SierraRx Formulary (List of Covered Drugs) - Sierra Health and Life
SierraRx Formulary (List of Covered Drugs) - Sierra Health and Life
SierraRx Formulary (List of Covered Drugs) - Sierra Health and Life
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<strong><strong>Sierra</strong>Rx</strong><br />
<strong>Formulary</strong><br />
(<strong>List</strong> <strong>of</strong> <strong>Covered</strong> <strong>Drugs</strong>)<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917 2021 <strong>Formulary</strong>
What is the <strong><strong>Sierra</strong>Rx</strong> <strong>Formulary</strong>?<br />
A formulary is a list <strong>of</strong> drugs selected by <strong><strong>Sierra</strong>Rx</strong> in consultation with a team <strong>of</strong> health<br />
care providers, which represents the prescription therapies believed to be a necessary<br />
part <strong>of</strong> a quality treatment program. <strong><strong>Sierra</strong>Rx</strong> will generally cover the drugs listed in our<br />
formulary as long as the drug is medically necessary, the prescription is filled at a<br />
<strong><strong>Sierra</strong>Rx</strong> network pharmacy, <strong>and</strong> other plan rules are followed. For more information on<br />
how to fill your prescriptions, please review your Evidence <strong>of</strong> Coverage.<br />
Can the <strong>Formulary</strong> change?<br />
Yes, <strong><strong>Sierra</strong>Rx</strong> may add or remove drugs from our formulary during the year. The<br />
enclosed formulary is current as <strong>of</strong> January 1, 2005. To get updated information about<br />
the drugs covered by <strong><strong>Sierra</strong>Rx</strong>, please visit our Website at www.sierrarx.com or call<br />
Customer Service at 866-789-1522, Monday through Friday, from 8 a.m. to 5 p.m.<br />
TTY/TDD users should call 866-789-1530. If we remove drugs from our formulary, or<br />
add prior authorization, quantity limits <strong>and</strong>/or step therapy restrictions on a drug, we<br />
must notify members who take the drug that it will be removed at least 60 days before<br />
the date that the change becomes effective, or at the time the member requests a refill <strong>of</strong><br />
the drug, at which time the member will receive a 60-day supply <strong>of</strong> the drug. If the Food<br />
<strong>and</strong> Drug Administration deems a drug on our formulary to be unsafe or the drug’s<br />
manufacturer removes the drug from the market, we will immediately remove the drug<br />
from our formulary <strong>and</strong> provide notice to members who take the drug.<br />
How do I use the <strong>Formulary</strong>?<br />
There are two ways to find your drug within the formulary:<br />
Medical Condition<br />
The formulary begins on page 5. The drugs in this formulary are grouped into<br />
categories depending on the type <strong>of</strong> medical conditions that they are used to treat.<br />
For example, drugs used to treat a heart condition are listed under the category,<br />
“Cardiovascular Agents.” If you know what your drug is used for, look for the category<br />
name in the list that begins on page 5. Then look under the category name for your<br />
drug.<br />
Alphabetical <strong>List</strong>ing<br />
If you are not sure what category to look under, you should look for your drug in the<br />
Index that begins on page 28. The Index provides an alphabetical list <strong>of</strong> all <strong>of</strong> the<br />
drugs included in this document. Both br<strong>and</strong>-name drugs <strong>and</strong> generic drugs are listed<br />
in the Index. Look in the Index <strong>and</strong> find your drug. Next to your drug, you will see<br />
the page number where you can find coverage information. Turn to the page listed in<br />
the Index <strong>and</strong> find the name <strong>of</strong> your drug in the first column <strong>of</strong> the list.<br />
How much will I pay for <strong><strong>Sierra</strong>Rx</strong> <strong>Covered</strong> <strong>Drugs</strong>?<br />
1
If you qualified for extra help with your drug costs, your costs for your drugs may be different<br />
than those described below. Please refer to your Evidence <strong>of</strong> Coverage or call Customer Service to<br />
find out what your costs are.<br />
The amount you pay depends on which drug tier your drug is in under our plan. (You can find<br />
out which drug tier your drug is in by looking in the formulary that begins on page 5.)<br />
You will pay a co-payment/coinsurance for your drugs until your total drugs costs (the amount<br />
you paid, including the deductible, plus the amount <strong><strong>Sierra</strong>Rx</strong> has paid) reach $2,250. Once<br />
your total drug costs reach $2,250, there is a gap in your coverage. This means you have to pay<br />
the full amount for your drugs. You pay the full amount until you have paid $3,600 out <strong>of</strong><br />
pocket. After you have paid $3,600 out <strong>of</strong> pocket, you will generally pay the greater <strong>of</strong> $2<br />
for each preferred or Non-Preferred Generic drug or Preferred br<strong>and</strong> drug, $5 for all<br />
other drugs (Non-Preferred Br<strong>and</strong> <strong>and</strong> Specialty drugs), or 5% coinsurance.<br />
You can ask <strong><strong>Sierra</strong>Rx</strong> to make an exception to your drug’s tier placement. See the section,<br />
“How do I request an exception to the <strong><strong>Sierra</strong>Rx</strong> <strong>List</strong> <strong>of</strong> <strong>Covered</strong> <strong>Drugs</strong>?,” for information<br />
about how to request an exception.<br />
Are there any other restrictions on coverage?<br />
Some covered drugs may have additional requirements or limits on coverage. These<br />
requirements <strong>and</strong> limits may include:<br />
• Prior Authorization: <strong><strong>Sierra</strong>Rx</strong> requires you to get prior authorization for certain drugs.<br />
(You may need prior authorization for drugs that are on the formulary or drugs that are<br />
not on the formulary <strong>and</strong> were approved for coverage through our exceptions<br />
process.) This means that you will need to get approval from <strong><strong>Sierra</strong>Rx</strong> before you fill<br />
your prescriptions. If you don’t get approval, <strong><strong>Sierra</strong>Rx</strong> may not cover the drug.<br />
• Quantity Limits: For certain drugs, <strong><strong>Sierra</strong>Rx</strong> limits the amount <strong>of</strong> the drug that <strong><strong>Sierra</strong>Rx</strong><br />
will cover. For example, <strong><strong>Sierra</strong>Rx</strong> provides 30 pills per prescription for Benicar. This<br />
may be in addition to a st<strong>and</strong>ard 30- or 90-day supply.<br />
• Step Therapy: In some cases, <strong><strong>Sierra</strong>Rx</strong> requires you to first try certain drugs to treat<br />
your medical condition before we will cover another drug for that condition. For<br />
example, if Drug A <strong>and</strong> Drug B both treat your medical condition, <strong><strong>Sierra</strong>Rx</strong> may<br />
not cover drug B unless you try Drug A first. If Drug A does not work for you, <strong><strong>Sierra</strong>Rx</strong><br />
will then cover Drug B.<br />
You can find out if your drug has any additional requirements or limits by looking in the<br />
formulary that begins on page 5.<br />
You can ask <strong><strong>Sierra</strong>Rx</strong> to make an exception to these restrictions or limits. See the<br />
section, “How do I request an exception to the <strong><strong>Sierra</strong>Rx</strong> formulary?” on page 3 for<br />
information about how to request an exception.<br />
What if my drug is not on the <strong>Formulary</strong>?<br />
If your drug is not included in this formulary, you should first contact Customer Service<br />
2
<strong>and</strong> ask if your drug is covered. If you learn that <strong><strong>Sierra</strong>Rx</strong> does not cover your drug, you<br />
have two options:<br />
• You can ask Customer Service for a list <strong>of</strong> similar drugs that are covered by<br />
<strong><strong>Sierra</strong>Rx</strong>. When you receive the list, show it to your doctor <strong>and</strong> ask him or her to<br />
prescribe a similar drug that is covered by <strong><strong>Sierra</strong>Rx</strong>.<br />
• You can ask <strong><strong>Sierra</strong>Rx</strong> to make an exception <strong>and</strong> cover your drug. See below for<br />
information about how to request an exception.<br />
How do I request an exception to the <strong><strong>Sierra</strong>Rx</strong> <strong>Formulary</strong>?<br />
You can ask <strong><strong>Sierra</strong>Rx</strong> to make an exception to our coverage rules. There are several<br />
types <strong>of</strong> exceptions that you can ask us to make.<br />
• You can ask us to cover your drug even if it is not on our formulary.<br />
• You can ask us to waive coverage restrictions or limits on your drug. For<br />
example, for certain drugs, <strong><strong>Sierra</strong>Rx</strong> limit the amount <strong>of</strong> the drug that we will<br />
cover. If your drug has a quantity limit, you can ask us to waive the limit <strong>and</strong><br />
cover more.<br />
Generally, <strong><strong>Sierra</strong>Rx</strong> will only approve your request for an exception if the alternative<br />
drugs included on the plan’s formulary, the low-tiered drug or additional utilization<br />
restrictions would not be as effective in treating your condition <strong>and</strong>/or would cause you<br />
to have adverse medical effects.<br />
You should contact us to ask us for an initial coverage decision for a formulary, tiering<br />
or utilization restriction exception. When you are requesting a formulary, tiering or<br />
utilization restriction exception you should submit a statement from your physician<br />
supporting your request. Generally, we must make our decision within 72 hours <strong>of</strong> your<br />
request.<br />
What are generic drugs?<br />
<strong><strong>Sierra</strong>Rx</strong> covers both br<strong>and</strong>-name drugs <strong>and</strong> generic drugs. A generic drug has the same<br />
active-ingredient formula as the br<strong>and</strong> name drug. Generic drugs usually cost less than<br />
br<strong>and</strong> name drugs <strong>and</strong> are approved by the Food <strong>and</strong> Drug Administration (FDA).<br />
Generic drugs are listed in lower-case italics (e.g. amoxicillin) within the formulary on page 5.<br />
Br<strong>and</strong>-name drugs are capitalized in the formulary (e.g. BENICAR).<br />
For more information<br />
For more detailed information about your <strong><strong>Sierra</strong>Rx</strong> prescription drug coverage, please review<br />
your Evidence <strong>of</strong> Coverage <strong>and</strong> other plan materials.<br />
3
If you have questions about <strong><strong>Sierra</strong>Rx</strong>, please call Customer Service at 866-789-1522, Monday<br />
through Friday, from 8 a.m. to 5 p.m. TTY/TDD users should call 866-789-1530. Or visit<br />
www.sierrarx.com.<br />
If you have general questions about Medicare prescription drug coverage, please call Medicare<br />
at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should<br />
call 1-877-486-2048. Or, visit www.medicare.gov.<br />
<strong><strong>Sierra</strong>Rx</strong> <strong>Formulary</strong><br />
The formulary that begins on the next page provides coverage information about some <strong>of</strong> the<br />
drugs covered by <strong><strong>Sierra</strong>Rx</strong>. If you have trouble finding your drug in the list, turn to the Index<br />
that begins on page 28.<br />
The first column <strong>of</strong> the chart lists the drug name. Br<strong>and</strong>-name drugs are capitalized (e.g.<br />
BENICAR) <strong>and</strong> generic drugs are listed in lower-case italics (e.g. amoxicillin).<br />
The information in the Requirements/Limits column tells you if <strong><strong>Sierra</strong>Rx</strong> has any special<br />
requirements for coverage <strong>of</strong> your drug.<br />
4
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
Analgesics<br />
acetaminophen <strong>and</strong> codeine generic X<br />
acetaminophen <strong>and</strong> hydrocodone generic X<br />
acetaminophen <strong>and</strong> oxycodone generic X<br />
ACTIQ br<strong>and</strong> X<br />
aspirin <strong>and</strong> codeine generic X<br />
aspirin <strong>and</strong> oxycodone generic X<br />
CELEBREX br<strong>and</strong> X X X<br />
choline <strong>and</strong> magnesium salicylates<br />
generic<br />
CODEINE PHOSPHATE br<strong>and</strong> X<br />
CODEINE SULFATE br<strong>and</strong> X<br />
dicl<strong>of</strong>enac generic X<br />
diflunisal<br />
generic<br />
etodolac generic X<br />
fenopr<strong>of</strong>en<br />
generic<br />
flurbipr<strong>of</strong>en<br />
generic<br />
hydromorphone<br />
generic<br />
ibupr<strong>of</strong>en generic X<br />
ibupr<strong>of</strong>en <strong>and</strong> hydrocodone generic X<br />
indomethacin<br />
generic<br />
ketopr<strong>of</strong>en<br />
generic<br />
methadone<br />
generic<br />
morphine<br />
generic<br />
nabumetone<br />
generic<br />
naproxen<br />
generic<br />
oxaprozin generic X<br />
oxycodone (immediate release only)<br />
generic<br />
pentazocine<br />
generic<br />
pentazocine <strong>and</strong> naloxone<br />
generic<br />
piroxicam<br />
generic<br />
salsalate<br />
generic<br />
sulindac<br />
generic<br />
tolmetin<br />
generic<br />
tramadol generic X<br />
Anesthetics<br />
tetracaine<br />
bupivicaine<br />
generic<br />
25% coinsurance<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 5<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
lidocaine<br />
25% coinsurance<br />
Antibacterials<br />
amoxicillin<br />
generic<br />
amoxicillin <strong>and</strong> clavulanate<br />
generic<br />
ampicillin<br />
generic<br />
cefaclor<br />
generic<br />
cefadroxil<br />
generic<br />
cefpodoxime<br />
generic<br />
cefuroxime<br />
generic<br />
cephalexin<br />
generic<br />
cipr<strong>of</strong>loxacin generic X<br />
clindamycin<br />
generic<br />
demeclocycline generic X<br />
dicloxacillin<br />
generic<br />
doxycycline<br />
generic<br />
ERY-TAB<br />
br<strong>and</strong><br />
erythromycin <strong>and</strong> sulfisoxazole<br />
generic<br />
erythromycin ethylsuccinate<br />
generic<br />
erythromycin stearate<br />
generic<br />
GEOCILLIN br<strong>and</strong> X<br />
KETEK br<strong>and</strong> X X<br />
LORABID br<strong>and</strong> X<br />
metronidazole<br />
generic<br />
NEGGRAM br<strong>and</strong> X<br />
neomycin<br />
generic<br />
nitr<strong>of</strong>urantoin<br />
generic<br />
<strong>of</strong>loxacin generic X<br />
paromomycin<br />
generic<br />
penicillin V potassium<br />
generic<br />
SULFADIAZINE<br />
br<strong>and</strong><br />
sulfamethoxazole <strong>and</strong> trimethoprim<br />
generic<br />
SULFISOXAZOLE<br />
br<strong>and</strong><br />
tetracycline<br />
generic<br />
TOBI 25% coinsurance X X<br />
trimethoprim<br />
generic<br />
VANCOCIN br<strong>and</strong> X X<br />
ZITHROMAX br<strong>and</strong> X X<br />
ZYVOX br<strong>and</strong> X X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 6<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
Anticonvulsants<br />
carbamazepine generic X<br />
CELONTIN br<strong>and</strong> X<br />
DEPAKOTE<br />
br<strong>and</strong><br />
ethosuximide generic X<br />
FELBATOL br<strong>and</strong> X<br />
gabapentin generic X X<br />
GABITRIL<br />
br<strong>and</strong><br />
KEPPRA br<strong>and</strong> X<br />
LAMICTAL br<strong>and</strong> X<br />
PEGANONE br<strong>and</strong> X<br />
phenytoin<br />
generic<br />
primidone<br />
generic<br />
TOPAMAX br<strong>and</strong> X X<br />
TRILEPTAL br<strong>and</strong> X X<br />
valproic acid generic X<br />
ZONEGRAN br<strong>and</strong> X X<br />
Antidementia Agents<br />
ARICEPT br<strong>and</strong> X<br />
ergoloid mesylates<br />
generic<br />
EXELON br<strong>and</strong> X<br />
NAMENDA br<strong>and</strong> X<br />
Antidepressants<br />
amitriptyline<br />
generic<br />
AMOXAPINE br<strong>and</strong> X<br />
bupropion generic X X<br />
citalopram generic X X<br />
clomipramine<br />
generic<br />
desipramine<br />
generic<br />
doxepin<br />
generic<br />
EFFEXOR/XR br<strong>and</strong> X X<br />
fluoxetine generic X<br />
fluvoxamine generic X<br />
imipramine hydrochloride<br />
generic<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 7<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
maprotiline<br />
generic<br />
mirtazapine generic X X<br />
NARDIL br<strong>and</strong> X<br />
nefazodone generic X<br />
nortriptyline<br />
generic<br />
PARNATE<br />
br<strong>and</strong><br />
paroxetine generic X X<br />
SURMONTIL<br />
br<strong>and</strong><br />
TOFRANIL-PM br<strong>and</strong> X<br />
trazodone generic X<br />
VIVACTIL<br />
br<strong>and</strong><br />
ZOLOFT br<strong>and</strong> X X<br />
Antiemetics<br />
chlorpromazine<br />
generic<br />
hydroxyzine<br />
generic<br />
KYTRIL br<strong>and</strong> X X<br />
meclizine<br />
generic<br />
metoclopramide<br />
generic<br />
perphenazine generic X<br />
prochlorperazine<br />
generic<br />
promethazine<br />
generic<br />
trimethobenzamide<br />
generic<br />
ZOFRAN br<strong>and</strong> X X<br />
Antifungals<br />
ANCOBON<br />
br<strong>and</strong><br />
clotrimazole<br />
generic<br />
fluconazole generic X<br />
GRIFULVIN/GRIS-PEG<br />
br<strong>and</strong><br />
GYNAZOLE<br />
br<strong>and</strong><br />
itraconazole<br />
generic<br />
ketoconazole<br />
generic<br />
LAMISIL br<strong>and</strong> X X<br />
nystatin<br />
generic<br />
terconazole<br />
generic<br />
Antigout Agents<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 8<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
allopurinol<br />
generic<br />
colchicine<br />
generic<br />
colchicine <strong>and</strong> probenecid<br />
generic<br />
probenecid<br />
generic<br />
Anti-inflammatories<br />
CELEBREX br<strong>and</strong> X X X<br />
choline <strong>and</strong> magnesium salicylates<br />
generic<br />
dexamethasone<br />
generic<br />
dicl<strong>of</strong>enac generic X<br />
diflunisal<br />
generic<br />
etodolac generic X<br />
fenopr<strong>of</strong>en<br />
generic<br />
flurbipr<strong>of</strong>en<br />
generic<br />
hydrocortisone<br />
generic<br />
ibupr<strong>of</strong>en generic X<br />
indomethacin<br />
generic<br />
ketopr<strong>of</strong>en<br />
generic<br />
methylprednisolone<br />
generic<br />
nabumetone<br />
generic<br />
naproxen<br />
generic<br />
oxaprozin generic X<br />
piroxicam<br />
generic<br />
prednisolone<br />
generic<br />
prednisone<br />
generic<br />
salsalate<br />
generic<br />
sulindac<br />
generic<br />
tolmetin<br />
generic<br />
Antimigraine Agents<br />
APAP-isometheptene-dichloralphenazone generic X<br />
DEPAKOTE ER<br />
br<strong>and</strong><br />
dihydroergotamine for injection<br />
generic<br />
ergotamine <strong>and</strong> caffeine<br />
generic<br />
propranolol<br />
generic<br />
RELPAX br<strong>and</strong> X<br />
timolol<br />
generic<br />
TOPAMAX br<strong>and</strong> X X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 9<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
Antimycobacterials<br />
DAPSONE<br />
ethambutol<br />
HEXALEN<br />
isoniazid<br />
MYCOBUTIN<br />
pyrazinamide<br />
rifampin<br />
br<strong>and</strong><br />
generic<br />
br<strong>and</strong><br />
generic<br />
br<strong>and</strong><br />
generic<br />
generic<br />
Antineoplastics<br />
ALKERAN<br />
br<strong>and</strong><br />
CAMPTOSAR<br />
25% coinsurance<br />
CEENU<br />
br<strong>and</strong><br />
CLADRIBINE<br />
25% coinsurance<br />
cyclophosphamide<br />
generic<br />
ELSPAR<br />
25% coinsurance<br />
etoposide<br />
generic<br />
fludarabine<br />
25% coinsurance<br />
GLEEVEC 25% coinsurance X<br />
hydroxyurea<br />
generic<br />
leucovorin<br />
generic<br />
LEUKERAN<br />
br<strong>and</strong><br />
MATULANE<br />
br<strong>and</strong><br />
mercaptopurine<br />
generic<br />
MESNEX<br />
br<strong>and</strong><br />
methotrexate<br />
generic<br />
MYLERAN<br />
br<strong>and</strong><br />
PROLEUKIN<br />
25% coinsurance<br />
TARCEVA 25% coinsurance X<br />
TARGRETIN<br />
25% coinsurance<br />
TEMODAR 25% coinsurance X<br />
THIOGUANINE<br />
br<strong>and</strong><br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 10<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
TICE BCG<br />
25% coinsurance<br />
VESANOID<br />
br<strong>and</strong><br />
XELODA br<strong>and</strong> X<br />
Antiparasitics<br />
ALBENZA<br />
br<strong>and</strong><br />
chloroquine<br />
generic<br />
DARAPRIM<br />
br<strong>and</strong><br />
hydroxychloroquine<br />
generic<br />
lindane<br />
generic<br />
mebendazole<br />
generic<br />
mefloquine<br />
generic<br />
MEPRON<br />
br<strong>and</strong><br />
NEBUPENT 25% coinsurance X<br />
permethrin<br />
generic<br />
quinine generic X<br />
YODOXIN<br />
br<strong>and</strong><br />
Antiparkinson Agents<br />
amantadine<br />
generic<br />
APOKYN 25% coinsurance X<br />
benztropine<br />
generic<br />
bromocriptine<br />
generic<br />
carbidopa <strong>and</strong> levodopa<br />
generic<br />
COMTAN br<strong>and</strong> X<br />
MIRAPEX br<strong>and</strong> X<br />
pergolide<br />
generic<br />
selegiline<br />
generic<br />
TASMAR<br />
br<strong>and</strong><br />
trihexyphenidyl<br />
generic<br />
Antipsychotics<br />
ABILIFY br<strong>and</strong> X X<br />
chlorpromazine<br />
generic<br />
clozapine<br />
generic<br />
fluphenazine generic X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 11<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
GEODON br<strong>and</strong> X X<br />
GEODON injectable 25% coinsurance X<br />
haloperidol<br />
generic<br />
loxapine generic X<br />
MOBAN<br />
br<strong>and</strong><br />
ORAP<br />
br<strong>and</strong><br />
perphenazine generic X<br />
prochlorperazine<br />
generic<br />
RISPERDAL br<strong>and</strong> X<br />
RISPERDAL CONSTA 25% coinsurance X<br />
SEROQUEL br<strong>and</strong> X X<br />
thioridazine<br />
generic<br />
thiothixene<br />
generic<br />
trifluoperazine<br />
generic<br />
ZYPREXA br<strong>and</strong> X X<br />
ZYPREXA injectable 25% coinsurance X<br />
Antivirals<br />
acyclovir<br />
generic<br />
AGENERASE<br />
br<strong>and</strong><br />
amantadine<br />
generic<br />
COMBIVIR<br />
br<strong>and</strong><br />
COPEGUS br<strong>and</strong> X X<br />
CRIXIVAN<br />
br<strong>and</strong><br />
didanosine<br />
generic<br />
EMTRIVA br<strong>and</strong> X<br />
EPIVIR br<strong>and</strong> X<br />
EPIVIR HBV br<strong>and</strong> X<br />
EPZICOM br<strong>and</strong> X<br />
FORTOVASE<br />
br<strong>and</strong><br />
FOSCAVIR<br />
25% coinsurance<br />
FUZEON 25% coinsurance X X<br />
ganciclovir<br />
generic<br />
HEPSERA br<strong>and</strong> X<br />
HIVID<br />
br<strong>and</strong><br />
INVIRASE<br />
br<strong>and</strong><br />
KALETRA<br />
br<strong>and</strong><br />
LEXIVA br<strong>and</strong> X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 12<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
NORVIR br<strong>and</strong> X<br />
RESCRIPTOR<br />
br<strong>and</strong><br />
RETROVIR<br />
br<strong>and</strong><br />
REYATAZ<br />
br<strong>and</strong><br />
ribavirin generic X X<br />
rimantadine generic X<br />
SUSTIVA<br />
br<strong>and</strong><br />
TRIZIVIR<br />
br<strong>and</strong><br />
TRUVADA br<strong>and</strong> X<br />
VALCYTE br<strong>and</strong> X<br />
VIRACEPT<br />
br<strong>and</strong><br />
VIRAMUNE<br />
br<strong>and</strong><br />
VIREAD br<strong>and</strong> X<br />
ZERIT<br />
br<strong>and</strong><br />
ZIAGEN<br />
br<strong>and</strong><br />
Anxiolytics<br />
buspirone<br />
generic<br />
doxepin<br />
generic<br />
meprobamate<br />
generic<br />
paroxetine generic X<br />
ZOLOFT br<strong>and</strong> X X<br />
Autonomic Agents<br />
acebutolol<br />
generic<br />
atenolol<br />
generic<br />
betaxolol<br />
generic<br />
bisoprolol<br />
generic<br />
CARTROL<br />
br<strong>and</strong><br />
clonidine<br />
generic<br />
dicyclomine<br />
generic<br />
dobutamine<br />
25% coinsurance<br />
dopamine<br />
25% coinsurance<br />
doxazosin generic X<br />
ENLON<br />
25% coinsurance<br />
EPIPEN br<strong>and</strong> X<br />
glycopyrrolate<br />
generic<br />
GUANIDINE<br />
br<strong>and</strong><br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 13<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
hyoscyamine<br />
generic<br />
labetalol<br />
generic<br />
LEVATOL<br />
br<strong>and</strong><br />
metoprolol<br />
generic<br />
midodrine<br />
generic<br />
nadolol<br />
generic<br />
pindolol<br />
generic<br />
prazosin<br />
generic<br />
propranolol<br />
generic<br />
pyridostigmine<br />
generic<br />
sotalol<br />
generic<br />
terazosin generic X<br />
timolol<br />
generic<br />
TOPROL XL br<strong>and</strong> X<br />
Bipolar Agents<br />
GEODON br<strong>and</strong> X X<br />
lithium<br />
generic<br />
Blood Glucose Regulators<br />
ACTOS br<strong>and</strong> X X<br />
AMARYL br<strong>and</strong> X<br />
AVANDIA br<strong>and</strong> X X<br />
glipizide generic X<br />
GLUCAGEN br<strong>and</strong> X<br />
glyburide generic X<br />
glyburide <strong>and</strong> metformin generic X<br />
LANTUS<br />
br<strong>and</strong><br />
metformin generic X<br />
NOVOLIN R/NPH<br />
br<strong>and</strong><br />
NOVOLOG<br />
br<strong>and</strong><br />
PRANDIN br<strong>and</strong> X<br />
PRECOSE br<strong>and</strong> X<br />
PROGLYCEM br<strong>and</strong> X<br />
Blood Products/Modifiers/Volume Exp<strong>and</strong>ers<br />
ALPHANATE 25% coinsurance X<br />
aminocaproic acid<br />
generic<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 14<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
ARANESP 25% coinsurance X<br />
ARIXTRA 25% coinsurance X<br />
AUTOPLEX T 25% coinsurance X<br />
BEBULIN VH 25% coinsurance X<br />
cilostazol generic X<br />
COUMADIN<br />
br<strong>and</strong><br />
dipyridamole<br />
generic<br />
EPOGEN 25% coinsurance X<br />
FEIBA VH IMMUNO 25% coinsurance X<br />
GENARC 25% coinsurance X<br />
heparin<br />
25% coinsurance<br />
KOATE-DVI 25% coinsurance X<br />
KOGENATE FS 25% coinsurance X<br />
LEUKINE 25% coinsurance X<br />
LOVENOX 25% coinsurance X<br />
MONOCATE-P 25% coinsurance X<br />
NEULASTA 25% coinsurance X<br />
NEUMEGA 25% coinsurance X<br />
NEUPOGEN 25% coinsurance X<br />
pentoxifylline generic X<br />
PLAVIX br<strong>and</strong> X<br />
PROCRIT 25% coinsurance X<br />
PROFILNINE SD 25% coinsurance X<br />
RECOMBINATE 25% coinsurance X<br />
warfarin<br />
generic<br />
Cardiovascular Agents<br />
acebutolol<br />
generic<br />
acetazolamide<br />
generic<br />
adenosine<br />
25% coinsurance<br />
amiloride<br />
generic<br />
amiloride <strong>and</strong> HCTZ<br />
generic<br />
amiodarone<br />
generic<br />
atenolol<br />
generic<br />
atenolol <strong>and</strong> chlorthalidone<br />
generic<br />
AVALIDE br<strong>and</strong> X<br />
AVAPRO br<strong>and</strong> X<br />
benazepril generic X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 15<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
benazepril <strong>and</strong> HCTZ generic X<br />
BENICAR br<strong>and</strong> X<br />
BENICAR HCT br<strong>and</strong> X<br />
betaxolol<br />
generic<br />
bisoprolol<br />
generic<br />
bisoprolol <strong>and</strong> HCTZ<br />
generic<br />
bumetanide<br />
generic<br />
captopril<br />
generic<br />
captopril <strong>and</strong> HCTZ<br />
generic<br />
CARTROL<br />
br<strong>and</strong><br />
chlorothiazide<br />
generic<br />
chlorthalidone<br />
generic<br />
cholestyramine<br />
generic<br />
clonidine<br />
generic<br />
CLORPRES<br />
br<strong>and</strong><br />
digoxin generic X<br />
diltiazem<br />
generic<br />
doxazosin generic X<br />
DYNACIRC CR br<strong>and</strong> X<br />
enalapril generic X<br />
enalapril <strong>and</strong> HCTZ generic X<br />
felodipine generic X<br />
flecainide<br />
generic<br />
fosinopril generic X<br />
fosinopril <strong>and</strong> HCTZ generic X<br />
furosemide<br />
generic<br />
gemfibrozil<br />
generic<br />
hydralazine<br />
generic<br />
hydrochlorothiazide<br />
generic<br />
indapamide<br />
generic<br />
INDERAL LA br<strong>and</strong> X<br />
INNOPRAN XL br<strong>and</strong> X<br />
isosorbide dinitrate<br />
generic<br />
isosorbide mononitrate<br />
generic<br />
labetalol<br />
generic<br />
LEVATOL<br />
br<strong>and</strong><br />
lidocaine<br />
25% coinsurance<br />
LIPITOR br<strong>and</strong> X X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 16<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
lisinopril generic X<br />
lisinopril <strong>and</strong> HCTZ generic X<br />
lovastatin generic X X<br />
mannitol<br />
25% coinsurance<br />
MAVIK br<strong>and</strong> X<br />
methazolamide<br />
generic<br />
methyclothiazide<br />
generic<br />
methyldopa <strong>and</strong> HCTZ<br />
generic<br />
metolazone<br />
generic<br />
metoprolol<br />
generic<br />
metoprolol <strong>and</strong> HCTZ<br />
generic<br />
mexiletine<br />
generic<br />
midodrine<br />
generic<br />
milrinone<br />
25% coinsurance<br />
minoxidil<br />
generic<br />
nadolol<br />
generic<br />
NIASPAN<br />
br<strong>and</strong><br />
nifedipine (SR)<br />
generic<br />
NITROBID<br />
br<strong>and</strong><br />
nitroglycerin<br />
generic<br />
NITROLINGUAL PUMPSPRAY<br />
br<strong>and</strong><br />
OSMOGLYN<br />
25% coinsurance<br />
pindolol<br />
generic<br />
prazosin<br />
generic<br />
procainamide<br />
generic<br />
PROGLYCEM br<strong>and</strong> X<br />
propafenone<br />
generic<br />
propranolol<br />
generic<br />
propranolol <strong>and</strong> HCTZ<br />
generic<br />
quinapril generic X<br />
quinapril <strong>and</strong> HCTZ generic X<br />
quinidine<br />
generic<br />
REMODULIN 25% coinsurance X<br />
sotalol<br />
generic<br />
spironolactone<br />
generic<br />
spironolactone <strong>and</strong> HCTZ<br />
generic<br />
SULAR br<strong>and</strong> X<br />
terazosin generic X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 17<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
timolol<br />
generic<br />
TRACLEER 25% coinsurance X<br />
triamterene <strong>and</strong> HCTZ<br />
generic<br />
verapamil<br />
generic<br />
ZETIA br<strong>and</strong> X X<br />
Central Nervous System Agents<br />
dextroamphetamine<br />
generic<br />
dextroamphetamine <strong>and</strong> amphetamine generic X<br />
METADATE CD br<strong>and</strong> X<br />
methamphetamine<br />
generic<br />
methylphenidate<br />
generic<br />
pemoline<br />
generic<br />
PROVIGIL br<strong>and</strong> X<br />
RILUTEK br<strong>and</strong> X<br />
Dental <strong>and</strong> Oral Agents<br />
chlorhexidine<br />
generic<br />
doxycycline<br />
generic<br />
pilocarpine generic X<br />
triamcinolone in orabase<br />
generic<br />
Dermatological Agents<br />
alclometasone (ointment)<br />
aluminum chloride soln<br />
amcinonide<br />
anthralin<br />
betamethasone dipropionate<br />
betamethasone valerate<br />
ciclopirox<br />
clobetasol propionate<br />
generic<br />
generic<br />
generic<br />
generic<br />
generic<br />
generic<br />
generic<br />
generic<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 18<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
clotrimazole<br />
generic<br />
clotrimazole <strong>and</strong> betamethasone<br />
generic<br />
DENAVIR<br />
br<strong>and</strong><br />
desonide<br />
generic<br />
desoximetasone<br />
generic<br />
dexamethasone<br />
generic<br />
diflorasone<br />
generic<br />
DOVONEX<br />
br<strong>and</strong><br />
doxepin<br />
generic<br />
econazole<br />
generic<br />
fluocinolone acetonide<br />
generic<br />
fluocinonide<br />
generic<br />
fluorouracil<br />
generic<br />
fluticasone propionate<br />
generic<br />
halobetasol propionate<br />
generic<br />
hydrocortisone<br />
generic<br />
hydrocortisone <strong>and</strong> iodoquinol<br />
generic<br />
hydrocortisone butyrate<br />
generic<br />
hydrocortisone valerate<br />
generic<br />
ketoconazole<br />
generic<br />
LEVULAN br<strong>and</strong> X<br />
lidocaine<br />
generic<br />
lidocaine <strong>and</strong> hydrocortisone<br />
generic<br />
lidocaine <strong>and</strong> prilocaine<br />
generic<br />
METROGEL/LOTION<br />
br<strong>and</strong><br />
metronidazole<br />
generic<br />
mometasone furoate<br />
generic<br />
mupirocin<br />
generic<br />
nystatin<br />
generic<br />
nystatin <strong>and</strong> triamcinolone<br />
generic<br />
OXSORALEN ULTRA br<strong>and</strong> X<br />
pod<strong>of</strong>ilox<br />
generic<br />
PONTOCAINE<br />
br<strong>and</strong><br />
pramoxine <strong>and</strong> hydrocortisone<br />
generic<br />
REGRANEX br<strong>and</strong> X<br />
SANTYL<br />
br<strong>and</strong><br />
selenium<br />
generic<br />
silver sulfadiazine<br />
generic<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 19<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
SOLARAZE br<strong>and</strong> X<br />
SORIATANE<br />
25% coinsurance<br />
triamcinolone acetonide<br />
generic<br />
ZOVIRAX topical<br />
br<strong>and</strong><br />
Deterrents/Replacements<br />
ANTABUSE<br />
br<strong>and</strong><br />
CAMPRAL br<strong>and</strong> X<br />
Enzyme Replacements/Modifiers<br />
CEREDASE 25% coinsurance X<br />
CEREZYME 25% coinsurance X<br />
CREON<br />
br<strong>and</strong><br />
FABRAZYME<br />
25% coinsurance<br />
LIPRAM<br />
br<strong>and</strong><br />
ORFADIN<br />
25% coinsurance<br />
PANCREASE<br />
br<strong>and</strong><br />
ULTRASE<br />
br<strong>and</strong><br />
Gastrointestinal Agents<br />
ACIPHEX br<strong>and</strong> X<br />
cimetidine<br />
generic<br />
dicyclomine<br />
generic<br />
diphenoxylate <strong>and</strong> atropine<br />
generic<br />
famotidine<br />
generic<br />
glycopyrrolate<br />
generic<br />
HELIDAC<br />
br<strong>and</strong><br />
hyoscyamine<br />
generic<br />
lactulose<br />
generic<br />
loperamide<br />
generic<br />
LOTRONEX br<strong>and</strong> X X<br />
misoprostol generic X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 20<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
nizatidine<br />
generic<br />
omeprazole generic X<br />
polyethylene glycol 3350 NF<br />
generic<br />
PREVACID br<strong>and</strong> X<br />
PREVPAK br<strong>and</strong> X<br />
ranitidine<br />
generic<br />
RENAGEL br<strong>and</strong> X<br />
SANDOSTATIN 25% coinsurance X<br />
sucralfate<br />
generic<br />
ursodiol<br />
generic<br />
ZELNORM br<strong>and</strong> X X<br />
Genitourinary Agents<br />
bethanechol<br />
generic<br />
doxazosin generic X<br />
flavoxate<br />
generic<br />
hyoscyamine<br />
generic<br />
LEVITRA br<strong>and</strong> X X<br />
MUSE br<strong>and</strong> X X<br />
oxybutynin<br />
generic<br />
phenazopyridine<br />
generic<br />
PROSCAR br<strong>and</strong> X<br />
terazosin generic X<br />
Hormonal Agents, Stimulants/Replacement/ Modifying<br />
ANDRODERM br<strong>and</strong> 1 1<br />
cortisone<br />
generic<br />
CYTOMEL br<strong>and</strong> X<br />
danazol<br />
generic<br />
desmopressin nasal<br />
generic<br />
dexamethasone<br />
generic<br />
ESTRACE<br />
br<strong>and</strong><br />
estradiol<br />
generic<br />
estropipate<br />
generic<br />
EVISTA br<strong>and</strong> X<br />
fludrocortisone generic X<br />
FORTEO 25% coinsurance X X<br />
FOSAMAX br<strong>and</strong> X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 21<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
GANITE<br />
25% coinsurance<br />
GENOTROPIN 25% coinsurance X<br />
HECTORAL<br />
br<strong>and</strong><br />
HUMATROPE 25% coinsurance X<br />
hydrocortisone<br />
generic<br />
levothyroxine generic X<br />
medroxyprogesterone<br />
generic<br />
megestrol<br />
generic<br />
methylprednisolone<br />
generic<br />
MIACALCIN<br />
br<strong>and</strong><br />
misoprostol generic X<br />
NORDITROPIN 25% coinsurance X<br />
norethindrone<br />
generic<br />
NUTROPIN 25% coinsurance X<br />
prednisolone<br />
generic<br />
prednisone<br />
generic<br />
PREMARIN br<strong>and</strong> X<br />
PREMARIN vaginal br<strong>and</strong> X<br />
PREMPHASE/PREMPRO br<strong>and</strong> X<br />
SAIZEN 25% coinsurance X<br />
SEROSTIM 25% coinsurance X<br />
SYNTEST D.S/H.S.<br />
br<strong>and</strong><br />
SYNTHROID br<strong>and</strong> X<br />
testosterone cypionate<br />
generic<br />
thyroid<br />
generic<br />
ZEMPLAR<br />
25% coinsurance<br />
ZORBTIVE 25% coinsurance X<br />
Hormonal Agents, Suppressant<br />
ARIMIDEX br<strong>and</strong> X<br />
AROMASIN br<strong>and</strong> X<br />
bromocriptine<br />
generic<br />
CASODEX<br />
br<strong>and</strong><br />
CYTADREN br<strong>and</strong> X<br />
ELIGARD 25% coinsurance X X<br />
EMCYT<br />
br<strong>and</strong><br />
FARESTON br<strong>and</strong> X<br />
FASLODEX 25% coinsurance X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 22<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
FEMARA br<strong>and</strong> X<br />
flutamide<br />
generic<br />
LUPRON 25% coinsurance X X<br />
LYSODREN<br />
br<strong>and</strong><br />
methimazole<br />
generic<br />
propylthiouracil<br />
generic<br />
PROSCAR br<strong>and</strong> X<br />
SANDOSTATIN 25% coinsurance X<br />
SENSIPAR br<strong>and</strong> X<br />
SOMAVERT 25% coinsurance X<br />
tamoxifen generic X<br />
TESLAC<br />
br<strong>and</strong><br />
VIADUR 25% coinsurance X X<br />
ZOLADEX 25% coinsurance X<br />
Immunological Agents<br />
ACTIHIB<br />
br<strong>and</strong><br />
ACTIMMUNE 25% coinsurance X<br />
ALDARA br<strong>and</strong> X<br />
ALFERON N 25% coinsurance X<br />
AMEVIVE 25% coinsurance X<br />
AVONEX 25% coinsurance X X<br />
azathioprine<br />
generic<br />
BETASERON 25% coinsurance X X<br />
CELLCEPT br<strong>and</strong> X<br />
COMVAX<br />
br<strong>and</strong><br />
COPAXONE 25% coinsurance X X<br />
CUPRIMINE<br />
br<strong>and</strong><br />
cyclosporine generic X<br />
DAPTACEL<br />
br<strong>and</strong><br />
ENBREL 25% coinsurance X X<br />
HUMIRA 25% coinsurance X<br />
INTRON 25% coinsurance X<br />
IPOL<br />
br<strong>and</strong><br />
leflunomide generic X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 23<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
MENACTRA<br />
br<strong>and</strong><br />
M-M-R II<br />
br<strong>and</strong><br />
MYFORTIC br<strong>and</strong> X<br />
PEDIARIX<br />
br<strong>and</strong><br />
PEGASYS 25% coinsurance X X<br />
PEG-INTRON 25% coinsurance X X<br />
PROGRAF br<strong>and</strong> X<br />
RAPAMUNE br<strong>and</strong> X<br />
RAPTIVA 25% coinsurance X<br />
REBIF 25% coinsurance X X<br />
RECOMBIVAX HB<br />
br<strong>and</strong><br />
REMICADE 25% coinsurance X<br />
ROFERON A 25% coinsurance X<br />
THALOMID 25% coinsurance X<br />
TWINRIX<br />
br<strong>and</strong><br />
TYPHIM VI<br />
br<strong>and</strong><br />
VAQTA<br />
br<strong>and</strong><br />
VARIVAX<br />
br<strong>and</strong><br />
XOLAIR 25% coinsurance X<br />
Inflammatory Bowel Disease Agents<br />
ASACOL<br />
br<strong>and</strong><br />
CANASA<br />
br<strong>and</strong><br />
COLAZAL br<strong>and</strong> X<br />
dexamethasone<br />
generic<br />
hydrocortisone<br />
generic<br />
methylprednisolone<br />
generic<br />
PENTASA<br />
br<strong>and</strong><br />
prednisolone<br />
generic<br />
prednisone<br />
generic<br />
sulfasalazine<br />
generic<br />
Ophthalmic Agents<br />
ACULAR/LS<br />
ALOCRIL<br />
ALPHAGAN P<br />
atropine ophthalmic<br />
bacitracin <strong>and</strong> polymyxin <strong>and</strong> neomycin <strong>and</strong> HC<br />
br<strong>and</strong><br />
br<strong>and</strong><br />
br<strong>and</strong><br />
generic<br />
generic<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 24<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
bacitracin <strong>and</strong> polymyxin ophthalmic<br />
generic<br />
bacitracin ophthalmic<br />
generic<br />
betaxolol<br />
generic<br />
BETIMOL<br />
br<strong>and</strong><br />
brimonidine<br />
generic<br />
carbachol<br />
generic<br />
carteolol ophthalmic<br />
generic<br />
cipr<strong>of</strong>loxacin ophthalmic<br />
generic<br />
COSOPT<br />
br<strong>and</strong><br />
cromolyn<br />
generic<br />
cyclopentolate<br />
generic<br />
dexamethasone<br />
generic<br />
dipivefrin<br />
generic<br />
erythromycin<br />
generic<br />
fluorometholone<br />
generic<br />
flurbipr<strong>of</strong>en<br />
generic<br />
FML FORTE/S.O.P<br />
br<strong>and</strong><br />
gentamicin<br />
generic<br />
homatropine ophthalmic<br />
generic<br />
IOPIDINE<br />
br<strong>and</strong><br />
levobunolol<br />
generic<br />
LUMIGAN br<strong>and</strong> X<br />
metipranolol<br />
generic<br />
naphazoline<br />
generic<br />
NATACYN<br />
br<strong>and</strong><br />
NATACYN<br />
br<strong>and</strong><br />
<strong>of</strong>loxacin<br />
generic<br />
phenylephrine ophthalmic<br />
generic<br />
pilocarpine<br />
generic<br />
PRED-G /SOP<br />
br<strong>and</strong><br />
prednisolone<br />
generic<br />
RESTASIS br<strong>and</strong> X X<br />
sulfacetamide<br />
generic<br />
timolol<br />
generic<br />
TOBRADEX<br />
br<strong>and</strong><br />
tobramycin<br />
generic<br />
trifluridine<br />
generic<br />
tropicamide<br />
generic<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 25<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
TRUSOPT<br />
br<strong>and</strong><br />
VISUDYNE<br />
25% coinsurance<br />
VITRASERT 25% coinsurance X<br />
XALATAN br<strong>and</strong> X<br />
ZADITOR<br />
br<strong>and</strong><br />
Otic Agents<br />
acetic acid in aluminum acetate otic<br />
benzocaine <strong>and</strong> antipyrine otic<br />
CIPRO HC<br />
CIPRODEX<br />
FLOXIN OTIC<br />
hydrocortisone <strong>and</strong> acetic acid otic<br />
generic<br />
generic<br />
br<strong>and</strong><br />
br<strong>and</strong><br />
generic<br />
Respiratory Tract Agents<br />
ACCOLATE br<strong>and</strong> X X<br />
albuterol generic X<br />
aminophylline<br />
generic<br />
ASMANEX br<strong>and</strong> X X<br />
ASTELIN br<strong>and</strong> X<br />
ATROVENT br<strong>and</strong> X<br />
CLARINEX br<strong>and</strong> X X<br />
COMBIVENT br<strong>and</strong> X<br />
cyproheptadine<br />
generic<br />
EPIPEN br<strong>and</strong> X<br />
FORADIL br<strong>and</strong> X<br />
hydroxyzine<br />
generic<br />
INTAL br<strong>and</strong> X<br />
ipratropium nasal<br />
generic<br />
metaproterenol<br />
generic<br />
n-acetylcysteine<br />
generic<br />
NASACORT AQ br<strong>and</strong> X<br />
NASONEX br<strong>and</strong> X<br />
PROLASTIN 25% coinsurance X<br />
promethazine<br />
generic<br />
PULMOZYME 25% coinsurance X<br />
QVAR br<strong>and</strong> X X<br />
SEREVENT br<strong>and</strong> X<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 26<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Requirements/Limits<br />
Drug Name Drug tier QL PA ST<br />
SINGULAIR br<strong>and</strong> X X<br />
SPIRIVA br<strong>and</strong> X X<br />
THEO 24<br />
br<strong>and</strong><br />
theophylline<br />
generic<br />
TILADE<br />
br<strong>and</strong><br />
TRACLEER 25% coinsurance X<br />
Sedatives/ Hypnotics<br />
AMBIEN br<strong>and</strong> X<br />
chloral hydrate<br />
generic<br />
Skeletal Muscle Relaxants<br />
bacl<strong>of</strong>en<br />
tizanidine<br />
generic<br />
generic<br />
Therapeutic Nutrients /Minerals/Electrolytes<br />
K-PHOS<br />
levocarnitine<br />
PHOSLO<br />
potassium chloride<br />
prenatal vitamins (generics)<br />
UROCIT<br />
br<strong>and</strong><br />
generic<br />
br<strong>and</strong><br />
generic<br />
generic<br />
br<strong>and</strong><br />
Toxicologic Agents<br />
naloxone generic X<br />
naltrexone<br />
generic<br />
QL = quantity limit applies<br />
PA = prior authorization required<br />
ST = step therapy applies 27<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
ABILIFY 11<br />
ACCOLATE 25<br />
acebutolol 13, 15<br />
acetaminophen <strong>and</strong> codeine 5<br />
acetaminophen <strong>and</strong> hydrocodone 5<br />
acetaminophen <strong>and</strong> oxycodone 5<br />
acetazolamide 15<br />
acetic acid in aluminum acetate otic 25<br />
ACIPHEX 20<br />
ACTIHIB 23<br />
ACTIMMUNE 23<br />
ACTIQ 5<br />
ACTOS 14<br />
ACULAR/LS 24<br />
acyclovir 12<br />
adenosine 15<br />
AGENERASE 12<br />
ALBENZA 11<br />
albuterol 25<br />
alclometasone (ointment) 18<br />
ALDARA 23<br />
ALFERON N 23<br />
ALKERAN 10<br />
allopurinol 8<br />
ALOCRIL 24<br />
ALPHAGAN P 24<br />
ALPHANATE 14<br />
aluminum chloride soln 18<br />
amantadine 11, 12<br />
AMARYL 14<br />
AMBIEN 26<br />
amcinonide 18<br />
AMEVIVE 23<br />
amiloride 15<br />
amiloride <strong>and</strong> HCTZ 15<br />
aminocaproic acid 14<br />
aminophylline 25<br />
amiodarone 15<br />
amitriptyline 7<br />
AMOXAPINE 7<br />
28<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
amoxicillin 6<br />
amoxicillin <strong>and</strong> clavulanate 6<br />
ampicillin 6<br />
ANCOBON 8<br />
ANDRODERM 21<br />
ANTABUSE 19<br />
anthralin 18<br />
APAP-isometheptene-dichloralphenazone 9<br />
APOKYN 11<br />
ARANESP 14<br />
ARICEPT 7<br />
ARIMIDEX 22<br />
ARIXTRA 14<br />
AROMASIN 22<br />
ASACOL 24<br />
ASMANEX 25<br />
aspirin <strong>and</strong> codeine 5<br />
aspirin <strong>and</strong> oxycodone 5<br />
ASTELIN 25<br />
atenolol 13, 15<br />
atenolol <strong>and</strong> chlorthalidone 15<br />
atropine ophthalmic 24<br />
ATROVENT 25<br />
AUTOPLEX T 14<br />
AVALIDE 15<br />
AVANDIA 14<br />
AVAPRO 15<br />
AVONEX 23<br />
azathioprine 23<br />
bacitracin <strong>and</strong> polymyxin <strong>and</strong> neomycin <strong>and</strong> HC 24<br />
bacitracin <strong>and</strong> polymyxin ophthalmic 24<br />
bacitracin ophthalmic 24<br />
bacl<strong>of</strong>en 26<br />
BEBULIN VH 14<br />
benazepril 15<br />
benazepril <strong>and</strong> HCTZ 15<br />
BENICAR 15<br />
BENICAR HCT 15<br />
benzocaine <strong>and</strong> antipyrine otic 25<br />
benztropine 11<br />
29<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
betamethasone dipropionate 18<br />
betamethasone valerate 18<br />
BETASERON 23<br />
betaxolol 13, 15, 24<br />
bethanechol 20<br />
BETIMOL 24<br />
bisoprolol 13<br />
bisoprolol 15<br />
bisoprolol <strong>and</strong> HCTZ 15<br />
brimonidine 24<br />
bromocriptine 11, 22<br />
bumetanide 15<br />
bupivicaine 5<br />
bupropion 7<br />
buspirone 13<br />
CAMPRAL 19<br />
CAMPTOSAR 10<br />
CANASA 24<br />
captopril 15<br />
captopril <strong>and</strong> HCTZ 15<br />
carbachol 24<br />
carbamazepine 7<br />
carbidopa <strong>and</strong> levodopa 11<br />
carteolol ophthalmic 24<br />
CARTROL 13, 15<br />
CASODEX 22<br />
CEENU 10<br />
cefaclor 6<br />
cefadroxil 6<br />
cefpodoxime 6<br />
cefuroxime 6<br />
CELEBREX 5, 9<br />
CELLCEPT 23<br />
CELONTIN 7<br />
cephalexin 6<br />
CEREDASE 20<br />
CEREZYME 20<br />
chloral hydrate 26<br />
chlorhexidine 18<br />
chloroquine 11<br />
30<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
chlorothiazide 15<br />
chlorpromazine 8, 7<br />
chlorthalidone 16<br />
cholestyramine 16<br />
choline <strong>and</strong> magnesium salicylates 5, 9<br />
ciclopirox 18<br />
cilostazol 14<br />
cimetidine 20<br />
CIPRO HC 25<br />
CIPRODEX 25<br />
cipr<strong>of</strong>loxacin 6<br />
cipr<strong>of</strong>loxacin ophthalmic 24<br />
citalopram 7<br />
CLADRIBINE 10<br />
CLARINEX 26<br />
clindamycin 6<br />
clobetasol propionate 18<br />
clomipramine 7<br />
clonidine 13, 16<br />
CLORPRES 16<br />
clotrimazole 8, 18<br />
clotrimazole <strong>and</strong> betamethasone 18<br />
clozapine 11<br />
CODEINE PHOSPHATE 5<br />
CODEINE SULFATE 5<br />
COLAZAL 24<br />
colchicine 8<br />
colchicine <strong>and</strong> probenecid 8<br />
COMBIVENT 26<br />
COMBIVIR 12<br />
COMTAN 11<br />
COMVAX 23<br />
COPAXONE 23<br />
COPEGUS 12<br />
cortisone 21<br />
COSOPT 24<br />
COUMADIN 14<br />
CREON 20<br />
CRIXIVAN 12<br />
cromolyn 24<br />
31<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
CUPRIMINE 23<br />
cyclopentolate 24<br />
cyclophosphamide 10<br />
cyclosporine 23<br />
cyproheptadine 26<br />
CYTADREN 22<br />
CYTOMEL 21<br />
danazol 21<br />
DAPSONE 10<br />
DAPTACEL 23<br />
DARAPRIM 11<br />
demeclocycline 6<br />
DENAVIR 18<br />
DEPAKOTE 7<br />
DEPAKOTE ER 9<br />
desipramine 7<br />
desmopressin nasal 21<br />
desonide 18<br />
desoximetasone 18<br />
dexamethasone 9, 18, 21, 24<br />
dextroamphetamine 18<br />
dextroamphetamine <strong>and</strong> amphetamine 18<br />
dicl<strong>of</strong>enac 5, 9<br />
dicloxacillin 6<br />
dicyclomine 13<br />
dicyclomine 20<br />
didanosine 12<br />
diflorasone 18<br />
diflunisal 5, 9<br />
digoxin 16<br />
dihydroergotamine for injection 9<br />
diltiazem 16<br />
diphenoxylate <strong>and</strong> atropine 20<br />
dipivefrin 24<br />
dipyridamole 14<br />
dobutamine 13<br />
dopamine 13<br />
DOVONEX 18<br />
doxazosin 13, 16, 20<br />
doxepin 7<br />
32<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
doxepin 13<br />
doxepin 18<br />
doxycycline 6<br />
doxycycline 18<br />
DYNACIRC CR 16<br />
econazole 18<br />
EFFEXOR/XR 7<br />
ELIGARD 22<br />
ELSPAR 10<br />
EMCYT 22<br />
EMTRIVA 12<br />
enalapril 16<br />
enalapril <strong>and</strong> HCTZ 16<br />
ENBREL 23<br />
ENLON 13<br />
EPIPEN 13, 26<br />
EPIVIR 12<br />
EPIVIR HBV 12<br />
EPOGEN 14<br />
EPZICOM 12<br />
ergoloid mesylates 7<br />
ergotamine <strong>and</strong> caffeine 9<br />
ERY-TAB 6<br />
erythromycin 24<br />
erythromycin <strong>and</strong> sulfisoxazole 6<br />
erythromycin ethylsuccinate 6<br />
erythromycin stearate 6<br />
ESTRACE 21<br />
estradiol 21<br />
estropipate 21<br />
ethambutol 10<br />
ethosuximide 7<br />
etodolac 5, 9<br />
etoposide 10<br />
EVISTA 21<br />
EXELON 7<br />
FABRAZYME 20<br />
famotidine 20<br />
FARESTON 22<br />
FASLODEX 22<br />
33<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
FEIBA VH IMMUNO 14<br />
FELBATOL 7<br />
felodipine 16<br />
FEMARA 22<br />
fenopr<strong>of</strong>en 5, 9<br />
flavoxate 20<br />
flecainide 16<br />
FLOXIN OTIC 25<br />
fluconazole 8<br />
fludarabine 10<br />
fludrocortisone 21<br />
fluocinolone acetonide 18<br />
fluocinonide 18<br />
fluorometholone 24<br />
fluorouracil 18<br />
fluoxetine 7<br />
fluphenazine 11<br />
flurbipr<strong>of</strong>en 5, 9, 24<br />
flutamide 22<br />
fluticasone propionate 18<br />
fluvoxamine 7<br />
FML FORTE/S.O.P 24<br />
FORADIL 26<br />
FORTEO 21<br />
FORTOVASE 12<br />
FOSAMAX 21<br />
FOSCAVIR 12<br />
fosinopril 16<br />
fosinopril <strong>and</strong> HCTZ 16<br />
furosemide 16<br />
FUZEON 12<br />
gabapentin 7<br />
GABITRIL 7<br />
ganciclovir 12<br />
GANITE 21<br />
gemfibrozil 16<br />
GENARC 14<br />
GENOTROPIN 21<br />
gentamicin 24<br />
GEOCILLIN 6<br />
34<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
GEODON 11, 14<br />
GEODON injectable 11<br />
GLEEVEC 10<br />
glipizide 14<br />
GLUCAGEN 14<br />
glyburide 14<br />
glyburide <strong>and</strong> metformin 14<br />
glycopyrrolate 13<br />
glycopyrrolate 20<br />
GRIFULVIN/GRIS-PEG 8<br />
GUANIDINE 13<br />
GYNAZOLE 8<br />
halobetasol propionate 19<br />
haloperidol 11<br />
HECTORAL 21<br />
HELIDAC 20<br />
heparin 15<br />
HEPSERA 12<br />
HEXALEN 10<br />
HIVID 12<br />
homatropine ophthalmic 24<br />
HUMATROPE 21<br />
HUMIRA 23<br />
hydralazine 16<br />
hydrochlorothiazide 16<br />
hydrocortisone 9, 19, 21, 24<br />
hydrocortisone <strong>and</strong> acetic acid otic 25<br />
hydrocortisone <strong>and</strong> iodoquinol 19<br />
hydrocortisone butyrate 19<br />
hydrocortisone valerate 19<br />
hydromorphone 5<br />
hydroxychloroquine 11<br />
hydroxyurea 10<br />
hydroxyzine 8, 26<br />
hyoscyamine 13, 20, 21<br />
ibupr<strong>of</strong>en 5, 9<br />
ibupr<strong>of</strong>en <strong>and</strong> hydrocodone 5<br />
imipramine hydrochloride 7<br />
indapamide 16<br />
INDERAL LA 16<br />
35<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
indomethacin 5, 9<br />
INNOPRAN XL 16<br />
INTAL 26<br />
INTRON 23<br />
INVIRASE 12<br />
IOPIDINE 24<br />
IPOL 23<br />
ipratropium nasal 26<br />
isoniazid 10<br />
isosorbide dinitrate 16<br />
isosorbide mononitrate 16<br />
itraconazole 8<br />
KALETRA 12<br />
KEPPRA 7<br />
KETEK 6<br />
ketoconazole 8, 19<br />
ketopr<strong>of</strong>en 5<br />
ketopr<strong>of</strong>en 9<br />
KOATE-DVI 15<br />
KOGENATE FS 15<br />
K-PHOS 27<br />
KYTRIL 8<br />
labetalol 13, 16<br />
lactulose 20<br />
LAMICTAL 7<br />
LAMISIL 8<br />
LANTUS 14<br />
leflunomide 23<br />
leucovorin 10<br />
LEUKERAN 10<br />
LEUKINE 15<br />
LEVATOL 13, 16<br />
LEVITRA 21<br />
levobunolol 25<br />
levocarnitine 27<br />
levothyroxine 21<br />
LEVULAN 19<br />
LEXIVA 12<br />
lidocaine 5, 16, 19<br />
lidocaine <strong>and</strong> hydrocortisone 19<br />
36<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
lidocaine <strong>and</strong> prilocaine 19<br />
lindane 11<br />
LIPITOR 16<br />
LIPRAM 20<br />
lisinopril 16<br />
lisinopril <strong>and</strong> HCTZ 16<br />
lithium 14<br />
loperamide 20<br />
LORABID 6<br />
LOTRONEX 20<br />
lovastatin 16<br />
LOVENOX 15<br />
loxapine 11<br />
LUMIGAN 25<br />
LUPRON 22<br />
LYSODREN 22<br />
mannitol 16<br />
maprotiline 7<br />
MATULANE 10<br />
MAVIK 16<br />
mebendazole 11<br />
meclizine 8<br />
medroxyprogesterone 21<br />
mefloquine 11<br />
megestrol 21<br />
MENACTRA 23<br />
meprobamate 13<br />
MEPRON 11<br />
mercaptopurine 10<br />
MESNEX 10<br />
METADATE CD 18<br />
metaproterenol 26<br />
metformin 14<br />
methadone 5<br />
methamphetamine 18<br />
methazolamide 16<br />
methimazole 22<br />
methotrexate 10<br />
methyclothiazide 16<br />
methyldopa <strong>and</strong> HCTZ 16<br />
37<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
methylphenidate 18<br />
methylprednisolone 9, 21, 24<br />
metipranolol 25<br />
metoclopramide 8<br />
metolazone 16<br />
metoprolol 13, 16<br />
metoprolol <strong>and</strong> HCTZ 16<br />
METROGEL/LOTION 19<br />
metronidazole 6, 19<br />
mexiletine 16<br />
MIACALCIN 21<br />
midodrine 13, 17<br />
milrinone 17<br />
minoxidil 17<br />
MIRAPEX 11<br />
mirtazapine 7<br />
misoprostol 20, 21<br />
M-M-R II 23<br />
MOBAN 11<br />
mometasone furoate 19<br />
MONOCATE-P 15<br />
morphine 5<br />
mupirocin 19<br />
MUSE 21<br />
MYCOBUTIN 10<br />
MYFORTIC 23<br />
MYLERAN 10<br />
nabumetone 5, 9<br />
n-acetylcysteine 26<br />
nadolol 13, 17<br />
naloxone 27<br />
naltrexone 27<br />
NAMENDA 7<br />
naphazoline 25<br />
naproxen 5, 9<br />
NARDIL 7<br />
NASACORT AQ 26<br />
NASONEX 26<br />
NATACYN 25<br />
NEBUPENT 11<br />
38<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
nefazodone 8<br />
NEGGRAM 6<br />
neomycin 6<br />
NEULASTA 15<br />
NEUMEGA 15<br />
NEUPOGEN 15<br />
NIASPAN 17<br />
nifedipine (SR) 17<br />
NITROBID 17<br />
nitr<strong>of</strong>urantoin 6<br />
nitroglycerin 17<br />
NITROLINGUAL PUMPSPRAY 17<br />
nizatidine 20<br />
NORDITROPIN 21<br />
norethindrone 21<br />
nortriptyline 8<br />
NORVIR 12<br />
NOVOLIN R/NPH 14<br />
NOVOLOG 14<br />
NUTROPIN 21<br />
nystatin 8, 19<br />
nystatin <strong>and</strong> triamcinolone 19<br />
<strong>of</strong>loxacin 6, 25<br />
omeprazole 20<br />
ORAP 11<br />
ORFADIN 20<br />
OSMOGLYN 17<br />
oxaprozin 5, 9<br />
OXSORALEN ULTRA 19<br />
oxybutynin 21<br />
oxycodone (immediate release only) 5<br />
PANCREASE 20<br />
PARNATE 8<br />
paromomycin 6<br />
paroxetine 8, 13<br />
PEDIARIX 23<br />
PEGANONE 7<br />
PEGASYS 23<br />
PEG-INTRON 23<br />
pemoline 18<br />
39<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
penicillin V potassium 6<br />
PENTASA 24<br />
pentazocine 5<br />
pentazocine <strong>and</strong> naloxone 5<br />
pentoxifylline 15<br />
pergolide 11<br />
permethrin 11<br />
perphenazine 8, 11<br />
phenazopyridine 21<br />
phenylephrine ophthalmic 25<br />
phenytoin 7<br />
PHOSLO 27<br />
pilocarpine 18, 25<br />
pindolol 13<br />
pindolol 17<br />
piroxicam 5, 9<br />
PLAVIX 15<br />
pod<strong>of</strong>ilox 19<br />
polyethylene glycol 3350 NF 20<br />
PONTOCAINE 19<br />
potassium chloride 27<br />
pramoxine <strong>and</strong> hydrocortisone 19<br />
PRANDIN 14<br />
prazosin 13, 17<br />
PRECOSE 14<br />
PRED-G /SOP 25<br />
prednisolone 9, 21, 24, 25<br />
prednisone 9, 21, 24<br />
PREMARIN 21<br />
PREMARIN vaginal 22<br />
PREMPHASE/PREMPRO 22<br />
prenatal vitamins (generics) 27<br />
PREVACID 20<br />
PREVPAK 20<br />
primidone 7<br />
probenecid 8<br />
procainamide 17<br />
prochlorperazine 8, 11<br />
PROCRIT 15<br />
PROFILNINE SD 15<br />
40<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
PROGLYCEM 14, 17<br />
PROGRAF 23<br />
PROLASTIN 26<br />
PROLEUKIN 10<br />
promethazine 8, 26<br />
propafenone 17<br />
propranolol 9, 13, 17<br />
propranolol <strong>and</strong> HCTZ 17<br />
propylthiouracil 22<br />
PROSCAR 21, 22<br />
PROVIGIL 18<br />
PULMOZYME 26<br />
pyrazinamide 10<br />
pyridostigmine 14<br />
quinapril 17<br />
quinapril <strong>and</strong> HCTZ 17<br />
quinidine 17<br />
quinine 11<br />
QVAR 26<br />
ranitidine 20<br />
RAPAMUNE 23<br />
RAPTIVA 23<br />
REBIF 23<br />
RECOMBINATE 15<br />
RECOMBIVAX HB 23<br />
REGRANEX 19<br />
RELPAX 9<br />
REMICADE 23<br />
REMODULIN 17<br />
RENAGEL 20<br />
RESCRIPTOR 12<br />
RESTASIS 25<br />
RETROVIR 12<br />
REYATAZ 12<br />
ribavirin 12<br />
rifampin 10<br />
RILUTEK 18<br />
rimantadine 12<br />
RISPERDAL 12<br />
RISPERDAL CONSTA 12<br />
41<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
ROFERON A 23<br />
SAIZEN 22<br />
salsalate 5, 9<br />
SANDOSTATIN 20, 22<br />
SANTYL 19<br />
selegiline 11<br />
selenium 19<br />
SENSIPAR 22<br />
SEREVENT 26<br />
SEROQUEL 12<br />
SEROSTIM 22<br />
silver sulfadiazine 19<br />
SINGULAIR 26<br />
SOLARAZE 19<br />
SOMAVERT 22<br />
SORIATANE 19<br />
sotalol 14<br />
sotalol 17<br />
SPIRIVA 26<br />
spironolactone 17<br />
spironolactone <strong>and</strong> HCTZ 17<br />
sucralfate 20<br />
SULAR 17<br />
sulfacetamide 25<br />
SULFADIAZINE 6<br />
sulfamethoxazole <strong>and</strong> trimethoprim 6<br />
sulfasalazine 24<br />
SULFISOXAZOLE 6<br />
sulindac 5<br />
sulindac 9<br />
SURMONTIL 8<br />
SUSTIVA 12<br />
SYNTEST D.S/H.S. 22<br />
SYNTHROID 22<br />
tamoxifen 22<br />
TARCEVA 10<br />
TARGRETIN 10<br />
TASMAR 11<br />
TEMODAR 10<br />
terazosin 14, 17, 21<br />
42<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
terconazole 8<br />
TESLAC 22<br />
testosterone cypionate 22<br />
tetracaine 5<br />
tetracycline 6<br />
THALOMID 23<br />
THEO 24 26<br />
theophylline 26<br />
THIOGUANINE 10<br />
thioridazine 12<br />
thiothixene 12<br />
thyroid 22<br />
TICE BCG 10<br />
TILADE 26<br />
timolol 9, 14, 17, 25<br />
tizanidine 26<br />
TOBI 6<br />
TOBRADEX 25<br />
tobramycin 25<br />
TOFRANIL-PM 8<br />
tolmetin 5<br />
tolmetin 9<br />
TOPAMAX 7, 9<br />
TOPROL XL 14<br />
TRACLEER 17, 26<br />
tramadol 5<br />
trazodone 8<br />
triamcinolone acetonide 19<br />
triamcinolone in orabase 18<br />
triamterene <strong>and</strong> HCTZ 17<br />
trifluoperazine 12<br />
trifluridine 25<br />
trihexyphenidyl 11<br />
TRILEPTAL 7<br />
trimethobenzamide 8<br />
trimethoprim 6<br />
TRIZIVIR 12<br />
tropicamide 25<br />
TRUSOPT 25<br />
TRUVADA 13<br />
43<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
TWINRIX 23<br />
TYPHIM VI 23<br />
ULTRASE 20<br />
UROCIT 27<br />
ursodiol 20<br />
VALCYTE 13<br />
valproic acid 7<br />
VANCOCIN 6<br />
VAQTA 23<br />
VARIVAX 23<br />
verapamil 17<br />
VESANOID 10<br />
VIADUR 22<br />
VIRACEPT 13<br />
VIRAMUNE 13<br />
VIREAD 13<br />
VISUDYNE 25<br />
VITRASERT 25<br />
VIVACTIL 8<br />
warfarin 15<br />
XALATAN 25<br />
XELODA 10<br />
XOLAIR 23<br />
YODOXIN 11<br />
ZADITOR 25<br />
ZELNORM 20<br />
ZEMPLAR 22<br />
ZERIT 13<br />
ZETIA 17<br />
ZIAGEN 13<br />
ZITHROMAX 6<br />
ZOFRAN 8<br />
ZOLADEX 22<br />
ZOLOFT 8, 13<br />
ZONEGRAN 7<br />
ZORBTIVE 22<br />
ZOVIRAX topical 19<br />
ZYPREXA 12<br />
ZYPREXA injectable 12<br />
ZYVOX 6<br />
44<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
Drug Name<br />
Page<br />
45<br />
CMS Approval Date: 10/2005<br />
Material ID: S5917<br />
2021 <strong>Formulary</strong>
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