Drug Formulary - Unity Health Insurance

FORMULARYNONFORMULARY1 Tier (Generic) 2 Tier (Brand) 3 TierOPHTHALMIC/OTIC (Eyes/Ears – Allergies, Glaucoma, Inflammation, Infection)Other Miscellaneous Eye Productsatropine homatropine 2% (Isopto Homatropine) benoxinate/fluorescein (Altafluor, Flurox)cyclopentolatecyclosporine (Restasis)homatropine 5%cysteamine (Cystaran)phenylephrinehydroxyamphetamine/tropicamide (Paremyd)proparacaine ophthalmichydroxypropyl cellulose ophthalmic insert(Lacrisert)tetracainescopolamine (Isopto Hyoscine)trifluridinetropicamideMiscellaneous Ear Productsacetic acid ciprofloxacin/hydrocortisone (Cipro HC) antipyrine/benzocaine/zinc (Otozin)antipyrine/benzocaine ciprofloxacin/dexamethasone (Ciprodex) chloroxylenol/benzoc/hydrocortisone (Trioxin)acetic acid/hydrocortisonefluocinolone otic (DermOtic)ciprofloxacin oticofloxacin oticneomycin/polymyxin/hydrocortisone oticPenicillinsamoxicillinamoxicillin/clavulanateamoxicillin/clavulanate ERamoxicillin/clavulanate ESampicillindicloxacillinpenicillin VK (Veetids, PenVee K)CephalosporinscephalexincefpodoximecefdinirINFECTIOUS DISEASEamoxicillin ER (Moxatag)cefaclorcefadroxilcefuroxime (Ceftin)cefprozil (generics, Cefzil)ceftibutencefditorencefixime (Suprax)Quinolonesciprofloxacin norfloxacin (Noroxin) ciprofloxacin XRlevofloxacin oralgatifloxacin (Tequin)moxifloxacin gemifloxacin (Factive) Qlomefloxacin (Maxaquin)ofloxacinMacrolide/Ketolideazithromycin clarithromycin (Biaxin suspension) azithromycin (Zmax) Qclarithromycin erythromycin (Erytab, Emycin) erythromycin ethyl succinate (Eryped)clarithromycin ER telithromycin (Ketek) PA Qerythromycinerythromycin ethyl succinate (EES)erythromycin ethyl succinateerythromycin stearate (Erythrocin)erythromycin/sulfisoxazolePA – Prior authorization required; H – Half tab; Q – Quantity limit; ST – Step therapy; A – Age edit;SP – Specialty; NTI – Narrow therapeutic index list; * – RX Outcomes benefit6-16-1416