NASONEX ........................ 36 

nateglinide.......................... 29 

needles, insulin disp., safety 

........................................ 55 

needles, insulin disposable . 55 

nefazodone hcl ................... 68 

neo/polymyx b sulf/dexameth 

........................................ 34 

neomy sulf/bacitra/polymyxin 

b...................................... 34 

neomy sulf/bacitrac zn/poly/ 

hc .................................... 34 

neomy sulf/polymyxin b 

sulfate ............................. 35 

neomycin sulfate ................. 22 

neomycin sulfate/dex na ph 34 

neomycin/polymyxin b sulf/hc 

........................................ 34 

neomycin/polymyxn b/ 

gramicidin ...................... 34 

neostigmine methylsulfate .. 66 

NEULASTA ...................... 60 

NEUMEGA........................ 60 

NEUPOGEN ...................... 60 

nevirapine .......................... 46 

NEXAVAR ........................ 42 

NEXIUM............................ 45 

niacin.................................. 38 

NIASPAN .......................... 38 

nicardipine hcl ................... 50 

nicotine ............................... 66 

NICOTROL NS ................. 66 

nifedipine............................ 50 

NILANDRON .................... 42 

nimodipine.......................... 50 

nisoldipine .......................... 50 

nitrofurantoin macrocrystal 

........................................ 78 

nitroglycerin ....................... 79 

nitroglycerin/d5w ............... 79 

NITROSTAT ..................... 79 

nizatidine ............................ 45 

NORDITROPIN FLEXPRO 

........................................ 67 

NORDITROPIN 

NORDIFLEX ................. 67 

norepinephrine bitartrate ... 76 

noreth a-et estra/fe fumarate 

........................................ 55 

noreth-ethinyl estradiol/iron 

........................................ 55 

norethind ac/ethinyl estradiol 

........................................ 57 

norethindrone ..................... 55 

norethindrone acetate ........ 67 

norethindrone a-e estradiol 55 

norethindrone-ethinyl estrad 

........................................ 55 

norethindrone-mestranol .... 55 

norgestimate-ethinyl estradiol 

........................................ 55 

norgestrel-ethinyl estradiol 55 

nortriptyline hcl .................. 68 

NORVIR............................. 46 

NOVAMINE ...................... 52 

NOVOLIN 70-30 ............... 29 

NOVOLIN 70-30 INNOLET 

........................................ 29 

NOVOLIN N ...................... 29 

NOVOLIN N INNOLET ... 29 

NOVOLIN R ...................... 29 

NOVOLOG ........................ 29 

NOVOLOG MIX 70-30 ..... 29 

NPLATE............................. 65 

NULOJIX ........................... 65 

NUTROPIN ........................ 67 

NUTROPIN AQ ................. 67 

NUTROPIN AQ NUSPIN . 67 

NUVARING ....................... 55 

NUVIGIL ........................... 21 

nylidrin hcl ......................... 79 

nystatin ......................... 32, 35 

nystatin/triamcin................. 35 

octreotide acetate ............... 65 

ofloxacin ....................... 25, 34 

olanzapine .......................... 70 

olanzapine/fluoxetine hcl ... 68 

OLEPTRO ER ................... 68 

omeprazole......................... 45 

omeprazole/sodium 

bicarbonate .................... 45 

OMNITROPE .................... 67 

ONCASPAR ...................... 42 

ondansetron ....................... 31 

ondansetron hcl ................. 31 

ondansetron in 0.9 % nacl/pf 

....................................... 31 

ONFI .................................. 49 

ONTAK ............................. 42 

opium tincture .................... 31 

ORAP................................. 70 

ORFADIN ......................... 65 

orphenadrine citrate .......... 74 

orphenadrine/aspirin/caffeine 

....................................... 75 

OSMOPREP ...................... 53 

oxacillin sodium ................. 24 

oxacillin sodium/dextrose,iso 

....................................... 25 

oxaliplatin .......................... 42 

oxandrolone ....................... 20 

oxaprozin ........................... 15 

oxazepam ........................... 49 

oxcarbazepine .................... 27 

OXSORALEN ................... 75 

OXSORALEN-ULTRA .... 75 

oxybutynin chloride ........... 57 

oxycodone hcl .................... 19 

oxycodone hcl/acetaminophen 

....................................... 19 

oxycodone hcl/aspirin ........ 19 

OXYCONTIN ................... 19 

oxymorphone hcl................ 19 

paclitaxel ........................... 42 

pamidronate disodium ....... 65 

PANRETIN ....................... 75 

pantoprazole sodium ......... 45 

papaverine hcl ................... 79 

paromomycin sulfate.......... 45 

paroxetine hcl .................... 68 

I-9 



Formulary

PASER ............................... 40 

PATADAY ........................ 21 

PAXIL ................................ 68 

PCE .................................... 24 

ped mv a,c,d3 #21 w-fluoride 

........................................ 80 

PEDVAXHIB .................... 78 

peg 3350/na sulf,bicarb,cl/kcl 

........................................ 53 

PEGANONE ...................... 28 

PEGASYS .......................... 47 

PEGASYS PROCLICK ..... 47 

PEGINTRON ..................... 47 

PEGINTRON REDIPEN ... 47 

pen g pot/dextrose-water.... 25 

penicillin g potassium ........ 25 

penicillin g potassium/d5w 25 

penicillin g procaine .......... 25 

penicillin v potassium ........ 25 

PENTAM 300 .................... 45 

pentamidine isethionate ..... 45 

PENTOLAIR ..................... 56 

pentostatin .......................... 42 

pentoxifylline ...................... 59 

p-epd tan/chlor-tan ............ 33 

perindopril erbumine ......... 71 

permethrin .......................... 36 

perphenazine ...................... 70 

perphenazine/amitriptyline 

hcl ................................... 69 

PEXEVA ............................ 69 

phenazopyridine hcl ........... 45 

phenelzine sulfate ............... 69 

phenobarbital ..................... 54 

phenobarbital sodium ........ 54 

phentolamine mesylate ....... 76 

phenylbutazone .................. 15 

phenylephrine hcl ......... 56, 77 

phenylephrine hcl/prometh 

hcl ................................... 33 

PHENYTEK ...................... 28 

phenytoin ............................ 28 

phenytoin sodium ............... 28 

phenytoin sodium extended 28 

PHISOHEX ........................ 36 

PHOSPHOLINE IODIDE .. 33 

phosphorus #1 .................... 65 

PHOTOFRIN ..................... 42 

physostigmine salicylate ..... 66 

pilocarpine hcl .............. 33, 66 

PILOPINE HS .................... 33 

pindolol............................... 49 

piperacillin sodium/ 

tazobactam ..................... 25 

piroxicam ............................ 15 

pnv with ca,no.72/iron/fa ... 80 

podofilox ............................. 75 

podophyllum resin .............. 75 

polyethylene glycol 3350 .... 53 

polymyxin b sulfate ............. 22 

polymyxin b sulfate/tmp ...... 34 

pot chloride/pot bicarb/cit ac 

........................................ 72 

potassium acetate ............... 72 

potassium bicarbonate/cit ac 

........................................ 72 

potassium chlorid/d10- 

0.2%nacl ......................... 72 

potassium chlorid/d5- 

0.225nacl ........................ 72 

potassium chloride ............. 72 

potassium chloride in 

0.9%nacl ......................... 72 

potassium chloride/d5-0.25ns 

........................................ 72 

potassium chloride/d5- 

0.33nacl .......................... 72 


0.45nacl .......................... 73 


0.9%nacl ......................... 73 

potassium chloride/d5lr...... 73 

potassium chloride/d5w...... 73 

potassium chloride-0.45% 

nacl ................................. 73 

potassium citrate ................ 65 

potassium citrate/citric acid 

........................................ 65 

potassium gluconate .......... 73 

potassium hydroxide .......... 62 

potassium phos,m-basic-dbasic 

............................... 73 

POTIGA............................. 27 

PRADAXA ........................ 59 

pramipexole di-hcl ............. 44 

PRANDIN ......................... 29 

pravastatin sodium ............ 39 

prazosin hcl........................ 14 

PRED-G ............................. 34 

prednicarbate..................... 38 

prednisolone ...................... 14 

prednisolone acetate .... 13, 37 

prednisolone sod phosphate 

................................. 13, 37 

prednisone ......................... 14 

PREMARIN....................... 57 

PREMASOL ...................... 52 

PREMPHASE .................... 57 

PREMPRO ........................ 57 

PREZISTA......................... 46 

PRIFTIN ............................ 40 

PRIMAQUINE .................. 45 

PRIMAXIN ....................... 24 

PRIMAXIN I.M................. 24 

primidone ........................... 54 

PRISTIQ ER ...................... 69 

PRIVIGEN......................... 74 

probenecid ......................... 65 

procainamide hcl ............... 53 

prochlorperazine edisylate 32 

prochlorperazine maleate .. 32 

PROCRIT .......................... 60 

progesterone ...................... 68 

progesterone,micronized ... 68 

PROGLYCEM................... 61 

PROGRAF ......................... 65 

PROLASTIN ..................... 73 

PROLEUKIN..................... 42 

PROMACTA ..................... 60 

promethazine hcl................ 33 

propafenone hcl ................. 53 

I-10 



propantheline/phenobarbital 

........................................ 26 

proparacaine hcl ................ 62 

proparacaine/fluorescein sod 

........................................ 62 

propranolol hcl .................. 49 

propranolol/ 


propylthiouracil ................. 77 

PROQUAD ........................ 78 

PROSOL ............................ 52 

protamine sulfate ............... 60 

PROTONIX IV .................. 45 

protriptyline hcl ................. 69 

PROVIGIL ......................... 21 

PULMICORT FLEXHALER 

........................................ 14 

PULMOZYME .................. 57 

pyrazinamide ...................... 40 

pyridostigmine bromide ..... 67 

quetiapine fumarate ........... 70 

quinapril hcl ....................... 71 

quinapril/hydrochlorothiazide 

........................................ 71 

quinidine gluconate ............ 53 

quinidine sulfate ................. 53 

QVAR ................................ 14 

RABAVERT ...................... 78 

ramipril .............................. 71 

RANEXA ........................... 53 

ranitidine hcl ...................... 45 

RAPAMUNE ..................... 65 

REBETOL.......................... 47 

RECOMBIVAX HB .......... 78 

REFLUDAN ...................... 59 

REGRANEX ...................... 75 

RELENZA ......................... 47 

RELISTOR ........................ 58 

REMICADE ....................... 65 

RENAGEL ......................... 61 

RENVELA ......................... 61 

RESCRIPTOR ................... 46 

reserpine ............................ 61 

reserpine/hydrochlorothiazide 

........................................ 61 

RESTASIS ......................... 37 

RETIN-A MICRO .............. 54 

RETROVIR ........................ 46 

REVATIO .......................... 79 

REVLIMID .................. 42, 65 

REYATAZ ......................... 46 

RHINOCORT AQUA ........ 37 

RIBATAB .......................... 48 

ribavirin .............................. 48 

RIDAURA .......................... 65 

rifampin .............................. 40 

rifampin/isoniazid............... 40 

RILUTEK ........................... 54 

rimantadine hcl .................. 47 

ringers solution ............ 61, 73 

RISPERDAL CONSTA ..... 70 

risperidone ......................... 70 

RITUXAN .......................... 42 

rivastigmine tartrate ........... 67 

ropinirole hcl ...................... 44 

ROTATEQ ......................... 78 

SABRIL .............................. 27 

sal-amide/acetamin/p-tlox/ 

caff .................................. 14 

sal-amide/acetaminophn/ptlox 

.................................. 14 

salicylic acid ....................... 62 

salicylic acid/ammon lact/ 

aloe ................................. 62 

salicylic acid/ceramide cmb 

#1 .................................... 62 

salsalate .............................. 15 

SANTYL ............................ 75 

SAPHRIS ........................... 70 

SAVELLA .......................... 54 

SCLEROSOL ..................... 74 

selegiline hcl ....................... 44 

selenium sulfide .................. 36 

SELZENTRY ..................... 46 

SENSIPAR ......................... 65 

SEREVENT DISKUS ........ 77 

SEROMYCIN .................... 40 

SEROQUEL XR ................ 70 

SEROSTIM ....................... 67 

sertraline hcl ...................... 69 

silver nitrate ....................... 36 

silver sulfadiazine .............. 36 

SIMPONI ........................... 65 

SIMULECT ....................... 65 

simvastatin ......................... 39 

SINGULAIR ...................... 37 

sod propionate/inosi/aa14/ 

urea ................................ 35 

sod/pot/k cit/sod cit/cit acid 65 

sodium acetate ................... 73 

sodium bicarbonate ........... 65 

sodium chloride ................. 73 

sodium chloride 0.45 % ..... 73 

sodium chloride 3% ........... 73 

sodium chloride 5% ........... 73 

sodium chloride irrig solution 

....................................... 61 

sodium chloride/nahco3/kcl/ 

peg ................................. 53 

sodium fluoride ............ 65, 80 

sodium lactate .................... 65 

sodium morrhuate .............. 74 

sodium phos,m-basic-d-basic 

....................................... 73 

sodium polystyrene sulfonate 

....................................... 61 

sodium tetradecyl sulfate ... 74 

sodium thiosulfate .............. 58 

sodium thiosulfate/sal acid 36 

SOLARAZE ...................... 15 

SOLU-MEDROL PF ......... 14 

SOMATULINE DEPOT ... 65 

SOMAVERT ..................... 75 

sorbitol solution ................. 61 

sotalol hcl .......................... 49 

SPIRIVA ............................ 26 

spironolact/ 

hydrochlorothiazid ........ 71 

spironolactone ................... 71 

SPRYCEL .......................... 43 

STALEVO 100 .................. 44 

I-11 



Formulary

STALEVO 125 .................. 44 

STALEVO 150 .................. 44 

STALEVO 200 .................. 44 

STALEVO 50 .................... 44 

STALEVO 75 .................... 44 

stannous fluoride ................ 66 

stavudine ............................ 46 

STAVZOR ......................... 27 

STELARA.................... 66, 75 

STRATTERA .................... 54 

streptomycin sulfate ........... 22 

STRIANT ........................... 20 

STROMECTOL ................. 21 

SUBOXONE ...................... 20 

sucralfate...................... 45, 46 

sulfacetamide sodium ... 34, 36 

sulfacetamide sodium/urea 62 

sulfacetamide/prednisolone 

sp .................................... 34 

sulfadiazine ........................ 25 

sulfamethoxazole/ 

trimethoprim .................. 25 

sulfasalazine ....................... 25 

sulindac .............................. 15 

sumatriptan ........................ 39 

sumatriptan succinate ........ 39 

SUPPRELIN ...................... 66 

SUPPRELIN LA ................ 66 

SUPRAX ............................ 23 

SUSTIVA ........................... 46 

SUTENT ............................ 43 

SYLATRON ...................... 47 

SYMBICORT .................... 14 

SYMBYAX........................ 69 

SYMLIN ............................ 29 

SYMLINPEN 120 .............. 29 

SYMLINPEN 60 ................ 29 

SYNAREL ......................... 66 

SYNTHROID .................... 77 

syring w-ndl,disp,insul,0.3ml 

........................................ 55 

syring w-ndl,disp,insul,0.5ml 

........................................ 55 

syringe & needle,insulin,1 ml 

........................................ 55 

TABLOID .......................... 43 

tacrolimus ........................... 66 

talc ...................................... 74 

TAMIFLU .......................... 47 

tamoxifen citrate ................. 43 

tamsulosin hcl ..................... 76 

TARCEVA ......................... 43 

TARGRETIN ............... 43, 75 

TASIGNA .......................... 43 

TASMAR ........................... 44 

TAXOTERE ....................... 43 

TAZORAC ......................... 75 

TE ANATOXAL BERNA . 77 

TEGRETOL XR ................. 27 

TEKTURNA ...................... 71 

TEKTURNA HCT ............. 71 

temazepam .......................... 49 

terazosin hcl ....................... 14 

terbinafine hcl .................... 32 

terbutaline sulfate ............... 77 

terconazole ......................... 36 

testosterone cypionate ........ 20 

testosterone enanthate ........ 20 

TETANUS DIPHTHERIA 

TOXOIDS ...................... 77 

TETANUS-DIPHTERIA- 

DECAVAC..................... 77 

tetracaine hcl/pf .................. 62 

tetracycline hcl ................... 26 

TEVETEN .......................... 71 

TEVETEN HCT ................. 70 

THALOMID ....................... 66 

theophylline anhydrous ...... 73 

theophylline/d5w ................ 73 

THERACYS ....................... 78 

THERMAZENE ................. 36 

thioridazine hcl ................... 70 

thiotepa ............................... 43 

thiothixene .......................... 70 

THYMOGLOBULIN ......... 66 

ticlopidine hcl ..................... 60 

TIKOSYN .......................... 53 

TIMENTIN ........................ 25 

timolol maleate ............ 33, 49 

tinidazole ........................... 45 

tizanidine hcl...................... 75 

TOBI .................................. 22 

TOBRADEX ..................... 34 

TOBRADEX ST ................ 34 

tobramycin sulf/ 

dexamethasone............... 34 

tobramycin sulfate ....... 22, 34 

tobramycin/sodium chloride 

....................................... 22 

tolazamide .................... 30, 31 

tolbutamide ........................ 31 

tolmetin sodium.................. 15 

tolterodine tartrate ............ 57 

topiramate .......................... 27 

topotecan hcl...................... 43 

TORISEL ........................... 43 

torsemide ........................... 56 

TPN ELECTROLYTES .... 73 

TRACLEER....................... 79 

tramadol hcl ................. 19, 20 

tramadol hcl/acetaminophen 

....................................... 20 

trandolapril ........................ 71 

tranexamic acid ................. 60 

tranylcypromine sulfate ..... 69 

TRAVAMULSION ........... 52 

TRAVASOL ...................... 52 

TRAVASOL W/DEXTROSE 

....................................... 52 

TRAVASOL W/ 


TRAVASOL with 

DEXTROSE .................. 52 

TRAVASOL with 


TRAVATAN Z .................. 33 

TRAVERT ......................... 52 

TRAVERT IN NORMAL 

SALINE ......................... 52 

trazodone hcl ..................... 69 

TREANDA ........................ 43 

I-12 



TRECATOR ...................... 40 

TRELSTAR ....................... 43 

tretinoin ........................ 43, 54 

triacetin .............................. 32 

triamcinolone acetonide .... 37, 

38 

triamterene/ 


TRICOR ............................. 38 

trifluoperazine hcl .............. 70 

trifluridine .......................... 34 

trihexyphenidyl hcl ............. 44 

TRIHIBIT .......................... 77 

TRILEPTAL ...................... 27 

TRILIPIX ........................... 38 

trimethoprim ...................... 78 

trimipramine maleate ......... 69 

TRIPEDIA ......................... 77 

tripelennamine hcl ............. 33 

TRISENOX ........................ 43 

TRIZIVIR .......................... 46 

TROPHAMINE ................. 52 

tropicamide ........................ 56 

trospium chloride ............... 57 

TRUVADA ........................ 46 

TWINJECT ........................ 77 

TWINRIX .......................... 78 

TYGACIL .......................... 26 

TYKERB............................ 43 

TYPHIM VI ....................... 79 

TYSABRI .......................... 66 

TYZEKA............................ 48 

TYZINE ............................. 56 

ULORIC ............................. 66 

ULTRASE.......................... 58 

ULTRASE MT 12.............. 58 

ULTRASE MT 18.............. 58 

ULTRASE MT 20.............. 58 

UNITHROID ..................... 77 

urea .................................... 62 

urea/lactic ac/zn 

undecylenate .................. 62 

urea/lactic acid/salicyl acid62 

UROLOGIC SOLUTION G 

........................................ 61 

ursodiol............................... 58 

UVADEX ........................... 75 

VAGIFEM .......................... 57 

valacyclovir hcl .................. 48 

VALCYTE ......................... 48 

valproate sodium ................ 27 

valproic acid ....................... 28 

VALSTAR ......................... 43 

vancomycin hcl ................... 22 

vancomycin hcl/d5w ........... 22 

VANDETANIB .................. 43 

VANTAS ............................ 66 

VAQTA .............................. 79 

VARIVAX VACCINE ....... 79 

vasopressin ......................... 67 

VECTIBIX ......................... 43 

VECTICAL ........................ 75 

VELCADE ......................... 43 

venlafaxine hcl .................... 69 

VENLAFAXINE HCL ER. 69 

VENTAVIS ........................ 79 

VENTOLIN HFA ............... 77 

verapamil hcl ...................... 50 

VERIPRED 20 ................... 14 

VESICARE ........................ 57 

VICTRELIS ....................... 47 

VIDAZA ............................. 43 

VIDEX ............................... 47 

VIGAMOX......................... 35 

VIIBRYD ........................... 69 

VIMPAT............................. 28 

vinblastine sulfate ............... 43 

vincristine sulfate ............... 43 

vinorelbine tartrate ............ 43 

VIRACEPT ........................ 47 

VIRAMUNE ...................... 47 

VIRAMUNE XR ................ 47 

VIREAD ............................. 47 

VISTIDE ............................ 48 

VIVAGLOBIN ................... 74 

VIVELLE-DOT ................. 57 

VIVOTIF BERNA ............. 79 

VORAXAZE ..................... 66 

voriconazole....................... 32 

VOTRIENT ....................... 43 

VUMON ............................ 43 

warfarin sodium ................. 59 

water for irrigation,sterile . 61 

WELCHOL ........................ 38 

XALKORI ......................... 43 

XARELTO......................... 59 

XENAZINE ....................... 54 

XOLAIR ............................ 73 

XYLOCAINE .................... 62 

XYREM ............................. 54 

YERVOY........................... 43 

YF-VAX ............................ 79 

zafirlukast .......................... 37 

zaleplon .............................. 48 

ZANOSAR ........................ 43 

ZAVESCA ......................... 66 

ZELBORAF....................... 43 

ZEMPLAR......................... 80 

ZENPEP............................. 58 

ZERIT ................................ 47 

ZETIA ................................ 38 

ZIAGEN ............................ 47 

zidovudine .......................... 47 

ziprasidone hcl ................... 70 

ZIRGAN ............................ 35 

ZOLADEX ........................ 43 

ZOLINZA .......................... 43 

zolpidem tartrate ............... 48 

ZOMETA........................... 66 

ZONALON ........................ 45 

zonisamide ......................... 28 

ZORBTIVE ....................... 67 

ZORTRESS ....................... 66 

ZOSTAVAX ...................... 79 

ZOVIRAX ......................... 36 

ZYCLARA ........................ 75 

ZYFLO CR ........................ 37 

ZYMAXID ........................ 35 

ZYPREXA RELPREVV ... 70 

ZYTIGA ............................ 44 

ZYVOX ............................. 22 

I-13 



Formulary

Notes

Notes

Accessories Program 

& 

SilverSneakers® Fitness 

Program

Accessories Program 

Valuable Discounts for Members 

Th e Accessories Program is available to all 

Geisinger Gold members. All you need is your 

member ID card, or use the online services 

available. No referrals are needed. Th ere is no 

charge for using the Accessories Program. Your 

health plan may already cover some services for 

which a discount is available through the 

Accessories Program. You should exhaust your 

covered benefi ts fi rst before taking advantage 

of the Accessories Program. 

What health discounts are available? 

• Fitness Center Discounts – Receive a discount on 

memberships at participating fi tness centers. See the 

most up-to-date list of these centers on our Web site. 

• Weight Watchers® – If you’re looking for help taking 

off a few pounds, consider joining Weight Watchers. It 

can teach you how to lose weight safely and keep it off 

through a combination of support and fl exible food, 

activity and maintenance plans. Please see the back of 

this brochure for more information. 

What about specialty services and products? 

ChooseHealthyTM provides discounts on 

complementary health care services, such as: 

• Chiropractic Care – Many people fi nd chiropractic 

treatment to be benefi cial, especially for ailments 

such as lower back pain and headaches originating 

in the neck. Receive a 25% discount off the usual 

fee for services from any American Specialty Health 

Networks chiropractor. Th is includes mobilization and 

adjustment of tissues and joints. It may also include 

x rays, ultrasound, cold pack treatments or electrical 

muscle stimulation. 

• M assage Th erapy – It’s often used to alleviate stress and 

boost blood fl ow. Visit any ASH Networks massage 

therapist and receive a 25% discount on fees. 

• Acupuncture – Used to treat back pains, headaches, 

chronic pain and neurological disorders, acupuncture 

is a way to modify or prevent pain. Receive a 25% 

discount from ASH Networks providers. Call (877) 

335-2746 for more information. 

• Fitness Centers – In addition to our own fi tness 

center network, members have access to fi tness centers 

through ASH Networks. Visit the Web for a complete 

list. 

• Health Products – Receive a 15 to 40% discount 

through Choose HealthyTM, plus free standard 

shipping on health products, including vitamins, 

nutritional supplements, exercise DVDs and much 

more. (Products are available through ASH Networks.) 

Are vision services included? 

Yes. Th e program includes ways to cut costs on vision 

care products and services. 

• Eyewear and Eye Exams – Get substantial savings 

through LensCrafters®, Target Optical, Sears 

Optical® and most Pearle Vision Centers®, as well 

as independent providers. Receive a $5 discount on 

routine examinations and $5 off contact lens exams. 

Discounts are available on eyeglass lenses, frames, 

coatings, tints, lens treatments, and conventional (not 

disposable) contact lenses. 

Accessories Program

• Mail Order Contact Lenses – You can receive 

replacement conventional lenses by mail. Ordering is 

easy, either online (www.eyemedcontacts.com) or by 

calling EyeMed Vision Care at (800) 508-1399. Th e 

contact lenses will be shipped directly to you. Lenses 

are 100% guaranteed. (Other Accessories Program 

discounts do not apply.) 

• Laser Vision Correction – Save 15% off the regular 

price for LASIK and PRK treatments (or 5% off 

promotional prices) through U.S. Laser Network. Th is 

includes pre- and post-operative care. LASIK and PRK 

procedures must be performed at a LasikPlus Center 

to receive discounts. Pre- and post-operative care may 

be received from other providers, but members will be 

responsible for costs. Call (877) 552-7376 for more 

information. 

If you have questions about 

the Accessories Program, call us today! 

Current members should call the Customer Service 

Team at (800) 498-9731 

Prospective members should call: (800) 514-0138 

8:00 a.m. to 8:00 p.m., 

7 days a week, Oct. - Feb. 

or 8:00 a.m. to 8:00 p.m., Mon. - Fri., March - Sept. 

TDD: 711 

For more information on additional discounts and 

recent additions to the Accessories Program, 

please visit and log in to the Member section 

at www.GeisingerGold.com. 

Special off ers on Weight Watchers programs vary by 

county. Members should call the Customer Service Team 

for more information. 

ChooseHealthy is a trademark of American Specialty Health Networks, Inc. ChooseHealthy is a discount 

program; it is not insurance. ChooseHealthy provides discount complementary health care services from participating 

providers. You are obligated to pay for all health care services but will receive a discount from those health 

care providers who have contracted with the discount plan. ChooseHealthy does not make payments directly to 

participating providers in the discount plan. ChooseHealthy has no liability for providing or guaranteeing service 

and assumes no liability for the quality of service rendered. 

Th e products and services described in this booklet are neither off ered nor guaranteed under our contract with 

the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding 

these products and services may be subject to the Geisinger Gold grievance process. 

Should a problem arise with a value-added service, please contact the Geisinger Gold Customer Service Team. 

Th e Accessories Program is made available solely for the convenience of those members who are interested in 

the discounted health items and services off ered. Geisinger Health Plan and Geisinger Indemnity Insurance 

Company (collectively “Health Plan”) do not endorse the individual practitioners, services and products of the 

Accessories Program and do not guarantee results or outcomes. Health Plan accepts no responsibility for loss that 

may arise from reliance on the services. Health Plan makes no representation or warranty about quality, suitability 

or fi tness for a particular purpose of any product or service off ered under the Program. Th e practitioners, services 

or products of the Accessories Program should not be used as a substitute for medical diagnosis and treatment. 

Health Plan recommends that members consult with their physician before using any health services or products 

pursuant to the Program. 

In order to take advantage of Accessories Program discounts, members may be required to show their Member 

Identifi cation Card or provide other information directly to vendors who participate in the Accessories Program. 

Member understands that his/her disclosure of information directly to the vendor whether in person, over-thephone, 

internet or any other manner is done at their own risk and Health Plan assumes no liability relative to the 

member’s voluntary disclosure of such information. Health Plan will not disclose member information to the 

vendor. 

Th ese discounts and services are not included in the Health Plan benefi ts plans and are provided strictly as a 

convenience as indicated above. Th is Program and any of the practitioners, services and products in the Program 

are not guaranteed for any length of time and may be discontinued with or without notice to members.

Be Healthy 

and feel younger 

with the SilverSneakers ® Fitness 

Program – one of the benefits you’ll 

receive when you join Geisinger Gold 

To find out more about what 

you’ll receive as a Geisinger Gold 

and SilverSneakers member, 

please call 1-800-631-1656, 

TTY 711, Monday through Friday, 

8 a.m. to 5 p.m. EST. 

GEISPA_77 8.12 

Check out the ways you can use your 

SilverSneakers membership. 

SilverSneakers at a fitness location 

As a SilverSneakers Fitness Program member you’ll have free access to 

more than 11,000 fitness locations across the country, where on-site 

staff members are available to help you meet your personal wellness 

goals. Many locations offer amenities such as exercise equipment, pools, 

saunas, SilverSneakers fitness classes and other fun classes and activities. 

Other types of fitness locations may also be available in your area. 

Join Geisinger Gold and get started today! 

SilverSneakers Online 

The SilverSneakers members-only website, 

silversneakers.com/member, is a comprehensive, easy-to-use wellness 

resource. Being part of a thriving and secure online community will 

allow you to create exercise and nutrition plans, track fitness progress, 

find health articles and recipes, and do much more. 

SilverSneakers ® Steps 

SilverSneakers Steps is a personalized fitness program for members who 

can’t get to a SilverSneakers location. Once you enroll in Steps, you 

may select one of four kits that best fits your lifestyle and fitness level – 

walking, cardio, resistance or yoga. The Steps wellness tools can help 

you get fit at home or on the go. 

Enroll in Geisinger Gold today 

and get SilverSneakers! 

facebook.com/silversneakers silversneakers.com 

Silver Sneakers®

Fitness Locations 

Lists are subject to change and updated regularly. Please visit silversneakers.com for the most recent location updates. 

Adams 

Gettysburg 

Gettysburg Rehab at Herr’s Ridge 

820 Chambersburg Rd. 

(717) 337-4206 

Amenities: E, P, SC 

Wellspan Rehabilitation at 

Deatrick Commons 

16C Deatrick Dr. 

(717) 337-3300 

Amenities: E, P, W, SC 

Berks 

Birdsboro 

Berks Encore 

201 E. Main St. 

(610) 582-1603 

Amenities: E, SC 

Douglassville 

Snap Fitness 

180 Old Swede Rd. 

(610) 385-5555 

Amenities: E 

Fleetwood 

Tri-Valley Branch YMCA 

607 Crisscross Rd. 

(610) 944-6515 


Hamburg 

Anytime Fitness 

500 Hawk Ridge Dr., Ste. 2 

(484) 660-3790 

Amenities: E 

Call before first visit 

Berks Encore 

61 N. 3rd St. 

(610) 562-4721 

Amenities: SC 

Kutztown 

The Gym Kutztown 

14943 Kutztown Rd. 

(610) 683-6465 


Mohnton 

Reading YMCA - Mifflin Branch 

140 Chestnut St. 

(610) 750-5036 


Reading 

Albright College Schumo Center 

for Fitness and Well-Being 

13th and Bern St. 

(610) 929-6715 


Berks Encore 

40 N. 9th St. 

(610) 374-3195 

Amenities: SC 

Flying Hills Fitness Center 

201 Love Rd. 

(610) 775-9651 

Amenities: E, S, SC 

St. Joseph’s Medical Center 

5438 Perkiomen Ave. 

(610) 404-2230 

Amenities: E 

Valhalla Health & Fitness Club 

4970 DeMoss Rd. 

(610) 779-6006 


Sinking Spring 

Colonial Fitness 

172 Shillington Rd. 

(610) 777-7801 


Sinking Spring Family YMCA 

4920 Penn Ave. 

(610) 678-0484 


Temple 

Bodyworks Health & Fitness Club 

5370 Allentown Pike 

(610) 921-2422 


Topton 

The Lutheran Home at Topton 

One S. Home Ave. 

(610) 682-1400 


Wyomissing 

Body Zone Sports & 

Wellness Complex 

3103 Paper Mill Rd. 

(610) 376-2100 


Blair 

Altoona 

Snap Fitness 

228 E. Chestnut Ave. 

(814) 941-7627 

Amenities: E 

The Summit Tennis & 

Athletic Club 

2900 Plank Rd., Ste. 1 

(814) 946-1668 

Amenities: E, S, P, W, SC 

Duncansville 

Snap Fitness 

167 Glimcher Dr. 

(814) 696-9996 

Amenities: E 

Hollidaysburg 

Hollidaysburg Area YMCA 

1111 Hewitt St. 

(814) 695-4467 


Roaring Spring 

The Garver Memorial YMCA 

820 Grove St. 

(814) 224-5101 


Tyrone 

ProCare Health Systems 

187 Hospital Dr. 

(814) 684-6309 

Amenities: E, SC

Women-only locations, including Curves ® , are available nationwide. For a 

location near you, please visit silversneakers.com or call 1-888-423-4632 

(TTY: 711), Monday through Friday 8 a.m. to 8 p.m. EST. 

Milton 

Greater Susquehanna Valley 

YMCA Milton Branch 

12 Bound Ave. 

(570) 742-7321 

Amenities: E, S, P, SC 

Mount Carmel 

Mt. Carmel Outpatient Rehab 

2616 Locust Gap Hwy. 

(570) 339-3909 

Amenities: E, P 

Sunbury 

Greater Susquehanna Valley 

YMCA Sunbury Branch 

1150 N. 4th St. 

(570) 286-5636 


Perry 

Duncannon 

Duncannon Senior 

Citizens Center 

27 N. High St. 

(717) 834-4777 

Amenities: SC 

Newport 

Kings Fitness 

235 Walnut St. 

(717) 567-2123 


Pike 

Dingmans Ferry 

Pike Physical Therapy & 

Fitness Center 

1346 Rte. 739 

(570) 686-4300 


Schuylkill 

Ashland 

Center Street Fitness 

1028 Center St. 

(570) 875-2086 


Orwigsburg 

Schuylkill Racquet & Fitness 

Rte. 61 

(570) 366-1422 


Pottsville 

Schuylkill YMCA 

520 N. Centre St. 

(570) 622-7850 


Schuylkill Haven 


950 E. Main St., Ste. 215 

(570) 593-8177 

Amenities: E 


St. Clair 

Gudinas & Kristoff Xtreme 


17 N. Front St. 

(570) 429-2404 


Tamaqua 

Reading YMCA -Tamaqua Branch 

1201 E. Broad St. 

(570) 668-2903 


Snyder 

Beaver Springs 

Middlecreek Area Community 

Center 

67 Elm St. 

(570) 658-2276 


Middleburg 

Grace Covenant Community 

Church - Step by Step Mentoring 

99 Cafe Ln. 

(570) 837-5809 

Amenities: SC 

Selinsgrove 

The Booty Boutique 

964 Rte. 522 

(570) 898-4977 

Amenities: SC 

Amenities Legend 

E Exercise 

Equipment 

S Steam/Sauna 

P Pool 

W Whirlpool 

SC SilverSneakers 

Classes 

* Seasonal Pool 

Shamokin Dam 

Champs Gym & Fitness 

15 Stetler Ave. 

(570) 743-6411 


Susquehanna 

New Milford 

Blue Ridge Racquet & Health Club 

305 Church St. 

(570) 465-3282 

Amenities: E, S 

Tioga 

Mansfield 

Tioga County Branch YMCA 

40-42 Besanceney Dr. 

(570) 662-2999 


Union 

Lewisburg 

Gold’s Gym - Lewisburg 

131 Silvermoon Ln. 

(570) 568-4653 


The Donald Heiter 

Community Center 

100 North 5th St. 

(570) 524-5000 

Amenities: SC 

(cont.)

Fitness Locations (cont.) 


Edwardsville 

Every Woman’s Workout 

7B Gateway Shopping Center 

(570) 718-1244 

Amenities: E 

Hazle Township 

Circuit For Women 

1090 N. Church St. 

(570) 453-3180 

Amenities: E 

Luzerne 

Changes Health and 


161 Main St. 

(570) 718-0440 

Amenities: E 

Pittston 

Greater Pittston YMCA 

10 N. Main St. 

(570) 655-2255 


Sugarloaf 

Gerrie’s Fitness Center 

20 Gould’s Ln. 

(570) 788-3881 


Wilkes-Barre 

Wilkes-Barre Family YMCA 

40 W. Northampton St. 

(570) 823-2191 


Lycoming 

Jersey Shore 

Jersey Shore Branch YMCA 

826 Allegheny St. 

(570) 398-2150 


Montoursville 

Lycoming Physical Therapy 

1009 Broad St. 

(570) 368-8389 


Muncy 

Eastern Lycoming YMCA 

50 Fitness Dr. 

(570) 546-8822 


Williamsport 

Williamsport YMCA 

320 Elmira St. 

(570) 323-7134 


Mifflin 

Burnham 

Juniata Valley YMCA 

105 1st Ave. 

(717) 248-5019 


Monroe 

Brodheadsville 

The Body Shop 

120 Shafer Dr. 

(570) 992-3020 


Kunkletown 

Pocono Family YMCA - 

Eldred Branch 

RR 2 Box 11 

(570) 421-2525 


Pocono Manor 

Pocono Mountain Fitness 

1 Manor Dr. 

(570) 606-3489 


Stroudsburg 

Pocono Family YMCA 

809 Main St. 

(570) 421-2525 


Montour 

Danville 

Danville Area Community Center 

1 Liberty St. 

(570) 275-3001 


Northampton 

Bangor 

Snap Fitness 

426 Blue Valley Dr. 

(610) 588-5300 

Amenities: E 

Bethlehem 

Bethlehem Township 


2900 Farmersville Rd. 

(610) 332-1900 


Bethlehem YMCA 

430 E. Broad St. 

(610) 867-7588 


Hanover Township 


3660 Jacksonville Rd. 

(610) 317-8701 


Easton 

Family YMCA of Easton, 

Philipsburg & Vicinity 

1225 W. Lafayette St. 

(610) 258-6158 


Nazareth 

Nazareth YMCA 

33 S. Main St. 

(610) 759-3440 


Penn Argyl 

Penn Argyl Community Center 


(610) 759-3440 

Amenities: SC 

Northumberland 

Marion Heights 

Star, Inc. Physical 

Therapy & Fitness 

600 Park Ave. 

(570) 373-3300 

Amenities: E, SC




Bradford 

Towanda 

YMCA of Bradford County 

9 College Ave. 

(570) 268-9622 

Amenities: E, P*, SC 

Cambria 

Ebensburg 

ShapeShifters Fitness 

162 Industrial Park Rd. 

(814) 472-8573 


Johnstown 

East Hills Recreation 

101 Community College Way 

Ste. 118 

(814) 269-0303 


Greater Johnstown 

Community YMCA 

100 Haynes St. 

(814) 535-8381 


Mineral Point 

Jackson Twp. Senior Center 

200 Adams Ave. 

(814) 322-3327 

Amenities: SC 

Northern Cambria 

X-Treme Fitness 

901 Philadelphia Ave. 

(814) 420-8195 


Centre 

Philipsburg 

Moshannon Valley YMCA 

103 N. 14th St. 

(814) 342-0889 


State College 

North Club 

1510 Martin St. 

(814) 237-1510 


State College (cont.) 

Victory Sports and Fitness 

178 Rolling Ridge Dr. 

Hills Plaza South 

(814) 235-7676 


Clearfield 

Clearfield 

Clearfield YMCA 

21 N. 2nd St. 

(814) 765-5521 


DuBois 

DuBois Area YMCA 

25 Parkway Dr. 

(814) 375-9622 


DuBois YMCA - Treasure Lake 

100 Coral Reef Rd. 

(814) 372-2374 


Clinton 

Lock Haven 

Fitness Unlimited - Lock Haven 

Rear 121 E. Main St. 

(570) 748-4164 


Columbia 

Berwick 

Berwick Area YMCA 

231 W. 3rd St. 

(570) 752-5981 


Bloomsburg 

Bloom Health and Fitness 

1150 Old Berwick Rd. 

(570) 784-6344 


Bloomsburg Area YMCA 

30 E. 7th St. 

(570) 784-0188 



E Exercise 

Equipment 

S Steam/Sauna 

P Pool 

W Whirlpool 


Classes 


Cumberland 

Camp Hill 

Center for Independent 

Living of Central PA 

207 House Ave., Ste. 107 

(717) 731-1900 


IGNITE Training & Fitness 

115 St. Johns Church Rd. 

(717) 920-1748 


Carlisle 

Gold’s Gym - Carlisle PA 

1225 Ritner Hwy. 

(717) 218-0282 


Mechanicsburg 

Synergy Fitness 

2151 Fisher Rd. 

(717) 609-2839 

Amenities: SC 

Shippensburg 

Shippensburg Fitness Center 

117 W. Burd St. 

(717) 530-1668 


Dauphin 

Halifax 

Kings Health and Fitness 

1299 Armstrong Valley Rd. 

(717) 896-8990 


(cont.)



Harrisburg 

Gold’s Gym - Linglestown 

4450 Oakhurst Blvd. 

(717) 579-7683 


Gold’s Gym Harrisburg 

4251 Chambers Hill Rd. 

(717) 564-1829 


Jewish Community 

Center of Harrisburg 

3301 N. Front St. 

(717) 236-9555 


Platinum Health & Fitness 

7015 Old Jonestown Rd. 

(717) 652-7490 


Snap Fitness 

2308 Patton Rd. 

(717) 540-5414 

Amenities: E 

Thrive 

100 N. Cameron St., Ste. 108 

(717) 238-1887 


Hershey 

The Athletic Club of Hershey 

3003 Elizabethtown Rd. 

(717) 534-2340 


Franklin 

Chambersburg 


1515 Lincoln Way E. 

(717) 809-7498 

Amenities: E 


Results Therapy & Fitness 

1600 Orchard Dr. 

(717) 262-4650 


Chambersburg (cont.) 

Snap Fitness 

89 St. Paul Dr. 

(717) 264-7627 

Amenities: E 

Greencastle 

Sports Inn 24 Hr. Fitness, Inc. 

50 Pine Dr. 

(717) 597-5099 

Amenities: E, S 

Fulton 

McConnellsburg 

Fulton County Medical Center 

214 Peach Orchard Rd. 

(717) 485-6149 


Huntingdon 

Huntingdon 

ProCare Health & Fitness - 

Huntingdon 

295 S. 4th St. 

(814) 643-4151 


Mount Union 

Snap Fitness 

1 W. Shirley St. 

(814) 542-4242 

Amenities: E 

Juniata 

McAlisterville 

Fayette Area Lions Den 

Fitness & Recreation Center 

158 Lions Den Dr. 

(717) 463-3300 


Lackawanna 

Carbondale 

Carbondale YMCA 

82 N. Main St. 

(570) 282-2210 


Clarks Summit 

Total Tone 

100 Old Lackawanna Trl., Unit 6 

(570) 585-7200 

Amenities: E 

Dunmore 

Greater Scranton YMCA 

706 N. Blakely St. 

(570) 342-8115 


Mayfield 

Racqueteers Fitness and Health 

603 Rte. 6 

(570) 876-5432 


Moosic 

Pro Fitness Club 

3356 Birney Ave. 

(570) 346-5211 


Moscow 

North Pocono FitnessQuest 

6270 Rte. 502 

(570) 842-2000 


Old Forge 



(570) 903-7220 

Amenities: E 


Scranton 

Uno Fitness 

3 W. Olive St., Ste. 210 

(570) 341-9811 


South Abington 

Birchwood Fitness 

105 Edella Rd. 

(570) 586-4030 

Amenities: E, S, SC




Lancaster 

Adamstown 

Reading YMCA - 

Adamstown Branch 


(717) 484-4996 


Elizabethtown 

Masonic Life Center 

Masonic Village at Elizabethtown 

One Masonic Dr. 

(717) 361-5699 


Lancaster 

Universal Athletic Club 

2323 Oregon Pike 

(717) 569-5396 


Landisville 

Hempfield Area 

Recreation Commission 

950 Church St. 

(717) 898-3102 


Lititz 

Lititz Rec Center 

301 W. Maple St. 

(717) 626-5096 


Marietta 

Snap Fitness 

312 Honeysuckle Dr. 

(717) 426-1600 

Amenities: E 


E Exercise 

Equipment 

S Steam/Sauna 

P Pool 

W Whirlpool 


Classes 


SilverSneakers eligibility limitations (including residency requirements) may apply. Geisinger Gold Medicare Advantage 

plans are offered by Geisinger Health Plan/Geisinger Indemnity Insurance Company, health plans with a Medicare 

contract. Geisinger Gold Medicare Supplement plans are offered by Geisinger Indemnity Insurance Company. 

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact 

the plan. Limitations, copayments, and restrictions may apply to Geisinger Gold services. Geisinger Gold benefits, 

formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Members 

must continue to pay your Medicare Part B premium. 

SilverSneakers ® is a registered mark of Healthways, Inc. 

Y0032 12243_6 File and Use 9/4/12 

Mount Joy 

Snap Fitness 


(717) 653-1044 

Amenities: E 

New Holland 

New Holland Recreation Center 

123 N. Shirk Rd. 

(717) 354-4747 


Lebanon 

Annville 

Annville Fitness Center 

807 E. Main St. (rear) 

(717) 867-2421 


Lehigh 

Allentown 

Allentown YMCA & YWCA 

425 S. 15th St. 

(610) 434-9333 


JCC of Allentown 

702 N. 22nd St. 

(610) 435-3571 


Lehigh County Senior Center 

1633 W. Elm St. 

(610) 437-3700 

Amenities: P, SC 

The Fitness Plaza 

1124 Glenlivet Dr. 

(610) 481-0100 

Amenities: E, S, W, SC 

Catasauqua 

Suburban North Family YMCA 

880 Walnut St. 

(610) 264-5221 


Macungie 

O2 OxyFit and Martial Arts Dojo 

6480 Alburtis Rd. 

(610) 391-0040 


Whitehall 

Fitness Line 

5581 Roosevelt St. 

(610) 262-9519 


Luzerne 

Dallas 

Big Bear Fitness Corp. 

1144 Memorial Hwy. 

(570) 675-2749 


(cont.)


Mifflinburg 

First Evangelical Lutheran Church 

404 Market St. 

(570) 966-0266 

Amenities: SC 

Wayne 

Honesdale 

Wayne County - YMCA 

105 Park St. 

(570) 253-2083 


Wyoming 

Tunkhannock 

High Energy Fitness & Karate 

112-B River St. 

(570) 836-0156 


York 

Dillsburg 


868 US 15 

(717) 432-5500 

Amenities: E 


Dover 

Bob Hoffman YMCA 

1705 Palomino Rd. 

(717) 292-5622 


Hanover 

Club 2000 Health & 


28 Baltimore St. 

(717) 632-6009 


Gold’s Gym - Hanover 

1665 Broadway St. 

(717) 634-5336 


Shrewsbury 

Southern Branch YMCA 

100 Constitution Ave. 

(717) 235-0446 


York 

Eastern York County YMCA 

4075 E. Market St., Ste. 2 

(717) 755-7144 


HardKohr Sports & Fitness 

2810 E Prospect Rd. 

(717) 757-4833 


Snap Fitness 

180 Leader Heights Rd. 

(717) 741-2348 

Amenities: E 

YMCA of York 

90 N. Newberry St. 

(717) 843-7884 



E Exercise 

Equipment 

S Steam/Sauna 

P Pool 

W Whirlpool 


Classes 


[Limitations may apply. Geisinger Gold is an HMO with a Medicare Advantage contract available to all Medicare 

beneficiaries residing in Blair, Cambria, Carbon, Clearfield, Clinton, Columbia, Dauphin, Huntington, Juniata, 

Lackawanna, Lancaster, Lebanon, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Schuylkill, 

Snyder, Union and Wyoming counties. All Medicare beneficiaries with Medicare Parts A and B may apply. 

SilverSneakers ® Red Lion 


3117 Cape Horn Rd. 

(717) 246-2420 

Amenities: E 


is a registered mark of Healthways Health Support, Inc.] 

HPM50 7187-1-a-r 7/12/07

Y0032 H8468 12243_5 File and Use 9/4/12 

Multi-language Interpreter Services 

English: We have free interpreter services to answer any questions you may have about our health or 

drug plan. To get an interpreter, just call us at 1-800-498-9731. Someone who speaks English/Language 

can help you. This is a free service. 

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que 

pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor 

llame al 1-800-498-9731. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. 

Chinese Mandarin: 

1-800-498-9731 

 

Chinese Cantonese: 

1-800-498-9731 

 

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga 

katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng 

tagasaling-wika, tawagan lamang kami sa 1-800-498-9731. Maaari kayong tulungan ng isang 

nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. 

French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions 

relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, 

il vous suffit de nous appeler au 1-800-498-9731. Un interlocuteur parlant Français pourra vous aider. 

Ce service est gratuit. 

Vietnamese: Chúng tôi có dch v thông dch min phí tr li các câu hi v chng sc khe và 

chng trình thuc men. Nu quí v cn thông dch viên xin gi 1-800-498-9731 s có nhân viên nói 

ting Vit giúp quí v. ây là dch v min phí . 

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- 

und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-498-9731. Man wird Ihnen dort auf 

Deutsch weiterhelfen. Dieser Service ist kostenlos. 

Korean: 

. 1-800-498-9731 . 

.

Russian: , 

. 

, 1-800-498-9731. 

, -p. . 

Arabic: . 

. 1379-894-008-1 

. . 

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul 

nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-498-9731. Un 

nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. 

Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que 

tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através 

do número 1-800-498-9731. Irá encontrar alguém que fale o idioma Português para o ajudar. Este 

serviço é gratuito. 

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan 

medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-498-9731. Yon moun ki 

pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. 

Polish: Umoliwiamy bezpatne skorzystanie z usug tumacza ustnego, który pomoe w uzyskaniu 

odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzysta z pomocy tumacza 

znajcego jzyk polski, naley zadzwoni pod numer 1-800-498-9731. Ta usuga jest bezpatna. 

Hindi: 

. , 1-800-498-9731 

. . . 

Japanese: 

 

 

Y0032 H8468 12243_5 File and Use 9/4/12

www.GeisingerGold.com 

(800) 514-0138

Preferred (PPO) - Geisinger Health Plan

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?