2012 Formulary Print document - Denver Health Medical Plan

Farmacopea de 2012
(Lista de medicamentos cubiertos)
LEA LO SIGUIENTE:
ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE
CUBRIMOS EN ESTE PLAN
NOTA PARA LOS AFILIADOS ACTUALES:
Esta farmacopea cambió desde el año pasado. Revise este documento para asegurarse de que todavía
incluye los medicamentos que usted toma.
Los beneficiarios deben utilizar las farmacias de la red para acceder a su beneficio de medicamentos
con receta médica. Los beneficios, la farmacopea, la red de farmacias, la prima y los
copagos/coaseguro
pueden cambiar en enero 1 de 2013
HMO aprobada por Medicare
This information is available for free in other languages. Please contact our Member Services department at
303-602-2111 or toll free at 1-877-956-2111 for more information. TTY/TDD users should call 303-602-
2129 or toll free at 1-866-538-5288. Our hours of operation are 8 a.m. - 8 p.m. seven days a week.
Este documento está disponible gratis en otros idiomas. Por favor comuníquese con nuestro departamento
de Servicios al Afiliado al 303-602-2111 o llame gratis al 1-877-956-2111, para obtener más información.
Los usuarios TTY/TDD favor de llamar al 303-602-2129 o gratis al
1-866-538-5288. Estamos disponibles de las 8 a.m. a las 8 p.m. los siete días de la semana.
H5608_5003_2012_Comprehensive Formulary_SP Effective Date: June 1, 2012
CMS File and Use 09/25/2011 Last Updated: May 25, 2012
Formulary ID: 12146.000, Version 11
1

¿Qué es la farmacopea de Denver Health Medical Plan, Inc.?
Una farmacopea contiene la lista de medicamentos cubiertos seleccionados por Denver Health Medical Plan
en consulta con un equipo de proveedores de atención médica, que representa los tratamientos por receta
médica que se cree son parte necesaria de un programa de un tratamiento de calidad. Denver Health Medical
Plan generalmente cubrirá los medicamentos descritos en nuestro farmacopea siempre que el medicamento
sea médicamente necesario, la receta médica sea surtida en una farmacia de la red de Denver Health
Medical Plan y se sigan otras reglas del plan. Para obtener más información acerca de cómo obtener sus
medicamentos con receta médica, revise su Evidencia de cobertura.
¿Puede cambiar la farmacopea?
Generalmente, si usted está tomando un medicamento que se encuentra en nuestra farmacopea de
2012 que fue cubierto al inicio del año, no descontinuaremos ni reduciremos la cobertura del medicamento
durante el año de cobertura 2012, excepto que esté disponible un medicamento genérico de menos costo o si
se publica nueva información adversa sobre la seguridad o efectividad de un medicamento. Otro tipo de
cambios, tal como retirar un medicamento de nuestra farmacopea, no afectará a los afiliados que actualmente
toman el medicamento. Permanecerá disponible al mismo costo compartido para los afiliados que lo toman,
por el resto del año de cobertura. Sentimos que es importante que tenga un acceso continuo para el resto del
año de cobertura a los medicamentos de la farmacopea que estaban disponibles cuando usted eligió nuestro
plan, excepto para los casos en que puede ahorrar más dinero o que podemos garantizar su seguridad.
Si eliminamos medicamentos de nuestra farmacopea o agregamos restricciones de autorización previa,
límites de cantidad o terapia de pasos en un medicamento o movemos un medicamento a un nivel de costo
compartido más alto, debemos notificar del cambio a los afiliados afectados por lo menos 60 días antes de
que el cambio llegue a ser efectivo, o cuando el afiliado solicite que le surtan el medicamento, momento en el
cual el afiliado recibirá un suministro del medicamento para 60 días. Si la Administración de alimentos y
medicamentos (Food and Drug Administration) considera que un medicamento de nuestra farmacopea no es
seguro o el fabricante del medicamento lo retira del mercado, inmediatamente lo retiraremos de nuestra
farmacopea y notificaremos a los afiliados que toman dicho medicamento.
La farmacopea adjunta se actualizó el 01 de junio del 2012. Para obtener información actualizada sobre los
medicamentos cubiertos por Denver Health Medical Plan, visite nuestro sitio web en
www.denverhealthmedicalplan.com o llame a Servicios al Afiliado al 303-602-2111 o gratis al 1-877-956-
2111. Los usuarios de TTY/TDD deberán llamar al 303-602-2129 o gratis al 1-866-538-5288. Nuestro
horario de atención es de 8:00 a.m. a 8:00 p.m., los siete días de la semana.
¿Cómo utilizo la farmacopea?
Hay dos maneras de encontrar su medicamento dentro de la farmacopea:
Afección
La farmacopea principia en la página 10. Los medicamentos en esta farmacopea se agrupan en categorías
de acuerdo con el tipo de afecciones médicas en que se utilizan para el tratamiento. Por ejemplo, los
medicamentos que se usan para tratar una afección cardíaca se muestran en la categoría Medicamentos
2

cardíacos. Si usted conoce para qué se utiliza su medicamento, busque el nombre de la categoría en la
lista que inicia en la página I-1. Luego busque su medicamento bajo el nombre de la categoría.
Lista alfabética
Si no está seguro bajo qué categoría buscar, deberá buscar su medicamento en el índice que inicia en la
página I-1. El índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en
este documento. Se incluyen en el índice tanto los medicamentos de nombre comercial como los
genéricos. Busque en el índice y encuentre su medicamento. Al lado de su medicamento verá el número
de la página en donde puede encontrar la información de cobertura. Vaya a la página que se detalla en el
Índice y encuentre el nombre de su medicamento en la primera columna de la lista.
¿Qué son medicamentos genéricos?
Denver Health Medical Plan cubre tanto medicamentos de marca, como medicamentos genéricos. Un
medicamento genérico es aprobado por la FDA ya que tiene el mismo ingrediente activo que el medicamento
de nombre comercial. Generalmente, los medicamentos genéricos cuestan menos que los medicamentos de
marca comercial.
¿Existe alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Es posible que
estos requisitos o límites incluyan:
Autorización previa: Denver Health Medical Plan requiere que usted (o su médico) obtenga una
autorización previa para algunos medicamentos. Esto significa que necesitará obtener aprobación de
Denver Health Medical Plan antes de surtir sus recetas médicas. Si no obtiene la aprobación, es
probable que Denver Health Medical Plan no cubra el medicamento.
Límites de cantidad: Para ciertos medicamentos Denver Health Medical Plan limita la cantidad del
medicamento que cubrirá Denver Health Medical Plan. Por ejemplo, Denver Health Medical Plan
proporciona 93 cápsulas de Lyrica por receta médica. Esto puede ser además de un mes o tres meses
estándar de suministro.
Terapia de pasos: En algunos casos, Denver Health Medical Plan requiere que usted pruebe
primero ciertos medicamentos para tratar su afección antes que cubramos otro medicamento para la
afección. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su condición
médica, Denver Health Medical Plan podría no cubrir el medicamento B a menos que primero
intente usar el medicamento A. Si el medicamento A no es efectivo en su caso, Denver Health
Medical Plan cubrirá el medicamento B.
Puede solicitar a Denver Health Medical Plan que hagan una excepción a estas restricciones o
límites. Consulte la sección “¿Cómo solicito una excepción a la farmacopea de Denver Health
Medical Plan?”, en la siguiente página para obtener información acerca de cómo solicitar una
excepción.
3

¿Qué pasa si mi medicamento no está en la farmacopea?
Si su medicamento no está incluido en esta farmacopea, primero debería comunicarse con Servicios al
Afiliado y confirmar que su medicamento no está cubierto. Si se entera de que su medicamento no tiene
cobertura de Denver Health Medical Plan, tiene dos opciones:
Puede solicitar en Servicios al Afiliado una lista de medicamentos similares que están cubiertos por
Denver Health Medical Plan. Cuando reciba la lista, muéstrela a su médico y pídale que le recete un
medicamento similar que esté cubierto por Denver Health Medical Plan.
Puede solicitar a Denver Health Medical Plan que haga una excepción y cubra su medicamento.
Consulte a continuación para obtener información acerca de cómo solicitar una excepción.
¿Cómo solicito una excepción a la farmacopea de Denver Health Medical Plan?
Puede solicitar a Denver Health Medical Plan que haga una excepción en sus reglas de cobertura. Existen
varios tipos de excepciones que nos puede solicitar.
• Usted puede solicitarnos que cubramos su medicamento, aunque no esté en nuestra farmacopea.
• Puede pedirnos que exoneremos las restricciones o límites de cobertura de su medicamento. Por
ejemplo, para ciertos medicamentos Denver Health Medical Plan limita la cantidad del medicamento
que cubrirá. Si su medicamento tiene un límite de cantidad, puede solicitarnos que exoneremos el
límite y cubramos una cantidad mayor.
• Usted puede solicitarnos que le proporcionemos un nivel más alto de cobertura para su
medicamento. Si su medicamento se encuentra en nuestro nivel no preferido de medicamentos de
marca, puede solicitar que cubramos la cantidad de costo compartido que se aplica a los
medicamentos en el nivel de medicamentos genéricos. Esto reducirá la cantidad de debe pagar
por su medicamento. Tenga en cuenta que si accedemos a su solicitud de cubrir un medicamento que
no se encuentra en nuestra farmacopea, no puede solicitarnos un mayor nivel de cobertura para ese
medicamento.
Generalmente, Denver Health Medical Plan sólo aprobará su solicitud de excepción si los medicamentos
alternativos incluidos en la farmacopea del plan, el medicamento del nivel inferior o la restricción de
utilización adicional no son tan efectivos en el tratamiento de su afección o podría ocasionar efectos médicos
adversos.
Debe contactarnos para solicitar una decisión inicial de excepción de cobertura por una restricción de la
farmacopea, nivelación o utilización. Cuando solicita una excepción de la farmacopea, nivelación o
restricción de uso debe presentar una declaración de su médico apoyando su solicitud. Generalmente
debemos tomar nuestra decisión en 72 horas de haber obtenido la declaración de respaldo de su médico que
dio la receta o la persona que le dio la receta. Puede solicitar una excepción expedita (rápida) si usted o su
médico consideran que su salud podría dañarse seriamente si espera hasta 72 horas por una decisión. Si se
otorga su solicitud de excepción expedita debemos otorgarle una decisión antes de 24 horas luego que
obtenga la declaración de respaldo de su médico que le receta o persona que le receta.
4

¿Qué debo hacer antes de hablar con mi médico sobre un cambio en mis medicamentos
o solicitar una excepción?
Como afiliado nuevo o continuado en nuestro plan usted puede estar tomando medicamentos que no están en
nuestra farmacopea. O puede estar tomando un medicamento que está en nuestra farmacopea, pero su
capacidad para obtenerlo es limitada. Por ejemplo, puede ser que necesite de nuestra autorización previa
antes de surtir su receta médica. Debe hablar con su médico para decidir si debe cambiar a un medicamento
apropiado que nosotros cubrimos o solicitar una excepción a la farmacopea para que cubramos el
medicamento que toma. Mientras que usted hable con su médico para determinar el curso correcto de acción
para usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días de ser un afiliado
de nuestro plan.
Por cada uno de sus medicamentos que no está en nuestra farmacopea, o si su capacidad de obtener los
medicamentos es limitada, cubriremos un suministro temporal de 30 días (a menos que usted tenga una
receta médica escrita por menos días) cuando usted se dirija a una farmacia de la red. Luego de su primer
suministro de 30 días, no pagaremos por estos medicamentos, incluso si usted ha sido un afiliado del plan por
menos de 90 días.
Si usted es un residente de un centro de atención médica a largo plazo, le permitiremos un nuevo surtido de
su receta hasta que le hayamos proporcionado un suministro de transición de 91 días consistente con el
incremento de administración, (a menos que tenga una receta médica escrita para menos días). Cubriremos
más de un nuevo surtido de estos medicamentos para los primeros 90 días que sea miembro de nuestro plan.
Si necesita un medicamento que no esté en nuestra farmacopea o si su capacidad para obtener sus
medicamentos es limitada, pero ya pasó los primeros 90 días de afiliación en nuestro plan, cubriremos un
suministro de emergencia de 31 días de ese medicamento (a menos que tenga una receta médica para menos
días) mientras consigue una excepción de la farmacopea.
Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos con receta médica de
Denver Health Medical Plan, revise su Evidencia de cobertura y otros materiales del plan.
Si tiene alguna pregunta acerca de Denver Health Medical Plan, llame a Servicios al Afiliado al 303-602-
2111 o gratis al 1-877-956-2111. Nuestro horario de atención es de 8:00 a.m. a 8:00 p.m., los siete días de la
semana. Los usuarios de TTY/TDD deberán llamar al 303-602-2129 o gratis al 1-866-538-5288. O bien
visite www.denverhealthmedicalplan.com.
Si tiene preguntas generales acerca de la cobertura de medicamentos con receta médica de Medicare, llame a
Medicare al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los usuarios
de TTY/TDD deben llamar al 1-877-486-2048. O bien, visite www.medicare.gov.
Farmacopea de Denver Health Medical Plan
La farmacopea que inicia en la página uno proporciona información sobre la cobertura de algunos
medicamentos cubiertos por Denver Health Medical Plan. Si tiene problemas para encontrar su medicamento
en la lista, diríjase al índice que inicia en la página I-1.
5

La primera columna del cuadro muestra el nombre del medicamento. Los medicamentos de marca están en
mayúsculas (por ejemplo, COUMADIN) y los medicamentos genéricos se muestran en minúsculas e itálicas
(por ejemplo, warfarina sódica).
La información de la columna de los requisitos/límites indica si Denver Health Medical Plan tiene algún
requisito especial para la cobertura de su medicamento. Las abreviaturas en la columna de los
requisitos/límites incluyen:
PA: Autorización previa: Usted (o su médico) deben obtener la autorización previa de Denver
Health Medical Plan antes de surtir sus recetas médicas para este medicamento. Sin la aprobación
previa, es probable que Denver Health Medical Plan no cubra este medicamento.
QL: Cantidad limitada: Denver Health Medical Plan limita la cantidad del medicamento que
tendrá cobertura por receta médica o dentro de un período específico.
ST: Terapia de pasos: Antes de que Denver Health Medical Plan, Inc. proporcione cobertura para
este medicamento, primero debe probar otros medicamentos para tratar su afección médica. Este
medicamento se puede cubrir sólo si el otro medicamento no funciona para usted.
LA: Acceso limitado: Esta receta médica puede estar disponible sólo en ciertas farmacias. Para
obtener más información, consulte su Directorio de farmacias o llame a Servicios al Afiliado al
303-602-2111 o gratis al 1-877-956-2111. Los usuarios de TTY/TDD deberán llamar al 303-
602-2129 o gratis al 1-866-538-5288. Nuestro horario de atención es de 8:00 a.m. a 8:00 p.m., los
siete días de la semana.
6

ABREVIATURAS DE EFECTIVIDAD Y PRESENTACIÓN DEL MEDICAMENTO
ABREVIATURA DESCRIPCIÓN
adh. patch parche adhesivo
aer pow ba polvo en aerosol, activado por respiración
aer refill relleno de aerosol
aer w/adap aerosol con adaptador
ampul ampula
blkbaginj bolsa para administración intravenosa
cap dr mp cápsula, liberación lenta, multifásica
cap ds pk cápsula, paquete de dosis
cap sprink cápsula, dispersable
cap sr pel cápsula con pellet de liberación sostenida
cap w/dev cápsula con dispositivo
cap.sa 24h cápsula de acción sostenida por 24 horas
cap.sr 12h cápsula de liberación sostenida por 12 horas
cap.sr 24h cápsula de liberación sostenida por 24 horas
cap24h pel cápsula con pellets de liberación sostenida por 24 horas
capsule cr cápsula, liberación controlada
capsule dr cápsula, liberación lenta
capsule sa cápsula, acción sostenida
combo. pkg paquete combinado
cpmp 12hr cápsula, multifásico, 12 horas
cpmp 24hr cápsula, multifásico, 24 horas
cpmp 30-70 cápsula, multifásico, 30%-70%
cpmp 50-50 cápsula, multifásico, 50%-50%
cream(gm) crema (gramos)
cream/appl crema con aplicador
crm sr(gm) crema de liberación sostenida (gramos)
dehp fr bg bolsa libre de di(etilhexil) ftalato
dis needle aguja, descartable
disk w/dev disco con dispositivo de inhalación
disp syrin jeringa descartable
drop recon gotas, reconstituidas
drops susp gotas, suspensión
emul packt paquete de emulsión
foam/appl. aerosol, espuma con aplicador
froz.piggy intravenosa en Y congelada
g gramo
gel (gm) gel (gramos)
gel md pmp gel en bomba de dosis fijas
gel (ml) gel (mililitros)
gel w/appl gel con aplicador
gel/pf app gel con aplicador prellenado
gran pack gránulos en paquete
7

ABREVIATURAS DE EFECTIVIDAD Y PRESENTACIÓN DEL MEDICAMENTO
ABREVIATURA DESCRIPCIÓN
hfa aer ad adaptador de aerosol hfa
infus. btl infusión en botella
insuln pen pluma de insulina
irrig soln solución para irrigación
iv soln. solución intravenosa
jel jalea
kt crm cs kit, crema corticosteroide
kt oint cs kit, ungüento corticosteroide
kt tpsp cc kit, suspensión tópica y crema complementaria
lozenge hd losange unido a una manija
m.ht patch parche medicado calentador
mcg microgramo
med. pad apósito medicado
med. swab hisopo medicado
med. tape cinta medicada
mg miligramo
ml mililitro
muc sr 12h sistema mucoadhesivo, 12 horas de liberación sostenida
oint.(gm) ungüento (gramos)
oral conc. concentrado oral
oral susp suspensión oral
paste (gm) pasta (gramos)
patch td24 parche, transdérmico 24 horas
patch td72 parche, transdérmico 72 horas
patch tdsw parche, transdérmico dos veces por semana
patch tdwk parche, transdérmico semanal
pca syring analgésico en jeringa controlado por el paciente
pca vial analgésico en vial controlado por el paciente
pe/2 fenitoína sódica en unidades equivalentes por vial de 2 mililitros
pe/10 fenitoína sódica en unidades equivalentes por vial de 10 mililitros
pen ij kit kit lapicera inyectora
pen injctr lapicera inyectora
pggybk btl botella de intravenosa en Y
powd pack polvo en paquete
sol/pf app solución con aplicador prellenado
sol-gel solución para formar gel
soln recon solución , reconstituida, oral
spray susp spray, suspensión
supp.rect supositorio, rectal
supp.vag supositorio, rectal
sus mc rec suspensión, microcápsula reconstituida
sus sr rec suspensión, liberación sostenida, reconstituida
8

ABREVIATURAS DE EFECTIVIDAD Y PRESENTACIÓN DEL MEDICAMENTO
ABREVIATURA DESCRIPCIÓN
suspdr pkt suspensión, paquete de libreación lenta
susp recon suspensión, reconstituida
syringekit kit de jeringa
tab chew comprimido masticable
tab disper comprimido dispersable
tab ds pk comprimido, paquete de dosis
tab er2 24 comprimido, liberación extendida 24 horas (2)
tab mphase comprimido, multifásico
tab osm 24 comprimido, osmótico 24 horas
tab part comprimido, partículas
tab prt sr comprimido, partículas de liberación sostenida
tab rap dr comprimido, desintegración rápida, liberación lenta
tab rapdis comprimido, desintegración rápida
tab subl comprimido sublingual
tab.sr 12h comprimido, liberación sostenida, 12 horas
tab.sr 24h comprimido, liberación sostenida, 24 horas
tablet dr comprimido, liberación lenta
tablet eff comprimido efervescente
tablet sa comprimido, acción sostenida
tablet sol comprimido, soluble
tabsrgr24h comprimidos de libreación regular 24 horas
tbdspk 3mo comprimido, paquete de dosis, 3 meses
tbmp 12hr comprimido, multifásico, 12 horas
tbmp 24hr comprimido, multifásico, 24 horas
u unidad
vag ring anillo vaginal
9

Drug Name
Acidifying and Alkalinizing Agents
Acidifying and Alkalinizing Agents
Drug
Tier
ammonium chloride (Ammonium Chloride) 1
citric acid/sodium citrate (Bicitra) 1
K-PHOS M.F. 2
K-PHOS NO.2 2
phosphorus #1 (K-phos Neutral) 1
potassium citrate (Urocit-K) 1
potassium citrate/citric
acid
(Polycitra-k) 1
sod/pot/k cit/sod cit/cit (Polycitra-lc) 1
acid
Requirements/Limits
sodium bicarbonate (Sodium Bicarbonate) 1 disp syrin: 0.5meq/
ml; iv soln., vial
sodium bicarbonate (Sodium Bicarbonate) 1 disp syrin: 0.9meq/
ml, 1meq/ml
sodium lactate
Adrenals
Adrenals
(Sodium Lactate) 1 vial
ADVAIR DISKUS 2 QL: 62 in
31 days
ADVAIR HFA 2 QL: 12 in
28 days
betamet acet/betamet na (Celestone) 1 PA
ph
budesonide (Entocort EC) 1 capdr & er
cortisone acetate (Cortisone Acetate) 1 PA
DEPO-MEDROL 2 PA vial: 20mg/ml
dexamethasone sod
phosphate
(Dexamethasone Sod Phosphate) 1 PA vial: 10mg/ml
dexamethasone sod (Dexamethasone Sod Phosphate) 1 PA vial: 4mg/ml
phosphate
dexamethasone (Dexamethasone) 1 PA elixir, tablet
dexamethasone (Dexpak) 1 PA tab ds pk
DULERA 2 QL: 13 in
28 days
FLOVENT DISKUS 2 QL: 120
in 30
days
disk w/dev: 250mcg
10
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
FLOVENT DISKUS 2 QL: 60 in disk w/dev: 50mcg,
30 days 100mcg
FLOVENT HFA 2 QL: 12 in aer w/adap: 110mcg
28 days
FLOVENT HFA 2 QL: 21.2
in 28
days
aer w/adap: 44mcg
FLOVENT HFA 2 QL: 24 in aer w/adap: 220mcg
28 days
fludrocortisone acetate (Florinef Acetate) 1
hydrocortisone sod
succinate
(Hydrocortisone Sod Succinate) 1 PA vial: 100mg
hydrocortisone (Cortef) 1 PA
methylprednisolone
acetate
(Depo-medrol) 1 PA
methylprednisolone sod
succ
(Solu-medrol) 1 PA
methylprednisolone (Medrol) 1 PA
prednisolone acetate (Prednisolone Acetate) 1 PA
prednisolone sod
phosphate
(Orapred) 1 PA
prednisolone (Prednisolone) 1 PA
PREDNISONE
INTENSOL
3 PA
prednisone (Prednisone) 1 PA solution, tablet
prednisone (Prednisone) 1 PA tab ds pk
QVAR 2 QL: 17.4
in 25
days
SOLU-MEDROL 2 PA vial: 2g
SYMBICORT 2 QL: 11 in
25 days
triamcinolone acetonide (Kenalog-40) 1 PA
VERIPRED 20 1 PA
Adrenocortical Insufficiency
Adrenocortical Insufficiency
ACTHAR H.P. 2 PA, QL:
45 in 28
days
11
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Alpha-Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
Drug
Tier
Requirements/Limits
doxazosin mesylate (Cardura) 1
prazosin hcl (Minipress) 1
terazosin hcl
Ammonia Detoxicants
(Hytrin) 1
Ammonia Detoxicants
BUPHENYL 2
CARBAGLU 2
lactulose (Lactulose) 1 solution
lactulose (Lactulose) 1 syrup
LITHOSTAT 2
Analgesics and Antipyretics
Analgesics And Antipyretics, Miscellaneous
acetaminophen/phenyltolx
cit
(Staflex) 1 tablet: 500mg-
30mg, 500mg-
50mg, 650mg-
50mg, 650mg-60mg
(Durabac Forte) 1
mg sal/acetaminophn/ptlox/caf
OFIRMEV 3
sal-amide/acetamin/p-tlox/
caff
(Durabac) 1
sal-amide/acetaminophn/
p-tlox
(Asp) 1
salicylamide/
acetaminophen
(Salicylamide/acetaminophen) 1
Nonsteroidal Anti-inflammatory Agents
aspirin (Easprin) 1
CALDOLOR 3
CELEBREX 2 ST, QL:
62 in 31
days
choline sal/mag salicylate (Choline Sal/mag Salicylate) 1
diclofenac potassium (Cataflam) 1
diclofenac sodium (Voltaren) 1
diflunisal (Diflunisal) 1
etodolac (Etodolac) 1
fenoprofen calcium (Fenoprofen Calcium) 1
flurbiprofen (Ansaid) 1
12
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
ibuprofen (Motrin) 1
INDOCIN 2 oral susp
indomethacin sodium
trihydrate
(Indocin I.v.) 1
indomethacin (Indomethacin) 1
ketoprofen (Ketoprofen) 1
ketorolac tromethamine (Ketorolac Tromethamine) 1 QL: 40 in vial: 15mg/ml
31 days
ketorolac tromethamine (Toradol) 1 QL: 20 in cartridge: 30mg/ml
31 days
ketorolac tromethamine (Toradol) 1 QL: 20 in tablet, vial: 60mg/
31 days 2ml
ketorolac tromethamine (Toradol) 1 QL: 40 in cartridge: 15mg/ml
31 days
magnesium salicylate (Novasal) 1
meclofenamate sodium (Meclofenamate Sodium) 1
mefenamic acid (Ponstel) 1
meloxicam (Mobic) 1
methyl salicylate (Methyl Salicylate) 1
nabumetone (Relafen) 1
naproxen sodium (Anaprox) 1
naproxen (Naprosyn) 1
oxaprozin (Daypro) 1
phenylbutazone (Phenylbutazone) 1
piroxicam (Feldene) 1
salsalate (Salflex) 1
sulindac (Clinoril) 1
tolmetin sodium (Tolmetin Sodium) 1
VIMOVO 2 ST
VOLTAREN
Opiate Agonists
2 ST gel (gram)
acetaminophen with (Tylenol-codeine No.3) 1 tablet: 300mgcodeine
15mg, 300mg-
30mg, 300mg-60mg
acetaminophen with (Tylenol-codeine No.3) 1 tablet: 650mgcodeine
30mg, 650mg-60mg
ASTRAMORPH-PF 1
codeine phos/
acetaminophen
(Codeine Phos/acetaminophen) 1
codeine phosphate (Codeine Phosphate) 1
codeine sulf (Codeine Sulf) 1
13
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
codeine/butalbit/acetamin/
caff
(Fioricet with Codeine) 1
codeine/butalbital/asa/
caffein
(Fiorinal with Codeine #3) 1
dhcodeine bt/
(Dhcodeine Bt/acetaminophn/ 1 capsule
acetaminophn/caff caff)
dhcodeine bt/
acetaminophn/caff
(Panlor SS) 1 tablet
fentanyl citrate (Actiq) 2 PA, QL:
120 in 30
days
fentanyl (Duragesic) 1 PA, QL: patch td72: 12mcg/
10 in 30 hr, 25mcg/hr,
days 50mcg/hr, 75mcg/hr
fentanyl (Duragesic) 1 PA, QL: patch td72: 100mcg/
20 in 30
days
hr
hydrocodone bit/ (Vicodin) 1 capsule, solution:
acetaminophen
7.5-325/15, 7.5-500/
15; tablet
hydrocodone bit/ (Zamicet) 1 solution: 10-300/15,
acetaminophen
10-325/cup
hydrocodone/ibuprofen (Vicoprofen) 1
hydromorphone hcl (Dilaudid) 1 tablet
hydromorphone hcl (Dilaudid) 1 vial
hydromorphone hcl/pf (Dilaudid) 1 ampul: 10mg/ml
hydromorphone hcl/pf (Hydromorphone HCl/PF) 1 ampul: 4mg/ml;
disp syrin
ibuprofen/oxycodone hcl (Combunox) 1
KADIAN 2 ST, QL:
120 in 30
days
cap er pel: 200mg
KADIAN 2 ST, QL:
60 in 30
days
cap er pel: 10mg
levorphanol tartrate (Levo-dromoran) 1
meperidine hcl (Demerol) 1
meperidine hcl/pf (Meperidine HCl/PF) 1 vial: 25mg/ml,
50mg/ml, 100mg/ml
meperidine hcl/pf (Meperidine HCl/PF) 1 vial: 75mg/ml
14
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
methadone hcl (Methadose) 1 oral conc, solution,
tablet, vial
methadone hcl (Methadose) 1 tablet sol
morphine sulfate in 0.9 % (Morphine Sulfate In 0.9 % 1
nacl
NaCl)
morphine sulfate (Kadian) 1 ST, QL: cap er pel: 20mg,
60 in 30 30mg, 50mg, 60mg,
days 80mg
morphine sulfate (Kadian) 2 ST, QL:
60 in 30
days
cap er pel: 100mg
morphine sulfate (Morphine Sulfate) 1 ampul, disp syrin,
pen injctr, supp.rect,
vial
morphine sulfate (MS Contin) 1 solution, tablet,
tablet er
morphine sulfate/0.9% (Morphine Sulfate/0.9% Nacl/ 1
nacl/pf
PF)
morphine sulfate/d5w (Morphine Sulfate/D5W) 1
morphine sulfate/pf (Morphine Sulfate/PF) 1 pca vial, vial:
0.5mg/ml, 1mg/ml
morphine sulfate/pf (Morphine Sulfate/PF) 1 vial: 25mg/ml
NUCYNTA ER 2 QL: 60 in
30 days
NUCYNTA 2 QL: 181
in 30
days
opium/belladonna
alkaloids
(B & O Supprettes No.15-a) 1
oxycodone hcl (Oxycodone HCl) 1 QL: 124
in 31
days
tab er 12h: 80mg
oxycodone hcl (Oxycodone HCl) 1 QL: 93 in tab er 12h: 10mg,
31 days 20mg, 40mg
oxycodone hcl (Roxicodone) 1 capsule, oral conc,
tablet: 5mg, 15mg,
30mg
oxycodone hcl (Roxicodone) 1 solution, tablet:
10mg, 20mg
oxycodone hcl/
acetaminophen
(Percocet) 1
15
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
oxycodone hcl/aspirin (Percodan) 1
oxycodone hcl/oxycodon (Oxycodone HCl/oxycodon Ter/ 1
ter/asa
asa)
OXYCONTIN 2 QL: 120 tab er 12h: 60mg,
in 30
days
80mg
OXYCONTIN 2 QL: 60 in tab er 12h: 10mg,
30 days 15mg, 20mg, 30mg,
40mg
oxymorphone hcl (Opana) 1
tramadol hcl (Ultram) 1 tab er 24h, tablet
tramadol hcl/
acetaminophen
(Ultracet) 1
Opiate Partial Agonists
BUPRENEX 2
buprenorphine hcl (Subutex) 1
butorphanol tartrate (Butorphanol Tartrate) 1 disp syrin
butorphanol tartrate (Butorphanol Tartrate) 1 QL: 5 in
28 days
spray
nalbuphine hcl (Nubain) 1
pentazocine hcl/
acetaminophen
(Talacen) 1
pentazocine hcl/naloxone
hcl
(Talwin NX) 1
SUBOXONE
Androgens
Androgens
3
ANADROL-50 2
ANDRODERM 2 QL: 30 in patch td24: 2mg/
30 days 24hr, 4mg/24hr
ANDRODERM 2 QL: 30 in patch td24: 5mg/
30 days 24hr
ANDRODERM 2 QL: 60 in patch td24: 2.5mg/
30 days 24hr
ANDROGEL 2 QL: 300
in 30
days
AXIRON 2 QL: 180
in 28
days
danazol (Danocrine) 1
16
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
fluoxymesterone (Fluoxymesterone) 1
oxandrolone (Oxandrin) 1
testosterone cypionate (Depo-testosterone) 1 PA
testosterone enanthate (Delatestryl) 1 PA, QL:
5 in 28
days
testosterone (Tesamone-100) 1 PA, QL:
40 in 28
days
Anorexigenics, Respiratory, Cerebral Stimulants
Amphetamines
amphet asp/amphet/d- (Adderall XR) 1 PA, QL: cap er 24h
amphet
30 in 30
days
amphet asp/amphet/d- (Adderall) 1 PA, QL: tablet
amphet
60 in 30
days
dextroamphetamine (Dexedrine) 1 PA, QL: capsule er
sulfate
120 in 30
days
dextroamphetamine (Dextrostat) 1 PA, QL: tablet
sulfate
180 in 30
days
methamphetamine hcl (Desoxyn) 1 QL: 150
in 30
days
Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous
caffeine citrated (Cafcit) 1
caffeine/sodium benzoate (Caffeine/sodium Benzoate) 1
CONCERTA 2 PA, QL:
31 in 31
days
dexmethylphenidate hcl (Focalin) 1 PA, QL:
60 in 30
days
methylphenidate hcl (Concerta) 1 PA, QL:
31 in 31
days
tab er 24
methylphenidate hcl (Methylin) 1 PA, QL:
900 in 30
days
solution
17
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
methylphenidate hcl (Ritalin LA) 1 PA, QL: cpmp 50-50: 20mg,
30 in 30
days
40mg
methylphenidate hcl (Ritalin LA) 1 PA, QL:
60 in 30
days
cpmp 50-50: 30mg
methylphenidate hcl (Ritalin) 1 PA, QL:
90 in 30
days
tablet, tablet er
modafinil (Provigil) 1 PA, QL:
62 in 31
days
PROVIGIL
Anthelmintics
Anthelmintics
2 PA, QL:
62 in 31
days
ALBENZA 2
BILTRICIDE 2
mebendazole (Mebendazole) 1
STROMECTOL
Antiallergic Agents
2
Antiallergic Agents
ALAMAST 2 ST
ASTEPRO 2 QL: 30 in
25 days
azelastine hcl (Astelin) 1 QL: 30 in spray/pump
25 days
azelastine hcl (Optivar) 1 drops
epinastine hcl (Elestat) 1
PATADAY 2 ST
PATANOL
Antibacterials
Aminoglycosides
2 ST
amikacin sulfate (Amikacin Sulfate) 1
gentamicin in nacl, iso- (Gentamicin In Nacl, Iso-osm) 1 piggyback: 100mg/
osm
50ml
18
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
gentamicin in nacl, iso- (Gentamicin In Nacl, Iso-osm) 1 piggyback: 60mg/
osm
100ml, 70mg/50ml,
80mg/100ml, 80mg/
50ml, 90mg/100ml,
100mg/0.1l, 120mg/
0.1l
gentamicin sulfate (Garamycin) 1
gentamicin sulfate/pf (Gentamicin Sulfate/PF) 1
kanamycin sulfate (Kanamycin Sulfate) 1 vial: 1g/3ml
kanamycin sulfate (Kanamycin Sulfate) 1 vial: 500mg/2ml
neomycin sulfate (Neomycin Sulfate) 1 solution
neomycin sulfate (Neomycin Sulfate) 1 tablet
streptomycin sulfate (Streptomycin Sulfate) 1
TOBI 2 PA
tobramycin sulfate (Nebcin) 1
tobramycin/sodium
chloride
(Tobramycin/sodium Chloride) 1
Antibacterials, Miscellaneous
bacitracin (Bacitracin) 1
chloramphenicol na succ (Chloramphenicol Na Succ) 1
clindamycin hcl (Cleocin HCl) 1 capsule: 150mg,
300mg
clindamycin hcl (Cleocin HCl) 1 capsule: 75mg
clindamycin palmitate hcl (Cleocin Palmitate) 1
clindamycin phosphate (Cleocin Phosphate) 1
colistin (colistimethate na) (Coly-mycin M Parenteral) 1
CUBICIN 2 PA (PA for ESRD only)
polymyxin b sulfate (Polymyxin B Sulfate) 1
SYNERCID 2
VANCOCIN HCL 2
vancomycin hcl (Vancocin HCl) 2 capsule
vancomycin hcl (Vancomycin HCl) 1 PA vial, (PA for ESRD
only)
vancomycin hcl/d5w (Vancomycin HCl/D5W) 1
VANCOMYCIN HCL 3
VIBATIV 2
XIFAXAN 2 PA, QL:
60 in 30
days
tablet: 550mg
19
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
XIFAXAN 2 PA, QL:
9 in 30
days
tablet: 200mg
ZYVOX
Cephalosporins
2
cefaclor (Ceclor) 1 capsule, tab er 12h
cefaclor (Ceclor) 1 susp recon
cefadroxil hydrate (Cefadroxil Hydrate) 1
cefazolin sodium (Ancef) 1
cefazolin sodium/
dextrose,iso
(Cefazolin Sodium/dextrose, Iso) 1
cefdinir (Omnicef) 1
cefditoren pivoxil (Spectracef) 1
cefepime hcl (Maxipime) 1
CEFEPIME 2
CEFEPIME-DEXTROSE 2
cefotaxime sodium (Claforan) 1
cefpodoxime proxetil (Vantin) 1
cefprozil (Cefzil) 1
ceftazidime pentahydrate (Fortaz) 1 vial port: 1g
ceftazidime pentahydrate (Fortaz) 1 vial, vial port: 2g
CEFTAZIDIME 1
ceftriaxone na/
dextrose,iso
(Ceftriaxone Na/dextrose, Iso) 1
ceftriaxone sodium (Rocephin) 1
CEFTRIAXONE 1
cefuroxime axetil (Ceftin) 1
cefuroxime sodium (Zinacef) 1
cefuroxime sodium/ (Cefuroxime Sodium/dextrose, 1
dextrose,iso
Iso)
cephalexin (Keflex) 1
FORTAZ IN ISO-
OSMOTIC DEXTROSE
2
SUPRAX 3 tablet
TAZICEF IN
DEXTROSE
Macrolides
2
azithromycin hydrogen (Azithromycin Hydrogen
1
citrate
Citrate)
azithromycin (Zithromax) 1 packet
20
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
azithromycin (Zithromax) 1 susp recon, tablet,
vial
clarithromycin (Biaxin) 1
DIFICID 2 QL: 20 in
10 days
ery e-succ/sulfisoxazole (Pediazole) 1
ERY-TAB 1
ERYTHROCIN
LACTOBIONATE
2 vial
ERYTHROCIN
LACTOBIONATE
2 vial port
erythromycin base (Eryc) 1 capsule dr
erythromycin base (Erythromycin Base) 1 tablet, tablet dr
erythromycin
(Erythromycin Ethylsuccinate) 1 oral susp: 200mg/
ethylsuccinate
5ml
erythromycin
ethylsuccinate
(Erythromycin Ethylsuccinate) 1 tablet
erythromycin stearate (Erythromycin Stearate) 1 tablet: 250mg
erythromycin stearate (Erythromycin Stearate) 1 tablet: 500mg
KETEK PAK 2 ST
KETEK 2 ST
ZMAX 2
Miscellaneous B-lactam Antibiotics
aztreonam (Azactam) 1
CAYSTON 2 LA
cefotetan disod/
dextrose,iso
(Cefotetan Disod/dextrose, Iso) 1
cefotetan disodium (Cefotetan Disodium) 1
cefoxitin sodium (Mefoxin) 1
cefoxitin sodium/
dextrose,iso
(Cefoxitin Sodium/dextrose, Iso) 1
DORIBAX 2
imipenem/cilastatin
sodium
(Primaxin) 1
INVANZ 2 vial
INVANZ 2 vial port
meropenem (Merrem) 1
PRIMAXIN I.M. 2
21
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
Penicillins
amoxicillin (Amoxil) 1 capsule, susp recon,
tab chew: 125mg,
200mg, 250mg;
tablet
amoxicillin (Amoxil) 1 tab chew: 400mg
amoxicillin/potassium clav (Augmentin) 1
ampicillin sodium (Totacillin-N) 1 vial port: 2g
ampicillin sodium (Totacillin-N) 1 vial, vial port: 1g
ampicillin sodium/
sulbactam na
(Unasyn) 1 vial
ampicillin sodium/ (Unasyn) 1 vial port
sulbactam na
ampicillin trihydrate (Ampicillin Trihydrate) 1
BICILLIN C-R 2
BICILLIN L-A 2
dicloxacillin sodium (Dicloxacillin Sodium) 1
nafcillin sodium (Unipen) 1 vial
nafcillin sodium (Unipen) 1 vial port
oxacillin sodium (Oxacillin Sodium) 1
oxacillin sodium/ (Oxacillin Sodium/dextrose, Iso) 1
dextrose,iso
pen g pot/dextrose-water (Pen G Pot/dextrose-water) 1 froz.piggy: 1mm/
50ml
pen g pot/dextrose-water (Pen G Pot/dextrose-water) 1 froz.piggy: 2mm/
50ml, 3mm/50ml
penicillin g potassium (Penicillin G Potassium) 1 vial: 20mmunit
penicillin g potassium (Penicillin G Potassium) 1 vial: 5mmunit
penicillin g potassium/d5w (Penicillin G Potassium/D5W) 1
penicillin g procaine (Penicillin G Procaine) 1 disp syrin: 1.2mm/
2ml
penicillin g procaine (Penicillin G Procaine) 1 disp syrin: 600000/
ml
PENICILLIN G SODIUM 1
penicillin v potassium (Veetids 500) 1
piperacillin sodium (Piperacillin Sodium) 1
piperacillin sodium/
tazobactam
(Zosyn) 1
ZOSYN
Quinolones
3 froz.piggy
AVELOX ABC PACK 2
22
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
AVELOX IV 2
AVELOX 2
ciprofloxacin hcl (Cipro) 1
ciprofloxacin lactate (Cipro I.V.) 1
ciprofloxacin lactate/d5w (Cipro I.V.) 1
ciprofloxacin/ciprofloxa
hcl
(Cipro XR) 1
levofloxacin (Levaquin) 1
levofloxacin/dextrose 5%water
(Levaquin) 1
nalidixic acid (Nalidixic Acid) 1
ofloxacin (Floxin) 1
Sulfonamides (Systemic)
sulfadiazine (Sulfadiazine) 1
sulfamethoxazole/
trimethoprim
(Bactrim DS) 1
sulfasalazine
Tetracyclines
(Azulfidine) 1
demeclocycline hcl (Declomycin) 1
doxycycline hyclate (Morgidox) 1
doxycycline monohydrate (Adoxa) 1 capsule: 150mg
doxycycline monohydrate (Adoxa) 1 capsule: 75mg;
tablet
MINOCIN 2 vial
minocycline hcl (Dynacin) 1
tetracycline hcl (Ala-tet) 1 capsule
tetracycline hcl (Tetracycline HCl) 1 oral susp
TYGACIL 2
VIBRAMYCIN 2 syrup
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine sulfate (Atropine Sulfate) 1 ampul, tablet, vial
atropine sulfate (Atropine Sulfate) 1 disp syrin
ATROVENT HFA 2 QL: 25.8
in 28
days
CANTIL 2
dicyclomine hcl (Bentyl) 1
glycopyrrolate (Robinul) 1
hyoscyamine sulfate (Levsin-sl) 1
23
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
isopropamide/
prochlorperazine
(Isopropamide/prochlorperazine) 1
methscopolamine bromide (Pamine) 1
propantheline bromide (Propantheline Bromide) 1
propantheline/
phenobarbital
(Propantheline/phenobarbital) 1
scopolamine
hydrobromide
(Scopolamine Hydrobromide) 1
SPIRIVA
Anticonvulsants
2 QL: 30 in
30 days
Anticonvulsants, Miscellaneous
BANZEL 3 ST
carbamazepine (Tegretol) 1
divalproex sodium (Depakote ER) 1
felbamate (Felbatol) 1
gabapentin (Neurontin) 1
GABITRIL 2
lamotrigine (Lamictal) 1 tablet, tb chw dsp
lamotrigine (Lamotrigine) 1 tab ds pk
levetiracetam in nacl (isoos)
(Levetiracetam In Nacl (iso-os)) 1
levetiracetam (Keppra) 1
LYRICA 2 QL: 93 in
31 days
magnesium chloride (Magnesium Chloride) 1
magnesium sulfate (Magnesium Sulfate) 1 disp syrin, infus. btl,
piggyback
magnesium sulfate (Magnesium Sulfate) 1 vial
magnesium sulfate/d5w (Magnesium Sulfate/D5W) 1 piggyback
magnesium sulfate/d5w (Magnesium Sulfate/D5W) 1 plast. bag
oxcarbazepine (Trileptal) 1
primidone (Mysoline) 1
SABRIL 2
TEGRETOL XR 2 tab er 12h: 100mg
topiramate (Topamax) 1
valproate sodium (Depakene) 1
valproic acid (Depakene) 1
24
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
VIMPAT 3 ST, QL:
1200 in
30 days
solution
VIMPAT 3 ST, QL:
200 in 5
days
vial
VIMPAT 3 ST, QL:
60 in 30
days
tablet
zonisamide
Hydantoins
(Zonegran) 1
DILANTIN 2 capsule: 30mg
DILANTIN 2 tab chew
fosphenytoin sodium (Cerebyx) 1
PEGANONE 2
PHENYTEK 2
phenytoin sodium
extended
(Dilantin) 1
phenytoin sodium (Phenytoin Sodium) 1 disp syrin
phenytoin sodium (Phenytoin Sodium) 1 vial
phenytoin
Succinimides
(Dilantin-125) 1
CELONTIN 2
ethosuximide
Antidiabetic Agents
(Zarontin) 1
Antidiabetic Agents, Miscellaneous
acarbose (Precose) 1 QL: 90 in
30 days
BYETTA 2 PA, QL: pen injctr: 5mcg/
1.2 in 28
days
0.02
BYETTA 2 PA, QL: pen injctr: 10mcg/
2.4 in 28
days
0.04
GLYSET 3 QL: 90 in
30 days
JANUMET XR 2 ST, QL: tbmp 24hr: 50mg-
30 in 30 500mg, 100days
1000mg
25
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
JANUMET XR 2 ST, QL: tbmp 24hr: 50-
60 in 30
days
1000mg
JANUMET 2 ST, QL:
60 in 30
days
JANUVIA 2 ST, QL:
30 in 30
days
JENTADUETO 2 ST, QL:
60 in 30
days
JUVISYNC 2 ST, QL:
30 in 30
days
KOMBIGLYZE XR 2 ST, QL:
30 in 30
days
metformin hcl (Fortamet) 1 QL: 60 in tab er 24
30 days
metformin hcl (Glucophage) 1 QL: 120 tab er 24h: 500mg;
in 30
days
tablet: 500mg
metformin hcl (Glucophage) 1 QL: 60 in tablet: 1000mg
30 days
metformin hcl (Glucophage) 1 QL: 90 in tab er 24h: 750mg;
30 days tablet: 850mg
nateglinide (Starlix) 1 QL: 90 in
30 days
ONGLYZA 2 ST, QL:
30 in 30
days
PRANDIMET 2 ST, QL:
150 in 30
days
PRANDIN 2 ST, QL:
240 in 30
days
SYMLIN 2 PA, QL:
20 in 28
days
26
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
SYMLINPEN 120 2 PA, QL:
5.4 in 28
days
SYMLINPEN 60 2 PA, QL:
3 in 28
days
TRADJENTA 2 ST, QL:
30 in 30
days
VICTOZA 3-PAK
Insulins
2 PA, QL:
9 in 28
days
HUMALOG MIX 50-50 2 QL: 30 in insuln pen
28 days
HUMALOG MIX 50-50 2 QL: 40 in vial
28 days
HUMALOG MIX 75-25 2 QL: 30 in insuln pen
28 days
HUMALOG MIX 75-25 2 QL: 40 in vial
28 days
HUMALOG 2 QL: 30 in insuln pen
28 days
HUMALOG 2 QL: 40 in vial
28 days
HUMULIN 50-50 2 QL: 40 in
28 days
HUMULIN 70-30 2 QL: 30 in insuln pen
28 days
HUMULIN 70-30 2 QL: 40 in vial
28 days
HUMULIN N 2 QL: 30 in insuln pen
28 days
HUMULIN N 2 QL: 40 in vial
28 days
HUMULIN R 2 QL: 40 in
28 days
LANTUS SOLOSTAR 2 QL: 30 in
28 days
LANTUS 2 QL: 40 in
28 days
27
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
LEVEMIR 2 ST, QL:
30 in 28
days
insuln pen
LEVEMIR 2 ST, QL:
40 in 28
days
vial
NOVOLIN 70-30
2 QL: 30 in
INNOLET
28 days
NOVOLIN 70-30 2 QL: 40 in
28 days
NOVOLIN N INNOLET 2 QL: 30 in
28 days
NOVOLIN N 2 QL: 40 in
28 days
NOVOLIN R 2 QL: 30 in insuln pen
28 days
NOVOLIN R 2 QL: 40 in vial
28 days
NOVOLOG MIX 70-30 2 QL: 30 in insuln pen
28 days
NOVOLOG MIX 70-30 2 QL: 40 in vial
28 days
NOVOLOG 2 QL: 30 in insuln pen
28 days
NOVOLOG
Sulfonylureas
2 QL: 40 in vial
28 days
chlorpropamide (Diabinese) 1 QL: 225
in 30
days
tablet: 100mg
chlorpropamide (Diabinese) 1 QL: 90 in tablet: 250mg
30 days
glimepiride (Amaryl) 1 QL: 30 in tablet: 1mg, 2mg
30 days
glimepiride (Amaryl) 1 QL: 60 in tablet: 4mg
30 days
glipizide (Glucotrol XL) 1 QL: 30 in tab er 24: 2.5mg,
30 days 5mg
glipizide (Glucotrol) 1 QL: 120
in 30
days
tablet: 10mg
28
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
glipizide (Glucotrol) 1 QL: 60 in tab er 24: 10mg;
30 days tablet: 5mg
glipizide/metformin hcl (Metaglip) 1 QL: 120 tablet: 2.5-500mg,
in 30
days
5mg-500mg
glipizide/metformin hcl (Metaglip) 1 QL: 60 in tablet: 2.5-250mg
30 days
glyburide (Micronase) 1 QL: 120
in 30
days
tablet: 5mg
glyburide (Micronase) 1 QL: 30 in tablet: 1.25mg,
30 days 2.5mg
glyburide,micronized (Glynase) 1 QL: 30 in tablet: 1.5mg, 3mg
30 days
glyburide,micronized (Glynase) 1 QL: 60 in tablet: 6mg
30 days
glyburide/metformin hcl (Glucovance) 1 QL: 120 tablet: 2.5-500mg,
in 30
days
5mg-500mg
glyburide/metformin hcl (Glucovance) 1 QL: 60 in tablet: 1.25-250mg
30 days
tolazamide (Tolazamide) 1 QL: 120
in 30
days
tablet: 250mg
tolazamide (Tolazamide) 1 QL: 60 in tablet: 500mg
30 days
tolbutamide
Thiazolidinediones
(Tolbutamide) 1 QL: 180
in 30
days
ACTOPLUS MET XR 2 ST, QL:
60 in 30
days
ACTOPLUS MET 2 ST, QL:
90 in 30
days
ACTOS 2 ST, QL:
30 in 30
days
29
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
AVANDAMET 2 ST, QL:
60 in 30
days
AVANDARYL 2 ST, QL:
30 in 30
days
AVANDIA 2 ST, QL:
30 in 30
days
DUETACT 2 ST, QL:
30 in 30
days
Antidiarrhea Agents
Antidiarrhea Agents
diphenoxylate hcl/atropine (Lomotil) 1
loperamide hcl (Loperamide HCl) 1
opium (Opium) 1
paregoric
Antiemetics
(Paregoric) 1
5-ht3 Receptor Antagonists
granisetron hcl (Kytril) 1 vial
granisetron hcl (Kytril) 1 PA solution, tablet
granisetron hcl/pf (Kytril) 1
ondansetron hcl (Zofran) 1 vial
ondansetron hcl (Zofran) 1 PA solution, tablet
ondansetron in 0.9 %
nacl/pf
(Ondansetron In 0.9 % Nacl/PF) 1
ondansetron (Zofran Odt) 1 PA
Antiemetics, Miscellaneous
CESAMET 3
dronabinol (Marinol) 1
EMEND 2 PA, QL: capsule: 40mg,
1 per fill 125mg
EMEND 2 PA, QL:
2 per fill
capsule: 80mg
EMEND 2 PA, QL:
3 per fill
cap ds pk
EMEND 2 QL: 2 in
28 days
vial
30
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
scopolamine
hydrobromide
(Scopolamine Hydrobromide) 1
Antihistamines (GI Drugs)
ANTIVERT 2 tablet: 50mg
dimenhydrinate (Dimenhydrinate) 1
meclizine hcl (Antivert) 1
prochlorperazine edisylate (Compazine) 1
prochlorperazine maleate (Compazine) 1
trimethobenzamide hcl
Antifungal (Systemic)
(Tigan) 1
Antifungals, Miscellaneous
ABELCET 2 PA
AMBISOME 2 PA
AMPHOTEC 2 PA
amphotericin b (Amphotericin B) 1 PA
flucytosine (Ancobon) 2
griseofulvin,microsize (Grifulvin V) 1
GRIS-PEG 3
nystatin (Nystatin) 1 oral susp, tablet
nystatin (Nystatin) 1 powder
terbinafine hcl (Lamisil) 1
triacetin
Azoles
(Triacetin) 1
fluconazole in nacl,isoosm
(Diflucan in Saline) 1
fluconazole (Diflucan) 1
itraconazole (Sporanox) 1
ketoconazole (Nizoral) 1
NOXAFIL 2
SPORANOX 2 solution
VFEND IV 2
VFEND 2 susp recon
voriconazole
Echinocandins
(Vfend) 2
CANCIDAS 2
ERAXIS (WATER
DILUENT)
Antiglaucoma Agents
2
Antiglaucoma Agents
acetazolamide sodium (Acetazolamide Sodium) 1
31
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
acetazolamide (Acetazolamide) 1
ALPHAGAN P 2 drops: 0.1%
AZOPT 2
betaxolol hcl (Betaxolol HCl) 1
BETIMOL 2 ST
brimonidine tartrate (Alphagan P) 1
COMBIGAN 2
dorzolamide hcl (Trusopt) 1
dorzolamide hcl/timolol
maleat
(Cosopt) 1
ISOPTO CARPINE 2 drops: 8%
ISTALOL 2
latanoprost (Xalatan) 1
levobunolol hcl (Betagan) 1
LUMIGAN 2 QL: 2.5
in 25
days
methazolamide (Neptazane) 1
metipranolol (Optipranolol) 1
PHOSPHOLINE IODIDE 3
pilocarpine hcl (Isopto Carpine) 1
PILOPINE HS 3
timolol maleate (Timoptic) 1
TRAVATAN Z 2 QL: 2.5
in 25
days
Anti-infectives (EENT)
Anti-infectives (EENT)
acetic acid (Vosol) 1
acetic acid/aluminum
acetate
(Domeboro) 1
acetic acid/hydrocortisone (Vosol HC) 1
bacitracin (Bacitracin) 1
bacitracin/polymyxin b
sulfate
(Polycin-b) 1
BLEPHAMIDE S.O.P. 2
BLEPHAMIDE 2
chlorhexidine gluconate (Peridex) 1
CIPRO HC 2
CIPRODEX 2
32
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
ciprofloxacin hcl (Ciloxan) 1
COLY-MYCIN S 2
CORTISPORIN-TC 2
cresyl ace/ben alc/
butanol/ipa
(Cresyl Ace/ben Alc/butanol/ipa) 1
doxycycline hyclate (Periostat) 1
erythromycin base (Ilotycin) 1
gentamicin sulfate (Garamycin) 1
levofloxacin (Quixin) 1
MOXEZA 2
NATACYN 2
neo/polymyx b sulf/
dexameth
(Maxitrol) 1
neomy sulf/bacitra/
polymyxin b
(Neo-polycin) 1
neomy sulf/bacitrac zn/
poly/hc
(Triple Antibiotic HC) 1
neomycin sulfate/dex na
ph
(Neomycin Sulfate/dex Na Ph) 1
neomycin/polymyxin b
sulf/hc
(Oticin HC) 1
neomycin/polymyxn b/
gramicidin
(Neosporin) 1
ofloxacin (Ocuflox) 1
polymyxin b sulfate/tmp (Polytrim) 1
POLY-PRED 2
sulfacetamide sodium (Sulfac) 1
sulfacetamide/
prednisolone sp
(Sulfacetamide/prednisolone Sp) 1
tobramycin sulf/
dexamethasone
(Tobradex) 1
tobramycin sulfate (Tobrex) 1
trifluridine (Viroptic) 1
VIGAMOX 2
ZYLET 2
ZYMAR 2
ZYMAXID 2
Requirements/Limits
33
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Anti-infectives (Skin and Mucous Membrane)
Antibacterials (Skin and Mucous Membrane)
Drug
Tier
Requirements/Limits
clindamycin phos/benzoyl
perox
(Benzaclin) 1
clindamycin phosphate (Cleocin T) 1
erythromycin base/ethanol (Emgel) 1
erythromycin/benzoyl
peroxide
(Benzamycin) 1
gentamicin sulfate (Gentamicin Sulfate) 1
metronidazole (Metrocream) 1
mupirocin (Bactroban) 1
neomy sulf/polymyxin b
sulfate
(Neosporin G.U. Irrigant) 1
Antifungals (Skin and Mucous Membrane)
ciclopirox olamine (Loprox) 1
ciclopirox (Penlac) 1
clotrimazole (Mycelex) 1
clotrimazole/
betamethasone dip
(Lotrisone) 1
econazole nitrate (Spectazole) 1
EXELDERM 2
GYNAZOLE-1 2
ketoconazole (Kuric) 1
LAMISIL 2
miconazole nitrate (Monistat 3) 1
NAFTIN 2 cream (g): 1%; gel
(gram)
NAFTIN 2 cream (g): 2%
nystatin (Mycostatin) 1 cream (g), oint. (g),
powder
nystatin (Nystatin) 1 tablet
nystatin/triamcin (Mycogen II) 1
sod propionate/inosi/aa14/
urea
(Sod Propionate/inosi/aa14/urea) 1
sodium thiosulfate/sal acid (Sodium Thiosulfate/sal Acid) 1
terconazole (Terazol 7) 1
Antivirals (Skin and Mucous Membrane)
DENAVIR 2
ZOVIRAX 2 QL: 10
per fill
cream (g)
34
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
ZOVIRAX 2 QL: 30
per fill
oint. (g)
Local Anti-infectives, Miscellaneous
acetic ac/ricinoleic/
oxyquinol
(Acetic Ac/ricinoleic/oxyquinol) 1
alcohol antiseptic pads (Alcohol Antiseptic Pads) 1
AVC 2
selenium sulfide (Selenium Sulfide) 1 suspension
selenium sulfide (Selseb) 1 shampoo
silver nitrate (Silver Nitrate) 1
silver sulfadiazine (Thermazene) 1 cream (g): 1%
sulfacetamide sodium (Klaron) 1
Scabicides and Pediculicides
EURAX 2
lindane (Lindane) 1
malathion (Ovide) 1
permethrin (Elimite) 1
Anti-infectives (systemic), Miscellaneous
Anti-infectives (systemic), Miscellaneous
FUROXONE 2
Anti-inflammatory Agents (EENT)
Anti-inflammatory Agents (EENT)
ALREX 2
BROMDAY 2
bromfenac sodium (Bromfenac Sodium) 1
dexamethasone sod
phosphate
(Ak-dex) 1
diclofenac sodium (Voltaren) 1
DUREZOL 2
flunisolide (Nasarel) 1 QL: 25 in
25 days
fluocinolone acetonide oil (Dermotic) 1
fluorometholone (Fluorometholone) 1
flurbiprofen sodium (Ocufen) 1
fluticasone propionate (Flonase) 1 QL: 16 in
30 days
ketorolac tromethamine (Acular LS) 1
LOTEMAX 2
NASONEX 2 QL: 34 in
28 days
35
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
NEVANAC 2
prednisolone acetate (Pred Forte) 1
prednisolone sod
phosphate
(Prednisol) 1
RESTASIS 3 PA, QL:
64 in 31
days
triamcinolone acetonide (Nasacort Aq) 1 QL: 16.5
in 30
days
Anti-inflammatory Agents (GI Drugs)
Anti-inflammatory Agents (GI Drugs)
APRISO 3
ASACOL HD 2
ASACOL 3
balsalazide disodium (Colazal) 1
DIPENTUM 2
mesalamine (Rowasa) 1
PENTASA 3
Anti-inflammatory Agents (Respiratory)
Anti-inflammatory Agents (Respiratory)
cromolyn sodium (Cromolyn Sodium) 1 drops, solution
cromolyn sodium (Intal) 1 PA ampul-neb
SINGULAIR 2
zafirlukast (Accolate) 1
ZYFLO CR 2
ZYFLO 2
Anti-inflammatory Agents (Skin and Mucous)
Anti-inflammatory Agents (Skin and Mucous)
alclometasone
dipropionate
(Aclovate) 1
amcinonide (Amcinonide) 1
APEXICON E 3
betamet diprop/prop gly (Diprolene AF) 1
betamethasone
dipropionate
(Betamethasone Dipropionate) 1 gel (gram)
betamethasone
(Del-beta) 1 cream (g), lotion,
dipropionate
oint. (g)
betamethasone valerate (Betamethasone Valerate) 1
clobetasol propionate (Temovate) 1
36
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
CLODERM 3
CORDRAN SP 3
CORDRAN 3 lotion, med. tape
CORDRAN 3 oint. (g)
CUTIVATE 3 lotion
desonide (Desowen) 1 cream (g), lotion,
oint. (g): 0.05%
desoximetasone (Topicort) 1 cream (g), gel
(gram), oint. (g):
0.25%
desoximetasone (Topicort) 1 oint. (g): 0.05%
diflorasone diacetate (Psorcon) 1
fluocinolone acetonide (Synalar) 1 cream (g): 0.01%
fluocinolone acetonide (Synalar) 1 cream (g): 0.025%;
cream(gm), oint.
(g), solution
fluocinolone/shower cap (Derma-smoothe-fs) 1
fluocinonide (Lidex) 1
fluticasone propionate (Cutivate) 1
halobetasol propionate (Ultravate) 1
hydrocortisone acetate (Hydrocortisone Acetate) 1
hydrocortisone acetate/
aloe v
(Nuzon) 1
hydrocortisone acetate/
urea
(Carmol HC) 1
hydrocortisone butyrate (Locoid) 1
hydrocortisone valerate (Westcort) 1
hydrocortisone (Anusol-HC) 1
mometasone furoate (Elocon) 1
prednicarbate (Dermatop) 1
triamcinolone acetonide (Triamcinolone Acetonide) 1 cream
triamcinolone acetonide
Antilipemic Agents
(Triamcinolone Acetonide) 1 cream (g), lotion,
oint. (g), paste (g)
Antilipemic Agents, Miscellaneous
LOVAZA 2
niacin (Niacin) 1 tablet: 500mg
NIASPAN 2
ZETIA 3
37
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Bile Acid Sequestrants
Drug
Tier
Requirements/Limits
cholestyramine (with
sugar)
(Questran) 1
cholestyramine/aspartame (Questran Light) 1
colestipol hcl (Colestid) 1
WELCHOL 2
Fibric Acid Derivatives
fenofibrate (Lofibra) 1
fenofibrate,micronized (Lofibra) 1
fenofibric acid (Fibricor) 1
gemfibrozil (Lopid) 1
LIPOFEN 2
TRICOR 2
TRILIPIX 2
HMG-CoA Reductase Inhibitors
amlodipine/atorvastatin (Caduet) 1
atorvastatin calcium (Lipitor) 1
CRESTOR 2
fluvastatin sodium (Lescol) 1
lovastatin (Mevacor) 1
pravastatin sodium (Pravachol) 1
simvastatin
Antimigraine Agents
(Zocor) 1
Selective Serotonin Agonists
MAXALT MLT 2 ST, QL:
18 in 28
days
MAXALT 2 ST, QL:
18 in 28
days
naratriptan hcl (Amerge) 1 QL: 9 in
28 days
RELPAX 3 ST, QL:
6 in 28
days
sumatriptan succinate (Imitrex) 1 QL: 4 in
28 days
cartridge, vial
sumatriptan succinate (Imitrex) 1 QL: 9 in
28 days
tablet
38
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
sumatriptan (Imitrex) 1 QL: 12 in spray: 20mg
28 days
sumatriptan (Imitrex) 1 QL: 18 in spray: 5mg
28 days
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE 2
cycloserine (Cycloserine) 3
dapsone (Dapsone) 1
ethambutol hcl (Myambutol) 1
isoniazid (Isoniazid) 1
MYCOBUTIN 2
PASER 2
PRIFTIN 2
pyrazinamide (Pyrazinamide) 1
rifampin (Rifadin) 1
rifampin/isoniazid (Rifamate) 1
RIFATER 2
SEROMYCIN 3
TRECATOR
Antineoplastic Agents
2
Antineoplastic Agents
ABRAXANE 2
ADCETRIS 2
AFINITOR 2
ALIMTA 2
anastrozole (Arimidex) 1 PA
ARRANON 2
ARZERRA 2 PA, QL:
80 in 30
days
AVASTIN 2
BEXXAR 2
bicalutamide (Casodex) 1
BICNU 2
bleomycin sulfate (Blenoxane) 1 PA
BUSULFEX 2
CAMPATH 2
39
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
CAPRELSA 2 PA, QL:
30 in 30
days
tablet: 300mg
CAPRELSA 2 PA, QL:
60 in 30
days
tablet: 100mg
carboplatin (Paraplatin) 1
CEENU 2
cisplatin (Cisplatin) 1
cladribine (Leustatin) 1 PA
CLOLAR 2
cyclophosphamide (Cytoxan) 1 PA, ST tablet
cyclophosphamide (Cytoxan) 1 PA vial
cytarabine/pf (Cytarabine/PF) 1 PA
dacarbazine (Dtic-Dome IV) 1
DACOGEN 2
dactinomycin (Cosmegen) 1
daunorubicin hcl (Cerubidine) 1
DAUNOXOME 2
DOCEFREZ 2
docetaxel (Taxotere) 2 vial: 20mg/2ml,
20mg/ml(1)
docetaxel (Taxotere) 2 vial: fnl20mg/2
DOXIL 2 PA
doxorubicin hcl liposomal (Doxil) 1 PA
doxorubicin hcl (Adriamycin RDF) 1 PA vial: 10mg
DROXIA 2
ELIGARD 2 QL: 1 in
112 days
disp syrin: 30mg
ELIGARD 2 QL: 1 in
168 days
disp syrin: 45mg
ELIGARD 2 QL: 1 in
28 days
disp syrin: 7.5mg
ELIGARD 2 QL: 1 in
84 days
disp syrin: 22.5mg
ELSPAR 2
EMCYT 2
epirubicin hcl (Ellence) 1
ERBITUX 2
40
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
ERIVEDGE 2 PA, QL:
30 in 30
days
ERWINAZE 2 PA, QL:
60 in 30
days
ETOPOPHOS 2
etoposide (Etoposide) 1
exemestane (Aromasin) 1 PA
FARESTON 2
FASLODEX 2 disp syrin: 125mg/
2.5
FASLODEX 2 disp syrin: 250mg/
5ml
FIRMAGON 3
floxuridine (FUDR) 1 PA
fludarabine phosphate (Fludara) 2
fluorouracil (Fluorouracil) 1 PA
flutamide (Flutamide) 1
FOLOTYN 2
gemcitabine hcl (Gemzar) 2
GLEEVEC 2
HALAVEN 2 PA, QL:
6 in 28
days
HERCEPTIN 2 PA
HEXALEN 2
hydroxyurea (Hydrea) 1
idarubicin hcl (Idamycin Pfs) 1
ifosfamide (Ifex) 1 PA
ifosfamide/mesna (Ifex/mesnex) 1 PA
INLYTA 2 PA, QL:
180 in 30
days
tablet: 1mg
INLYTA 2 PA, QL:
60 in 30
days
tablet: 5mg
IRESSA 2 PA, QL:
30 in 30
days
irinotecan hcl (Camptosar) 2
41
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
ISTODAX 2 PA
IXEMPRA 2
JAKAFI 2 PA, QL:
60 in 30
days
JEVTANA 2
letrozole (Femara) 1 PA
LEUKERAN 2
leuprolide acetate (Lupron) 1 QL: 2 in
28 days
LUPRON DEPOT 2 ST, QL:
1 in 112
days
syringekit: 30mg
LUPRON DEPOT 2 ST, QL:
1 in 168
days
syringekit: 45mg
LUPRON DEPOT 2 ST, QL: syringekit: 3.75mg,
1 in 28
days
7.5mg
LUPRON DEPOT 2 ST, QL: syringekit:
1 in 84
days
11.25mg, 22.5mg
LUPRON DEPOT-PED 2 ST, QL:
1 in 28
days
LYSODREN 2
MATULANE 2
MEGACE ES 2
megestrol acetate (Megace) 1
melphalan hcl (Alkeran) 2
mercaptopurine (Purinethol) 1
methotrexate sodium (Methotrexate Sodium) 1 PA, ST tablet
methotrexate sodium (Methotrexate Sodium) 1 PA vial
methotrexate sodium/pf (Methotrexate Sodium/PF) 1 PA
MITHRACIN 2
mitomycin (Mutamycin) 1 PA
mitoxantrone hcl (Novantrone) 1
MUSTARGEN 2
MYLOTARG 2
NEXAVAR 2
NILANDRON 2
42
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
ONCASPAR 2
ONTAK 2
oxaliplatin (Oxaliplatin) 2
paclitaxel (Taxol) 1
pentostatin (Nipent) 2
PHOTOFRIN 2
PROLEUKIN 2
REVLIMID 2 LA, QL:
30 in 30
days
RITUXAN 2 PA
SPRYCEL 2
SUTENT 2
TABLOID 2
tamoxifen citrate (Nolvadex) 1
TARCEVA 2 PA, QL:
30 in 30
days
TARGRETIN 2
TASIGNA 2
TAXOTERE 2
thiotepa (Thiotepa) 1
topotecan hcl (Hycamtin) 2
TORISEL 2 PA
TREANDA 2
TRELSTAR 2 ST, QL:
1 in 168
days
vial
TRELSTAR 2 ST, QL: disp syrin: 3.75mg/
1 in 28
days
2ml
TRELSTAR 2 ST, QL: disp syrin: 11.25/
1 in 84
days
2ml
tretinoin (Tretinoin) 2
TREXALL 2 PA, ST
TRISENOX 2
TYKERB 2
VALSTAR 2
43
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
VANDETANIB 2 PA, QL:
30 in 30
days
tablet: 300mg
VANDETANIB 2 PA, QL:
60 in 30
days
tablet: 100mg
VECTIBIX 2
VELCADE 2
VIDAZA 2
vinblastine sulfate (Vinblastine Sulfate) 1 PA
vincristine sulfate (Vincristine Sulfate) 1 PA
vinorelbine tartrate (Navelbine) 1
VOTRIENT 2
VUMON 2
XALKORI 2 PA, QL:
60 in 30
days
YERVOY 2 PA, QL:
30 in 21
days
ZANOSAR 2
ZELBORAF 2 PA, QL:
240 in 30
days
ZOLADEX 3 QL: 1 in
28 days
implant: 3.6mg
ZOLADEX 3 QL: 1 in
84 days
implant: 10.8mg
ZOLINZA 2
ZYTIGA 2 PA, QL:
120 in 30
days
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl (Amantadine HCl) 1
APOKYN 2
AZILECT 2
benztropine mesylate (Benztropine Mesylate) 1
bromocriptine mesylate (Parlodel) 1
cabergoline (Cabergoline) 1
carbidopa/levodopa (Sinemet 25-100) 1
44
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
carbidopa/levodopa/
entacapone
(Stalevo 50) 1
COMTAN 2
pramipexole di-hcl (Mirapex) 1
ropinirole hcl (Requip) 1
selegiline hcl (Eldepryl) 1
STALEVO 100 2
STALEVO 125 2
STALEVO 150 2
STALEVO 200 2
STALEVO 50 2
STALEVO 75 2
TASMAR 2
trihexyphenidyl hcl (Trihexyphenidyl HCl) 1
ZELAPAR
Antiprotozoal Agents
2
Antiprotozoal Agents
ALINIA 3
atovaquone/proguanil hcl (Malarone) 1 tablet: 250-100mg
atovaquone/proguanil hcl (Malarone) 1 tablet: 62.5-25mg
chloroquine phosphate (Aralen Phosphate) 1
COARTEM 3
DARAPRIM 2
HALFAN 2
hydroxychloroquine
sulfate
(Plaquenil) 1
MALARONE 2 tablet: 62.5-25mg
mefloquine hcl (Lariam) 1
MEPRON 2
metronidazole (Flagyl) 1
metronidazole/sodium
chloride
(Metro IV) 1
paromomycin sulfate (Humatin) 1
pentamidine isethionate (Pentam 300) 1
PRIMAQUINE 2
QUALAQUIN 3 PA, QL:
42 in 30
days
YODOXIN 2
45
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Antipruritics and Local Anesthetics
Antipruritics and Local Anesthetics
Drug
Tier
Requirements/Limits
AMERICAINE 2
ANACAINE 2
lidocaine hcl (Xylocaine) 1 PA (PA for ESRD only)
lidocaine/prilocaine (EMLA) 1 PA (PA for ESRD only)
LIDODERM 3
phenazopyridine hcl
Antiulcer Agents
Antiulcer Agents
(Urodol) 1
cimetidine hcl (Cimetidine HCl) 1
cimetidine in 0.9 % nacl (Cimetidine In 0.9 % NaCl) 1
cimetidine (Tagamet) 1
DEXILANT 2 ST
famotidine in nacl,iso- (Famotidine In Nacl,iso-osm/PF) 1
osm/pf
famotidine (Pepcid) 1
lansoprazole (Prevacid) 1 ST
misoprostol (Cytotec) 1
nizatidine (Axid) 1
omeprazole (Prilosec) 1 capsule dr: 10mg,
20mg, 40mg
omeprazole/sodium (Zegerid) 1
bicarbonate
pantoprazole sodium (Protonix) 1
PROTONIX IV 3
ranitidine hcl (Zantac) 1
sucralfate (Carafate) 1 tablet
sucralfate (Sucralfate) 1 oral susp
Antivirals (Systemic)
Antiretrovirals
APTIVUS 2 capsule
APTIVUS 3 solution
ATRIPLA 2
COMPLERA 2
CRIXIVAN 2
didanosine (Videx EC) 1
EDURANT 2
EMTRIVA 2
EPIVIR HBV 3
46
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
EPIVIR 3 solution
EPZICOM 2
FUZEON 2
INTELENCE 2
INVIRASE 2
ISENTRESS 2
KALETRA 2
lamivudine (Epivir) 1
lamivudine/zidovudine (Combivir) 2
LEXIVA 2
NORVIR 2
PREZISTA 2
RESCRIPTOR 3
RETROVIR 2 vial
REYATAZ 2
SELZENTRY 2
stavudine (Zerit) 1
SUSTIVA 3 capsule: 100mg
SUSTIVA 3 capsule: 50mg,
200mg; tablet
TRIZIVIR 2
TRUVADA 2
VIDEX 2
VIRACEPT 3
VIRAMUNE XR 3
VIRAMUNE 2
VIREAD 2
ZIAGEN 3
zidovudine (Retrovir) 1
Antivirals, Miscellaneous
foscarnet sodium (Foscavir) 1 PA
INCIVEK 2 PA, QL:
168 in 28
days
RELENZA 3
rimantadine hcl (Flumadine) 1
SYNAGIS 3
TAMIFLU 2 QL: 42 in capsule: 75mg
180 days
47
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
TAMIFLU 2 QL: 48 in capsule: 45mg
180 days
TAMIFLU 2 QL: 525 susp recon: 12mg/
in 180
days
ml
TAMIFLU 2 QL: 540
in 180
days
susp recon: 6mg/ml
TAMIFLU 2 QL: 84 in capsule: 30mg
180 days
VICTRELIS
Interferons
2 PA, QL:
336 in 28
days
ALFERON N 2
INTRON A 2 PA pen ij kit, vial:
6mmunit/ml,
10mmunit
INTRON A 2 PA vial: 50mmunit
PEGASYS PROCLICK 2 PA
PEGASYS 2 PA
PEGINTRON REDIPEN 2 PA
PEGINTRON 2 PA kit: 50mcg/0.5
PEGINTRON 2 PA kit: 80mcg/0.5,
120mcg/0.5,
150mcg/0.5
SYLATRON 4-PACK 2 PA, QL:
1 in 28
days
Nucleosides and Nucleotides
acyclovir sodium (Acyclovir Sodium) 1 PA
acyclovir (Zovirax) 1
BARACLUDE 2 tablet
BARACLUDE 3 solution
famciclovir (Famvir) 1
ganciclovir sodium (Cytovene) 1 PA
ganciclovir (Cytovene) 1 capsule: 250mg
ganciclovir (Cytovene) 2 capsule: 500mg
HEPSERA 2
REBETOL 2 solution
ribavirin (Rebetol) 1 capsule, tablet
48
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
ribavirin (Ribatab) 2 tab ds pk
TYZEKA 2
valacyclovir hcl (Valtrex) 1
VALCYTE 2 tablet
VALCYTE 3 PA soln recon
VISTIDE 2
Anxiolytics, Sedatives and Hypnotics
Anxiolytics, Sedatives and Hypnotics, Miscellaneous
buspirone hcl (Buspar) 1
chloral hydrate (Chloral Hydrate) 1
droperidol (Inapsine) 1
glutethimide (Glutethimide) 1
hydroxyzine hcl (Hydroxyzine HCl) 1
hydroxyzine pamoate (Vistaril) 1
LUNESTA 2
meprobamate (Miltown) 1
zaleplon (Sonata) 1
zolpidem tartrate
Astringents
Astringents
(Ambien) 1
aluminum chloride (Drysol) 1
XERAC AC 2
Beta-Adrenergic Blocking Agents
Beta-Adrenergic Blocking Agents
acebutolol hcl (Sectral) 1
atenolol (Tenormin) 1
atenolol/chlorthalidone (Tenoretic 100) 1
betaxolol hcl (Kerlone) 1
bisoprolol fumarate (Zebeta) 1
bisoprolol fumarate/hctz (Ziac) 1
BYSTOLIC 2
carvedilol (Coreg) 1
COREG CR 2
DUTOPROL 2
esmolol hcl (Esmolol HCl) 1 PA
labetalol hcl (Trandate) 1
metoprolol succinate (Toprol XL) 1
metoprolol tartrate (Lopressor) 1
metoprolol/
hydrochlorothiazide
(Lopressor HCT) 1
49
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
nadolol (Corgard) 1
nadolol/
bendroflumethiazide
(Corzide) 1
pindolol (Pindolol) 1
propranolol hcl (Inderal) 1
propranolol/
hydrochlorothiazid
(Inderide-40/25) 1
sotalol hcl (Betapace) 1
SOTALOL HCL 3
timolol maleate
Blood Derivatives
Blood Derivatives
(Timolol Maleate) 1
ALBUKED-25 2
ALBUKED-5 2
ALBUMARC 2
ALBUMIN (HUMAN) 2
ALBUMINAR-25 2
ALBUMINAR-5 2
ALBURX 2
ALBUTEIN 2
BUMINATE 2
FLEXBUMIN 2
KEDBUMIN 2
PLASBUMIN-25 2
PLASBUMIN-5 2
STERILE DILUENT 2
Calcium-Channel Blocking Agents
Calcium-Channel Blocking Agents, Miscellaneous
CARDIZEM CD 2 cap er 24h: 360mg
diltiazem hcl (Cardizem CD) 1 various dosage and/
or strengths are
available
diltiazem hcl (Dilacor XR) 1 cap er deg: 240mg
verapamil hcl (Calan) 1 ampul, cap24h pct,
cap24h pel: 120mg,
180mg, 240mg;
tablet, tablet er
verapamil hcl (Verelan) 1 cap24h pel: 360mg;
disp syrin
50
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Dihydropyridines
Drug
Tier
Requirements/Limits
amlodipine besylate (Norvasc) 1
amlodipine besylate/
benazepril
(Lotrel) 1
AZOR 3 ST
CARDENE I.V. 3 piggyback
CLEVIPREX 3
EXFORGE HCT 2 ST
EXFORGE 2 ST
felodipine (Plendil) 1
isradipine (Dynacirc) 1
nicardipine hcl (Nicardipine HCl) 1
nifedipine (Procardia XL) 1
nimodipine (Nimotop) 1
nisoldipine
Caloric Agents
Caloric Agents
(Sular) 1
AMINOSYN II 3.5% M-
DEXTROSE 5%
2 PA
AMINOSYN II 3.5%-
DEXTROSE 25%
2 PA
AMINOSYN II 3.5%-
DEXTROSE 5%
2 PA
AMINOSYN II 4.25% M-
DEXT 10%
2 PA
AMINOSYN II 4.25%-
DEXTROSE 25%
2 PA
AMINOSYN II 5% IN
25% DEXTROSE
2 PA
AMINOSYN II IN
DEXTROSE
2 PA
AMINOSYN II with
LYTES-CA-DW
2 PA iv soln: 3.5%
AMINOSYN II with
LYTES-CA-DW
2 PA iv soln: 4.25%
AMINOSYN II 2 PA iv soln: 10%
AMINOSYN II 2 PA iv soln: 15%
AMINOSYN II 2 PA iv soln: 7%
AMINOSYN II 2 PA iv soln: 8.5%
AMINOSYN M 2 PA
51
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
AMINOSYN with
ELECTROLYTES
2 PA
AMINOSYN 2 PA iv soln: 10%
AMINOSYN 2 PA iv soln: 3.5%
AMINOSYN 2 PA iv soln: 5%
AMINOSYN 2 PA iv soln: 7%
AMINOSYN 2 PA iv soln: 8.5%
AMINOSYN-HBC 2 PA
AMINOSYN-HF 2 PA
AMINOSYN-PF 2 PA iv soln: 10%
AMINOSYN-PF 2 PA iv soln: 7%
AMINOSYN-RF 2 PA
BRANCHAMIN 2 PA
CLINIMIX E 2 PA iv soln: 2.75%
CLINIMIX E 2 PA iv soln: 4.25%
CLINIMIX E 2 PA iv soln: 5%
CLINIMIX 2 PA iv soln: 2.75%
CLINIMIX 2 PA iv soln: 4.25%
CLINIMIX 2 PA iv soln: 5%
CLINISOL 2 PA
cysteine hcl (Cysteine HCl) 1 PA
dextrose 10 % and 0.225 (Dextrose 10 % and 0.225 % 1
% nacl
NaCl)
dextrose 10 % and 0.9 %
nacl
(Dextrose 10 % and 0.9 % NaCl) 1
dextrose 10%-0.5 normal (Dextrose 10%-0.5 Normal 1
saline
Saline)
dextrose 10%-water (Dextrose 10%-water) 1 PA
dextrose 2.5%-0.5normal (Dextrose 2.5%-0.5 Normal 1
saline
Saline)
dextrose 2.5%-water (Dextrose 2.5%-water) 1 PA
dextrose 20%-water (Dextrose 20%-water) 1 PA
dextrose 25%-water (Dextrose 25%-water) 1 PA
dextrose 40%-water (Dextrose 40%-water) 1 PA
dextrose 5 % and 0.33 %
nacl
(Dextrose 5 % and 0.33 % NaCl) 1
dextrose 5 % and 0.9 %
nacl
(Dextrose 5 % and 0.9 % NaCl) 1
dextrose 5 %-0.225 %
nacl
(Dextrose 5 %-0.225 % NaCl) 1
52
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 % NaCl) 1
dextrose 5%-water (Dextrose 5%-water) 1
dextrose 50%-water (Dextrose 50%-water) 1 PA
dextrose 60%-water (Dextrose 60%-water) 1 PA
dextrose 70%-water (Dextrose 70%-water) 1 PA
ethyl alcohol/d5w (Ethyl Alcohol/D5W) 1
FREAMINE HBC 2 PA
FREAMINE III with
ELECTROLYTES
2 PA
FREAMINE III 2 PA iv soln: 10%
FREAMINE III 2 PA iv soln: 8.5%
fructose 10% (Fructose 10%) 1 PA
HEPATAMINE 2 PA
HEPATASOL 2 PA
INTRALIPID 2 PA emulsion: 10%
INTRALIPID 2 PA emulsion: 20%,
30%
LIPOSYN II 2 PA
LIPOSYN III 2 PA
NEPHRAMINE 2 PA
NOVAMINE 2 PA
NUTRESTORE 2
PREMASOL 2 PA iv soln: 10%
PREMASOL 2 PA iv soln: 6%
PROCALAMINE 2 PA
PROSOL 2 PA
QUICK MIX with LYTES 2 PA
RENAMIN 2 PA
TRAVAMULSION 2 PA
TRAVASOL W/
ELECTROLYTES
2 PA iv soln.: 5.5%
TRAVASOL W/
ELECTROLYTES
2 PA iv soln.: 8.5%
TRAVASOL with
DEXTROSE
2 PA iv soln: 8.5%
TRAVASOL with
ELECTROLYTES
2 PA
TRAVASOL 2 PA iv soln: 10%
TRAVASOL 2 PA iv soln: 5.5%
TRAVASOL 2 PA iv soln: 8.5%
53
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
TRAVERT IN NORMAL
SALINE
2 PA
TRAVERT 2 PA iv soln: 10%
TRAVERT 2 PA iv soln: 5%
TROPHAMINE 2 PA iv soln: 10%
TROPHAMINE
Cardiac Drugs
2 PA iv soln: 6%
Antiarrhythmic Agents
amiodarone hcl (Amiodarone HCl) 1 disp syrin
amiodarone hcl (Cordarone) 1 ampul, tablet
disopyramide phosphate (Norpace) 1 capsule
disopyramide phosphate (Norpace) 1 capsule er
flecainide acetate (Tambocor) 1
lidocaine hcl (Lidocaine HCl) 1
lidocaine hcl/d5w/pf (Lidocaine HCl/d5w/PF) 1 iv soln: 2mg/ml,
8mg/ml
lidocaine hcl/d7.5w/pf (Lidocaine HCl/d7.5w/PF) 1
lidocaine hcl/pf (Lidocaine HCl) 1
LIDOCAINE HCL 1
mexiletine hcl (Mexitil) 1
MULTAQ 2
procainamide hcl (Procainamide HCl) 1 capsule, tablet er,
tablet sa
procainamide hcl (Procainamide HCl) 1 vial
PRONESTYL 2
propafenone hcl (Rythmol) 1
quinidine gluconate (Quinidine Gluconate) 1
quinidine sulfate (Quinidine Sulfate) 1
TIKOSYN 2
Cardiac Drugs, Miscellaneous
digoxin (Lanoxin) 1
DIGOXIN 2
inamrinone lactate (Inamrinone Lactate) 1 PA
LANOXIN PEDIATRIC 2
milrinone lactate (Milrinone Lactate) 2 PA
milrinone lactate/d5w (Primacor in 5% Dextrose) 2 PA
RANEXA 2 QL: 120
in 30
days
tab er 12h: 500mg
54
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
RANEXA 2 QL: 60 in tab er 12h: 1000mg
30 days
Cathartics and Laxatives
Cathartics and Laxatives
AMITIZA 2 QL: 60 in
30 days
peg 3350/na sulf,bicarb,cl/
kcl
(Colyte with Flavor Packets) 1
polyethylene glycol 3350 (Polyethylene Glycol 3350) 1 powd pack: 17g
sodium chloride/nahco3/
kcl/peg
(Nulytely) 1
Cell Stimulants and Proliferants
Cell Stimulants and Proliferants
KEPIVANCE 2
tretinoin (Retin-A) 1 PA
Central Nervous System Agents, Miscellaneous
Central Nervous System Agents, Miscellaneous
CAMPRAL 2 tab ds pk
CAMPRAL 2 tablet dr
flumazenil (Romazicon) 1
lithium carbonate (Eskalith) 1
lithium citrate (Lithium Citrate) 1
LODOSYN 2
NAMENDA 2 PA, QL:
360 in 30
days
solution
NAMENDA 2 PA, QL:
49 in 28
days
tab ds pk
NAMENDA 2 PA, QL:
62 in 31
days
tablet
RILUTEK 2
SAVELLA 2 QL: 60 in
30 days
STRATTERA 2
XENAZINE 2 PA, QL:
112 in 28
days
XYREM 2 LA
55
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Contraceptives
Contraceptives
desogestrel-ethinyl
estradiol
Drug Name
Drug
Tier
(Desogen) 1
Requirements/Limits
desog-et estra/ethin estra (Mircette) 1
ethinyl estradiol/
drospirenone
(Yaz) 1
ethynodiol d-ethinyl
estradiol
(Demulen 1-50-21) 1
levonorgestrel (Plan B) 1
levonorgestrel-eth
estradiol
(Lybrel) 1 tablet
levonorgestrel-eth (Seasonale) 1 QL: 91 in tbdspk 3mo
estradiol
84 days
l-norgest-eth estr/ethin (Seasonique) 1 QL: 91 in tbdspk 3mo: 100estra
84 days 20(84), 150-30(84)
l-norgest-eth estr/ethin (Seasonique) 1 QL: 91 in tbdspk 3mo: 150estra
84 days 30(84)
noreth a-et estra/fe
fumarate
(Loestrin Fe) 1
noreth-ethinyl estradiol/
iron
(Femcon Fe) 1
norethindrone a-e
estradiol
(Loestrin) 1
norethindrone (Nor-Q-D) 1
norethindrone-ethinyl
estrad
(Ortho-novum) 1
norethindrone-mestranol (Ortho-novum) 1
norgestimate-ethinyl
estradiol
(Ortho-cyclen) 1
norgestrel-ethinyl
estradiol
(Lo-ovral-28) 1
NUVARING 2 ST, QL:
1 in 28
days
ORTHO EVRA 3 ST, QL:
3 in 28
days
56
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Devices
Devices
Drug Name
Drug
Tier
Requirements/Limits
needles, insulin disposable (Needles, Insulin Disposable) 1
syring wndl,disp,insul,0.3ml
(Syring W-ndl,disp,insul,0.3ml) 1
syring wndl,disp,insul,0.5ml
(Syring W-ndl,disp,insul,0.5ml) 1
syringe & needle,insulin,1
ml
Diuretics
(Syringe & Needle,insulin,1 Ml) 1
Diuretics, Miscellaneous
chlorthalidone (Chlorthalidone) 1
indapamide (Lozol) 1
metolazone (Zaroxolyn) 1
SAMSCA 2 QL: 30 in tablet: 15mg
30 days
SAMSCA
Loop Diuretics
2 QL: 60 in tablet: 30mg
30 days
bumetanide (Bumex) 1
furosemide (Furosemide) 1 disp syrin
furosemide (Lasix) 1 solution, tablet, vial
torsemide (Demadex) 1
Potassium-sparing Diuretics
amiloride hcl (Midamor) 1
amiloride/
hydrochlorothiazide
(Amiloride/hydrochlorothiazide) 1
DYRENIUM 3
triamterene/
hydrochlorothiazid
Thiazide Diuretics
(Maxzide-25mg) 1
chlorothiazide sodium (Diuril Sodium) 1
chlorothiazide (Chlorothiazide) 1
hydrochlorothiazide (Hydrochlorothiazide) 1
methyclothiazide (Methyclothiazide) 1
EENT Drugs, Miscellaneous
EENT Drugs, Miscellaneous
apraclonidine hcl (Iopidine) 1
carteolol hcl (Carteolol HCl) 1
57
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
ipratropium bromide (Atrovent) 1 QL: 15 in spray: 42mcg
10 days
ipratropium bromide (Atrovent) 1 QL: 30 in spray: 21mcg
28 days
LACRISERT 2
naphazoline hcl (Albalon) 1
naphazoline hcl/antazoline (Naphazoline HCl/antazoline) 1
phenylephrine hcl (Mydfrin) 1
TYZINE 2 drops
TYZINE
Enzymes
Enzymes
2 spray
ADAGEN 2
ALDURAZYME 2
CEREDASE 2
CEREZYME 2
ELAPRASE 2
ELITEK 2
FABRAZYME 2
KRYSTEXXA 2
LUMIZYME 2
MYOZYME 2
NAGLAZYME 2
PULMOZYME 2 PA
SUCRAID 2
VPRIV 2
XIAFLEX 2 PA, QL:
1 in 28
days
Estrogens and Antiestrogens
Estrogens and Antiestrogens
COMBIPATCH 2 QL: 8 in
28 days
ESTRACE 2 cream/appl
ESTRADERM 2 QL: 8 in
28 days
estradiol valerate (Delestrogen) 1
estradiol (Climara) 1 QL: 4 in
28 days
patch tdwk
estradiol (Estrace) 1 tablet
58
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
estradiol/noreth ac (Activella) 1 tablet: 0.5-0.1mg
estradiol/noreth ac (Activella) 1 tablet: 1-0.5mg
ESTRASORB 3 QL:
97.44 in
28 days
estropipate (Ogen) 1
EVISTA 2
MENEST 3
norethind ac/ethinyl
estradiol
(Femhrt) 1 tablet: 1mg-5mcg
PREMARIN 2
PREMPHASE 2
PREMPRO 2
VIVELLE-DOT 2 QL: 8 in
28 days
First Generation Antihistamines
First Generation Antihistamines
carbinoxamine maleate (Palgic) 1
chlorpheniramine maleate (Chlorpheniramine Maleate) 1
clemastine fumarate (Clemastine Fumarate) 1 syrup, tablet:
2.68mg
clemastine fumarate (Clemastine Fumarate) 1 tablet: 1.34mg
cyproheptadine hcl (Cyproheptadine HCl) 1
dexchlorpheniramine
maleate
(Dexchlorpheniramine Maleate) 1 syrup
dexchlorpheniramine
maleate
(Dexchlorpheniramine Maleate) 1 tablet er
diphenhydramine hcl (Diphenhydramine HCl) 1 capsule: 25mg; disp
syrin
diphenhydramine hcl (Diphenhydramine HCl) 1 capsule: 50mg; vial
doxylamine succinate (Doxylamine Succinate) 1
p-epd tan/chlor-tan (P-epd Tan/chlor-tan) 1
phenyleph/acetaminop/p- (Phenyleph/acetaminop/p-tlox/ 1
tlox/cp
cp)
phenylephrine hcl/prometh (Phenylephrine HCl/prometh 1
hcl
HCl)
phenylephrine/chlor-tan (Rynatan) 1
phenylephrine/dp-hydram (Phenylephrine/dp-hydram Tan) 1 tab chew: 5mgtan
12.5mg
promethazine hcl (Promethazine HCl) 1
59
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
tripelennamine hcl (Tripelennamine HCl) 1
Genitourinary Smooth Muscle Relaxants
Genitourinary Smooth Muscle Relaxants
DETROL LA 2
DETROL 2
flavoxate hcl (Urispas) 1
oxybutynin chloride (Ditropan) 1
TOVIAZ 2
trospium chloride (Sanctura) 1
VESICARE 2
GI Drugs, Miscellaneous
GI Drugs, Miscellaneous
CHENODAL 2 PA, QL:
120 in 30
days
CIMZIA 2 PA, QL:
3 in 28
days
CREON 2
lipase/protease/amylase (Zenpep) 1
LOTRONEX 2
metoclopramide hcl (Metoclopramide HCl) 1 disp syrin
metoclopramide hcl (Reglan) 1 solution, tablet, vial
RELISTOR 3 PA, QL:
28 in 28
days
disp syrin
RELISTOR 3 PA, QL:
28 in 28
days
kit
ursodiol (Actigall) 1
ZENPEP 2
Heavy Metal Antagonists
Heavy Metal Antagonists
BAL IN OIL 2
CA-DTPA 2
CALCIUM DISODIUM
VERSENATE
2
CHEMET 2
CUPRIMINE 2
deferoxamine mesylate (Desferal) 1 PA
60
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
DEPEN 2
edetate disodium (Edetate Disodium) 1
ENDRATE 2
EXJADE 2
FERRIPROX 2
GALZIN 2
na nitrite/na thiosul/amyl
nit
(Na Nitrite/na Thiosul/amyl Nit) 1
sodium thiosulfate (Sodium Thiosulfate) 1
SYPRINE 2
ZN-DTPA
Hematologic Agents
Anticoagulants
2
CEPROTIN 2
citrate-phos-dex solution (Citrate-phos-dex Solution) 1
COUMADIN 2 vial
enoxaparin sodium (Lovenox) 1 QL: 13.6 disp syrin: 40mg/
in 30
days
0.4ml
enoxaparin sodium (Lovenox) 1 QL: 18 in disp syrin: 30mg/
30 days 0.3ml
enoxaparin sodium (Lovenox) 1 QL: 20.4 disp syrin: 60mg/
in 30
days
0.6ml
enoxaparin sodium (Lovenox) 2 QL: 12 in vial
30 days
enoxaparin sodium (Lovenox) 2 QL: 27.2 disp syrin: 80mg/
in 30
days
0.8ml, 120mg/.8ml
enoxaparin sodium (Lovenox) 2 QL: 34 in disp syrin: 150mg/
30 days ml
enoxaparin sodium (Lovenox) 2 QL: 36 in disp syrin: 100mg/
30 days ml
fondaparinux sodium (Arixtra) 1 QL: 11.2 disp syrin: 10mg/
in 28
days
0.8ml
fondaparinux sodium (Arixtra) 1 QL: 5.6 disp syrin: 5mg/
in 28
days
0.4ml
fondaparinux sodium (Arixtra) 1 QL: 7 in disp syrin: 2.5mg/
28 days 0.5
61
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
fondaparinux sodium (Arixtra) 1 QL: 8.4 disp syrin: 7.5mg/
in 28
days
0.6
FRAGMIN 2 PA, QL: disp syrin: 15000/
10.2 in
30 days
0.6
FRAGMIN 2 PA, QL: disp syrin: 2500/
12 in 30
days
0.2ml
FRAGMIN 2 PA, QL: disp syrin: 18000/
12.24 in
30 days
0.72
FRAGMIN 2 PA, QL:
15.2 in
30 days
vial
FRAGMIN 2 PA, QL:
17 in 30
days
disp syrin: 10000/ml
FRAGMIN 2 PA, QL: disp syrin: 7500/
5.1 in 30
days
0.3ml
FRAGMIN 2 PA, QL: disp syrin: 5000/
6 in 30
days
0.2ml
FRAGMIN 2 PA, QL: disp syrin: 12500/
8.5 in 30
days
0.5
heparin sodium,porcine (Hep-lock) 1 PA (PA for ESRD only)
heparin sodium,porcine/
d5w
(Heparin Sodium, porcine/D5W) 1
heparin sodium,porcine/
ns/pf
(Heparin Sodium, porcine/ns/PF) 1 iv soln: 1000/500ml
heparin sodium,porcine/
ns/pf
(Heparin Sodium, porcine/ns/PF) 1 iv soln: 2k/1000ml
heparin sodium,porcine/pf (Hep-lock) 1 vial port: 10000/5ml
heparin sodium,porcine/pf (Hep-lock) 1 vial port: 25k/10ml
heparin sodium,porcine/pf (Monoject Prefill Advanced) 1 PA disp syrin, (PA for
ESRD only)
heparin sodium,pork in 1/ (Heparin Sodium, pork in 1/2 1
2 ns
NS)
62
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
IPRIVASK 2 PA, QL:
24 in 28
days
LOVENOX 2 QL: 12 in vial
30 days
warfarin sodium (Coumadin) 1
Hematologic Agents, Miscellaneous
aminocaproic acid (Amicar) 1
anagrelide hcl (Agrylin) 1
LYSTEDA 3 QL: 30 in
30 days
pentoxifylline (Trental) 1
protamine sulfate (Protamine Sulfate) 1 PA (PA for ESRD only)
tranexamic acid (Tranexamic Acid) 1
Platelet-aggregation Inhibitors
cilostazol (Pletal) 1
EFFIENT 2
PLAVIX 2
ticlopidine hcl
Hematopoietic Agents
(Ticlid) 1
Hematopoietic Agents
ARANESP 2 PA, QL: disp syrin: 60mcg/
1.2 in 28
days
0.3, 150mcg/0.3
ARANESP 2 PA, QL: disp syrin: 40mcg/
1.6 in 28
days
0.4, 200mcg/0.4
ARANESP 2 PA, QL: disp syrin: 25mcg/
1.68 in
28 days
0.42
ARANESP 2 PA, QL: disp syrin: 100mcg/
2 in 28
days
0.5
ARANESP 2 PA, QL: disp syrin: 300mcg/
2.4 in 28
days
0.6
ARANESP 2 PA, QL: disp syrin: 500mcg/
4 in 28
days
ml; vial
63
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
EPOGEN 2 PA, QL: vial: 2000/ml, 3000/
12 in 28 ml, 4000/ml, 10000/
days ml, 20000/ml
EPOGEN 2 PA, QL:
6 in 28
days
vial: 40000/ml
LEUKINE 2
MOZOBIL 2 PA, QL:
9.6 per
fill
NEULASTA 2
NEUMEGA 2
NEUPOGEN 2
PROCRIT 2 PA, QL: vial: 2000/ml, 3000/
12 in 28 ml, 4000/ml, 10000/
days ml, 20000/ml
PROCRIT 2 PA, QL:
6 in 28
days
vial: 40000/ml
PROMACTA
Hypotensive Agents
2 PA, QL:
30 in 30
days
Hypotensive Agents, Miscellaneous
clonidine hcl (Catapres) 1
clonidine hcl/
chlorthalidone
(Clonidine HCl/chlorthalidone) 1
clonidine (Catapres-TTS 3) 1 QL: 4 in patch tdwk: 0.1mg/
28 days 24hr, 0.2mg/24hr
clonidine (Catapres-TTS 3) 1 QL: 8 in patch tdwk: 0.3mg/
28 days 24hr
fenoldopam mesylate (Fenoldopam Mesylate) 1 PA
guanabenz acetate (Guanabenz Acetate) 1 tablet: 4mg
guanabenz acetate (Guanabenz Acetate) 1 tablet: 8mg
guanfacine hcl (Tenex) 1
hydralazine hcl (Apresoline) 1
hydralazine/
(Hydralazine/
1
hydrochlorothiazid hydrochlorothiazid)
hydralazine/reserpin/hctz (Hydralazine/reserpin/hctz) 1
methyldopa (Aldomet) 1
64
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
methyldopa/
(Methyldopa/
1
hydrochlorothiazide hydrochlorothiazide)
methyldopate hcl (Methyldopate HCl) 1
minoxidil (Minoxidil) 1
PROGLYCEM 2
reserpine (Reserpine) 1
reserpine/
hydrochlorothiazide
Ion-Removing Agents
(Reserpine/hydrochlorothiazide) 1
Ion-Removing Agents
calcium acetate (Phoslo) 1
calcium carbonate/mag (Calcium Carbonate/mag Carb/ 1
carb/fa
fa)
PHOSLYRA 3
RENAGEL 2
RENVELA 2 powd pack: 2.4g;
tablet
sodium polystyrene
sulfonate
Irrigating Solutions
(Sodium Polystyrene Sulfonate) 1
Irrigating Solutions
acetic acid (Acetic Acid) 1
IRRIGATING
SOLUTION G
2
LACTATED RINGERS 2
mannitol/sorbitol solution (Mannitol/sorbitol Solution) 1
ringers solution (Tis-u-sol) 1
sod chloride 0.45% irrig.
soln
(Sod Chloride 0.45% Irrig. Soln) 1
sodium chloride irrig
solution
(Sodium Chloride Irrig Solution) 1
sorbitol solution (Sorbitol Solution) 1
urologic solution-g (Urologic Solution-g) 1
water for irrigation,sterile (Water for Irrigation, Sterile)
Keratolytic Agents
Keratolytic Agents
1
benzoyl peroxide
microspheres
(Neobenz Micro) 1
benzoyl peroxide&skin
cleansr5
(Brevoxyl-4) 1
65
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
benzoyl peroxide (Delos) 1
benzoyl peroxide/aloe
vera
(Benziq) 1
benzoyl peroxide/ (Benzoyl Peroxide/
1
hydrocortison
hydrocortison)
benzoyl peroxide/skin
clnsr7
(Benzoyl Peroxide/skin Clnsr7) 1
benzoyl peroxide/urea (Zoderm) 1
potassium hydroxide (Potassium Hydroxide) 1
salicylic acid (Salex) 1
salicylic acid/ammon lact/
aloe
(Salkera) 1
salicylic acid/ceramide
cmb #1
(Salex) 1
silver nitrate applicator (Silver Nitrate Applicator) 1 stick (ea): 75%-25%
urea (Uramaxin) 1
urea/lactic ac/zn
undecylenate
(Kerol) 1
urea/lactic acid/salicyl
acid
Keratoplastic Agents
(Kerol) 1
Keratoplastic Agents
CARMOL SCALP 2
DRITHO-SCALP 2
sulfacetamide sodium/urea (Rosula Ns)
Local Anesthetics
Local Anesthetics
1
aa/antipyrn/bcaine/
polico#1/al
(Auralgan) 1
aa/antpy/bcaine/polico/al
acet
(Aa/antpy/bcaine/polico/al Acet) 1
AKTEN 3
antipyrine/benzocaine/
glycerin
(Otra Nr) 1
benzocaine (Omedia Otic) 1
chloroprocaine hcl/pf (Nesacaine-MPF) 1
chloroxylenol/pramoxine
hcl
(Oticin) 1
cocaine hcl (Cocaine HCl) 1
66
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
lidocaine hcl (Xylocaine) 1 jel (ml), jel/pf app,
solution
lidocaine hcl (Xylocaine) 1 PA vial: 10mg/ml, (PA
for ESRD only)
lidocaine hcl (Xylocaine) 1 PA vial: 20mg/ml, (PA
for ESRD only)
lidocaine hcl/pf (Xylocaine-MPF) 1 PA ampul, (PA for
ESRD only)
lidocaine hcl/pf (Xylocaine-MPF) 1 PA vial, (PA for ESRD
only)
mepivacaine hcl/pf (Mepivacaine HCl/PF) 1
NESACAINE 2 vial: 10mg/ml
phenylephrine/antipy/bcaine
(Otogesic) 1
proparacaine hcl (Ophthetic) 1
proparacaine/fluorescein
sod
(Proparacaine/fluorescein Sod) 1
tetracaine hcl/pf (Tetracaine HCl/PF) 1
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA 2 PA, QL:
40 in 30
days
ACTIMMUNE 2
ACTONEL with
2 ST, QL:
CALCIUM
28 in 28
days
ACTONEL 2 ST, QL:
1 in 28
days
tablet: 150mg
ACTONEL 2 ST, QL:
31 in 31
days
tablet: 5mg, 30mg
ACTONEL 2 ST, QL:
4 in 28
days
tablet: 35mg
alendronate sodium (Fosamax) 1 tablet: 5mg, 10mg,
40mg
alendronate sodium (Fosamax) 1 QL: 4 in
28 days
tablet: 35mg, 70mg
allopurinol sodium (Aloprim) 1
67
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
allopurinol (Zyloprim) 1
amifostine crystalline (Ethyol) 1
AMPYRA 2 PA, QL:
60 in 30
days
ARCALYST 2
ATGAM 2
AVODART 2
AVONEX
ADMINISTRATION
PACK
2
AVONEX PEN 2
AVONEX 2
azathioprine sodium (Azathioprine Sodium) 1 PA
azathioprine (Imuran) 1 PA
BENLYSTA 2 PA, QL:
2 in 28
days
BERINERT 2
BETASERON 2 ST
BONIVA 2 PA, ST, disp syrin, (PA for
QL: 1 in
84 days
ESRD only)
BONIVA 2 ST, QL:
1 in 28
days
tablet: 150mg
BONIVA 2 ST, QL:
31 in 31
days
tablet: 2.5mg
BOTOX 2 PA, QL:
1 in 90
days
vial: 200unit
BOTOX 2 PA, QL:
3 in 90
days
vial: 100unit
CELLCEPT 2 PA susp recon
CELLCEPT 3 PA vial
CINRYZE 2 PA, QL:
20 in 28
days
colchicine/probenecid (Colchicine/probenecid) 1
68
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
COLCRYS 2
COPAXONE 2
cyclosporine (Sandimmune) 1 PA capsule, vial
cyclosporine (Sandimmune) 1 PA solution
cyclosporine, modified (Neoral) 1 PA
CYSTADANE 3
CYSTAGON 2
dexrazoxane (Totect) 1
disulfiram (Antabuse) 1
DUODOTE 2
DYSPORT 3 PA, QL:
2 in 90
days
ELMIRON 2
ENBREL 2 PA, QL:
7.84 in
28 days
pen injctr
ENBREL 2 PA, QL:
8 in 28
days
kit
ENBREL 2 PA, QL:
8.16 in
28 days
disp syrin
ergoloid mesylates (Ergoloid Mesylates) 1 tab subl
ergoloid mesylates (Ergoloid Mesylates) 1 tablet
etidronate disodium (Didronel) 1
EXTAVIA 2 ST
finasteride (Proscar) 1
FIRAZYR 2
FLUOR-A-DAY 3 drops
FLUOR-A-DAY 3 tab chew
FLUORITAB 3
FLURA-DROPS 3
fomepizole (Antizol) 2
FOSAMAX 2 QL: 300
in 28
days
solution
FUSILEV 2
gauze bandage (Gauze Bandage) 1
69
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
GILENYA 2 PA, QL:
28 in 28
days
GLUCAGEN 2
GLUCAGON
EMERGENCY KIT
2
gold sodium thiomalate (Myochrysine) 1
HUMIRA 2 PA, QL: kit, pen ij kit: 40mg/
4 in 28
days
0.8ml
HUMIRA 2 PA, QL: pen ij kit: 40mg/
6 in 28
days
0.8ml
ibandronate sodium (Boniva) 1 QL: 1 in
28 days
ILARIS 2
KALBITOR 2
KINERET 2 PA, QL:
18.76 in
28 days
KUVAN 2
leflunomide (Arava) 1
leucovorin calcium (Leucovorin Calcium) 1
levocarnitine (with sugar) (Carnitor) 1 PA (PA for ESRD only)
levocarnitine (Carnitor) 1 PA (PA for ESRD only)
mesna (Mesnex) 1
MESNEX 2 tablet
methylene blue (Methylene Blue) 1
methylergonovine maleate (Methergine) 1 tablet
methylergonovine maleate (Methylergonovine Maleate) 1 vial
mycophenolate mofetil (Cellcept) 1 PA
MYFORTIC 3 PA
MYOBLOC 3 PA, QL:
1 in 90
days
NPLATE 2 PA, QL:
8 in 28
days
NULOJIX 2 PA
70
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
octreotide acetate (Sandostatin) 1 vial: 50mcg/ml,
100mcg/ml,
200mcg/ml
octreotide acetate (Sandostatin) 2 ampul, vial:
1000mcg/ml
ORENCIA 2 PA, QL:
4 in 28
days
disp syrin
ORENCIA 2 PA, QL:
4 in 28
days
vial
ORFADIN 2
ORTHOCLONE OKT-3 2 PA
pamidronate disodium (Aredia) 1 PA (PA for ESRD only)
PRALIDOXIME
CHLORIDE
2
probenecid (Probenecid) 1
PROGRAF 3 PA ampul
PROLIA 3 PA, QL:
1 in 180
days
PROTOPAM CHLORIDE 3
RAPAMUNE 2 PA
REBIF 2
RECLAST 3 QL: 100
in 300
days
REMICADE 2 PA, QL:
35 in 150
days
REVLIMID 2 LA, QL:
30 in 30
days
RIDAURA 2
SANDOSTATIN LAR 2
SENSIPAR 2
SIMPONI 2 PA, QL:
0.5 in 28
days
SIMULECT 2 PA
sodium fluoride (Sodium Fluoride) 3 drops, tab chew
71
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
SOLIRIS 2
SOMATULINE DEPOT 2 QL: 1 in
28 days
STELARA 2 PA, QL: disp syrin: 45mg/
10 in 360 0.5ml
days
STELARA 2 PA, QL:
10 in 360
days
vial
STELARA 2 PA, QL:
5 in 360
days
disp syrin: 90mg/ml
SUPPRELIN LA 2 QL: 1 in
360 days
SUPPRELIN 2
SYNAREL 2
tacrolimus (Prograf) 1 PA
THALOMID 2 QL: 60 in
30 days
THIOLA 2
THYMOGLOBULIN 2
TYSABRI 2 LA, PA,
QL: 15 in
28 days
ULORIC 2 ST, QL:
31 in 31
days
VANTAS 3 QL: 1 in
360 days
XGEVA 2 PA, QL:
1.7 in 28
days
ZAVESCA 2
ZOMETA 3 infus. btl
ZOMETA 3 vial
ZORTRESS 2 PA, QL: tablet: 0.5mg,
60 in 30
days
0.75mg
ZORTRESS 3 PA, QL:
60 in 30
days
tablet: 0.25mg
72
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Myasthenia Gravis
Myasthenia Gravis
Drug
Tier
Requirements/Limits
ENLON-PLUS
Mydriatics
Mydriatics
2
atropine sulfate (Isopto Atropine) 1
CYCLOGYL 2 drops: 0.5%, 2%
cyclopentolate hcl (Cyclogyl) 1
homatropine hbr (Isopto Homatropine) 1
ISOPTO
2 drops: 2%
HOMATROPINE
PROPINE 2
tropicamide
Opiate Antagonists
(Mydriacyl) 1
Opiate Antagonists
naloxone hcl (Naloxone HCl) 1 disp syrin
naloxone hcl (Naloxone HCl) 1 vial
naltrexone hcl (Revia) 1
Parasympathomimetics (Cholinergic Agents)
Parasympathomimetics (Cholinergic Agents)
ARICEPT 2 PA, QL:
31 in 31
tablet: 23mg
days
bethanechol chloride (Urecholine) 1
CHANTIX 3 PA, QL:
168 in 84
days
CHANTIX 3 PA, QL:
53 in 28
days
donepezil hcl (Aricept) 1 QL: 31 in
31 days
EVOXAC 2
EXELON 3 PA, QL:
30 in 30
days
EXELON 3 QL: 240
in 31
days
tablet
tab ds pk
patch td24
solution
73
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
galantamine hbr (Razadyne ER) 1 QL: 30 in cap24h pel
30 days
galantamine hbr (Razadyne) 1 QL: 200
in 30
days
solution
galantamine hbr (Razadyne) 1 QL: 60 in tablet
30 days
guanidine hcl (Guanidine HCl) 1
MESTINON 2 syrup, tablet er
MYTELASE 2
neostigmine methylsulfate (Neostigmine Methylsulfate) 1
NICOTROL 3 QL: 2016
in 365
days
physostigmine salicylate (Physostigmine Salicylate) 1
pilocarpine hcl (Salagen) 1
PROSTIGMIN 2
pyridostigmine bromide (Mestinon) 1
REGONOL 2
rivastigmine tartrate
Parathyroid
Parathyroid
(Exelon) 1 QL: 62 in
31 days
calcitonin,salmon,syntheti (Miacalcin) 1 QL: 3.7
c
in 28
days
FORTEO 3 PA, QL:
3 in 28
days
FORTICAL 2 QL: 3.7
in 28
days
MIACALCIN
Pituitary
Pituitary
2 PA vial, (PA for ESRD
only)
DDAVP 2 ampul: 15mcg/ml
desmopressin acetate (DDAVP) 1 tablet, vial
desmopressin acetate (Minirin) 1 QL: 15 in solution, spray/
30 days pump
74
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
GENOTROPIN 2 PA, QL:
28 in 28
days
disp syrin
GENOTROPIN 2 PA, QL:
5 in 28
days
cartridge
HUMATROPE 2 PA, QL:
18 in 28
days
cartridge: 6mg
HUMATROPE 2 PA, QL:
25 in 28
days
vial
HUMATROPE 2 PA, QL:
5 in 28
days
cartridge: 24mg
HUMATROPE 2 PA, QL:
9 in 28
days
cartridge: 12mg
NORDITROPIN
2 PA, QL: pen injctr: 15mg/
NORDIFLEX
13 in 28
days
1.5ml
NORDITROPIN
2 PA, QL: pen injctr: 30mg/
NORDIFLEX
15 in 28
days
3ml
NORDITROPIN
2 PA, QL: pen injctr: 10mg/
NORDIFLEX
20 in 28
days
1.5ml
NORDITROPIN
2 PA, QL: pen injctr: 5mg/
NORDIFLEX
39 in 28
days
1.5ml
NORDITROPIN 2 PA, QL:
17 in 28
days
vial: 8mg
NORDITROPIN 2 PA, QL:
33 in 28
days
vial: 4mg
NOVAREL 3
NUTROPIN AQ NUSPIN 2 PA, QL:
20 in 28
days
cartridge: 10mg/2ml
75
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
NUTROPIN AQ NUSPIN 2 PA, QL:
34 in 28
days
cartridge: 5mg/2ml
NUTROPIN AQ 2 PA, QL:
10 in 28
days
cartridge: 20mg/2ml
NUTROPIN AQ 2 PA, QL:
20 in 28
days
cartridge: 10mg/2ml
NUTROPIN 2 PA, QL:
10 in 28
days
OMNITROPE 2 PA, QL: cartridge: 10mg/
13.5 in
28 days
1.5ml
OMNITROPE 2 PA, QL: cartridge: 5mg/
22.5 in
28 days
1.5ml
OMNITROPE 2 PA, QL:
8 in 28
days
vial
SAIZEN 2 PA, QL:
3 in 28
days
cartridge
SAIZEN 2 PA, QL:
3 in 28
days
vial: 8.8mg
SAIZEN 2 PA, QL:
4 in 28
days
vial: 5mg
SEROSTIM 2 PA, QL:
28 in 28
days
TEV-TROPIN 2 PA, QL:
17 in 28
days
vasopressin (Pitressin) 1
ZORBTIVE 2 PA, QL:
28 in 28
days
76
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
Progestins
Progestins
DEPO-PROVERA 2 QL: 10 in vial: 400mg/ml
28 days
DEPO-SUBQ PROVERA
2 QL: 1 in
104
84 days
medroxyprogesterone acet (Depo-provera) 1 QL: 1 in
84 days
disp syrin
medroxyprogesterone acet (Depo-provera) 1 QL: 1 in
84 days
vial
medroxyprogesterone acet (Provera) 1 tablet
norethindrone acetate (Aygestin) 1
progesterone (Progesterone In Oil) 1
progesterone,micronized (Prometrium) 1
PROMETRIUM 2
Psychotherapeutic Agents
Antidepressants
amitrip hcl/
chlordiazepoxide
(Limbitrol) 1
amitriptyline hcl (Amitriptyline HCl) 1
amoxapine (Amoxapine) 1
bupropion hcl (Wellbutrin SR) 1
citalopram hydrobromide (Celexa) 1
clomipramine hcl (Anafranil) 1
CYMBALTA 2 QL: 30 in capsule dr: 30mg
30 days
CYMBALTA 2 QL: 60 in capsule dr: 20mg,
30 days 60mg
desipramine hcl (Norpramin) 1
doxepin hcl (Doxepin HCl) 1
EMSAM 3 QL: 30 in
30 days
escitalopram oxalate (Lexapro) 1 QL: 31 in tablet
31 days
escitalopram oxalate (Lexapro) 1 QL: 720
in 31
days
solution
fluoxetine hcl (Prozac) 1 capsule, capsule dr,
solution, tablet:
10mg, 20mg
77
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
fluoxetine hcl (Rapiflux) 1 tablet: 60mg
fluvoxamine maleate (Fluvoxamine Maleate) 1
imipramine hcl (Tofranil) 1
imipramine pamoate (Tofranil-PM) 1
LEXAPRO 3 ST, QL:
31 in 31
days
tablet
LEXAPRO 3 ST, QL:
720 in 31
days
solution
LUVOX CR 3 ST, QL:
62 in 31
days
cap er 24h: 150mg
LUVOX CR 3 ST, QL:
93 in 31
days
cap er 24h: 100mg
maprotiline hcl (Maprotiline HCl) 1
MARPLAN 3
mirtazapine (Remeron) 1
nefazodone hcl (Serzone) 1
nortriptyline hcl (Pamelor) 1
paroxetine hcl (Paxil) 1
perphenazine/
(Perphenazine/amitriptyline 1
amitriptyline hcl HCl)
phenelzine sulfate (Nardil) 1
PRISTIQ ER 3 ST, QL:
31 in 31
days
protriptyline hcl (Vivactil) 1
sertraline hcl (Zoloft) 1
tranylcypromine sulfate (Parnate) 1
trazodone hcl (Desyrel) 1
trimipramine maleate (Surmontil) 1
VENLAFAXINE HCL
ER
1
venlafaxine hcl (Effexor XR) 1
VIIBRYD 3 PA, QL:
30 in 30
days
tab ds pk
78
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
VIIBRYD 3 PA, QL:
30 in 30
days
tablet
Antipsychotic Agents
ABILIFY DISCMELT 2 QL: 62 in tab rapdis: 15mg
31 days
ABILIFY DISCMELT 2 QL: 93 in tab rapdis: 10mg
31 days
ABILIFY 2 QL:
161.2 in
28 days
vial
ABILIFY 2 QL: 31 in tablet
31 days
ABILIFY 2 QL: 930
in 31
days
solution
chlorpromazine hcl (Chlorpromazine HCl) 1 ampul, tablet
chlorpromazine hcl (Chlorpromazine HCl) 1 oral conc.
clozapine (Clozaril) 1 QL: 140
in 31
days
tablet: 200mg
clozapine (Clozaril) 1 QL: 279
in 31
days
tablet: 100mg
clozapine (Clozaril) 1 QL: 93 in tablet: 25mg, 50mg
31 days
FANAPT 3 ST, QL:
60 in 30
days
tablet
FANAPT 3 ST, QL:
8 in 28
days
tab ds pk
FAZACLO 3 ST, QL:
124 in 31
days
tab rapdis: 200mg
FAZACLO 3 ST, QL:
186 in 31
days
tab rapdis: 150mg
FAZACLO 3 ST, QL: tab rapdis: 12.5mg,
93 in 31
days
25mg, 100mg
79
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
fluphenazine decanoate (Fluphenazine Decanoate) 1
fluphenazine hcl (Fluphenazine HCl) 1
GEODON 3 QL: 6 in
28 days
vial
GEODON 3 QL: 62 in capsule
31 days
HALDOL DECANOATE
100
3
HALDOL DECANOATE
50
3
HALDOL 3
haloperidol decanoate (Haloperidol Decanoate) 1
haloperidol lactate (Haloperidol Lactate) 1
haloperidol (Haloperidol) 1
INVEGA SUSTENNA 2 QL: 0.25 disp syrin: 39mg/
in 28
days
0.25
INVEGA SUSTENNA 2 QL: 0.5 disp syrin: 78mg/
in 28
days
0.5ml
INVEGA SUSTENNA 2 QL: 0.75 disp syrin: 117mg/
in 28
days
0.75
INVEGA SUSTENNA 2 QL: 1 in disp syrin: 156mg/
28 days ml
INVEGA SUSTENNA 2 QL: 1.5 disp syrin: 234mg/
in 28
days
1.5
INVEGA 3 ST, QL: tab er 24: 1.5mg,
31 in 31
days
3mg, 9mg
INVEGA 3 ST, QL:
62 in 31
days
tab er 24: 6mg
LATUDA 3 ST, QL:
30 in 30
days
tablet: 20mg
LATUDA 3 ST, QL:
30 in 30
days
tablet: 40mg, 80mg
loxapine succinate (Loxitane) 1
80
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
MOBAN 3
NAVANE 3 capsule: 20mg
olanzapine (Zyprexa) 1 QL: 31 in
31 days
ORAP 3
perphenazine (Perphenazine) 1
quetiapine fumarate (Seroquel) 1 QL: 93 in
31 days
RISPERDAL CONSTA 3 QL: 4 in
28 days
risperidone (Risperdal M-tab) 1 QL: 124 tab rapdis: 3mg,
in 31
days
4mg
risperidone (Risperdal) 1 QL: 496
in 31
days
solution
risperidone (Risperdal) 1 QL: 62 in tab rapdis: 0.25mg,
31 days 0.5mg, 1mg, 2mg;
tablet
SAPHRIS 3 ST, QL:
60 in 30
days
SEROQUEL XR 2 QL: 31 in tab er 24h: 200mg
31 days
SEROQUEL XR 2 QL: 62 in tab er 24h: 50mg,
31 days 150mg, 300mg,
400mg
SEROQUEL 2 QL: 93 in
31 days
thioridazine hcl (Thioridazine HCl) 1 oral conc.
thioridazine hcl (Thioridazine HCl) 1 tablet
thiothixene (Navane) 1
trifluoperazine hcl (Trifluoperazine HCl) 1
ziprasidone hcl (Geodon) 1 QL: 62 in
31 days
ZYPREXA RELPREVV 2 QL: 2 in
28 days
Renin-Angiotensin-Aldosterone System Inhibitors
Angiotensin II Receptor Antagonists
BENICAR HCT 2 ST
BENICAR 2 ST
81
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
DIOVAN HCT 2 ST
DIOVAN 2 ST
eprosartan mesylate (Teveten) 1
irbesartan (Avapro) 1
irbesartan/
hydrochlorothiazide
(Avalide) 1
losartan potassium (Cozaar) 1
losartan/
hydrochlorothiazide
(Hyzaar) 1
TRIBENZOR 3 ST
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl (Lotensin) 1
benazepril/
hydrochlorothiazide
(Lotensin HCT) 1
captopril (Capoten) 1
captopril/
hydrochlorothiazide
(Capozide) 1
enalapril maleate (Vasotec) 1
enalapril/
hydrochlorothiazide
(Vaseretic) 1
enalaprilat dihydrate (Enalaprilat Dihydrate) 1
fosinopril sodium (Monopril) 1
fosinopril/
hydrochlorothiazide
(Monopril HCT) 1
lisinopril (Zestril) 1
lisinopril/
hydrochlorothiazide
(Prinzide) 1
moexipril hcl (Univasc) 1
moexipril/
hydrochlorothiazide
(Uniretic) 1
perindopril erbumine (Aceon) 1
quinapril hcl (Accupril) 1
quinapril/
hydrochlorothiazide
(Accuretic) 1
ramipril (Altace) 1
trandolapril (Mavik) 1
trandolapril/verapamil hcl (Trandolapril/verapamil HCl)
Renin-Angiotensin-Aldosterone System Inhibitors
1
eplerenone (Inspra) 1
spironolact/
hydrochlorothiazid
(Aldactazide) 1
82
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
spironolactone (Aldactone) 1
Replacement Preparations
Replacement Preparations
0.9 % sodium chloride (0.9 % Sodium Chloride) 1
calcium chloride (Calcium Chloride) 1
calcium gluconate (Calcium Gluconate) 1 PA (PA for ESRD only)
dex 2.5%-half str
lact.ringers
(Dex 2.5%-half Str Lact.ringers) 1
dextrose 2.5% in half
ringers
(Dextrose 2.5% In Half Ringers) 1
dextrose 5% in ringers (Dextrose 5% In Ringers) 1
dextrose 5%-lactated
ringers
(Dextrose 5%-Lactated Ringers) 1
DEXTROSE W/
ELECTROLYTE A
2
DEXTROSE W/
ELECTROLYTE B
2
electrolyte-48 solution/
d10w
(Electrolyte-48 Solution/d10w) 1
electrolyte-48 solution/
d5w
(Electrolyte-48 Solution/D5W) 1
electrolyte-48/fructose
10%
(Electrolyte-48/fructose 10%) 1
electrolyte-48/fructose 5% (Electrolyte-48/fructose 5%) 1
electrolyte-75 solution/
d5w
(Electrolyte-75 Solution/D5W) 1
electrolyte-75/fructose 5% (Electrolyte-75/fructose 5%) 1
electrolyte-r solution/d5w (Normosol-r and Dextrose) 1
HYPERLYTE CR 2
HYPERLYTE R 2
IONOSOL B with
DEXTROSE 5%
2
IONOSOL MB-
DEXTROSE 5%
2
IONOSOL T-DEXTROSE
5%
2
ISOLYTE E 2
ISOLYTE H W/
DEXTROSE
2
ISOLYTE M W/
DEXTROSE
2
83
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
ISOLYTE P with
DEXTROSE
2
ISOLYTE S with
DEXTROSE
2
ISOLYTE S 2
LACTATED RINGERS 3
NORMOSOL-M and
DEXTROSE
2
NORMOSOL-R PH 7.4 2
NUTRILYTE II 2
NUTRILYTE 2
PLASMA-LYTE 148 2
PLASMA-LYTE 56 IN
DEXTROSE
2
PLASMA-LYTE A PH
7.4
2
PLASMA-LYTE M IN
DEXTROSE
2
pot chloride/pot bicarb/cit
ac
(K-lyte-cl) 1
potassium acetate (Potassium Acetate) 1
potassium bicarbonate/cit
ac
(K-lyte) 1
potassium chlorid/d10- (Potassium Chlorid/d10-
1
0.2%nacl
0.2%NaCl)
potassium chlorid/d5- (Potassium Chlorid/d5-
1 iv soln: 10meq/l,
0.225nacl
0.225NaCl)
20meq/l, 40meq/l,
10meq/l, 20meq/l,
40meq/l
potassium chlorid/d5- (Potassium Chlorid/d5-
1 iv soln: 30meq/l
0.225nacl
0.225NaCl)
potassium chloride in (Potassium Chloride In
1
0.9%nacl
0.9%NaCl)
potassium chloride (Kaon-cl) 1 liquid, packet
potassium chloride (K-dur) 1 capsule er,
piggyback, tab er
prt, tablet er, tablet
sa, vial
potassium chloride/d5- (Potassium Chloride/D5-0.25 1 30meq/l
0.25ns
NS)
84
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
potassium chloride/d5- (Potassium Chloride/d5-
1
0.33nacl
0.33NaCl)
potassium chloride/d5- (Potassium Chloride/d5-
1
0.45nacl
0.45NaCl)
potassium chloride/d5- (Potassium Chloride/d5-
1
0.9%nacl
0.9%NaCl)
potassium chloride/d5lr (Potassium Chloride/D5 LR) 1
potassium chloride/d5w (Potassium Chloride/D5W) 1
potassium chloride-0.45% (Potassium Chloride-0.45% 1
nacl
NaCl)
potassium gluconate (Potassium Gluconate) 1
potassium phos,m-basic-d- (Potassium Phos,m-basic-d- 1
basicbasic)
ringers solution (Ringers Solution) 1
sodium acetate (Sodium Acetate) 1
sodium chloride 0.45 % (Sodium Chloride 0.45 %) 1
sodium chloride 3% (Sodium Chloride 3%) 1
sodium chloride 5% (Sodium Chloride 5%) 1
sodium chloride (Sodium Chloride) 1 vial: 2.5meq/ml
sodium chloride (Sodium Chloride) 1 vial: 4meq/ml
sodium phos,m-basic-dbasic
(Sodium Phos,m-basic-d-basic) 1
TPN ELECTROLYTES 2
TRAVERT-
ELECTROLYTE NO.1
2
TRAVERT-
ELECTROLYTE NO.2
2 iv soln: 10%
TRAVERT-
ELECTROLYTE NO.2
2 iv soln: 5%
TRAVERT-
ELECTROLYTE NO.3
2
TRAVERT-
ELECTROLYTE NO.4
2
Respiratory Tract Agents, Miscellaneous
Respiratory Tract Agents, Miscellaneous
acetylcysteine (Acetylcysteine) 1
aminophylline (Aminophylline) 1 liquid
aminophylline (Aminophylline) 1 tablet, vial
ARALAST NP 2
85
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
DALIRESP 3 ST, QL:
30 in 30
days
guaifen/theop anhyd/pephed
(Guaifen/theop Anhyd/p-ephed) 1
PROLASTIN C 2
PROLASTIN 2
theophylline anhydrous (Theochron) 1 elixir, tab er 12h:
100mg, 200mg,
300mg, 450mg;
tablet er
theophylline anhydrous (Theochron) 1 solution, tab er 12h:
200mg
theophylline/dextrose 5%- (Theophylline/dextrose 5%- 1
waterwater)
XOLAIR 2 PA, QL:
6 in 28
days
ZEMAIRA
Sclerosing Agents
Sclerosing Agents
2
ethanolamine oleate (Ethanolamine Oleate) 1
sodium morrhuate (Sodium Morrhuate) 1
sodium tetradecyl sulfate (Sodium Tetradecyl Sulfate) 1
talc (Talc) 1
Second Generation Antihistamines
Second Generation Antihistamines
fexofenadine hcl (Allegra) 1
levocetirizine
dihydrochloride
Serums
Serums
(Xyzal) 1
ANASCORP 2
ANTIVENIN
LATRODECTUS
MACTANS
2
ANTIVENIN
MICRURUS FULVIUS
2
CARIMUNE NF
NANOFILTERED
2 PA
86
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
CROFAB 2
CYTOGAM 2
DIGIBIND 2
DIGIFAB 2
FLEBOGAMMA DIF 2 PA
FLEBOGAMMA 2 PA
GAMASTAN S-D 2 PA
GAMMAGARD S-D 2 PA
GAMMAPLEX 2 PA
GAMUNEX 2 PA
HIZENTRA 2 PA
HYPERRAB S-D 2
HYPERRHO S-D 2
IMOGAM RABIES-HT 2
MICRHOGAM PLUS 2
OCTAGAM 2 PA
PRIVIGEN 2 PA
RHOGAM PLUS 2
RHOPHYLAC 2
VIVAGLOBIN 2 PA
WINRHO SDF 2
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen (Baclofen) 1
carisoprodol (Soma) 1 QL: 120
in 30
days
tablet: 250mg
carisoprodol (Soma) 1 QL: 120
in 30
days
tablet: 350mg
carisoprodol/aspirin (Soma Compound) 1 QL: 240
in 30
days
chlorzoxazone (Parafon Forte DSC) 1
chlorzoxazone/
acetaminophen
(Chlorzoxazone/acetaminophen) 1
codeine phos/
carisoprodol/asa
(Soma Compound with Codeine) 1
cyclobenzaprine hcl (Flexeril) 1
dantrolene sodium (Dantrium) 1 capsule
87
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
dantrolene sodium (Dantrium) 1 vial
metaxalone (Skelaxin) 1
methocarbamol (Robaxin-750) 1
orphenadrine citrate (Norflex) 1
orphenadrine/aspirin/
caffeine
(Norgesic Forte) 1
tizanidine hcl (Zanaflex) 1
Skin and Mucous Membrane Agents, Miscellaneous
Skin and Mucous Membrane Agents, Miscellaneous
8-MOP 2
adapalene (Differin) 1
AMEVIVE 2 PA, QL:
4 in 28
days
ammonium lactate (Lac-hydrin) 1
calcipotriene (Dovonex) 1
calcitriol (Vectical) 1
CARAC 2
CONDYLOX 3 gel (gram)
DOVONEX 2 cream
ELIDEL 2 PA
FLUOROPLEX 2
fluorouracil (Efudex) 1
imiquimod (Aldara) 1 PA, QL:
24 in 30
days
isotretinoin (Accutane) 1
LEVULAN 2
METVIXIA 2
OXSORALEN-ULTRA 2
PANRETIN 2
PICATO 3 PA, QL:
2 in 56
days
gel (ea): 0.05%
PICATO 3 PA, QL:
3 in 56
days
gel (ea): 0.015%
podofilox (Condylox) 1
podophyllum resin (Pododerm) 1
PROTOPIC 3 PA
88
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
REGRANEX 2 PA, QL:
30 in 30
days
SANTYL 2
TARGRETIN 2
TAZORAC 2
UVADEX 2
VECTICAL 3
ZYCLARA 3 PA, QL:
28 in 28
days
Somatotropin Agonists and Antagonists
Somatotropin Agonists and Antagonists
INCRELEX 2
SOMAVERT 2
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
alfuzosin hcl (Uroxatral) 1
DIBENZYLINE 2
dihydroergotamine
mesylate
(D.H.E. 45) 1
ERGOMAR 2
ergotamine tartrate/
caffeine
(Ergotamine Tartrate/caffeine) 1
phentolamine mesylate (Phentolamine Mesylate) 1 PA
tamsulosin hcl (Flomax) 1
Sympathomimetic (Adrenergic) Agents
Sympathomimetic (Adrenergic) Agents
albuterol sulfate (Accuneb) 1 PA solution, vial-neb:
0.63mg/3ml,
1.25mg/3ml, 2.5mg/
3ml
albuterol sulfate (Proventil) 1 syrup, tab er 12h,
tablet
albuterol (Albuterol) 1
COMBIVENT 2 QL: 29.4
in 30
days
dobutamine hcl (Dobutamine HCl) 1 PA
dobutamine hcl/d5w (Dobutamine HCl/D5W) 1 PA
89
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
dopamine hcl (Dopamine HCl) 1 PA
dopamine hcl/dextrose (Dopamine HCl/dextrose 5%- 1 PA
5%-water
water)
ephedrine sulfate (Ephedrine Sulfate) 1
epinephrine (Adrenaclick) 1 QL: 2 in
30 days
pen injctr
epinephrine (Epinephrine) 1 disp syrin
epinephrine/pf (Epinephrine/PF) 1
EPIPEN JR 3 QL: 2 in
30 days
EPIPEN 3 QL: 2 in
30 days
FORADIL 2 QL: 62 in
31 days
isoproterenol hcl (Isoproterenol HCl) 1
metaproterenol sulfate (Metaproterenol Sulfate) 1 syrup, tablet
midodrine hcl (Proamatine) 1
norepinephrine bit/0.9 % (Norepinephrine Bit/0.9 % 1 PA
nacl
NaCl)
norepinephrine bitartrate (Norepinephrine Bitartrate) 1 PA
phenylephrine hcl (Phenylephrine HCl) 1
phenylephrine tannate (Phenylephrine Tannate) 1
PROAIR HFA 2 QL: 17 in
25 days
SEREVENT DISKUS 2 QL: 62 in
31 days
terbutaline sulfate (Brethine) 1
Thyroid and Antithyroid Agents
Thyroid and Antithyroid Agents
ARMOUR THYROID 3
levothyroxine sodium (Levothyroxine Sodium) 1 vial
levothyroxine sodium (Synthroid) 1 tablet
liothyronine sodium (Cytomel) 1
methimazole (Tapazole) 1 tablet: 20mg
methimazole (Tapazole) 1 tablet: 5mg, 10mg
propylthiouracil (Propylthiouracil) 1
thyroid
Toxoids
Toxoids
(Thyroid) 1
ADACEL 2 disp syrin
90
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
ADACEL 2 vial
BOOSTRIX 2
DAPTACEL 2
DIPHTHERIA-
TETANUS TOXOID
2
INFANRIX 2 vial: 25-58-10
TE ANATOXAL BERNA 2 PA
TENIVAC 2
TETANUS DIPHTHERIA
TOXOIDS
1
TETANUS TOXOID
ADSORBED
2 PA
TETANUS-DIPHTERIA-
DECAVAC
2
TRIHIBIT 2
TRIPEDIA 2
Urinary Anti-infectives
Urinary Anti-infectives
methen mand/naphos m-b (Methen Mand/naphos M-b M- 1
m-h
h)
methen/m-blue/sal/na
phos/hyos
(Uro Blue) 1
methenamine hippurate (Hiprex) 1
methenamine mandelate (Mandelamine) 1
MONUROL 2
mth/me blue/sod phos/ (Mth/me Blue/sod Phos/phen/ 1
phen/hyos
hyos)
nitrofurantoin
macrocrystal
(Macrobid) 1
nitrofurantoin (Furadantin) 1
PRIMSOL 2
trimethoprim
Vaccines
Vaccines
(Trimethoprim) 1
ACTHIB 2
ATTENUVAX
VACCINE with
DILUENT
2 PA
BCG VACCINE (TICE
STRAIN)
2 PA
91
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
BIOTHRAX 2
CERVARIX 3
COMVAX 2
ENGERIX-B 2 PA disp syrin: 10mcg/
0.5
ENGERIX-B 2 PA disp syrin: 20mcg/
ml; vial
GARDASIL 3 disp syrin
GARDASIL 3 vial
HAVRIX 2 PA disp syrin
HAVRIX 2 PA vial
HIBERIX 2
IMOVAX RABIES
VACCINE
2 PA
IPOL 2
IXIARO 2
JE-VAX 2
KINRIX 2
MENACTRA 2 disp syrin
MENACTRA 2 vial
MENOMUNE-A-C-Y-W-
135
2
MENVEO A-C-Y-W-135-
DIP
2
MERUVAX II VACCINE
W-DILUENT
2
M-M-R II VACCINE 2
MUMPSVAX VACCINE
W-DILUENT
2
PEDIARIX 2
PEDVAXHIB 2
PENTACEL 2
PROQUAD 3
RABAVERT 2 PA
RECOMBIVAX HB 2 PA disp syrin
RECOMBIVAX HB 2 PA vial
ROTARIX 2
ROTATEQ 2
THERACYS 2 PA
TWINRIX 2 disp syrin
92
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
TWINRIX 2 vial
TYPHIM VI 2
VAQTA 2 PA disp syrin
VAQTA 2 PA vial
VARIVAX VACCINE 2
VIVOTIF BERNA 2
YF-VAX 2
ZOSTAVAX
Vasodilating Agents
2
Vasodilating Agents
ADCIRCA 2 PA, QL:
60 in 30
days
AGGRENOX 2 QL: 60 in
30 days
alprostadil (Prostin Vr Pediatric) 1 PA
amyl nitrite (Amyl Nitrite) 1
dipyridamole (Persantine) 1
epoprostenol sodium
(glycine)
(Flolan) 1 PA vial: 0.5mg
epoprostenol sodium
(glycine)
(Flolan) 2 PA vial: 1.5mg
isosorbide dinitrate (Isordil) 1
isosorbide mononitrate (Imdur) 1
ISOVEX 2
LETAIRIS 2 PA, QL:
30 in 30
days
NITRO-BID 2
nitroglycerin (Nitro-dur) 1 QL: 30 in patch td24: 0.1mg/
30 days hr, 0.2mg/hr, 0.6mg/
hr
nitroglycerin (Nitro-dur) 1 QL: 60 in patch td24: 0.4mg/
30 days hr
nitroglycerin (Nitroglycerin) 1 vial
nitroglycerin (Nitrolingual) 1 spray
nitroglycerin/d5w (Nitroglycerin/D5W) 1
NITROSTAT 2
nylidrin hcl (Nylidrin HCl) 1 tablet: 12mg
papaverine hcl (Papaverine HCl) 1 PA
93
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

Drug Name
Drug
Tier
Requirements/Limits
REMODULIN 2 PA
REVATIO 2 PA, QL:
37.5 in 1
day
vial
REVATIO 2 PA, QL:
90 in 30
days
tablet
TRACLEER 2 LA, PA,
QL: 60 in
30 days
Vitamins and Minerals
Vitamins and Minerals
calcitriol (Rocaltrol) 1 PA (PA for ESRD only)
CYANOKIT 2
FLUOR-A-DAY 3
fluoride/iron/vit a,c&d (Fluoride/iron/vit A,c&d) 3
FLURA 3
GESTICARE DHA 2
HECTOROL 2 PA (PA for ESRD only)
iron,carbonyl/vit c/vit b12/
fa
(Iron,carbonyl/vit C/vit B12/fa) 2
LOZI-FLUR 3
multivitamins with
fluoride
(Multivitamins with Fluoride) 3 drops
multivitamins with
fluoride
(Multivitamins with Fluoride) 3 tab chew
ped mv a,c,d3 #21 wfluoride
(Ped Mv A,c,d3 #21 W-fluoride) 3
pedi mvi no.12/sodium
fluoride
(Mvc-fluoride) 3
pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/fa) 2
sodium fluoride (Luride) 3
94
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

INDEX
0.9 % sodium chloride .......83 ADCIRCA..........................93 amiloride/
8-MOP................................88 ADVAIR DISKUS.............10 hydrochlorothiazide....... 57
aa/antipyrn/bcaine/polico#1/ ADVAIR HFA ...................10 aminocaproic acid ............. 63
al ....................................66 AFINITOR .........................39 aminophylline .................... 85
aa/antpy/bcaine/polico/al AGGRENOX .....................93 AMINOSYN...................... 52
acet.................................66 AKTEN ..............................66 AMINOSYN II.................. 51
ABELCET..........................31 ALAMAST.........................18 AMINOSYN II 3.5% M-
ABILIFY............................79 ALBENZA .........................18 DEXTROSE 5%............ 51
ABILIFY DISCMELT.......79 ALBUKED-25 ...................50 AMINOSYN II 3.5%-
ABRAXANE ..................... 39 ALBUKED-5 .....................50 DEXTROSE 25%.......... 51
acarbose.............................25 ALBUMARC .....................50 AMINOSYN II 3.5%acebutolol
hcl.....................49 ALBUMIN HUMAN .........50 DEXTROSE 5%............ 51
acetaminophen with codeine ALBUMINAR-25 ..............50 AMINOSYN II 4.25% M-
........................................13 ALBUMINAR-5 ................50 DEXT 10% .................... 51
acetaminophen/phenyltolx cit ALBURX ...........................50 AMINOSYN II 4.25%-
........................................12 ALBUTEIN........................50 DEXTROSE 25%.......... 51
acetazolamide ....................32 albuterol .............................89 AMINOSYN II 5% IN 25%
acetazolamide sodium........31 albuterol sulfate..................89 DEXTROSE .................. 51
acetic ac/ricinoleic/oxyquinol alclometasone dipropionate AMINOSYN II IN
........................................35 ........................................36 DEXTROSE .................. 51
acetic acid ....................32, 65 alcohol antiseptic pads.......35 AMINOSYN II with LYTESacetic
acid/aluminum acetate ALDURAZYME................58 CA-DW.......................... 51
........................................32 alendronate sodium............67 AMINOSYN M ................. 51
acetic acid/hydrocortisone.32 ALFERON N......................48 AMINOSYN with
acetylcysteine .....................85 alfuzosin hcl........................89 ELECTROLYTES......... 52
ACTEMRA........................67 ALIMTA ............................39 AMINOSYN-HBC ............ 52
ACTHAR H.P....................11 ALINIA ..............................45 AMINOSYN-HF ............... 52
ACTHIB.............................91 allopurinol..........................68 AMINOSYN-PF................ 52
ACTIMMUNE...................67 allopurinol sodium .............67 AMINOSYN-RF ............... 52
ACTONEL.........................67 ALPHAGAN P...................32 amiodarone hcl.................. 54
ACTONEL with CALCIUM alprostadil ..........................93 AMITIZA .......................... 55
........................................67 ALREX...............................35 amitrip hcl/chlordiazepoxide
ACTOPLUS MET .............29 aluminum chloride..............49 ....................................... 77
ACTOPLUS MET XR.......29 amantadine hcl ...................44 amitriptyline hcl................. 77
ACTOS ..............................29 AMBISOME ......................31 amlodipine besylate ........... 51
acyclovir.............................48 amcinonide .........................36 amlodipine besylate/
acyclovir sodium ................48 AMERICAINE...................46 benazepril ...................... 51
ADACEL .....................90, 91 AMEVIVE .........................88 amlodipine/atorvastatin..... 38
ADAGEN...........................58 amifostine crystalline .........68 ammonium chloride ........... 10
adapalene...........................88 amikacin sulfate..................18 ammonium lactate.............. 88
ADCETRIS........................39 amiloride hcl ......................57 amoxapine.......................... 77
I-1
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

amoxicillin..........................22 atenolol...............................49 BCG VACCINE TICE
amoxicillin/potassium clav.22 atenolol/chlorthalidone ......49 STRAIN......................... 91
amphet asp/amphet/d-amphet ATGAM .............................68 benazepril hcl .................... 82
........................................17 atorvastatin calcium...........38 benazepril/
AMPHOTEC......................31 atovaquone/proguanil hcl ..45 hydrochlorothiazide....... 82
amphotericin b ...................31 ATRIPLA...........................46 BENICAR.......................... 81
ampicillin sodium...............22 atropine sulfate.............23, 73 BENICAR HCT................. 81
ampicillin sodium/sulbactam ATROVENT HFA .............23 BENLYSTA ...................... 68
na....................................22 ATTENUVAX VACCINE benzocaine ......................... 66
ampicillin trihydrate ..........22 with DILUENT ..............91 benzoyl peroxide................ 66
AMPYRA ..........................68 AVANDAMET ..................30 benzoyl peroxide
amyl nitrite.........................93 AVANDARYL...................30 microspheres.................. 65
ANACAINE.......................46 AVANDIA .........................30 benzoyl peroxide&skin
ANADROL-50................... 16 AVASTIN ..........................39 cleansr5 ......................... 65
anagrelide hcl ....................63 AVC ...................................35 benzoyl peroxide/aloe vera 66
ANASCORP ......................86 AVELOX ...........................23 benzoyl peroxide/
anastrozole.........................39 AVELOX ABC PACK.......22 hydrocortison................. 66
ANDRODERM..................16 AVELOX IV ......................23 benzoyl peroxide/skin clnsr7
ANDROGEL......................16 AVODART ........................68 ....................................... 66
antipyrine/benzocaine/
AVONEX...........................68 benzoyl peroxide/urea........ 66
glycerin ..........................66 AVONEX
benztropine mesylate ......... 44
ANTIVENIN
ADMINISTRATION
BERINERT........................ 68
LATRODECTUS
PACK .............................68 betamet acet/betamet na ph10
MACTANS....................86 AVONEX PEN ..................68 betamet diprop/prop gly .... 36
ANTIVENIN MICRURUS AXIRON ............................16 betamethasone dipropionate
FULVIUS.......................86 azathioprine........................68 ....................................... 36
ANTIVERT........................31 azathioprine sodium ...........68 betamethasone valerate ..... 36
APEXICON E....................36 azelastine hcl......................18 BETASERON.................... 68
APOKYN...........................44 AZILECT ...........................44 betaxolol hcl ................ 32, 49
apraclonidine hcl ...............57 azithromycin.................20, 21 bethanechol chloride ......... 73
APRISO .............................36 azithromycin hydrogen citrate BETIMOL ......................... 32
APTIVUS...........................46 ........................................20 BEXXAR........................... 39
ARALAST NP...................85 AZOPT...............................32 bicalutamide ...................... 39
ARANESP .........................63 AZOR.................................51 BICILLIN C-R .................. 22
ARCALYST ......................68 aztreonam...........................21 BICILLIN L-A .................. 22
ARICEPT...........................73 bacitracin .....................19, 32 BICNU............................... 39
ARMOUR THYROID.......90 bacitracin/polymyxin b sulfate BILTRICIDE..................... 18
ARRANON........................39 ........................................32 BIOTHRAX....................... 92
ARZERRA.........................39 baclofen ..............................87 bisoprolol fumarate ........... 49
ASACOL............................36 BAL IN OIL.......................60 bisoprolol fumarate/hctz.... 49
ASACOL HD.....................36 balsalazide disodium..........36 bleomycin sulfate ............... 39
aspirin ................................12 BANZEL ............................24 BLEPHAMIDE ................. 32
ASTEPRO..........................18 BARACLUDE ...................48 BLEPHAMIDE S.O.P. ...... 32
ASTRAMORPH-PF ..........13 BONIVA............................ 68
I-2
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

BOOSTRIX........................91 CARBAGLU......................12 cefuroxime sodium/
BOTOX..............................68 carbamazepine ...................24 dextrose,iso.................... 20
BRANCHAMIN ................52 carbidopa/levodopa............44 CELEBREX....................... 12
brimonidine tartrate...........32 carbidopa/levodopa/
CELLCEPT ....................... 68
BROMDAY .......................35 entacapone .....................45 CELONTIN ....................... 25
bromfenac sodium..............35 carbinoxamine maleate ......59 cephalexin.......................... 20
bromocriptine mesylate......44 carboplatin .........................40 CEPROTIN........................ 61
budesonide .........................10 CARDENE I.V...................51 CEREDASE....................... 58
bumetanide.........................57 CARDIZEM CD ................50 CEREZYME...................... 58
BUMINATE ......................50 CARIMUNE NF
CERVARIX....................... 92
BUPHENYL ......................12 NANOFILTERED .........86 CESAMET......................... 30
BUPRENEX ...................... 16 carisoprodol .......................87 CHANTIX ......................... 73
buprenorphine hcl..............16 carisoprodol/aspirin...........87 CHEMET........................... 60
bupropion hcl.....................77 CARMOL SCALP .............66 CHENODAL ..................... 60
buspirone hcl......................49 carteolol hcl........................57 chloral hydrate .................. 49
BUSULFEX....................... 39 carvedilol............................49 chloramphenicol na succ... 19
butorphanol tartrate...........16 CAYSTON.........................21 chlorhexidine gluconate .... 32
BYETTA............................25 CEENU...............................40 chloroprocaine hcl/pf ........ 66
BYSTOLIC........................49 cefaclor...............................20 chloroquine phosphate ...... 45
cabergoline ........................44 cefadroxil hydrate ..............20 chlorothiazide .................... 57
CA-DTPA ..........................60 cefazolin sodium.................20 chlorothiazide sodium ....... 57
caffeine citrated .................17 cefazolin sodium/dextrose,iso chloroxylenol/pramoxine hcl
caffeine/sodium benzoate...17 ........................................20 ....................................... 66
calcipotriene ......................88 cefdinir ...............................20 chlorpheniramine maleate. 59
calcitonin,salmon,synthetic 74 cefditoren pivoxil................20 chlorpromazine hcl............ 79
calcitriol.......................88, 94 CEFEPIME.........................20 chlorpropamide ................. 28
calcium acetate ..................65 cefepime hcl........................20 chlorthalidone.................... 57
calcium carbonate/mag carb/ CEFEPIME-DEXTROSE ..20 chlorzoxazone .................... 87
fa ....................................65 cefotaxime sodium..............20 chlorzoxazone/acetaminophen
calcium chloride.................83 cefotetan disod/dextrose,iso21 ....................................... 87
CALCIUM DISODIUM
cefotetan disodium..............21 cholestyramine (with sugar)
VERSENATE ................60 cefoxitin sodium..................21 ....................................... 38
calcium gluconate ..............83 cefoxitin sodium/dextrose,iso cholestyramine/aspartame. 38
CALDOLOR......................12 ........................................21 choline sal/mag salicylate . 12
CAMPATH........................39 cefpodoxime proxetil ..........20 ciclopirox........................... 34
CAMPRAL ........................55 cefprozil..............................20 ciclopirox olamine ............. 34
CANCIDAS .......................31 CEFTAZIDIME .................20 cilostazol............................ 63
CANTIL.............................23 ceftazidime pentahydrate....20 cimetidine........................... 46
CAPASTAT SULFATE ....39 CEFTRIAXONE ................20 cimetidine hcl..................... 46
CAPRELSA .......................40 ceftriaxone na/dextrose,iso.20 cimetidine in 0.9 % nacl .... 46
captopril.............................82 ceftriaxone sodium .............20 CIMZIA............................. 60
captopril/hydrochlorothiazide cefuroxime axetil ................20 CINRYZE.......................... 68
........................................82 cefuroxime sodium..............20 CIPRO HC......................... 32
CARAC..............................88
CIPRODEX ....................... 32
I-3
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

ciprofloxacin hcl ..........23, 33 codeine/butalbital/asa/caffein cysteine hcl ........................ 52
ciprofloxacin lactate ..........23 ........................................14 cytarabine/pf...................... 40
ciprofloxacin lactate/d5w...23 colchicine/probenecid ........68 CYTOGAM....................... 87
ciprofloxacin/ciprofloxa hcl COLCRYS .........................69 dacarbazine ....................... 40
........................................23 colestipol hcl ......................38 DACOGEN........................ 40
cisplatin..............................40 colistin (colistimethate na).19 dactinomycin...................... 40
citalopram hydrobromide ..77 COLY-MYCIN S ...............33 DALIRESP ........................ 86
citrate-phos-dex solution ...61 COMBIGAN ......................32 danazol............................... 16
citric acid/sodium citrate ...10 COMBIPATCH..................58 dantrolene sodium ....... 87, 88
cladribine ...........................40 COMBIVENT ....................89 dapsone.............................. 39
clarithromycin....................21 COMPLERA ......................46 DAPTACEL ...................... 91
clemastine fumarate...........59 COMTAN...........................45 DARAPRIM ...................... 45
CLEVIPREX......................51 COMVAX ..........................92 daunorubicin hcl................ 40
clindamycin hcl ..................19 CONCERTA ......................17 DAUNOXOME................. 40
clindamycin palmitate hcl..19 CONDYLOX .....................88 DDAVP ............................. 74
clindamycin phos/benzoyl COPAXONE ......................69 deferoxamine mesylate ...... 60
perox ..............................34 CORDRAN ........................37 demeclocycline hcl............. 23
clindamycin phosphate.19, 34 CORDRAN SP...................37 DENAVIR ......................... 34
CLINIMIX ......................... 52 COREG CR........................49 DEPEN .............................. 61
CLINIMIX E......................52 cortisone acetate ................10 DEPO-MEDROL............... 10
CLINISOL .........................52 CORTISPORIN-TC ...........33 DEPO-PROVERA............. 77
clobetasol propionate.........36 COUMADIN......................61 DEPO-SUBQ PROVERA
CLODERM........................37 CREON ..............................60 104 ................................. 77
CLOLAR............................40 CRESTOR..........................38 desipramine hcl.................. 77
clomipramine hcl ...............77 cresyl ace/ben alc/butanol/ipa desmopressin acetate......... 74
clonidine.............................64 ........................................33 desogestrel-ethinyl estradiol
clonidine hcl.......................64 CRIXIVAN ........................46 ....................................... 56
clonidine hcl/chlorthalidone CROFAB............................87 desog-et estra/ethin estra... 56
........................................64 cromolyn sodium ................36 desonide............................. 37
clotrimazole........................34 CUBICIN ...........................19 desoximetasone.................. 37
clotrimazole/betamethasone CUPRIMINE......................60 DETROL ........................... 60
dip ..................................34 CUTIVATE........................37 DETROL LA ..................... 60
clozapine ............................79 CYANOKIT.......................94 dex 2.5%-half str lact.ringers
COARTEM........................45 cyclobenzaprine hcl............87 ....................................... 83
cocaine hcl .........................66 CYCLOGYL ......................73 dexamethasone................... 10
codeine phos/acetaminophen cyclopentolate hcl...............73 dexamethasone sod phosphate
........................................13 cyclophosphamide ..............40 ................................. 10, 35
codeine phos/carisoprodol/ cycloserine..........................39 dexchlorpheniramine maleate
asa..................................87 cyclosporine .......................69 ....................................... 59
codeine phosphate..............13 cyclosporine, modified .......69 DEXILANT....................... 46
codeine sulf ........................13 CYMBALTA .....................77 dexmethylphenidate hcl ..... 17
codeine/butalbit/acetamin/ cyproheptadine hcl .............59 dexrazoxane....................... 69
caff..................................14 CYSTADANE....................69
CYSTAGON ......................69
dextroamphetamine sulfate 17
I-4
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

dextrose 10 % and 0.225 % DIGIFAB............................87 DUETACT......................... 30
nacl.................................52 digoxin................................54 DULERA........................... 10
dextrose 10 % and 0.9 % nacl DIGOXIN...........................54 DUODOTE........................ 69
........................................52 dihydroergotamine mesylate DUREZOL......................... 35
dextrose 10%-0.5 normal
........................................89 DUTOPROL...................... 49
saline..............................52 DILANTIN.........................25 DYRENIUM...................... 57
dextrose 10%-water ...........52 diltiazem hcl .......................50 DYSPORT......................... 69
dextrose 2.5% in half ringers dimenhydrinate...................31 econazole nitrate................ 34
........................................83 DIOVAN ............................82 edetate disodium................ 61
dextrose 2.5%-0.5normal DIOVAN HCT ...................82 EDURANT ........................ 46
saline..............................52 DIPENTUM .......................36 EFFIENT ........................... 63
dextrose 2.5%-water ..........52 diphenhydramine hcl..........59 ELAPRASE....................... 58
dextrose 20%-water ...........52 diphenoxylate hcl/atropine.30 electrolyte-48 solution/d10w
dextrose 25%-water ...........52 DIPHTHERIA-TETANUS
....................................... 83
dextrose 40%-water ...........52 TOXOID.........................91 electrolyte-48 solution/d5w 83
dextrose 5 % and 0.33 % nacl dipyridamole.......................93 electrolyte-48/fructose 10%83
........................................52 disopyramide phosphate.....54 electrolyte-48/fructose 5%. 83
dextrose 5 % and 0.9 % nacl disulfiram ...........................69 electrolyte-75 solution/d5w 83
........................................52 divalproex sodium ..............24 electrolyte-75/fructose 5%. 83
dextrose 5 %-0.225 % nacl 52 dobutamine hcl ...................89 electrolyte-r solution/d5w.. 83
dextrose 5 %-0.45 % nacl ..53 dobutamine hcl/d5w ...........89 ELIDEL ............................. 88
dextrose 5% in ringers.......83 DOCEFREZ .......................40 ELIGARD.......................... 40
dextrose 5%-lactated ringers docetaxel.............................40 ELITEK ............................. 58
........................................83 donepezil hcl.......................73 ELMIRON......................... 69
dextrose 5%-water .............53 dopamine hcl ......................90 ELSPAR ............................ 40
dextrose 50%-water ...........53 dopamine hcl/dextrose 5%- EMCYT ............................. 40
dextrose 60%-water ...........53 water...............................90 EMEND............................. 30
dextrose 70%-water ...........53 DORIBAX..........................21 EMSAM............................. 77
DEXTROSE W/
dorzolamide hcl..................32 EMTRIVA......................... 46
ELECTROLYTE A .......83 dorzolamide hcl/timolol
enalapril maleate............... 82
DEXTROSE W/
maleat.............................32 enalapril/hydrochlorothiazide
ELECTROLYTE B........83 DOVONEX ........................88 ....................................... 82
dhcodeine bt/acetaminophn/ doxazosin mesylate.............12 enalaprilat dihydrate ......... 82
caff..................................14 doxepin hcl .........................77 ENBREL............................ 69
DIBENZYLINE.................89 DOXIL ...............................40 ENDRATE......................... 61
diclofenac potassium..........12 doxorubicin hcl...................40 ENGERIX-B...................... 92
diclofenac sodium ........12, 35 doxorubicin hcl liposomal..40 ENLON-PLUS .................. 73
dicloxacillin sodium...........22 doxycycline hyclate ......23, 33 enoxaparin sodium ............ 61
dicyclomine hcl ..................23 doxycycline monohydrate...23 ephedrine sulfate................ 90
didanosine..........................46 doxylamine succinate .........59 epinastine hcl..................... 18
DIFICID.............................21 DRITHO-SCALP...............66 epinephrine ........................ 90
diflorasone diacetate..........37 dronabinol ..........................30 epinephrine/pf.................... 90
diflunisal ............................12 droperidol...........................49 EPIPEN.............................. 90
DIGIBIND .........................87 DROXIA ............................40 EPIPEN JR ........................ 90
I-5
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

epirubicin hcl .....................40 ethynodiol d-ethinyl estradiol FLOVENT DISKUS.... 10, 11
EPIVIR...............................47 ........................................56 FLOVENT HFA................ 11
EPIVIR HBV .....................46 etidronate disodium............69 floxuridine.......................... 41
eplerenone..........................82 etodolac ..............................12 fluconazole......................... 31
EPOGEN............................64 ETOPOPHOS.....................41 fluconazole in nacl,iso-osm 31
epoprostenol sodium (glycine) etoposide.............................41 flucytosine.......................... 31
........................................93 EURAX ..............................35 fludarabine phosphate ....... 41
eprosartan mesylate...........82 EVISTA..............................59 fludrocortisone acetate...... 11
EPZICOM..........................47 EVOXAC ...........................73 flumazenil........................... 55
ERAXIS WATER DILUENT EXELDERM ......................34 flunisolide .......................... 35
........................................31 EXELON............................73 fluocinolone acetonide....... 37
ERBITUX ..........................40 exemestane .........................41 fluocinolone acetonide oil . 35
ergoloid mesylates .............69 EXFORGE .........................51 fluocinolone/shower cap.... 37
ERGOMAR........................89 EXFORGE HCT ................51 fluocinonide ....................... 37
ergotamine tartrate/caffeine EXJADE.............................61 FLUOR-A-DAY.......... 69, 94
........................................89 EXTAVIA ..........................69 fluoride/iron/vit a,c&d....... 94
ERIVEDGE........................41 FABRAZYME ...................58 FLUORITAB..................... 69
ERWINAZE.......................41 famciclovir..........................48 fluorometholone................. 35
ery e-succ/sulfisoxazole .....21 famotidine...........................46 FLUOROPLEX ................. 88
ERY-TAB ..........................21 famotidine in nacl,iso-osm/pf fluorouracil.................. 41, 88
ERYTHROCIN
........................................46 fluoxetine hcl................ 77, 78
LACTOBIONATE.........21 FANAPT ............................79 fluoxymesterone................. 17
erythromycin base........21, 33 FARESTON .......................41 fluphenazine decanoate ..... 80
erythromycin base/ethanol.34 FASLODEX.......................41 fluphenazine hcl................. 80
erythromycin ethylsuccinate FAZACLO .........................79 FLURA .............................. 94
........................................21 felbamate ............................24 FLURA-DROPS................ 69
erythromycin stearate ........21 felodipine............................51 flurbiprofen........................ 12
erythromycin/benzoyl
fenofibrate ..........................38 flurbiprofen sodium ........... 35
peroxide..........................34 fenofibrate,micronized........38 flutamide ............................ 41
escitalopram oxalate..........77 fenofibric acid ....................38 fluticasone propionate . 35, 37
esmolol hcl .........................49 fenoldopam mesylate..........64 fluvastatin sodium.............. 38
ESTRACE..........................58 fenoprofen calcium.............12 fluvoxamine maleate.......... 78
ESTRADERM ...................58 fentanyl...............................14 FOLOTYN......................... 41
estradiol .............................58 fentanyl citrate....................14 fomepizole.......................... 69
estradiol valerate ...............58 FERRIPROX......................61 fondaparinux sodium ... 61, 62
estradiol/noreth ac.............59 fexofenadine hcl..................86 FORADIL.......................... 90
ESTRASORB ....................59 finasteride...........................69 FORTAZ IN ISO-OSMOTIC
estropipate..........................59 FIRAZYR...........................69 DEXTROSE .................. 20
ethambutol hcl....................39 FIRMAGON.......................41 FORTEO............................ 74
ethanolamine oleate...........86 flavoxate hcl .......................60 FORTICAL........................ 74
ethinyl estradiol/drospirenone FLEBOGAMMA ...............87 FOSAMAX........................ 69
........................................56 FLEBOGAMMA DIF........87 foscarnet sodium................ 47
ethosuximide ......................25 flecainide acetate................54 fosinopril sodium ............... 82
ethyl alcohol/d5w...............53 FLEXBUMIN.....................50
I-6
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

fosinopril/
glyburide,micronized..........29 HUMALOG....................... 27
hydrochlorothiazide .......82 glyburide/metformin hcl .....29 HUMALOG MIX 50-50.... 27
fosphenytoin sodium...........25 glycopyrrolate ....................23 HUMALOG MIX 75-25.... 27
FRAGMIN .........................62 GLYSET.............................25 HUMATROPE .................. 75
FREAMINE HBC..............53 gold sodium thiomalate ......70 HUMIRA........................... 70
FREAMINE III .................. 53 granisetron hcl ...................30 HUMULIN 50-50.............. 27
FREAMINE III with
granisetron hcl/pf ...............30 HUMULIN 70-30.............. 27
ELECTROLYTES .........53 griseofulvin,microsize ........31 HUMULIN N .................... 27
fructose 10% ......................53 GRIS-PEG..........................31 HUMULIN R..................... 27
furosemide..........................57 guaifen/theop anhyd/p-ephed hydralazine hcl .................. 64
FUROXONE...................... 35 ........................................86 hydralazine/
FUSILEV ...........................69 guanabenz acetate..............64 hydrochlorothiazid ........ 64
FUZEON............................47 guanfacine hcl ....................64 hydralazine/reserpin/hctz .. 64
gabapentin..........................24 guanidine hcl......................74 hydrochlorothiazide........... 57
GABITRIL.........................24 GYNAZOLE-1...................34 hydrocodone bit/
galantamine hbr.................74 HALAVEN.........................41 acetaminophen............... 14
GALZIN.............................61 HALDOL ...........................80 hydrocodone/ibuprofen...... 14
GAMASTAN S-D .............87 HALDOL DECANOATE hydrocortisone............. 11, 37
GAMMAGARD S-D.........87 100..................................80 hydrocortisone acetate ...... 37
GAMMAPLEX..................87 HALDOL DECANOATE 50 hydrocortisone acetate/aloe v
GAMUNEX .......................87 ........................................80 ....................................... 37
ganciclovir .........................48 HALFAN............................45 hydrocortisone acetate/urea
ganciclovir sodium.............48 halobetasol propionate.......37 ....................................... 37
GARDASIL .......................92 haloperidol .........................80 hydrocortisone butyrate..... 37
gauze bandage ...................69 haloperidol decanoate........80 hydrocortisone sod succinate
gemcitabine hcl ..................41 haloperidol lactate .............80 ....................................... 11
gemfibrozil .........................38 HAVRIX ............................92 hydrocortisone valerate..... 37
GENOTROPIN..................75 HECTOROL.......................94 hydromorphone hcl............ 14
gentamicin in nacl, iso-osm heparin sodium,porcine......62 hydromorphone hcl/pf........ 14
..................................18, 19 heparin sodium,porcine/d5w hydroxychloroquine sulfate 45
gentamicin sulfate ..19, 33, 34 ........................................62 hydroxyurea....................... 41
gentamicin sulfate/pf..........19 heparin sodium,porcine/ns/pf hydroxyzine hcl.................. 49
GEODON...........................80 ........................................62 hydroxyzine pamoate ......... 49
GESTICARE DHA............94 heparin sodium,porcine/pf .62 hyoscyamine sulfate........... 23
GILENYA..........................70 heparin sodium,pork in 1/2 ns HYPERLYTE CR.............. 83
GLEEVEC .........................41 ........................................62 HYPERLYTE R ................ 83
glimepiride .........................28 HEPATAMINE..................53 HYPERRAB S-D .............. 87
glipizide........................28, 29 HEPATASOL.....................53 HYPERRHO S-D .............. 87
glipizide/metformin hcl ......29 HEPSERA ..........................48 ibandronate sodium ........... 70
GLUCAGEN......................70 HERCEPTIN......................41 ibuprofen............................ 13
GLUCAGON EMERGENCY HEXALEN.........................41 ibuprofen/oxycodone hcl.... 14
KIT.................................70 HIBERIX............................92 idarubicin hcl..................... 41
glutethimide........................49 HIZENTRA........................87 ifosfamide........................... 41
glyburide ............................29 homatropine hbr.................73 ifosfamide/mesna ............... 41
I-7
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

ILARIS...............................70 ISOLYTE E........................83 ketorolac tromethamine13, 35
imipenem/cilastatin sodium21 ISOLYTE H W/DEXTROSE KINERET .......................... 70
imipramine hcl ...................78 ........................................83 KINRIX ............................. 92
imipramine pamoate ..........78 ISOLYTE M W/DEXTROSE KOMBIGLYZE XR .......... 26
imiquimod ..........................88 ........................................83 K-PHOS M.F..................... 10
IMOGAM RABIES-HT.....87 ISOLYTE P with
K-PHOS NO.2................... 10
IMOVAX RABIES
DEXTROSE...................84 KRYSTEXXA................... 58
VACCINE......................92 ISOLYTE S........................84 KUVAN............................. 70
inamrinone lactate .............54 ISOLYTE S with
labetalol hcl ....................... 49
INCIVEK ...........................47 DEXTROSE...................84 LACRISERT ..................... 58
INCRELEX........................89 isoniazid .............................39 LACTATED RINGERS... 65,
indapamide.........................57 isopropamide/
84
INDOCIN...........................13 prochlorperazine ............24 lactulose............................. 12
indomethacin......................13 isoproterenol hcl ................90 LAMISIL........................... 34
indomethacin sodium
ISOPTO CARPINE............32 lamivudine ......................... 47
trihydrate........................13 ISOPTO HOMATROPINE73 lamivudine/zidovudine....... 47
INFANRIX ........................91 isosorbide dinitrate ............93 lamotrigine......................... 24
INLYTA.............................41 isosorbide mononitrate.......93 LANOXIN PEDIATRIC ... 54
INTELENCE......................47 isotretinoin .........................88 lansoprazole ...................... 46
INTRALIPID .....................53 ISOVEX .............................93 LANTUS ........................... 27
INTRON A.........................48 isradipine............................51 LANTUS SOLOSTAR...... 27
INVANZ ............................21 ISTALOL ...........................32 latanoprost......................... 32
INVEGA ............................80 ISTODAX ..........................42 LATUDA........................... 80
INVEGA SUSTENNA ......80 itraconazole........................31 leflunomide ........................ 70
INVIRASE.........................47 IXEMPRA..........................42 LETAIRIS ......................... 93
IONOSOL B with
IXIARO..............................92 letrozole ............................. 42
DEXTROSE 5% ............83 JAKAFI ..............................42 leucovorin calcium ............ 70
IONOSOL MB-DEXTROSE JANUMET .........................26 LEUKERAN...................... 42
5% ..................................83 JANUMET XR.............25, 26 LEUKINE.......................... 64
IONOSOL T-DEXTROSE JANUVIA...........................26 leuprolide acetate .............. 42
5% ..................................83 JENTADUETO ..................26 LEVEMIR ......................... 28
IPOL...................................92 JE-VAX..............................92 levetiracetam ..................... 24
ipratropium bromide..........58 JEVTANA..........................42 levetiracetam in nacl (iso-os)
IPRIVASK .........................63 JUVISYNC.........................26 ....................................... 24
irbesartan...........................82 KADIAN ............................14 levobunolol hcl .................. 32
irbesartan/
KALBITOR........................70 levocarnitine ...................... 70
hydrochlorothiazide .......82 KALETRA .........................47 levocarnitine (with sugar) . 70
IRESSA..............................41 kanamycin sulfate...............19 levocetirizine dihydrochloride
irinotecan hcl .....................41 KEDBUMIN ......................50 ....................................... 86
iron,carbonyl/vit c/vit b12/fa KEPIVANCE .....................55 levofloxacin.................. 23, 33
........................................94 KETEK...............................21 levofloxacin/dextrose 5%-
IRRIGATING SOLUTION G KETEK PAK......................21 water .............................. 23
........................................65 ketoconazole.................31, 34 levonorgestrel .................... 56
ISENTRESS.......................47 ketoprofen...........................13 levonorgestrel-eth estradiol56
I-8
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

levorphanol tartrate...........14 LYRICA.............................24 metaproterenol sulfate....... 90
levothyroxine sodium .........90 LYSODREN.......................42 metaxalone......................... 88
LEVULAN.........................88 LYSTEDA..........................63 metformin hcl..................... 26
LEXAPRO .........................78 magnesium chloride ...........24 methadone hcl.................... 15
LEXIVA.............................47 magnesium salicylate .........13 methamphetamine hcl........ 17
lidocaine hcl...........46, 54, 67 magnesium sulfate..............24 methazolamide................... 32
LIDOCAINE HCL.............54 magnesium sulfate/d5w ......24 methen mand/naphos m-b m-h
lidocaine hcl/d5w/pf...........54 MALARONE .....................45 ....................................... 91
lidocaine hcl/d7.5w/pf........54 malathion............................35 methen/m-blue/sal/na phos/
lidocaine hcl/pf.............54, 67 mannitol/sorbitol solution ..65 hyos................................ 91
lidocaine/prilocaine ...........46 maprotiline hcl ...................78 methenamine hippurate ..... 91
LIDODERM ......................46 MARPLAN ........................78 methenamine mandelate .... 91
lindane................................35 MATULANE .....................42 methimazole....................... 90
liothyronine sodium ...........90 MAXALT...........................38 methocarbamol .................. 88
lipase/protease/amylase.....60 MAXALT MLT .................38 methotrexate sodium.......... 42
LIPOFEN ...........................38 mebendazole.......................18 methotrexate sodium/pf...... 42
LIPOSYN II.......................53 meclizine hcl.......................31 methscopolamine bromide. 24
LIPOSYN III......................53 meclofenamate sodium .......13 methyclothiazide ................ 57
lisinopril.............................82 medroxyprogesterone acet .77 methyl salicylate ................ 13
lisinopril/hydrochlorothiazide mefenamic acid...................13 methyldopa......................... 64
........................................82 mefloquine hcl ....................45 methyldopa/
lithium carbonate...............55 MEGACE ES .....................42 hydrochlorothiazide....... 65
lithium citrate.....................55 megestrol acetate................42 methyldopate hcl................ 65
LITHOSTAT......................12 meloxicam...........................13 methylene blue ................... 70
l-norgest-eth estr/ethin estra melphalan hcl .....................42 methylergonovine maleate. 70
........................................56 MENACTRA .....................92 methylphenidate hcl..... 17, 18
LODOSYN ........................55 MENEST............................59 methylprednisolone............ 11
loperamide hcl ...................30 MENOMUNE-A-C-Y-W-135 methylprednisolone acetate11
losartan potassium.............82 ........................................92 methylprednisolone sod succ
losartan/hydrochlorothiazide MENVEO A-C-Y-W-135-
....................................... 11
........................................82 DIP .................................92 metipranolol ...................... 32
LOTEMAX........................ 35 meperidine hcl....................14 metoclopramide hcl ........... 60
LOTRONEX......................60 meperidine hcl/pf................14 metolazone......................... 57
lovastatin............................38 mepivacaine hcl/pf..............67 metoprolol succinate.......... 49
LOVAZA ...........................37 meprobamate......................49 metoprolol tartrate ............ 49
LOVENOX ........................63 MEPRON ...........................45 metoprolol/
loxapine succinate..............80 mercaptopurine ..................42 hydrochlorothiazide....... 49
LOZI-FLUR.......................94 meropenem .........................21 metronidazole .............. 34, 45
LUMIGAN.........................32 MERUVAX II VACCINE metronidazole/sodium
LUMIZYME......................58 W-DILUENT .................92 chloride.......................... 45
LUNESTA .........................49 mesalamine.........................36 METVIXIA ....................... 88
LUPRON DEPOT..............42 mesna..................................70 mexiletine hcl..................... 54
LUPRON DEPOT-PED.....42 MESNEX ...........................70 mg sal/acetaminophn/p-tlox/
LUVOX CR .......................78 MESTINON .......................74 caf .................................. 12
I-9
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

MIACALCIN.....................74 MYOZYME .......................58 NEULASTA ...................... 64
miconazole nitrate..............34 MYTELASE.......................74 NEUMEGA ....................... 64
MICRHOGAM PLUS .......87 na nitrite/na thiosul/amyl nit NEUPOGEN...................... 64
midodrine hcl .....................90 ........................................61 NEVANAC........................ 36
milrinone lactate ................54 nabumetone ........................13 NEXAVAR........................ 42
milrinone lactate/d5w ........54 nadolol................................50 niacin ................................. 37
MINOCIN..........................23 nadolol/bendroflumethiazide NIASPAN.......................... 37
minocycline hcl ..................23 ........................................50 nicardipine hcl................... 51
minoxidil ............................65 nafcillin sodium..................22 NICOTROL....................... 74
mirtazapine ........................78 NAFTIN .............................34 nifedipine ........................... 51
misoprostol.........................46 NAGLAZYME...................58 NILANDRON ................... 42
MITHRACIN.....................42 nalbuphine hcl....................16 nimodipine ......................... 51
mitomycin...........................42 nalidixic acid......................23 nisoldipine ......................... 51
mitoxantrone hcl ................42 naloxone hcl .......................73 NITRO-BID....................... 93
M-M-R II VACCINE.........92 naltrexone hcl.....................73 nitrofurantoin .................... 91
MOBAN.............................81 NAMENDA .......................55 nitrofurantoin macrocrystal
modafinil ............................18 naphazoline hcl ..................58 ....................................... 91
moexipril hcl ......................82 naphazoline hcl/antazoline.58 nitroglycerin ...................... 93
moexipril/
naproxen.............................13 nitroglycerin/d5w............... 93
hydrochlorothiazide .......82 naproxen sodium ................13 NITROSTAT..................... 93
mometasone furoate...........37 naratriptan hcl....................38 nizatidine ........................... 46
MONUROL .......................91 NASONEX.........................35 NORDITROPIN ................ 75
morphine sulfate.................15 NATACYN ........................33 NORDITROPIN
morphine sulfate in 0.9 % nateglinide..........................26 NORDIFLEX................. 75
nacl.................................15 NAVANE...........................81 norepinephrine bit/0.9 % nacl
morphine sulfate/0.9% nacl/pf needles, insulin disposable.57 ....................................... 90
........................................15 nefazodone hcl....................78 norepinephrine bitartrate .. 90
morphine sulfate/d5w.........15 neo/polymyx b sulf/dexameth noreth a-et estra/fe fumarate
morphine sulfate/pf ............15 ........................................33 ....................................... 56
MOXEZA ..........................33 neomy sulf/bacitra/polymyxin noreth-ethinyl estradiol/iron
MOZOBIL .........................64 b......................................33 ....................................... 56
mth/me blue/sod phos/phen/ neomy sulf/bacitrac zn/poly/ norethind ac/ethinyl estradiol
hyos ................................91 hc ....................................33 ....................................... 59
MULTAQ ..........................54 neomy sulf/polymyxin b
norethindrone .................... 56
multivitamins with fluoride 94 sulfate .............................34 norethindrone acetate........ 77
MUMPSVAX VACCINE W- neomycin sulfate.................19 norethindrone a-e estradiol56
DILUENT ......................92 neomycin sulfate/dex na ph 33 norethindrone-ethinyl estrad
mupirocin ...........................34 neomycin/polymyxin b sulf/hc ....................................... 56
MUSTARGEN...................42 ........................................33 norethindrone-mestranol... 56
MYCOBUTIN ...................39 neomycin/polymyxn b/
norgestimate-ethinyl estradiol
mycophenolate mofetil .......70 gramicidin ......................33 ....................................... 56
MYFORTIC.......................70 neostigmine methylsulfate ..74 norgestrel-ethinyl estradiol 56
MYLOTARG..................... 42 NEPHRAMINE..................53 NORMOSOL-M and
MYOBLOC........................70 NESACAINE .....................67 DEXTROSE .................. 84
I-10
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

NORMOSOL-R PH 7.4.....84 ONTAK..............................43 PEDIARIX......................... 92
nortriptyline hcl .................78 opium..................................30 PEDVAXHIB .................... 92
NORVIR ............................47 opium/belladonna alkaloids peg 3350/na sulf,bicarb,cl/kcl
NOVAMINE...................... 53 ........................................15 ....................................... 55
NOVAREL ........................75 ORAP .................................81 PEGANONE...................... 25
NOVOLIN 70-30............... 28 ORENCIA ..........................71 PEGASYS ......................... 48
NOVOLIN 70-30 INNOLET ORFADIN ..........................71 PEGASYS PROCLICK..... 48
........................................28 orphenadrine citrate...........88 PEGINTRON..................... 48
NOVOLIN N .....................28 orphenadrine/aspirin/caffeine PEGINTRON REDIPEN... 48
NOVOLIN N INNOLET ... 28 ........................................88 pen g pot/dextrose-water ... 22
NOVOLIN R......................28 ORTHO EVRA ..................56 penicillin g potassium........ 22
NOVOLOG........................28 ORTHOCLONE OKT-3 ....71 penicillin g potassium/d5w 22
NOVOLOG MIX 70-30.....28 oxacillin sodium .................22 penicillin g procaine.......... 22
NOXAFIL..........................31 oxacillin sodium/dextrose,iso PENICILLIN G SODIUM. 22
NPLATE ............................ 70 ........................................22 penicillin v potassium ........ 22
NUCYNTA........................15 oxaliplatin...........................43 PENTACEL....................... 92
NUCYNTA ER.................. 15 oxandrolone........................17 pentamidine isethionate..... 45
NULOJIX...........................70 oxaprozin............................13 PENTASA ......................... 36
NUTRESTORE..................53 oxcarbazepine.....................24 pentazocine hcl/
NUTRILYTE .....................84 OXSORALEN-ULTRA.....88 acetaminophen............... 16
NUTRILYTE II ................. 84 oxybutynin chloride............60 pentazocine hcl/naloxone hcl
NUTROPIN .......................76 oxycodone hcl.....................15 ....................................... 16
NUTROPIN AQ................. 76 oxycodone hcl/acetaminophen pentostatin ......................... 43
NUTROPIN AQ NUSPIN 75, ........................................15 pentoxifylline ..................... 63
76 oxycodone hcl/aspirin ........16 p-epd tan/chlor-tan............ 59
NUVARING ......................56 oxycodone hcl/oxycodon ter/ perindopril erbumine......... 82
nylidrin hcl.........................93 asa ..................................16 permethrin ......................... 35
nystatin.........................31, 34 OXYCONTIN ....................16 perphenazine...................... 81
nystatin/triamcin ................34 oxymorphone hcl ................16 perphenazine/amitriptyline
OCTAGAM .......................87 paclitaxel ............................43 hcl .................................. 78
octreotide acetate...............71 pamidronate disodium........71 phenazopyridine hcl........... 46
OFIRMEV..........................12 PANRETIN ........................88 phenelzine sulfate .............. 78
ofloxacin.......................23, 33 pantoprazole sodium ..........46 phentolamine mesylate ...... 89
olanzapine..........................81 papaverine hcl....................93 phenylbutazone .................. 13
omeprazole.........................46 paregoric ............................30 phenyleph/acetaminop/p-tlox/
omeprazole/sodium
paromomycin sulfate ..........45 cp ................................... 59
bicarbonate ....................46 paroxetine hcl.....................78 phenylephrine hcl ........ 58, 90
OMNITROPE ....................76 PASER ...............................39 phenylephrine hcl/prometh
ONCASPAR ...................... 43 PATADAY.........................18 hcl .................................. 59
ondansetron........................30 PATANOL .........................18 phenylephrine tannate ....... 90
ondansetron hcl..................30 ped mv a,c,d3 #21 w-fluoride phenylephrine/antipy/b-caine
ondansetron in 0.9 % nacl/pf ........................................94 ....................................... 67
........................................30 pedi mvi no.12/sodium
phenylephrine/chlor-tan .... 59
ONGLYZA ........................26 fluoride ...........................94
I-11
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

phenylephrine/dp-hydram tan potassium chloride .............84 PRIMAXIN I.M................. 21
........................................59 potassium chloride in
primidone........................... 24
PHENYTEK ...................... 25 0.9%nacl.........................84 PRIMSOL.......................... 91
phenytoin............................25 potassium chloride/d5-0.25ns PRISTIQ ER...................... 78
phenytoin sodium ...............25 ........................................84 PRIVIGEN......................... 87
phenytoin sodium extended 25 potassium chloride/d5-
PROAIR HFA ................... 90
PHOSLYRA ......................65 0.33nacl..........................85 probenecid ......................... 71
PHOSPHOLINE IODIDE . 32 potassium chloride/d5-
procainamide hcl ............... 54
phosphorus #1....................10 0.45nacl..........................85 PROCALAMINE .............. 53
PHOTOFRIN .....................43 potassium chloride/d5-
prochlorperazine edisylate 31
physostigmine salicylate ....74 0.9%nacl.........................85 prochlorperazine maleate.. 31
PICATO .............................88 potassium chloride/d5lr......85 PROCRIT .......................... 64
pilocarpine hcl .............32, 74 potassium chloride/d5w......85 progesterone ...................... 77
PILOPINE HS....................32 potassium chloride-0.45% progesterone,micronized ... 77
pindolol ..............................50 nacl.................................85 PROGLYCEM................... 65
piperacillin sodium ............22 potassium citrate ................10 PROGRAF......................... 71
piperacillin sodium/
potassium citrate/citric acid PROLASTIN ..................... 86
tazobactam .....................22 ........................................10 PROLASTIN C ................. 86
piroxicam ...........................13 potassium gluconate...........85 PROLEUKIN..................... 43
PLASBUMIN-25 ...............50 potassium hydroxide...........66 PROLIA............................. 71
PLASBUMIN-5 .................50 potassium phos,m-basic-d- PROMACTA..................... 64
PLASMA-LYTE 148.........84 basic ...............................85 promethazine hcl................ 59
PLASMA-LYTE 56 IN
PRALIDOXIME
PROMETRIUM................. 77
DEXTROSE................... 84 CHLORIDE....................71 PRONESTYL .................... 54
PLASMA-LYTE A PH 7.4 84 pramipexole di-hcl..............45 propafenone hcl ................. 54
PLASMA-LYTE M IN
PRANDIMET.....................26 propantheline bromide ...... 24
DEXTROSE................... 84 PRANDIN ..........................26 propantheline/phenobarbital
PLAVIX.............................63 pravastatin sodium .............38 ....................................... 24
pnv with ca,no.72/iron/fa ...94 prazosin hcl ........................12 proparacaine hcl................ 67
podofilox ............................88 prednicarbate .....................37 proparacaine/fluorescein sod
podophyllum resin..............88 prednisolone.......................11 ....................................... 67
polyethylene glycol 3350....55 prednisolone acetate ....11, 36 PROPINE........................... 73
polymyxin b sulfate ............19 prednisolone sod phosphate propranolol hcl.................. 50
polymyxin b sulfate/tmp .....33 ..................................11, 36 propranolol/
POLY-PRED......................33 prednisone ..........................11 hydrochlorothiazid ........ 50
pot chloride/pot bicarb/cit ac PREDNISONE INTENSOL propylthiouracil................. 90
........................................84 ........................................11 PROQUAD........................ 92
potassium acetate...............84 PREMARIN .......................59 PROSOL............................ 53
potassium bicarbonate/cit ac PREMASOL.......................53 PROSTIGMIN................... 74
........................................84 PREMPHASE ....................59 protamine sulfate ............... 63
potassium chlorid/d10-
PREMPRO .........................59 PROTONIX IV.................. 46
0.2%nacl ........................84 PREZISTA .........................47 PROTOPAM CHLORIDE 71
potassium chlorid/d5-
PRIFTIN.............................39 PROTOPIC........................ 88
0.225nacl........................84 PRIMAQUINE...................45 protriptyline hcl ................. 78
I-12
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

PROVIGIL.........................18 RIDAURA..........................71 sertraline hcl...................... 78
PULMOZYME .................. 58 rifampin ..............................39 silver nitrate....................... 35
pyrazinamide......................39 rifampin/isoniazid...............39 silver nitrate applicator..... 66
pyridostigmine bromide .....74 RIFATER ...........................39 silver sulfadiazine.............. 35
QUALAQUIN....................45 RILUTEK...........................55 SIMPONI........................... 71
quetiapine fumarate ...........81 rimantadine hcl ..................47 SIMULECT ....................... 71
QUICK MIX with LYTES. 53 ringers solution ............65, 85 simvastatin......................... 38
quinapril hcl.......................82 RISPERDAL CONSTA .....81 SINGULAIR...................... 36
quinapril/hydrochlorothiazide risperidone .........................81 sod chloride 0.45% irrig. soln
........................................82 RITUXAN..........................43 ....................................... 65
quinidine gluconate............54 rivastigmine tartrate...........74 sod propionate/inosi/aa14/
quinidine sulfate.................54 ropinirole hcl......................45 urea................................ 34
QVAR ................................11 ROTARIX ..........................92 sod/pot/k cit/sod cit/cit acid10
RABAVERT...................... 92 ROTATEQ .........................92 sodium acetate ................... 85
ramipril ..............................82 SABRIL..............................24 sodium bicarbonate ........... 10
RANEXA.....................54, 55 SAIZEN..............................76 sodium chloride ................. 85
ranitidine hcl......................46 sal-amide/acetamin/p-tlox/ sodium chloride 0.45 %..... 85
RAPAMUNE .....................71 caff..................................12 sodium chloride 3%........... 85
REBETOL..........................48 sal-amide/acetaminophn/p- sodium chloride 5%........... 85
REBIF ................................71 tlox..................................12 sodium chloride irrig solution
RECLAST..........................71 salicylamide/acetaminophen ....................................... 65
RECOMBIVAX HB .......... 92 ........................................12 sodium chloride/nahco3/kcl/
REGONOL ........................74 salicylic acid.......................66 peg ................................. 55
REGRANEX......................89 salicylic acid/ammon lact/ sodium fluoride............ 71, 94
RELENZA ......................... 47 aloe.................................66 sodium lactate.................... 10
RELISTOR ........................ 60 salicylic acid/ceramide cmb sodium morrhuate.............. 86
RELPAX............................38 #1....................................66 sodium phos,m-basic-d-basic
REMICADE.......................71 salsalate..............................13 ....................................... 85
REMODULIN.................... 94 SAMSCA ...........................57 sodium polystyrene sulfonate
RENAGEL.........................65 SANDOSTATIN LAR.......71 ....................................... 65
RENAMIN.........................53 SANTYL ............................89 sodium tetradecyl sulfate... 86
RENVELA.........................65 SAPHRIS ...........................81 sodium thiosulfate.............. 61
RESCRIPTOR ...................47 SAVELLA..........................55 sodium thiosulfate/sal acid 34
reserpine ............................65 scopolamine hydrobromide SOLIRIS ............................ 72
reserpine/hydrochlorothiazide ..................................24, 31 SOLU-MEDROL............... 11
........................................65 selegiline hcl.......................45 SOMATULINE DEPOT ... 72
RESTASIS .........................36 selenium sulfide..................35 SOMAVERT ..................... 89
RETROVIR........................47 SELZENTRY.....................47 sorbitol solution................. 65
REVATIO..........................94 SENSIPAR.........................71 sotalol hcl .......................... 50
REVLIMID..................43, 71 SEREVENT DISKUS........90 SOTALOL HCL................ 50
REYATAZ.........................47 SEROMYCIN ....................39 SPIRIVA............................ 24
RHOGAM PLUS...............87 SEROQUEL.......................81 spironolact/
RHOPHYLAC ...................87 SEROQUEL XR ................81 hydrochlorothiazid ........ 82
ribavirin .......................48, 49 SEROSTIM ........................76 spironolactone ................... 83
I-13
Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

SPORANOX...................... 31 syring w-ndl,disp,insul,0.5ml thiothixene ......................... 81
SPRYCEL..........................43 ........................................57 THYMOGLOBULIN ........ 72
STALEVO 100 ..................45 syringe & needle,insulin,1 ml thyroid................................ 90
STALEVO 125 ..................45 ........................................57 ticlopidine hcl .................... 63
STALEVO 150 ..................45 TABLOID ..........................43 TIKOSYN.......................... 54
STALEVO 200 ..................45 tacrolimus...........................72 timolol maleate ............ 32, 50
STALEVO 50 ....................45 talc......................................86 tizanidine hcl...................... 88
STALEVO 75 ....................45 TAMIFLU ....................47, 48 TOBI.................................. 19
stavudine ............................47 tamoxifen citrate.................43 tobramycin sulf/
STELARA..........................72 tamsulosin hcl.....................89 dexamethasone............... 33
STERILE DILUENT .........50 TARCEVA.........................43 tobramycin sulfate ....... 19, 33
STRATTERA ....................55 TARGRETIN ...............43, 89 tobramycin/sodium chloride
streptomycin sulfate ...........19 TASIGNA ..........................43 ....................................... 19
STROMECTOL.................18 TASMAR ...........................45 tolazamide.......................... 29
SUBOXONE...................... 16 TAXOTERE.......................43 tolbutamide ........................ 29
SUCRAID..........................58 TAZICEF IN DEXTROSE 20 tolmetin sodium.................. 13
sucralfate............................46 TAZORAC.........................89 topiramate.......................... 24
sulfacetamide sodium...33, 35 TE ANATOXAL BERNA .91 topotecan hcl...................... 43
sulfacetamide sodium/urea 66 TEGRETOL XR.................24 TORISEL........................... 43
sulfacetamide/prednisolone TENIVAC ..........................91 torsemide ........................... 57
sp....................................33 terazosin hcl .......................12 TOVIAZ ............................ 60
sulfadiazine ........................23 terbinafine hcl ....................31 TPN ELECTROLYTES .... 85
sulfamethoxazole/
terbutaline sulfate...............90 TRACLEER....................... 94
trimethoprim ..................23 terconazole .........................34 TRADJENTA .................... 27
sulfasalazine.......................23 testosterone.........................17 tramadol hcl....................... 16
sulindac..............................13 testosterone cypionate........17 tramadol hcl/acetaminophen
sumatriptan ........................39 testosterone enanthate........17 ....................................... 16
sumatriptan succinate ........38 TETANUS DIPHTHERIA trandolapril........................ 82
SUPPRELIN ......................72 TOXOIDS ......................91 trandolapril/verapamil hcl 82
SUPPRELIN LA................72 TETANUS TOXOID
tranexamic acid ................. 63
SUPRAX............................20 ADSORBED ..................91 tranylcypromine sulfate ..... 78
SUSTIVA...........................47 TETANUS-DIPHTERIA- TRAVAMULSION ........... 53
SUTENT ............................43 DECAVAC.....................91 TRAVASOL...................... 53
SYLATRON 4-PACK .......48 tetracaine hcl/pf..................67 TRAVASOL W/
SYMBICORT ....................11 tetracycline hcl ...................23 ELECTROLYTES......... 53
SYMLIN ............................26 TEV-TROPIN ....................76 TRAVASOL with
SYMLINPEN 120..............27 THALOMID.......................72 DEXTROSE .................. 53
SYMLINPEN 60................27 theophylline anhydrous ......86 TRAVASOL with
SYNAGIS ..........................47 theophylline/dextrose 5%-
ELECTROLYTES......... 53
SYNAREL .........................72 water...............................86 TRAVATAN Z.................. 32
SYNERCID........................19 THERACYS.......................92 TRAVERT......................... 54
SYPRINE...........................61 THIOLA.............................72 TRAVERT IN NORMAL
syring w-ndl,disp,insul,0.3ml thioridazine hcl...................81 SALINE......................... 54
........................................57 thiotepa...............................43
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Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

TRAVERT-ELECTROLYTE ULORIC.............................72 vinorelbine tartrate............ 44
NO.1...............................85 urea.....................................66 VIRACEPT........................ 47
TRAVERT-ELECTROLYTE urea/lactic ac/zn
VIRAMUNE...................... 47
NO.2...............................85 undecylenate...................66 VIRAMUNE XR ............... 47
TRAVERT-ELECTROLYTE urea/lactic acid/salicyl acid66 VIREAD ............................ 47
NO.3...............................85 urologic solution-g .............65 VISTIDE............................ 49
TRAVERT-ELECTROLYTE ursodiol...............................60 VIVAGLOBIN .................. 87
NO.4...............................85 UVADEX...........................89 VIVELLE-DOT................. 59
trazodone hcl......................78 valacyclovir hcl ..................49 VIVOTIF BERNA............. 93
TREANDA ........................43 VALCYTE .........................49 VOLTAREN...................... 13
TRECATOR ...................... 39 valproate sodium................24 voriconazole....................... 31
TRELSTAR .......................43 valproic acid.......................24 VOTRIENT ....................... 44
tretinoin........................43, 55 VALSTAR .........................43 VPRIV ............................... 58
TREXALL .........................43 VANCOCIN HCL..............19 VUMON ............................ 44
triacetin..............................31 vancomycin hcl...................19 warfarin sodium................. 63
triamcinolone acetonide....11, VANCOMYCIN HCL .......19 water for irrigation,sterile. 65
36, 37
vancomycin hcl/d5w ...........19 WELCHOL........................ 38
triamterene/
VANDETANIB..................44 WINRHO SDF .................. 87
hydrochlorothiazid.........57 VANTAS............................72 XALKORI ......................... 44
TRIBENZOR .....................82 VAQTA..............................93 XENAZINE....................... 55
TRICOR.............................38 VARIVAX VACCINE.......93 XERAC AC ....................... 49
trifluoperazine hcl..............81 vasopressin.........................76 XGEVA ............................. 72
trifluridine..........................33 VECTIBIX .........................44 XIAFLEX .......................... 58
trihexyphenidyl hcl.............45 VECTICAL ........................89 XIFAXAN ................... 19, 20
TRIHIBIT ..........................91 VELCADE .........................44 XOLAIR ............................ 86
TRILIPIX........................... 38 venlafaxine hcl....................78 XYREM............................. 55
trimethobenzamide hcl.......31 VENLAFAXINE HCL ER.78 YERVOY........................... 44
trimethoprim ......................91 verapamil hcl......................50 YF-VAX ............................ 93
trimipramine maleate.........78 VERIPRED 20 ...................11 YODOXIN......................... 45
TRIPEDIA .........................91 VESICARE ........................60 zafirlukast .......................... 36
tripelennamine hcl .............60 VFEND...............................31 zaleplon.............................. 49
TRISENOX........................43 VFEND IV .........................31 ZANOSAR ........................ 44
TRIZIVIR .......................... 47 VIBATIV ...........................19 ZAVESCA......................... 72
TROPHAMINE .................54 VIBRAMYCIN ..................23 ZELAPAR ......................... 45
tropicamide ........................73 VICTOZA 3-PAK..............27 ZELBORAF....................... 44
trospium chloride...............60 VICTRELIS .......................48 ZEMAIRA......................... 86
TRUVADA........................47 VIDAZA.............................44 ZENPEP............................. 60
TWINRIX ....................92, 93 VIDEX ...............................47 ZETIA................................ 37
TYGACIL..........................23 VIGAMOX.........................33 ZIAGEN ............................ 47
TYKERB............................43 VIIBRYD .....................78, 79 zidovudine.......................... 47
TYPHIM VI....................... 93 VIMOVO ...........................13 ziprasidone hcl................... 81
TYSABRI ..........................72 VIMPAT.............................25 ZMAX ............................... 21
TYZEKA............................49 vinblastine sulfate...............44 ZN-DTPA .......................... 61
TYZINE .............................58 vincristine sulfate ...............44 ZOLADEX ........................ 44
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Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11

ZOLINZA ..........................44
zolpidem tartrate................49
ZOMETA...........................72
zonisamide..........................25
ZORBTIVE........................76
ZORTRESS........................72
ZOSTAVAX ......................93
ZOSYN...............................22
ZOVIRAX....................34, 35
ZYCLARA.........................89
ZYFLO...............................36
ZYFLO CR.........................36
ZYLET............................... 33
ZYMAR............................. 33
ZYMAXID ........................ 33
ZYPREXA RELPREVV ... 81
ZYTIGA ............................ 44
ZYVOX ............................. 20
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Denver Health Medical Plan, Inc. 2012 Part D Formulary Effective: June 01, 2012
Formulary ID: 12146.000, Version: 11