2011 Commercial Drug Formulary _List of Covered Drugs_ by dfgh4bnmu

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									                     2011 Commercial Drug
                           Formulary
                     (List of Covered Drugs)


27-921/01-01/06 Rev. 01-11               2011 Commercial Drug Formulary
                                          Last Updated: July 1, 2011
                                                                      COMMERCIAL FORMULARY INTRODUCTION

Your prescription drug benefit provides coverage for drugs listed in the therapeutic drug classes of the FHCP Formulary.

A Formulary is a listing of therapeutic drug classes, and a therapeutic drug class is defined as a group of similar drugs that are used to treat a specific condition. Any drug not listed in the
FHCP Formulary is considered a non-covered drug and is subject to a higher co-payment.

This list represents the major therapeutic classes of the FHCP Formulary and should serve as a quick reference to you, your physician, or pharmacist for those covered drugs within the
major therapeutic classes listed. If your physician prescribes a drug that is not covered, show your physician this list, and ask the physician to prescribe a drug from within the FHCP
Formulary.

The FHCP Formulary is developed by FHCP's Pharmacy and Therapeutics Committee. This committee, which meets quarterly, is made up of physicians, pharmacists, and nurses who
review drugs on the basis of effectiveness, safety, tolerability, and cost. Since there are similar drugs within a therapeutic class to treat a specific condition, FHCP does not cover all drugs that
are made, but only those selected by this committee.

This Formulary does not represent all therapeutic classes of drugs and is subject to change. Information on drug coverage for a non-listed therapeutic drug class should be directed to a FHCP
pharmacist or physician.

In this guide, brand-name drugs are capitalized (for example, MEVACOR) and generic drugs are listed in lower-case italics (for example, lovastatin). For example, a brand name medication
in the first column, such as MEVACOR, followed by a generic drug in the second column (for example, lovastatin) indicates that drug is available generically and that brand name becomes
uncovered. All injectables are capitalized.

Formulary Tier Structure
The amount you pay for each prescription is dependent on these factors:
    1. The pharmacy you use to fill your prescription.
    2. The type of drug you’re taking – generic or brand (preferred or non-preferred), formulary or non-formulary. Based on these factors, the drug is assigned a Tier Code as follows:
             •   Tier 1 –Formulary Preferred Generic
             •   Tier 2 –Formulary Non-Preferred Generic
             •   Tier 3 –Formulary Preferred Brand
             •   Tier 4 –Formulary Non-Preferred Brand
             •   Tier 5 –Formulary Injectables
             •   Tier 6 – Specialty Drugs

DON'T SEE YOUR MEDICATION ON THE FHCP FORMULARY?
FHCP can respond to all of your medication needs. Our Preferred Drug List, or Formulary, is broad and is composed of proven medications in every therapeutic drug class to assist our
Members to better manage their health care. However, if you need a medication not on the FHCP Preferred Drug List, you can always obtain your medication from an FHCP Member
Pharmacy at 85% of FHCP's already low price.




Note: FHCP’s Formulary can also be found on our website at www.fhcp.com. If you are unable to find a certain drug within this booklet, please check out our website, as it is updated
more frequently.



27-921/01-01/06 Rev. 01-11                                                                                                                         2011Commercial Drug Formulary
                                                                                                                                                   Last Updated: July 1, 2011
       HOW TO SEARCH FOR A DRUG IN THE FLORIDA HEALTH CARE PLAN
                  PREFERRED DRUG LIST (FORMULARY)




On the FHCP Website, click on the Members tab, Quick Link “Formulary”

http://www.fhcp.com/members/formulary/formulary.htm

Click on Commercial Formulary

http://www.fhcp.com/members/plansAndBenefits/Commercial%20Formulary.pdf

When the PDF file comes up, press Control F. A pop-up search text box will appear at the top of the page. Type
the drug name for which you are searching and click the right arrow in the pop-up search text box to begin the
search.

To close the pop-up search text box, click on the “x” in the pop-up search text box.




27-921/01-01/06 Rev. 01-11                                                             2011Commercial Drug Formulary
                                                                                       Last Updated: July 1, 2011
                                           Formulary
                                      Alphabetical Drug List

A                                                   ADALAT CC 90
                                                    adderall xr 5mg capsule 98
a/a 2% & alum acet otic soln 127                    adderall xr 10mg capsule 98
a/b otic sol 127                                    adderall xr 15mg capsule 98
a-hydrocort 100mg inj 58-59                         adderall xr 20mg capsule 98
a-methapred 125mg vial 111                          adderall xr 25mg capsule 99
A/T/S 101                                           adderall xr 30mg capsule 99
ABILIFY 1MG/ML SOLN 70                              ADRENALIN 80
ABILIFY 2MG TABLET 70                               adriamycin 50mg sdv inj 64
ABILIFY 5MG TABLET 70                               ADRUCIL 64
ABILIFY 9.75MG INJ 70                               ADVAIR 100/50 DISKUS INH 131
ABILIFY 10MG TABLET 70                              ADVAIR 250/50 DISKUS INH 131
ABILIFY 15MG TABLET 70                              ADVAIR 500/50 DISKUS INH 131
ABILIFY 20MG TABLET 70                              ADVAIR HFA 45/21MCG INHALER 131
ABILIFY 30MG TABLET 70                              ADVAIR HFA 115/21MCG INHALER 131
ABILIFY ODT 10MG TAB 70                             ADVAIR HFA 230/21MCG INHALER 131
ABILIFY ODT 15MG TAB 70                             AEROBID INHALER 129
acarbose 25mg tablet 80, 82                         afeditab cr 30mg gx-adalat-cc 90
acarbose 50mg tablet 80, 82                         AFINITOR 2.5MG TABLET 65
acarbose 100mg tablet 80, 82                        AFINITOR 5MG TABLET 65
ACCOLATE 128                                        AFINITOR 10MG TABLET 65
acebutolol hcl 200mg capsule 88-89                  AGGRENOX 200/25MG CAPSULE 85
acebutolol hcl 400mg capsule 88-89                  AGRYLIN 84
acetazolamide 125mg tablet 124-125                  ak-pentolate 1% ophth soln 124-125
acetazolamide 250mg tablet 124-125                  ak-poly-bac o/o gx polysporin 123
acetazolamide er 500mg caps 124-125                 AK-TRACIN 123
acetic acid 2% otic soln 127                        albuterol 0.083% neb soln 129-130
acetylcysteine 10% soln 131                         albuterol 0.5% neb soln 129-130
acetylcysteine 20% soln 131                         albuterol 2mg/5ml syrup 129-130
ACT-HIB INJ 118                                     albuterol 2mg tablet 129-130
ACTIGALL 108-109                                    albuterol 4mg tablet 129-130
ACTIMMUNE 3MU/.5ML INJ 118                          ALCAINE 122
ACTOS 15MG TABLET 82                                ALCOHOL PREP PADS 101
ACTOS 30MG TABLET 82                                ALDACTAZIDE 91, 93
ACTOS 45MG TABLET 82                                ALDACTONE 91, 93
ACULAR 126                                          aldara 5% cream 105
ACULAR LS 126                                       ALDOMET 86
acyclovir 200mg/5ml susp 75                         ALDURAZYME 2.9MG/5ML INJ 107
acyclovir 200mg capsule 75                          alendronate 5mg tablet 111-112
acyclovir 400mg tablet 75                           alendronate 10mg tablet 111-112
acyclovir 800mg tablet 75                           alendronate 70mg tab 112
ADACEL INJ 118                                      alendronate 70mg tablet 112
ADAGEN 250U/ML INJ 107                              ALESSE 113


                                                     [1]                          2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                        Last Updated: July 1, 2011
                                          Formulary
                                     Alphabetical Drug List

ALIMTA 500MG INJ 64                                amlodipine bes 5mg tablet 90-91
ALKERAN 2MG TABLET 63                              amlodipine bes 10mg tablet 90-91
ALLEGRA 127-128                                    amox/clav pot 200/5ml susp 39-40
ALLEGRA 30MG/5ML SUSP 127                          amox/clav pot 250/125mg tab 39-40
ALLEGRA-D 127                                      amox/clav pot 250/5ml susp 39-40
ALLEGRA-D 180 (24HR) 127                           amox/clav pot 400/5ml susp 39-40
allopurinol 100mg tablet 57                        amox/clav pot 500/125mg tab 39-40
allopurinol 300mg tablet 57                        amox/clav pot 600/5ml es sus 39-40
ALOMIDE 0.1% OPHTHALMIC SOLN 122                   amox/clav pot 875/125mg tab 39-40
ALOXI 0.25MG/5ML SDV INJ 55                        amox/clav pot 1000/62.5mg tab 39-40
ALPHAGAN (NOT P) 124                               amox/clav pot chew 200mg tab 39-40
alprazolam 0.25mg tablet 78-79                     amox/clav pot chew 400mg tab 39-40
alprazolam 0.5mg tablet 78-79                      amoxapine 25mg tablet 50
alprazolam 1mg tab(gx xanax) 78-79                 amoxapine 50mg tablet 50
alprazolam 2mg tab(gx xanax) 78-79                 amoxapine 100mg tablet 50
ALREX 0.2% OPHTH SUSP 126                          amoxapine 150mg tablet 50
ALTACE 94-96                                       amoxicillin 125mg/5ml susp 39-40
ALUPENT 130                                        amoxicillin 200mg/5ml susp 39-40
amantadine 50mg/5ml syrup 77                       amoxicillin 250mg/5ml susp 39-40
amantadine 100mg capsule 68-69                     amoxicillin 250mg capsule 39-40
AMARYL 81                                          amoxicillin 400mg/5ml susp 39-40
AMBIEN (NOT CR) 132-133                            amoxicillin 500mg capsule 39-40
amicar 250mg/ml syrup 85                           amoxicillin 875mg tablet 39-40
amicar 500mg tablet 85                             amoxicillin chewable 125mg 39-40
AMICAR 1000MG TABLET 85                            amoxicillin chewable 200mg 39-40
amifostine 500mg inj 136                           amoxicillin chewable 250mg 40
amikacin 250mg/ml inj 36                           amoxicillin chewable 400mg 40
AMIKIN 36                                          AMOXIL 39-40
amiloride 5mg tablet 91-92                         ampicil/sulbac 1.5gm inj vl 40-41
amiloride/hctz 5/50mg tablet 91-92                 ampicillin 2gm inj 40-41
aminophyllin 25mg/ml inj 130                       ampicillin 125mg/5ml susp 40-41
aminophylline 100mg tablet 130                     ampicillin 250mg/5ml susp 40-41
aminophylline 200mg tablet 130                     ampicillin 250mg cap(princip 40-41
AMINOSYN/D25 II 3.5% INJ 136                       ampicillin 500mg cap(princip 40-41
amiodarone 50mg/ml inj sdv 87                      ANADROL-50 TABLET 113
amiodarone 200mg tablet 87                         ANAFRANIL 50-51
amitriptyline 10mg tablet 50-51                    anagrelide 0.5mg capsule 84
amitriptyline 25mg tablet 50-51                    anagrelide 1mg capsule 84
amitriptyline 50mg tablet 50, 52                   ANAPROX DS 59, 61
amitriptyline 75mg tablet 50-51                    anastrozole 1mg tablet 117
amitriptyline 100mg tablet 50-51                   ANCEF 37-38
amitriptyline 150mg tablet 50, 52                  ANCOBON 250MG CAP 56
amlodipine bes 2.5mg tablet 90-91                  ANCOBON 500MG CAP 56


                                                    [2]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                        Last Updated: July 1, 2011
                                            Formulary
                                       Alphabetical Drug List

ANDRODERM 2.5MG/24HR PATCH 113                       AROMASIN 117-118
ANDRODERM 5MG/24HR PATCH 113                         ARTANE 67-68
ANTABUSE 107                                         asa/but/caff/cod cap 34-35
ANTABUSE 500MG TAB 107                               asa/but/caff(gx fiorinal) tab 62
ANTIZOL 1GM/ML INJ 136                               ASACOL 400MG TABLET 122
anucort-hc 25mg supp 109                             ASACOL HD 800MG TABLET 122
ANUSOL HC 103, 109                                   ASCENSIA CONTOUR HIGH SOLN 136
ANUSOL-HC 121                                        ASCENSIA CONTOUR LOW SOLN 136
ANZEMET 20MG/ML SDV INJ 55                           ASCENSIA CONTOUR NORM SOLN 136
apap/codeine (#2) 300/15 tab 34, 36                  ASCENSIA ELITE HI/LO CTRL SOL 136
apap/codeine (#3) 300/30 tab 34, 36                  ASENDIN 50
apap/codeine (#4) 300/60 tab 34, 36                  ATARAX 79, 127-128
apap/hydrocod 500/ 5 tablet 34, 36                   atenolol 25mg tablet 88-89
apap/hydrocodone 660/10 tab 34, 36                   atenolol 50mg tablet 88-89
apap w/codeine elixir 34, 36                         atenolol 100mg tablet 88-89
APOKYN 10MG/ML INJ 67                                ATIVAN 78-79
apraclonidine 0.5% ophth sol 124-125                 ATRIPLA TABLET 75
APRESOLINE 96-97                                     atropine 1% ophth ointment 122
apri tablet (gx desogen) 113-114                     atropine 1% ophth soln 122
APTIVUS 100MG/ML SOLN 76                             atropine sul 0.1mg/ml inj syg 79
APTIVUS 250MG CAPSULE 76                             ATROVENT HFA INHALER 128
ARALEN 67                                            ATROVENT NASAL 128-129
ARANESP 25MCG/ML INJ 84                              ATROVENT NEB 128-129
ARANESP 40MCG/0.4ML SURECLCK 84                      AUGMENTIN 39-40
ARANESP 40MCG/ML INJ 84                              AUGMENTIN XR 39-40
ARANESP 60MCG/0.3ML INJ 84                           AVANDIA 2MG TABLET 82
ARANESP 60MCG/ML INJ 84                              AVANDIA 4MG TABLET 82
ARANESP 100MCG/0.5ML SNGLJCT 84                      AVANDIA 8MG TABLET 82
ARANESP 100MCG/ML INJ 85                             AVASTIN 25MG/ML INJ 64
ARANESP 200MCG/ML INJ 85                             aviane-28 tablet 113
ARANESP 300MCG/0.6ML INJ 85                          AVODART 0.5MG CAPSULE 111
ARAVA 121                                            AVONEX ADMIN PACK 30MCG PFS 118
ARCALYST 220MG INJ 136                               AVONEX ADMIN PACK 33MCG VIAL 118
AREDIA 90MG INJ 112                                  AYGESTIN 113, 115
ARICEPT 48                                           azathioprine 50mg tablet 120
ARIMIDEX 117                                         azithromycin 100mg/5ml susp 41-42
ARISOCORT 103, 105                                   azithromycin 200mg/5ml susp 41-42
ARISOTCORT 103, 105                                  azithromycin 250mg 3x6 tablt 41-42
ARISTOCORT 103, 105                                  azithromycin 500mg inj 41-42
ARIXTRA 2.5MG/0.5ML INJ 83                           azithromycin 500mg tablet 41-42
ARIXTRA 5MG/0.4ML INJ 83                             azithromycin 600mg tablet 41-42
ARIXTRA 7.5MG/0.6ML INJ 83                           AZULFADINE (NOT EN) 122
ARIXTRA 10MG/0.8ML INJ 83


                                                      [3]                          2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                         Last Updated: July 1, 2011
                                              Formulary
                                         Alphabetical Drug List

B                                                      bethanechol 5mg tablet 80
                                                       bethanechol 10mg tablet 80
bac/neo/poly o/o(gx neospor) 123                       bethanechol 25mg tab 80
bacitracin ophth oint 123                              bethanechol 50mg tab 80
BACITRACIN OPHTH OINT 123                              BETOPTIC 124
baclofen 10mg tablet 133                               BETOPTIC-S OPHTH SUSP 124
baclofen 20mg tablet 133                               BIAXIN 41
BACTROBAN 101                                          BIAXIN (NOT XL) 41
BACTROBAN 2% CREAM 101                                 bicalutamide 50mg tablet 117
balsalazide 750mg capsule 122                          BICILLIN L-A 2.4MMU/4ML INJ 40
BANZEL 40MG/ML SUSP 43                                 BICILLIN L-A 600MU/ML INJ 40
BANZEL 200MG TABLET 43                                 bleomycin 30 unit inj 64
BANZEL 400MG TABLET 43                                 BLEPH-10 123-124
BARACLUDE 0.5MG TABLET 77                              BLEPHAMIDE OPHTH SUSP 123
BARACLUDE 1MG TABLET 77                                BLEPHAMIDE S.O.P. OINTMENT 123
bell al/phen tab(gx donnatal) 108                      BONIVA 3MG/3ML INJ KIT 112
bella/pb elix 108                                      BOOSTRIX INJ (PF) 118
benazepril 5mg tablet 95-96                            BOTOX 100U INJ 133
benazepril 10mg tab 95-96                              breeze 2 ascensia test strip 136
benazepril 10mg tablet 95-96                           BRETHINE 130
benazepril 20mg tablet 95-96                           brimonidine tart 0.2% op soln 124
benazepril 40mg tablet 95-96                           brometane dx (gx dimetane dx) 131
BENEMID 57                                             bromocriptine 2.5mg tablet 68
BENTYL 108                                             bromocriptine 5mg capsule 68
BENTYL 10MG/5ML SYRUP 108                              budeprion 150mg sr tab 48, 50
benzonatate 100mg cap 131-132                          budeprion xl 150mg tab 48, 50
benzonatate 100mg capsule 131-132                      budesonide 0.25mg/2ml neb sus 129
benzonatate 200mg cap 131-132                          budesonide 0.5mg/2ml neb sus 129
benzonatate 200mg capsule 131-132                      bumetanide 0.25mg/ml inj 91
benztropine 0.5mg tablet 67                            bumetanide 0.5mg tablet 91
benztropine 1.0mg tablet 67                            bumetanide 1mg tablet 91
benztropine 2.0mg tablet 67                            bumetanide 2mg tablet 91
BEROCCA PLUS 134-135                                   BUMEX 91
BETAGAN 124-125                                        BUPHENYL 500MG TAB 136
betamethasone diprop .05% crm 103                      buprenorphine 2mg sl tablet 99-100
betamethasone diprop .05% lot 103                      buprenorphine 8mg sl tablet 99-100
betamethasone diprop.05% oint 103-104                  bupropion 100mg er tablet 49-50
betamethasone val 0.1% cream 103, 105                  bupropion 300mg xl tablet 49-50
betamethasone val 0.1% lotion 103, 105                 bupropion hcl 75mg tablet 49
betamethasone val 0.1% oint 103, 105                   bupropion hcl 100mg tablet 49-50
BETAPACE 87-88                                         BUSPAR 78
BETASERON 0.3MG/VIAL INJ 118                           buspirone 5mg tab(gx buspar) 78
betaxolol 0.5% ophth sol 10ml 124                      buspirone 10mg tab(gx buspar) 78


                                                        [4]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                            Last Updated: July 1, 2011
                                              Formulary
                                         Alphabetical Drug List

buspirone 15mg tab(gx buspar) 78                       carbidopa/levo er 25/100 tab 68-69
butal/apap/caff (gx fioricet) 62                       carbidopa/levo er 50/200 tab 68-69
BYETTA 5MCG/0.02ML INJ 136                             carbidopa/levodopa 10/100 tab 68-69
BYETTA 10MCG/0.04ML INJ 136                            carbidopa/levodopa 25/100 tab 68-69
                                                       carbidopa/levodopa 25/250 tab 68-69
C                                                      carboplatin 50mg/5ml inj 64-65
                                                       carboplatin 150mg/15ml inj 64-65
c-phen 1mg-3.5mg/ml drops 131-132                      carboplatin 450mg/45ml inj 64-65
c-phen 12.5-4mg/5ml syp 127-128                        CARDIZEM (NOT SR) 90
c-phen dm 3.5-1-3mg/ml drops 131-132                   CARDIZEM CD 90
c-phen dm syrup 15/12.5/4 131-132                      CARDURA (NOT XL) 86
cabergoline 0.5mg tablet 117                           carisoprodol 350mg tablet 133
CAFERGOT 62                                            CARMOL 106
CALAN 90-91                                            carteolol hcl 1% ophth soln 124-125
CALAN SR 90-91                                         carvedilol 3.125mg tablet 88
CALAN-SR 90-91                                         carvedilol 6.25mg tablet 88
calcipotriene 0.005% oint 107                          carvedilol 12.5mg tablet 88
calcipotriene 0.005% soln 107                          carvedilol 25mg tablet 88
calcitonin-salmon 200u/inh ns 112                      CASODEX 117
calcitriol 0.25mcg capsule 112                         CATAPRESS (NOT TTS) 86
calcitriol 0.5mcg capsule 112                          CECLOR 37-38
calcitriol 1mcg/ml soln 112                            CECLOR SUSP 37-38
calcium acetate 667mg gel cap 109                      CEENU 10MG CAPSULE 63
camila 0.35mgtab(gx micronor) 113, 115                 CEENU 40MG CAPSULE 63
CAMPATH 30MG/ML INJ 64                                 cefaclor 125mg/5ml(gx ceclor) 37
CAMPRAL 333MG TAB 107                                  cefaclor 250mg/5ml(gx ceclor) 37
CAMPTOSAR 66-67                                        cefaclor 250mg cap gxceclor 37
CANASA 1000MG SUPP 122                                 cefaclor 375mg/5ml(gx ceclor) 37-38
CANCIDAS 50MG INJ 56                                   cefaclor 500mg cap gxceclor 37
CAPASTAT 1 GM INJ 63                                   cefadroxil 250mg/5ml susp 38
CAPOTEN 95                                             cefadroxil 500mg/5ml susp 38
CAPOZIDE 95                                            cefazolin 1gm inj 37-38
captopril 12.5mg tablet 95                             cefdinir 125mg/5ml susp 38-39
captopril 25mg tablet 95                               cefdinir 250mg/5ml susp 38-39
captopril 50mg tablet 95                               cefdinir 300mg cap 38-39
captopril 100mg tablet 95                              cefepime 1gm inj 38-39
captopril/hctz 25/15mg tablt 95                        cefprozil 125mg/5ml susp 38
captopril/hctz 50/15mg tablt 95                        cefprozil 250mg/5ml susp 38
CARAFATE 111                                           cefprozil 250mg tablet 38
CARAFATE SUSP 1GM/10ML 111                             cefprozil 500mg tab 38
carbamazepine 100mg/5ml susp 47                        CEFTIN 38
carbamazepine 100mg chewable 47                        ceftriaxone 1gm inj 38-39
carbamazepine 200mg tablet 47                          ceftriaxone 2gm inj 38-39


                                                        [5]                            2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                             Last Updated: July 1, 2011
                                             Formulary
                                        Alphabetical Drug List

ceftriaxone 250mg inj 38-39                           choline mag/tris 1000mg tab 59, 61
ceftriaxone 500mg inj 38-39                           choline mag/trisal 500mg tab 59, 61
cefuroxime 1.5gm inj 38-39                            choline mag/trisal 750mg tab 59, 61
cefuroxime 250mg tablet 38                            ciclopirox 0.77% cream 102
cefuroxime 500mg tablet 38                            ciclopirox 0.77% gel 102
CEFZIL 38                                             ciclopirox 0.77% susp 102
CELEXA 50-51                                          ciclopirox 8% soln 102
CELLCEPT 120                                          cilostazol 50mg tablet 85
CELLCEPT 200MG/ML SUSP 120                            cilostazol 100mg tablet 85
CELONTIN 300MG CAPSULE 43                             CILOXAN 123
cephalexin 125mg/5ml susp 38                          CILOXAN 0.3% OPHTH OINT 123
cephalexin 250mg/5ml susp 38                          cimetidine 300mg/5ml liquid 109-110
cephalexin 250mg capsule 38                           cimetidine 300mg tablet 109-110
cephalexin 500mg capsule 38                           cimetidine 400mg tablet 110
CEREDASE 80U/ML INJECTABLE 107                        cimetidine 800mg tablet 110
CEREZYME 200U INJ 107                                 CIPRO (NOT XR, NOT SUSP) 42
CERVARIX INJ PFS 118                                  CIPRO 400MG INJ 42
CHEMET 100MG CAP 136                                  CIPRODEX OTIC SUSP 127
cheratussin ac syrup 131-132                          ciprofloxacin 0.3% ophth soln 123
cheratussin dac syp 131-132                           ciprofloxacin 250mg tablet 42
chloral hydrate 500mg/5ml syp 132-133                 ciprofloxacin 500mg tablet 42
chlordiaz/clid 5mg-2.5mg cap 110                      ciprofloxacin 750mg tablet 42
chlordiazepoxide 5mg capsule 78-79                    cisplatin 50mg inj 64-65
chlordiazepoxide 10mg capsul 78-79                    citalopram 10mg/5ml oral soln 50-51
chlordiazepoxide 25mg capsul 78-79                    citalopram 10mg tablet 50-51
chlorhexidine gluc 0.12% soln 100-101                 citalopram 20mg tablet 50-51
chloroquine 500mg tablet 67                           citalopram 40mg tablet 51
chlorothiazide 250mg tablet 92                        cladribine 1mg/ml inj 66
chlorothiazide 500mg tablet 92                        clarithromycin 125mg/5ml sus 41
chlorpromazine 10mg tablet 73-74                      clarithromycin 250mg/5ml sus 41
chlorpromazine 25mg/ml inj 73-74                      clarithromycin 250mg tablet 41
chlorpromazine 25mg tablet 73-74                      clarithromycin 500mg tablet 41
chlorpromazine 50mg tablet 73-74                      clemastine 0.67mg/5ml syrup 127-128
chlorpromazine 100mg tablet 73-74                     CLEOCIN (150MG ONLY) 36
chlorpromazine 200mg tablet 73-74                     CLEOCIN 900MG INJ 36
chlorpropamide 100mg tablet 81                        CLEOCIN INJ 36
chlorpropamide 250mg tablet 81                        CLEOCIN VAGINAL 36
chlorthalidone 25mg tablet 92                         CLIMARA (NOT PRO) 113-114
chlorthalidone 50mg tablet 92                         clindamax 2% vaginal crm 36
cholestyramine 4gm pwd pckt 93-94                     clindamycin 150mg capsule 36
cholestyramine light powder 93-94                     clindamycin 150mg/ml inj 36
cholestyramine lite 4gm pwdpk 93-94                   CLINORIL 59, 61
cholestyramine reg powder 93-94                       clobetasol e 0.05% cream 103, 105


                                                       [6]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                           Last Updated: July 1, 2011
                                             Formulary
                                        Alphabetical Drug List

clobetasol prop. 0.05% cream 103, 105                 CORDARONE 87
clobetasol prop. 0.05% gel 103, 105                   CORDRAN TAPE LARGE 103
clobetasol prop. 0.05% oint 103, 105                  COREG 88-89
clobetasol prop. 0.05% soln 103, 105                  COREG CR 10MG CAPSULE 88
clomipramine hcl 25mg capsle 50-51                    COREG CR 20MG CAPSULE 88
clomipramine hcl 50mg capsle 50-51                    COREG CR 40MG CAPSULE 89
clomipramine hcl 75mg capsle 50-51                    COREG CR 80MG CAPSULE 89
clonazepam 0.125mg odt tab 78-79                      CORTEF 58-59, 111
clonazepam 0.5mg tablet 78-79                         cortisone ac 25mg tablet 121
clonazepam 1mg tablet 78-79                           CORTISPORIN 123, 127
clonazepam 2mg tablet 78-79                           CORTISPORIN CREAM 101
clonidine 0.1mg tablet 86                             CORTISPORIN OINTMENT 101
clonidine 0.2mg tablet 86                             cortomycin 1% otic sus 127
clonidine 0.3mg tablet 86                             COSOPT 124-125
clorazepate 3.75mg tablet 78-79                       COUMADIN 83-84
clorazepate 7.5mg tablet 78-79                        COZAAR 95-96
clorazepate 15mg tablet 78-79                         CREON CAPSULE 6OOO UNITS 107
clotrim/betam dip/0.05% crm 102                       CREON CAPSULE 12000 UNITS 107
clotrim/betam dip/0.05% lot 102                       CREON CAPSULE 24000 UNITS 107
clozapine 25mg tab 70                                 CRESTOR 5MG TABLET 93
clozapine 50mg tab 70-71                              CRESTOR 10MG TABLET 93
clozapine 100mg tab 70-71                             CRESTOR 20MG TABLET 93
clozapine 100mg tablet 70-71                          CRESTOR 40MG TABLET 93
CLOZARIL 70-71                                        CRIXIVAN 100MG CAPSULE 76
codeine sulf 30mg tab 34                              CRIXIVAN 200MG CAPSULE 76
COGENTIN 67                                           CRIXIVAN 333MG CAPSULE 76
COLAZAL 122                                           CRIXIVAN 400MG CAPSULE 76
COLBENEMID 57                                         cromolyn sod 4% ophth soln 122
colchicine 0.6mg tablet 57                            cromolyn solution 20mg/2ml 131
COLCRYS 0.6MG TABLET 57                               cryselle-28 tab (gx lo/ovral) 114-115
colistimethate 150mg inj 36                           CUBICIN 500MG VIAL IV INJ 36
collodion (flexible) liq 107                          CUPRIMINE 250MG CAPSULE 120
colocort 100mg/60ml enema 109                         CUTIVATE 103-104
COLY-MYCIN M 36                                       CUTIVATE 0.05% LOTION 103
COMBIVIR TABLET 75                                    cyanocobalamin 1000mcg/ml inj 134
COMPAZINE 55-56, 109                                  cyclobenzaprine 10mg tablet 133
COMPAZINE SUPP 109                                    CYCLOGYL 122, 124-125
compro 25mg rectal supp 109                           CYCLOGYL 0.5% OPHTH SOLN 122
COMTAN 200MG TABLET 68                                cyclopentolate hcl 1% op soln 122
COMVAX INJ 118                                        cyclophosphamide 25mg tablet 63
CONCERTA 99-100                                       cyclophosphamide 50mg tablet 63
CONDYLOX 106                                          cyclosporine 25mg capsule 120
COPAXONE 20MG/ML P.F. SYRINGE 121                     cyclosporine 50mg capsule 120


                                                       [7]                              2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                              Last Updated: July 1, 2011
                                            Formulary
                                       Alphabetical Drug List

cyclosporine 100mg capsule 120                       DEMULEN 114-116
cyclosporine 100mg/ml soln 120                       DENAVIR 1% CREAM 105
CYKLOKAPRON 100MG/ML INJ 85                          dentagel 1.1% gel 100-101
CYMBALTA 20MG CAPSULE 51                             DEPAKENE 44-45
CYMBALTA 30MG CAPSULE 51                             DEPAKOTE 44
CYMBALTA 60MG CAPSULE 51                             DEPAKOTE ER 44
cyproheptadine 4mg tablet 127-128                    DEPAKOTE SPRINKLE 44
cyproheptadine syrup 2mg/5ml 127-128                 DEPO-ESTRAD 5MG/ML INJ 114
CYSTADANE POWD 136                                   DEPO-MEDROL 58
CYSTAGON 150MG CAP 136                               DEPO-PROVERA 114-115
CYTOMEL 116-117                                      DEPO-TESTOST 100MG/ML INJ 114
CYTOTEC 111                                          DEPO-TESTOSTERONE 114, 116
CYTOVENE 77-78                                       DERMOTIC 0.01% OIL DROPS 127
CYTOXAN 63                                           desipramine 10mg tablet 51-52
cytra-k soln 133-134                                 desipramine 25mg tablet 51-52
                                                     desipramine 50mg tablet 51-52
D                                                    desipramine 75mg tablet 51-52
                                                     desipramine 100mg tablet 51-52
DALMANE 132-133                                      desipramine 150mg tablet 51-52
danazol 100mg capsule 118                            desmopressin 0.01mg/inh n.s. 112
danazol 200mg capsule 118                            desmopressin 0.1mg tablet 112
DANOCRINE 118                                        desmopressin 0.2mg tablet 112
DANTRIUM 133                                         DESOGEN 113-114
dantrolene 50mg cap 133                              desonide 0.05% cream 103, 105
DAPSONE 25MG TABLET 62                               desonide 0.05% lotion 103
DAPSONE 100MG TABLET 63                              desonide 0.05% ointment 103, 105
DAPTACEL INJ 118                                     DESOWEN 103
DARAPRIM 25MG TABLET 67                              desoximetasone 0.05% cream 103, 105
DARVOCET N-100 34, 36                                desoximetasone 0.05% gel 103, 105
DARVON 34, 36                                        desoximetasone 0.25% cream 103, 105
DAYPRO 59, 61                                        desoximetasone 0.25% ointment 103, 105
DDAVP 112                                            DESYREL 49
DECADRON 58, 126                                     dex/neo/poly o/o (gxmaxitrol) 123
DECADRON ELIXIR 58                                   dex/neo/poly o/s (gxmaxitrol) 123
DECADRON OPTH SOLN 126                               dexameth 0.1% ophth soln 126
DECAVAC ADULT 5-2LF 118                              dexamethasone 0.5/5ml elix 58
DELESTROGEN 114                                      dexamethasone 0.5/5ml soln 58
DELESTROGEN 10MG/ML INJ 114                          dexamethasone 0.5mg tablet 58
DELESTROGEN 20MG/ML INJ 114                          dexamethasone 0.75mg tablet 58
DELESTROGEN 40MG/ML INJ 114                          DEXAMETHASONE 1MG/ML CONC 58
DELTASONE 58-59                                      dexamethasone 1mg tab 58
DEMEROL 34-35                                        dexamethasone 1.5mg tablet 58
DEMEROL 50MG/ML INJ 10X1ML 34                        dexamethasone 4mg/ml inj 58


                                                      [8]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                          Last Updated: July 1, 2011
                                             Formulary
                                        Alphabetical Drug List

dexamethasone 4mg tablet 58                           DILANTIN 50MG CHW INFATABS 47
DEXEDRINE 99                                          DILAUDID 34-35
DEXEDRINE CR 99                                       DILAUDID-5 1MG/ML LIQUID 34
dextroamphetamine 5mg tablet 99                       diltiazem 30mg tablet 90
dextroamphetamine 10mg tablet 99                      diltiazem 60mg tablet 90
dextroamphetamine cr 5mg cap 99                       diltiazem 90mg tablet 90
dextroamphetamine cr 10mg cap 99                      diltiazem 120mg tablet 90
dextroamphetamine cr 15mg cap 99                      diltiazem cd 120mg cap 90
dextrose 5% 20x4x100ml inj 134                        diltiazem cd 300mg cap 90
dextrose 5%-nacl 0.45% 1000ml 134                     diltiazem er 180mg capsule 90
dextrose 5%-nacl 0.9% 1000ml 134                      diltiazem er 240mg capsule 90
dextrose 10% inj 134                                  DIMETANE DX 131
DEXTROSTAT 99                                         DIOVAN 40MG TABLET 95
D.H.E-45 62                                           DIOVAN 80MG TABLET 95
DIABETA 81                                            DIOVAN 160MG TABLET 95
DIABETIC GAUZE PADS 2X2 136                           DIOVAN 320MG TABLET 95
DIABINESE 81                                          DIP/TET TOXOID PED 6.7-5LF 119
DIAMOX 124-125                                        DIPENTUM 250MG CAP 122
DIAMOX SEQUELS 124-125                                diphenhydramine 50mg/ml inj 55
diazepam 2mg tablet 78-79                             diphenoxylate/atropine liq 109
DIAZEPAM 5MG/5ML ORAL SOLN 78-79                      diphenoxylate/atropine tablt 109
diazepam 5mg tablet 78-79                             DIPROSONE 103-104
diazepam 10mg tablet 78-79                            dipyridamole 25mg tablet 85
diclofenac sod 0.1% ophth sol 126                     dipyridamole 50mg tablet 85
diclofenac sod 25mg tablet 59, 62                     dipyridamole 75mg tablet 85
diclofenac sod 50mg tablet 59, 62                     DISALCID 59, 61
diclofenac sod 75mg tablet 59, 62                     disopyramide 100mg capsule 87
dicloxacillin 250mg capsule 40                        disopyramide 150mg capsule 87
dicloxacillin 500mg capsule 40                        disulfiram 250mg tablet 107
dicyclomine 10mg capsule 108                          DITROPAN (NOT XL) 111
dicyclomine 20mg tab 108                              DITROPAN SYRUP (NOT XL) 111
didanosine 200mg capsule 75-76                        DIURIL 92
didanosine 250mg capsule 75-76                        DIURIL SUSP 250MG/5ML 92
didanosine 400mg capsule 75-76                        divalproex 125mg dr tablet 44
diflorasone diac 0.05% cream 103, 105                 divalproex 250mg dr tablet 44
diflorasone diac 0.05% oint 103, 105                  divalproex 500mg dr tablet 44
DIFLUCAN 56-57                                        divalproex er 250mg tablet 44
DIFLUCAN IV 56-57                                     divalproex er 500mg tablet 44
digoxin 0.05mg/ml ped elixir 91                       divalproex spr 125mg capsule 44
digoxin 0.25mg/ml inj 91                              DOCETAXEL 10MG/ML INJ 64-65
dihydroergotam mes 1mg/ml inj 62                      DOLOPHINE 34-35
DILANTIN 47                                           DOMEBORO OTIC 127
DILANTIN 30MG CAPSULE 47                              donepezil hcl 5mg tablet 48


                                                       [9]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                           Last Updated: July 1, 2011
                                           Formulary
                                      Alphabetical Drug List

donepezil hcl 10mg tablet 48                        EFFEXOR 51, 54
donepezil hcl odt 5mg tablt 48                      EFFEXOR-XR 51, 54
donepezil hcl odt 10mg tablt 48                     EFUDEX 106
DONNATAL 108                                        EFUDEX 5% SOLN 106
dorzolam/timolol 2-0.5% o/s 124-125                 ELAPRASE 6MG/3ML INJ 107
dorzolamide 2% ophth soln 125-126                   ELAVIL 50-52
DOSTINEX 117                                        ELDEPRYL 67-68
DOVONEX 107                                         ELEDPRYL 67-68
DOVONEX 0.005% CREAM 107                            ELIDEL 1% CREAM 104
doxazosin 1mg tab (gx cardura 86                    ELIMITE 67
doxazosin 2mg tab (gx cardura 86                    ELITEK 1.5MG INJ 107
doxazosin 4mg tab (gx cardura 86                    ELOCON 104
doxazosin 8mg tab (gx cardura 86                    ELOXATIN 100MG INJ 64
doxepin 10mg capsule 51, 54                         ELVIL 50, 52
doxepin 25mg capsule 51, 54                         EMCYT 140MG CAPSULE 63
doxepin 50mg capsule 51, 54                         EMEND 40MG CAPSULE 55
doxepin 75mg capsule 51, 54                         EMEND 80MG CAPSULE 55
doxepin 100mg capsule 51, 54                        EMEND 125-80MG CAPSULE 55
doxepin 150mg capsule 51, 54                        EMLA 101
doxepin hcl 10mg/ml conc 51, 54                     EMSAM 6MG/24HR PATCH 50
doxycycline 20mg tablet 43                          EMSAM 9MG/24HR PATCH 50
doxycycline 50mg capsule 43                         EMTRIVA 10MG/ML SOLN 75
doxycycline 100mg capsule 43                        EMTRIVA 200MG CAPSULE 75
doxycycline 100mg tablet 43                         enalapril 2.5mg tabgxvasotec 95-96
doxycycline hyc 100mg inj 43                        enalapril 5mg tab gx vasotec 95-96
dronabinol 2.5mg cap 55                             enalapril 10mgtab gx vasotec 95-96
dronabinol 5mg capsule 55                           enalapril 20mgtab gxvasotec 95-96
dronabinol 10mg capsule 55                          ENBREL 25MG/0.5ML INJ (PFS) 120
DROXIA 200MG CAPSULE 64                             ENBREL 25MG INJ VIAL KIT 120
DULERA 100MCG/5MCG INHALER 131                      ENBREL 50MG/ML INJ (PFS) 120
DULERA 200MCG/5MCG INHALER 131                      ENDURON 92
DURAGESIC 34-35                                     ENGERIX-B 10MCG/.5ML INJ SYR 119
DURICEF 38                                          ENGERIX-B 20MCG/ML INJ SYRN 119
DYAZIDE 92-93                                       enoxaparin 30mg/0.3ml inj 83-84
DYNAPEN 40                                          enoxaparin 40mg/0.4ml inj 83-84
dyphylline gg 200-200mg tab 130                     enoxaparin 60mg/0.6ml inj 83-84
                                                    enoxaparin 80mg/0.8ml inj 83-84
E                                                   enoxaparin 100mg/ml inj 83-84
                                                    enoxaparin 120mg/0.8ml inj 83-84
econazole nitrate 1% cream 102                      enoxaparin 150mg/ml inj 83-84
EDECRIN 25MG TABLET 92                              enpresse-28 tab(gx triphasil) 114, 116
ees 400 tablet 41                                   ENTOCORT EC 3MG/24HR CAP 121
ees/sulfisoxazole 200/600 42                        ENULOSE 109


                                                    [10]                              2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                            Last Updated: July 1, 2011
                                             Formulary
                                        Alphabetical Drug List

epidrin cap (gx midrin) 62                            ethosuximide 250mg/5ml syrup 43
epinephrine 0.1mg/ml inj 80                           ethosuximide 250mg capsule 43
EPIPEN 0.3MG INJ 130                                  ETHYOL 136
EPIPEN-JR 0.15MG INJ 130                              etodolac 200mg cap(gx lodine 59-60
EPIVIR 10MG/ML ORAL SOLUTION 76                       etodolac 300mg cap(gx lodine 59-60
EPIVIR 150MG TABLET 76                                etodolac 400mg tab (gxlodine) 59-60
EPIVIR 300MG TABLET 76                                etodolac 500mg tab (gxlodine) 60
EPIVIR HBV 100MG TABLET 77                            etodolac er 400mg tablet 60
EPZICOM TABLET 76                                     etodolac er 500mg tablet 60
EQUANIL 78-79                                         etodolac er 600mg tablet 60
ERAXIS 50MG INJ 56                                    etoposide 20mg/ml mdv inj 67
ergoloid mesylates 1mg oral 48                        etoposide 50mg capsule 67
ergotamine/caff 1-100mg tab 62                        ETRAFON 52-53
ERY-C 41-42                                           EUFLEXXA 10MG/ML (3X2ML) INJ 136
erythrocin 250mg tablet 41                            EULEXIN 118
erythrocin 500mg tablet 42                            EVISTA 60MG TABLET 112
ERYTHROCIN LAC 500MG INJ 42                           exemestane 25mg tablet 117-118
erythromycin 2% topical soln 101                      EXJADE 125MG TABLET 136
erythromycin-dr 250mg capsle 41-42                    EXJADE 250MG TABLET 136
erythromycin ophth ointment 123                       EXJADE 500MG TABLET 136
ESKALITH 80
ESKALITH CR 80                                        F
ESTRA-TEST 114
ESTRACE 114                                           FABRAZYME 5MG INJ 107
ESTRACE VAG CREAM 0.1MG/GM 114                        FANAPT 1MG TABLET 71
estradiol 0.025mg/24hr patch 113-114                  FANAPT 2MG TABLET 71
estradiol 0.0375mg/24hr patch 113-114                 FANAPT 4MG TABLET 71
estradiol 0.05mg/24hr patch 113-114                   FANAPT 6MG TABLET 71
estradiol 0.06mg/24hr patch 113-114                   FANAPT 8MG TABLET 71
estradiol 0.075mg/24hr patch 113-114                  FANAPT 10MG TABLET 71
estradiol 0.1mg/24hr patch 113-114                    FANAPT 12MG TABLET 71
estradiol 0.5mg (gx estrace) 114                      FARESTON 60MG TABLET 118
estradiol 1mg (gx estrace) 114                        FASLODEX 50MG/ML INJ 118
estradiol 2mg (gx estrace) 114                        FAZACLO 25MG TABLET 71
estradiol val 20mg/ml inj 114                         FAZACLO 100MG TABLET 71
ESTRATEST HS 114                                      FELBATOL 400MG TABLET 46
estrogen/me-test ds tablet 114                        FELBATOL 600MG/5ML SUSP 46
estrogen/me-test hs tablet 114                        FELBATOL 600MG TABLET 46
estropipate 0.625mg (gx ogen) 114-115                 FELDENE 60-61
estropipate 1.25mg (gx ogen) 114-115                  FEMARA 118
estropipate 2.5mg (gx ogen) 114-115                   fenoprofen 600mg tablet 60-61
ethambutol 100mg tablet 63                            fentanyl 12mcg/hr patch 34
ethambutol 400mg tablet 63                            fentanyl 25mcg/hr patch 34


                                                      [11]                            2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                            Last Updated: July 1, 2011
                                         Formulary
                                    Alphabetical Drug List

fentanyl 50mcg/hr patch 34-35                     fluocinolone 0.01% cream 104-105
fentanyl 75mcg/hr patch 34-35                     fluocinolone 0.01% soln 104-105
fentanyl 100mcg/hr patch 34-35                    fluocinolone 0.025% cream 104-105
fentanyl cit 0.05mg/ml inj 35                     fluocinolone 0.025% oint 104-105
ferocon cap (gx trinsicon) 134                    fluocinonide 0.05% cream 104
fexofenad/pse er 120/60mg tab 127                 fluocinonide 0.05% gel 104
fexofenad/pse er 180/240mgtab 127                 fluocinonide 0.05% ointment 104
fexofenadine 30mg tablet 127                      fluocinonide 0.05% soln 104
fexofenadine 60mg tablet 127-128                  fluocinonide-e 0.05% cream 104
fexofenadine 180mg tablet 127-128                 fluorometholone 0.1% o/s 126
finasteride 5mg tablet 111                        fluorouracil 2% top soln 106
FIORICET 62                                       fluorouracil 5% cream 106
FIORINAL 34-35, 62                                fluorouracil 5% top soln 106
FIORINAL WITH CODEINE 34-35                       fluorouracil 50mg/ml inj 64
FLAGYL 37                                         fluoxetine 20mg/5ml liquid 52-53
FLAGYL (NOT ER) 37                                fluoxetine hcl 10mg capsule 52-53
FLAGYL INJ 37                                     fluoxetine hcl 20mg capsule 52-53
flavoxate 100mg tablet 111                        fluoxymesterone 10mg tablet 114-115
flecainide 50mg tablet 87-88                      fluphenazine 1mg tablet 69-70
flecainide 100mg tablet 87-88                     fluphenazine 2.5mg/5ml elixir 73-74
flecainide 150mg tablet 87-88                     FLUPHENAZINE 2.5MG/ML INJ 73
FLEXERIL (NOT 5MG) 133                            fluphenazine 2.5mg tablet 73-74
FLOMAX 111                                        fluphenazine 5mg tab 69-70
FLONASE 129                                       fluphenazine 5mg tablet 73-74
FLORINEF 111                                      fluphenazine 10mg tablet 69-70
FLOVENT DISKUS 50MCG 129                          fluphenazine dec 25mg/ml inj 73-74
FLOVENT DISKUS 100MCG 129                         flurazepam 15mg capsule 132-133
FLOVENT DISKUS 250MCG 129                         flurazepam 30mg capsule 132-133
FLOVENT HFA 44MCG INHALER 129                     flurbiprofen 0.03% ophth sol 126
FLOVENT HFA 110MCG INHALER 129                    flutamide 125mg capsule 118
FLOVENT HFA 220MCG INHALER 129                    fluticasone 0.005% ointment 103-104
FLOXIN OTIC 127                                   fluticasone 0.05% cream 103-104
fluconazole 10mg/ml oral susp 56                  fluticasone 50mcg nasal spry 129
fluconazole 40mg/ml susp 56                       fluvoxamine 25mg tablet 52
fluconazole 50mg tablet 56                        fluvoxamine 50mg tablet 52
fluconazole 100mg tablet 56                       fluvoxamine 100mg tablet 52
fluconazole 150mg tablet 56                       FML 126
fluconazole 200mg tablet 56                       FML FORTE 0.25% OPHTH SUSP 126
fluconazole/dex 2mg/ml inj 56-57                  FML OPHTH OINTMENT 126
FLUDARA 50MG INJ 66                               folic acid 1mg tablet 134
fludrocortisone 0.1mg tablet 111                  folic acid 5mg/ml inj 135
FLUMADINE 77                                      FORTAZ 38-39
flunisolide 0.025% nasal spr 131                  FORTEO 600MCG/2.4ML INJ PEN 112


                                                  [12]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                       Last Updated: July 1, 2011
                                       Formulary
                                  Alphabetical Drug List

FOSAMAX 111-112                                 GENOTROPIN 1.2MG INJ 113
fosinopril 10mg tablet 95-96                    GENOTROPIN 1.4MG INJ 113
fosinopril 20mg tablet 95-96                    GENOTROPIN 1.6MG INJ 113
fosinopril 40mg tablet 95-96                    GENOTROPIN 5.8MG INJ 113
FOSRENOL 500MG CHEW TAB 109                     GENOTROPIN 13.8MG INJ 113
FOSRENOL 750MG CHEW TAB 109                     gentak 0.3% ophth ointment 123
FOSRENOL 1000MG CHEW TAB 109                    gentamicin 0.1% cream 101
furosemide 10mg/ml inj sdv 92                   gentamicin 0.1% ointment 101
furosemide 10mg/ml soln 92                      gentamicin 0.3% ophth soln 123
furosemide 20mg tablet 92                       gentamicin 10mg/ml inj 37
furosemide 40mg/5ml soln 92                     gentamicin 80mg/2ml inj 37
furosemide 40mg tablet 92                       GEODON 20MG CAPSULE 71
furosemide 80mg tablet 92                       GEODON 20MG INJ 71
FUZEON KIT 75                                   GEODON 40MG CAPSULE 71
                                                GEODON 60MG CAPSULE 71
G                                               GEODON 80MG CAPSULE 71
                                                gianvi-28 3-0.02mg tablet 115-116
gabapentin 100mg capsule 44-45                  GLEEVEC 100MG TABLET 65
gabapentin 250mg/5ml soln 44-45                 GLEEVEC 400MG TABLET 65
gabapentin 300mg capsule 44-45                  glimepiride 1mg tablet 81
gabapentin 400mg capsule 44-45                  glimepiride 2mg tablet 81
gabapentin 600mg tablet 44-45                   glimepiride 4mg tablet 81
gabapentin 800mg tablet 44-45                   glipizide 5mg (gx glucotrol 81
GABITRIL 2MG TABLET 44                          glipizide 10mg (gx glucotrol 81
GABITRIL 4MG TABLET 44                          GLUCAGON 1MG KIT 80
GABITRIL 16MG TABLET 44                         GLUCOPHAGE 81-82
galantamine 4mg/ml soln 48                      GLUCOPHAGE XR 81-82
galantamine 4mg tablet 48                       GLUCOTROL (NOT XL) 81
galantamine 8mg tablet 48                       glyburide 1.25mg tablet 81
galantamine 12mg tablet 48                      glyburide 2.5mg (gx diabeta) 81
galantamine er 8mg capsule 48                   glyburide 5mg tab (gxdiabeta) 81
galantamine er 16mg capsule 48                  glycopyrrolate 0.2mg/ml inj 108
galantamine er 24mg capsule 48                  glycopyrrolate 1mg tablet 108
GAMMAGARD 1G/10ML INJ 119                       glycopyrrolate 2mg tablet 108
ganciclovir 250mg capsule 77-78                 GLYNASE 81-82
ganciclovir 500mg capsule 77-78                 golytely 109
ganciclovir 500mg inj 78                        golytely powder 109
GARAMYCIN 101, 123                              GRIFULVIN V SUSP 57
GARDASIL INJ 119                                griseofulvin 125mg/5ml susp 57
GASTROCROM 100MG/5ML CONC. 109                  guanfacine 1mg tablet 86
gemfibrozil 600mg tablet 93                     guanfacine 2mg tablet 86
GENOTROPIN 0.8MG INJ 113                        GUANIDINE 125MG TAB 80
GENOTROPIN 1MG INJ 113                          GYNAZOLE-1 2% VAG CRM 57


                                                [13]                            2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                      Last Updated: July 1, 2011
                                          Formulary
                                     Alphabetical Drug List

H                                                  hydrocortisone 10mg tablet 111
                                                   hydrocortisone 20mg tablet 111
HALDOL 69                                          hydrocortisone 25mg supp 121
haloperidol 0.5mg tablet 69                        hydrocortisone but 0.1% cream 104
haloperidol 1mg tablet 69                          hydrocortisone but 0.1% oint 104
haloperidol 2mg/ml conc liq 69                     hydrocortisone but 0.1% soln 104
haloperidol 2mg tablet 69                          HYDRODIURIL 92
haloperidol 5mg tablet 69                          hydromorphone 2mg tablet 34-35
haloperidol 10mg tablet 69                         hydromorphone 4mg tablet 34-35
haloperidol 20mg tablet 69                         hydromorphone 8mg tablet 34-35
haloperidol dec 50mg/ml inj 69                     hydroxychloroquine 200mg tab 67
haloperidol lact 5mg/ml inj 69                     hydroxyurea 500mg capsule 64
HALOTESTIN 114-115                                 hydroxyzine 10mg/5ml syrup 127-128
HAVRIX (ADULT HEP A)INJ SYRN 119                   hydroxyzine 50mg/ml inj 79
HAVRIX (PED HEP A) INJ SYRN 119                    hydroxyzine hcl 10mg tablet 127-128
heparin sod 1,000 u/ml inj 83                      hydroxyzine hcl 25mg tablet 127-128
heparin sod 5,000 u/ml inj 83                      hydroxyzine hcl 50mg tablet 127-128
heparin sod 10,000 u/ml inj 83                     hydroxyzine pamoate 25mg cap 79
heparin sod 20,000 u/ml inj 84                     hydroxyzine pamoate 50mg cap 79
HEPSERA 10MG TABLET 77                             hydroxyzine pamoate 100mg cap 79
HEXALEN 50MG CAPSULE 63                            HYGROTON 92
HIZENTRA 200MG/ML INJ 119                          hyomax 0.125mg tab 108
HUMATROPE 5MG/VIAL INJ 113                         hyomax-sl 0.125mg subl tab 108
HUMATROPE 12MG CARTRIDGE KIT 113                   hyomax-sr 0.375mg tab 108
HUMATROPE 24MG CARTRIDGE KIT 113                   hyoscyamine 0.125/5ml elixir 108
HUMIRA 40MG/0.8ML INJ KIT 120                      hyoscyamine 0.125mg/ml drop 108
HUMULIN R 500U/ML INJ (CONC) 82                    hyoscyamine 0.375mg er tab 108
HYCODAN 128                                        hyoscyamine-sr 0.375mg caps 108
HYDERGINE 48                                       HYTONE 104
hydralazine 10mg tablet 96-97                      HYTRIN 86-87
hydralazine 20mg/ml inj 97
hydralazine 25mg tablet 97                         I
hydralazine 50mg tablet 97
hydralazine 100mg tablet 97                        ibuprofen 400mg tablet 60-61
HYDREA 64                                          ibuprofen 600mg tablet 60-61
hydrochlorothiazide 25mg tab 92                    ibuprofen 800mg tablet 60-61
hydrochlorothiazide 50mg tab 92                    ILOTYCIN 123
hydrocod/hom syp (gx hycodan) 128                  IMDUR 97
hydrocodone/apap 7.5/750 tab 35-36                 imipramine 10mg tablet 52, 54
hydrocortisone 2.5% cream 104                      imipramine 25mg tablet 52, 54
hydrocortisone 2.5% lotion 104                     imipramine 50mg tablet 52, 54
hydrocortisone 2.5% ointment 104                   IMITREX 62
hydrocortisone 5mg tablet 111                      IMODIUM 109


                                                   [14]                            2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                         Last Updated: July 1, 2011
                                            Formulary
                                       Alphabetical Drug List

IMOVAX RABIES VAC 2.5/ML INJ 119                     IRESSA 250MG TABLET 65
IMURAN 120                                           irinotecan 20mg/ml sdv inj 66-67
INCRELEX 40MG/4ML INJ 113                            ISENTRESS 400MG TABLET 77
INDERAL 89                                           ISO-HOMATROP 2% OPHTH SOLN 122
INDERAL (NOT LA) 89                                  ISO-HOMATROP 5% OPHTH SOLN 122
INDERAL SOLN 89                                      isoniazid 100mg tablet 63
INDERIDE 89                                          isoniazid 300mg tablet 63
INDOCIN 60                                           ISOPTO ATROPINE 122
INDOCIN SR 60                                        ISOPTO CARBA 1.5% OPHTH SOLN 125
indomethacin 25mg capsule 60                         ISOPTO CARBA 3% OPHTH SOLN 125
indomethacin 50mg capsule 60                         ISOPTO-CARPIN 125
indomethacin-er 75mg capsule 60                      ISOPTO-CARPINE 125
INFANRIX INJ 119                                     ISORDIL 97
INFLAMASE FORTE 126                                  isosorbide 2.5mg sl tablet 97
INS/SYG ULT-TH-II 0.5CC/29G 136                      isosorbide 5mg oral tablet 97
INS/SYG ULT-TH-II 1CC/29G 136                        isosorbide 5mg sl tablet 97
INS/SYG ULT-TH-II 3/10CC 29G 136                     isosorbide 10mg oral tablet 97
INS/SYG ULT-TH-II 3/10CC 30G 137                     isosorbide 20mg oral tablet 97
INS/SYG ULT-TH-II 3/10CC 31G 137                     isosorbide 30mg oral tablet 97
INS/SYG ULT-TH-II-SHRT0.5/30G 137                    isosorbide-er 40mg tablet 97-98
INS/SYG ULT-TH-II-SHRT0.5/31G 137                    isosorbide mon er 30mg tab 97
INS/SYG ULT-TH-II-SHRT1CC/30G 137                    isosorbide mon er 60mg tab 97
INTAL NEB 131                                        isosorbide mon er 120mg tab 97
INTELENCE 100MG TAB 77                               itraconazole 100mg capsule 57
INTELENCE 200MG TAB 77
INTRALIPID 30% INJ 135                               J
INTRON A 3MMU/0.2ML PEN INJ 119
INTRON A 10MMU INJ W/DIL 119                         JANUVIA 25MG TABLET 81
INTRON A 18MMU MDV(3MMU/.5ML) 119                    JANUVIA 50MG TABLET 81
INTRON A 50MMU INJ W/DIL 119                         JANUVIA 100MG TABLET 81
INTRON A HSAF 25MMU/2.5ML INJ 119
INVANZ 1GM INJ 39                                    K
INVEGA 3MG TABLET 71
INVEGA 6MG TABLET 71                                 K-LYTE 134
INVEGA 9MG TABLET 71                                 K-PHOS 500MG ORIGINAL TAB 134
INVEGA SUST 39MG/0.25ML INJ 71                       k-tab 10meq er tablet 134
INVIRASE 200MG CAPSULE 76                            k-vescent tab 25meq ef 134
INVIRASE 500MG TABLET 76                             KALETRA 200MG/50MG TABLET 76
IOPIDINE 124-125                                     KALETRA ORAL SOLUTION 77
IPOL (POLIO VAC INACTIVATED) 119                     KAYEXALATE 109
ipratrop brom 0.02% neb soln 128-129                 KCL/D5W/LR 0.15% INJ 134
ipratropium 0.03% nasal spry 128-129                 KEFLEX 38
ipratropium 0.06% nasal spry 128-129                 kelnor 1/35 tab (gx demulen) 114-115


                                                     [15]                            2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                           Last Updated: July 1, 2011
                                        Formulary
                                   Alphabetical Drug List

KENALOG 100-101                                  LANOXIN PED ELIX 91
KEPPRA 46                                        lansoprazole 15mg capsule 110
KEPPRA (NOT XR) 46                               lansoprazole 30mg capsule 110
ketoconazole 2% cream 102                        LANTUS 100U/ML INJ 83
ketoconazole 200mg tablet 57                     LARIUM 67
ketoprofen 50mg capsule 60-61                    LASIX 92
ketoprofen 75mg capsule 60-61                    latanoprost 0.005% ophth sol 125-126
ketorolac 0.5% ophth soln 126                    LATUDA 40MG TABLET 71
ketorolac 10mg tablet 60-61                      LATUDA 80MG TABLET 71
ketorolac 30mg/ml inj 1ml 60-61                  leflunomide 10mg tablet 121
ketorolac 60mg/2ml inj 60-61                     leflunomide 20mg tablet 121
ketorolac ls 0.4% ophth soln 126                 letrozole 2.5mg tablet 118
KINERET 100MG/.67ML INJ 121                      leucovorin ca 100mg inj 66
kionex 15gm/60ml susp 109                        leucovorin ca 200mg inj 66
kionex powder 109                                leucovorin calcium 5mg tablt 66
KLONOPIN (NOT WAFERS) 78-79                      leucovorin calcium 10mg tab 66
KLONOPIN ODT 78-79                               leucovorin calcium 15mg tablt 66
klor-con 20meq pwd pack 134                      LEUKERAN 2MG TABLET 63
klor-con er 8meq tablet 134                      LEUKINE 250MCG INJ 137
KUVAN 100MG TABLET 107                           leuprolide 1mg/.2ml mdv inj 117
                                                 LEUSTATIN 66
L                                                LEVAQUIN 42
                                                 LEVAQUIN 5MG/ML 100ML IV BAG 42
labetalol hcl 100mg tablet 89-90                 LEVAQUIN 25MG/ML SOLN 42
labetalol hcl 200mg tablet 89-90                 LEVAQUIN 250MG TABLET 42
labetalol hcl 300mg tablet 89-90                 LEVBID 108
LACRISERT DIS OPHTHAL 122                        LEVEMIR 100U/ML INJ 83
lactated ringer/d5w inj 134                      levetiracetam 100mg/ml soln 46
LACTATED RINGER'S 500ML INJ 134                  levetiracetam 250mg tablet 46
lactated ringer's 1000ml inj 134                 levetiracetam 500/5ml inj 46
lactulose 10gm/15ml syrup 109                    levetiracetam 500mg tablet 46
LAMICTAL (NOT XR & ODT) 46                       levetiracetam 750mg tablet 46
LAMISIL 57                                       levetiracetam 1000mg tablet 46
lamotrigine 5mg chew tab 46                      levobunolol (0.25%)gx betagan 124-125
lamotrigine 25mg chew tablt 46                   levobunolol 0.5% (gx betagan) 124-125
lamotrigine 25mg tablet 46                       levofloxacin 500mg tablet 42
lamotrigine 100mg tablet 46                      levofloxacin 750mg tablet 42
lamotrigine 150mg tablet 46                      LEVORA-28 TAB (GX NORDETTE) 115
lamotrigine 200mg tablet 46                      levoxyl 0.025mg tablet 116
LANIAZID 63                                      levoxyl 0.05mg tablet 116
LANOXIN 91                                       levoxyl 0.075mg tablet 116
LANOXIN 0.125 MG (YELLOW) TAB 91                 levoxyl 0.088mg tablet 116
LANOXIN 0.25MG (WHITE) TAB 91                    levoxyl 0.1mg tablet 117


                                                 [16]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                      Last Updated: July 1, 2011
                                         Formulary
                                    Alphabetical Drug List

levoxyl 0.112mg tablet 116                        LOCOID 104
levoxyl 0.125mg tablet 116                        LODINE 59-60
levoxyl 0.137mg tablet 116                        LODINE XL 60
levoxyl 0.15mg tablet 116                         LOMOTIL 109
levoxyl 0.175mg tablet 116                        LOMOTIL LIQ 109
levoxyl 0.2mg tablet 117                          LONITEN 97
LEVSIN 108                                        loperamide 2mg cap 109
LEVSIN DROPS 108                                  LOPID 93
LEVSIN S/L 108                                    LOPRESSOR (NOT HCT) 89
LEVSINEX 108                                      LOPROX 102
LEXAPRO 5MG/5ML ORAL SOLN 52                      LOPROX (NOT SHAMPOO) 102
LEXAPRO 5MG TABLET 52                             lorazepam 0.5mg tablet 78-79
LEXAPRO 10MG TABLET 52                            lorazepam 1.0mg tablet 78-79
LEXAPRO 20MG TABLET 52                            lorazepam 2mg/ml oral conc 78-79
LEXIVA 50MG/ML SUSP 77                            lorazepam 2.0mg tablet 78-79
LEXIVA 700MG TABLET 77                            losartan 25mg tablet 95-96
LIBRAX 110                                        losartan 50mg tablet 95-96
LIBRIUM 78-79                                     losartan 100mg tablet 95-96
LIDEX 104                                         LOTEMAX 0.5% OPHTH SUSP 126
LIDEX -E 104                                      LOTENSIN (NOT HCT) 95-96
lido/prilocaine 2.5% cream 101                    LOTRISONE 102
lidocaine 1% 10mg/ml inj mdv 36                   LOTRONEX 0.5MG TABLET 110
lidocaine 1% 10mg/ml inj sdpf 36                  LOTRONEX 1MG TABLET 110
lidocaine 5% ointment 101                         lovastatin 10mg tablet 93
lidocaine viscous 2% soln 101                     lovastatin 20mg tablet 93
LIDODERM 5% PATCH 101                             lovastatin 40mg tablet 93
LIORESAL 133                                      LOVAZA 1GM CAPSULE 93
liothyronine 5mcg tablet 116-117                  LOVENOX 83-84
liothyronine 25mcg tablet 116-117                 LOVENOX 30MG/0.3ML INJ 84
LIPITOR 20MG TABLET 93                            LOVENOX 40MG/0.4ML INJ 84
LIPITOR 40MG TABLET 93                            LOVENOX 60MG/0.6ML INJ 84
LIPITOR 80MG TABLET 93                            LOVENOX 80MG/0.8ML INJ 84
lisinopril 2.5mg tablet 95-96                     LOVENOX 100MG/ML INJ 84
lisinopril 5mg tablet 95-96                       LOVENOX 120MG/0.8ML INJ 84
lisinopril 10mg tablet 95-96                      LOVENOX 150MG/1ML INJ 84
lisinopril 20mg tablet 95-96                      LOVENOX 300MG/3ML MDV 1X3MLVL      84
lisinopril 30mg tablet 96                         loxapine 5mg capsule 70
lisinopril 40mg tablet 96                         loxapine 10mg capsule 70
lithium carb 450mg er tablet 80                   loxapine 25mg capsule 70
lithium carbonate 150mg caps 80                   loxapine 50mg capsule 70
lithium carbonate 300mg caps 80                   LOXITANE 70
lithium citrate 8meq/5ml syr 80                   LUDIOMIL 49
LO-OVRAL 114-115                                  LUFYLLIN-GG 130


                                                  [17]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                       Last Updated: July 1, 2011
                                         Formulary
                                    Alphabetical Drug List

LUPRON 117                                        meclofenamate 50mg capsule 60
LUPRON DEPOT 3.75MG INJ 117                       meclofenamate 100mg capsule 60
LUPRON DEPOT 7.5MG INJ 117                        MECLOMEN 60
LUPRON DEPOT 11.25MG INJ 117                      MEDROL 58-59, 111
LUPRON DEPOT 11.25MG PED INJ 117                  MEDROL 16MG TABLET 111
LUPRON DEPOT 15MG PED INJ 117                     medroxyprog 150mg/ml sdv inj 114-115
LUPRON DEPOT 22.5MG INJ 117                       medroxyprogesterone 2.5mgtab 115-116
LURIDE 100-101, 135                               medroxyprogesterone 5mg tab 115-116
LUVOX (NOT CR) 52                                 medroxyprogesterone 10mg tab 115-116
LYRICA 25MG CAPSULE 44                            mefloquine 250mg tablet 67
LYRICA 50MG CAPSULE 44                            MEGACE 115
LYRICA 75MG CAPSULE 44                            megestrol 40mg/ml susp 115
LYRICA 100MG CAPSULE 45                           megestrol acetate 20mg tablt 115
LYRICA 150MG CAPSULE 45                           megestrol acetate 40mg tablt 115
LYRICA 200MG CAPSULE 45                           MELLARIL 73-74
LYRICA 225MG CAPSULE 45                           meloxicam 7.5mg/5ml susp 60-61
LYRICA 300MG CAPSULE 45                           meloxicam 7.5mg tablet 60-61
LYSODREN 500MG TAB 117                            meloxicam 15mg tablet 60-61
                                                  MENACTRA INJ 119
M                                                 MENOMUNE-A/C/Y/W-135 INJ 119
                                                  meperidine 50mg tablet 34-35
M-M-R II INJ LIVE 119                             meperidine 100mg tablet 34-35
MACROBID 37                                       MEPHYTON 5MG TABLET 135
MACRODANTIN 37                                    meprobamate 200mg tablet 78-79
magnesium sulfate 1gm/2ml inj 134                 meprobamate 400mg tablet 79
malathion 0.5% lotion 67                          MEPRON 750MG/5ML SUSP 67
maprotiline 25mg tablet 49                        mercaptopurine 50mg tablet 64
maprotiline 50mg tablet 49                        mesalamine 4gm/60ml rec ene 122
maprotiline 75mg tablet 49                        mesna 1gm inj 66
MARINOL 55                                        MESNEX 400MG TAB 66
MARPLAN 10MG TABLET 50                            MESTINON 80
MATULANE 50MG CAP 63                              MESTINON TIMESPAN 180MG TAB 80
MAXALT 5MG TABLET 62                              METADATE CD 10MG CAPSULE 99
MAXALT 10MG TABLET 62                             METADATE CD 20MG CAPSULE 99
MAXALT-MLT 5MG (4X3) TABLET 62                    METADATE CD 30MG CAPSULE 99
MAXALT-MLT 10MG (4X3) TABLET 62                   METADATE CD 40MG CAPSULE 99
MAXIPIME 38-39                                    METADATE CD 50MG CAPSULE 99
MAXIPIME 1GM INJ 39                               METADATE CD 60MG CAPSULE 99
MAXITROL 123                                      metaproterenol 10mg/5ml syrup 130
MAXITROL SUSP 123                                 metaproterenol 10mg tablet 130
MAXZIDE 92-93                                     metaproterenol 20mg tablet 130
MAXZIDE 25 92-93                                  metformin-er 500mg tablet 81-82
mebendazole 100mg chew tab 67                     metformin-er 750mg tablet 81-82


                                                  [18]                          2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                      Last Updated: July 1, 2011
                                            Formulary
                                       Alphabetical Drug List

metformin hcl 500mg tablet 81                        metoprolol 50mg tablet 89
metformin hcl 850mg tablet 81                        metoprolol 100mg tablet 89
metformin hcl 1000mg tablet 81-82                    METROCREAM 101
methadone (methadose)10mg tab 34-35                  METROGEL 37, 101
methadone 5mg/5ml solution 34-35                     METROGEL 1% GEL 101
methadone 5mg tablet 34-35                           METROGEL-VAGINAL GEL 37
methadose conc 10mg/ml soln 34-35                    METROLOTION 101
methazolamide 25mg tablet 125                        metronidazole 0.75% cream 101
methazolamide 50mg tablet 125                        metronidazole 0.75% gel 101
METHERGINE 0.2MG TABLET 85                           metronidazole 0.75% lotion 101
methimazole 5mg tablet 118                           metronidazole 0.75% vag gel 37
methimazole 10mg tablet 118                          metronidazole 250mg tablet 37
methocarbamol 500mg tablet 133                       metronidazole 500mg/100ml inj 37
methocarbamol 750mg tablet 133                       metronidazole 500mg tablet 37
methotrexate 2.5mg tab 120-121                       MEVACOR 93
methotrexate 2.5mg tablet 120-121                    mexiletine 150mg capsule 87
methotrexate 25mg/ml 2ml sdv 64                      mexiletine 200mg capsule 87
methotrexate 25mg/ml 10ml mdv 64                     mexiletine 250mg capsule 87
methyclothiazide 5mg tablet 92                       MEXITIL 87
methyldopa 250mg tablet 86                           MIACALCIN 112
methyldopa 500mg tablet 86                           MICARDIS 20MG TABLET 96
methylin 5mg tablet 99-100                           MICARDIS 40MG TABLET 96
methylin 10mg tablet 99-100                          MICARDIS 80MG TABLET 96
methylin 20mg tablet 99-100                          micronized glyburide 3mg tab 81-82
methylin er 20mg tablet 99-100                       MICRONOR 113, 115
methylphenidate 10mg/5ml soln 99-100                 MIDAMOR 91-92
methylphenidate er 18mg tab 99-100                   midodrine 2.5mg tablet 86
methylphenidate er 27mg tab 99-100                   midodrine 5mg tablet 86
methylphenidate er 36mg tab 99-100                   midodrine 10mg tablet 86
methylphenidate er 54mg tab 99-100                   MIDRIN 62
methylpred ss 125mg vial 58-59                       migergot supp (gx cafergot) 62
methylprednis acet 40mg/mlinj 58                     MINIPRESS 87
methylprednis acet 80mg/mlinj 58                     MINOCIN 43
methylprednisolone 4mg dospak 58                     minocycline 50mg capsule 43
methylprednisolone 4mg tab 58                        minocycline 100mg capsule 43
metoclopramide 5mg/5ml syrup 109                     minoxidil 2.5mg tablet 97
metoclopramide 5mg/ml inj sdv 55                     minoxidil 10mg tablet 97
metoclopramide 5mg tablet 109                        MIRAPEX (NOT ER) 68
metoclopramide 10mg tablet 109                       mirtazapine 7.5mg tablet 49
metolazone 2.5mg tablet 92-93                        mirtazapine 15mg tab (odt) 49
metolazone 5mg tablet 92-93                          mirtazapine 15mg tablet 49
metolazone 10mg tablet 92-93                         mirtazapine 30mg tab (odt) 49
metoprolol 25mg tablet 89                            mirtazapine 30mg tablet 49


                                                     [19]                            2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                           Last Updated: July 1, 2011
                                          Formulary
                                     Alphabetical Drug List

mirtazapine 45mg tab (odt) 49                      MYFORTIC 360MG TABLET 120
mirtazapine 45mg tablet 49                         MYLERAN 2MG TABLET 64
misoprostol 100mcg tablet 111                      MYSOLINE 45
misoprostol 200mcg tablet 111
MITOMYCIN 20MG INJ 63                              N
mitoxantrone 2mg/ml inj mdv 64-65
MOBIC 60-61                                        nabumetone 500mg tablet 61
MODICON 115                                        nabumetone 750mg tablet 61
MODURETIC 91-92                                    NAGLAZYME 1MG/ML INJ 107
mometasone 0.1% cream 104                          NALFON 60-61
mometasone 0.1% ointment 104                       naloxone 0.4mg/ml inj 136
mometasone 0.1% soln 104                           naltrexone 50mg tablet 136
MONOPRIL (NOT HCT) 95-96                           NAMENDA 5/10MG TAB TITRA PACK 48
MORPHINE SULF 10MG/ 5ML SOLN 35                    NAMENDA 5MG TABLET 48
MORPHINE SULF 20MG/ 5ML SOLN 35-36                 NAMENDA 10MG/5ML ORAL SOLN 48
morphine sulf 20mg/ml soln 35-36                   NAMENDA 10MG TABLET 48
morphine sulf er 15mg tablt 35                     NAPROSYN 61
morphine sulf er 30mg tablt 35                     naproxen 125mg/5ml susp 61
morphine sulf er 60mg tablt 35                     naproxen 250mg tablet 61
morphine sulf er 100mg tablt 35                    naproxen 375mg tablet 61
morphine sulf er 200mg tablt 35                    naproxen 500mg tablet 61
morphine sulf ir 15mg tablet 35                    naproxen sodium-ds 550mg tab 59, 61
morphine sulf ir 30mg tablet 35                    NARCAN 136
MOTRIN 60-61                                       NARDIL 50
MOXEZA 0.5% OPHTH SOLN 123                         NASALIDE 131
mpd lancets thin 137                               NATACYN OPHTH SOLN 124
MS CONTIN 35                                       nateglinide 60mg tablet 82
MS IR 35-36                                        nateglinide 120mg tablet 82
MS IR ORAL SOLN 35-36                              NAVANE 73-74
MUCOMYST 131                                       necon 1/35-28 tab 115
multi-vit fl/fe 0.25mg drops 135                   necon 1/50-28 tablet 115
multi-vit fluor 0.25mg drops 135                   necon 10/11-28 115
multi vita-bets/fl 0.5mg 135                       nefazodone 50mg tablet 52, 54
multi vita-bets/fl 1mg tablet 135                  nefazodone 100mg tablet 52, 54
mupirocin 2% ointment 101                          nefazodone 150mg tablet 52, 54
MYAMBUTOL 63                                       nefazodone 200mg tablet 52, 54
MYCOBUTIN 150MG CAPSULE 63                         nefazodone 250mg tablet 52, 54
MYCOLOG II 102                                     neo/poly b/hc o/s (gx cortis) 123
mycophenolate 250mg capsule 120                    neo/poly b/hc otic soln 127
mycophenolate 500mg tablet 120                     neo/poly/bac/hc o/o(gxcortis) 123
MYCOSTATIN 57, 102                                 neomycin 500mg tablet 37
MYDRIACYL 122                                      NEORAL 120
MYFORTIC 180MG TABLET 120                          NEOSPORIN 123


                                                   [20]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                        Last Updated: July 1, 2011
                                          Formulary
                                     Alphabetical Drug List

NEOSPORIN OPHTH 123                                NORDETTE 115
NEPTAZANE 125                                      NORDITROPIN CART 15MG/1.5ML 113
NEULASTA 6MG/0.6ML INJ 85                          NORDITROPIN NRDFLEX 5MG/1.5ML 113
NEUMEGA 5MG VIAL 85                                NORDITROPIN NRDFLX 10MG/1.5ML 113
NEUPOGEN 300MCG/ML 1ML VIAL 85                     norethindrone ace 5mg tablet 113, 115
NEUPOGEN 480MCG/1.6ML VIAL 85                      NORPACE 87
NEURONTIN 44-45                                    NORPACE CR 100MG CAPSULE 87
NEVANAC 0.1% OPHTH SUSP 126                        NORPRAMIN 51-52
NEXAVAR 200MG TABLET 65                            nortrel 0.5/35-28 tablet 115
NIASPAN 500MG ER TABLET 93                         nortriptyline 10mg/5ml soln 52-53
NIASPAN 750MG ER TABLET 94                         nortriptyline 10mg capsule 52-53
NIASPAN 1000MG ER TABLET 94                        nortriptyline 25mg capsule 53
nifediac cc 60mg(gx adalat-cc 90                   nortriptyline 50mg capsule 53
nifediac cc 90mg(gx adalat-cc 90                   nortriptyline 75mg capsule 53
nifedipine 10mg capsule 90-91                      NORVASC 90-91
nifedipine 20mg capsule 91                         NORVIR 80MG/ML SOLN 75
NILANDRON 150MG TABLET 118                         NORVIR 100MG SOFT GEL CAPSULE 75
nimodipine 30mg capsule 91                         NORVIR 100MG TABLET 75
NIMOTOP 91                                         NOVANTRONE 64-65
nitro-bid 2% ointment 97                           NOVAREL 10000U IM INJ 115
NITRO DUR 97-98                                    NOVOLIN 70/30 100U/ML INJ 83
NITRO-DUR 98                                       NOVOLIN N 100U/ML INJ 83
nitrofurantoin 50mg capsle 37                      NOVOLIN R 100U/ML INJ 83
nitrofurantoin 100mg capsul 37                     NOVOLOG 100U/ML INJ 83
nitrofurantoin bid 100mg cap 37                    NOVOLOG MIX 70/30 INJ 83
nitroglycerin 0.1mg/hr patch 98                    NUTROPIN 10MG INJ 113
nitroglycerin 0.2mg/hr patch 97-98                 NUTROPIN AQ 5MG/ML INJ 113
nitroglycerin 0.4mg/hr patch 97-98                 ny-tannic 9-25mg tablet 128
nitroglycerin 0.6mg/hr patch 98                    nystatin 100m un/ml susp 57, 102
nitroglycerin 2.5mg capsule 98                     nystatin 500,000 units oral 57
nitroglycerin 6.5mg capsule 98                     nystatin cream 102
nitroglycerin 9mg capsule 98                       nystatin ointment 102
nitroglycerin s/l 0.3mg tablt 98                   nystatin/triamcinolone cream 102
nitroglycerin s/l 0.4mg tablt 98                   nystatin/triamcinolone oint 102
nitroglycerin s/l 0.6mg tablt 98
nitroquick 0.4mg sl tab 98                         O
NITROSTAT 98
NITROSTAT 0.3MG SUBLING 98                         octreotide 0.05mg/ml inj 117
NITROSTAT 0.4MG SUBLING 98                         octreotide 0.1mg/ml inj 117
NITROSTAT 0.6MG SUBLING 98                         octreotide 0.2mg/ml inj mdv 117
NIZORAL 57, 102                                    octreotide 0.5mg/ml inj 117
NOCTEC 132-133                                     octreotide 1mg/ml inj mdv 117
NOLVADEX 118                                       OCUFEN 126


                                                   [21]                              2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                           Last Updated: July 1, 2011
                                        Formulary
                                   Alphabetical Drug List

OCUFLOX 123                                      OXSORALEN 1% LOTION 106
OCUPRESS OPHTHALMIC SOLN 124-125                 OXSORALEN ULTRA 10MG CAP 106
ocutricin o/s (gx neosporin) 123                 oxybutynin 5mg/5ml syrup 111
ofloxacin 0.3% ophth soln 123                    oxybutynin 5mg tablet 111
ofloxacin otic 0.3% soln 127                     oxycod/apap 5-325mg/5ml soln 36
OGEN 114-115                                     oxycodone/apap 5/325 tablet 36
ogestrel-28 tab (gx ovral) 115                   oxycodone/apap 5/500 capsle 36
omeprazole dr 10mg capsule 110
omeprazole dr 20mg capsule 110                   P
OMNICEF 38-39
OMNITROPE 5.8MG INJ 113                          paclitaxel 30mg/5ml inj 65
ONCOVORIN 65                                     paclitaxel 100mg/16.7ml inj 65
ondansetron 2mg/ml inj sdv 55-56                 paclitaxel 300mg/50ml inj 65
ondansetron 4mg/5ml soln 55-56                   PAMELOR 52-53
ondansetron 4mg tablet 55-56                     PANCREAZE 10,500UN CAPSULE 107
ondansetron 8mg tablet 55-56                     PANCREAZE 21,000UN CAPSULE 107
ondansetron odt 4mg tablet 55-56                 PANRETIN 0.1% GEL 65
ondansetron odt 8mg tablet 55-56                 pantoprazole 20mg tablet 110
ONGLYZA 2.5MG TABLET 82                          pantoprazole 40mg tablet 110
ONGLYZA 5MG TABLET 82                            papaverine 150mg capsule 98
ONTAK 150MCG/ML INJ 65                           PARAPLATIN 64-65
OPTICROM 122                                     paregoric 2mg/5ml elixer 108
ORAP 1MG TABLET 70                               PARLODEL 68
ORAP 2MG TABLET 70                               PARNATE 10MG TABLET 50
ORAPRED (NOT ODT) 58-59                          paroxetine hcl 10mg tablet 53
ORENCIA 250MG INJ 121                            paroxetine hcl 12.5mg er tab 53
ORFADIN 10MG CAP 107                             paroxetine hcl 20mg tablet 53
ORINASE 82                                       paroxetine hcl 25mg er tab 53
ORTHO-CYCLEN 115-116                             paroxetine hcl 30mg tablet 53
ORTHO NOVUM 115                                  paroxetine hcl 37.5mg er tab 53
ORTHO-TRICYCLEN 115-116                          paroxetine hcl 40mg tablet 53
ORUDIS 60-61                                     PASER 4 GM GRANULES 63
OVIDE 67                                         PATANASE 0.6% NASAL SPRAY 128
OVRAL 114-115                                    PAVABID 98
OXACILLIN 1GM INJ 40                             PAXIL 53
OXANDRIN 2.5MG TABLET 115                        PAXIL 10MG/5ML SUSP 53
oxaprozin 600mg tablet 59, 61                    PAXIL CR 53
oxcarbazepine 150mg tablet 47                    PEDIAPRED 59
oxcarbazepine 300mg/5ml susp 47                  PEDIAZOLE 42
oxcarbazepine 300mg tablet 47                    PEDVAXHIB INJ (10X0.5ML) 119
oxcarbazepine 600mg tablet 47                    PEG-INTRON 50MCG/0.5ML KIT 119
OXISTAT 1% CREAM 102                             PEG-INTRON 80MCG REDIPEN KIT 119
OXISTAT 1% LOTION 102                            PEG-INTRON 120MCG REDIPEN KIT 119


                                                 [22]                          2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                     Last Updated: July 1, 2011
                                           Formulary
                                      Alphabetical Drug List

PEG-INTRON 150MCG REDIPEN KIT 119                   phenytoin 100mg er capsule 47
PEGANONE 250MG TABLET 47                            phenytoin 125mg/5ml susp 47
PEGASYS 180MCG/0.5ML KIT 119                        phluorivit 0.5mg drops 135
PEN G PROC 600000 U/ML INJ 41                       PHOSLO 109
PEN VEE K 41                                        phospha 250mg neutral tablet 134
penicillin g pot 5mmu inj 41                        PHOSPHOLINE SOL 0.125% O/S 125
penicillin vk 125mg/5ml susp 41                     pilocarpine 0.5% (pilostat) 125
penicillin vk 250mg/5ml susp 41                     pilocarpine 1% soln(pilostat) 125
penicillin vk 250mg tablet 41                       pilocarpine 2% soln(pilostat) 125
penicillin vk 500mg tablet 41                       pilocarpine 3% soln(pilostat) 125
PENLAC 102                                          pilocarpine 4% ophth soln 125
pentoxifylline 400mg tablet 85-86                   pilocarpine 5mg tablet 80
PERCOCET 5 ONLY 36                                  pilocarpine 6% ophth soln 125
PERIACTIN 127-128                                   PILOPINE HS GEL OPTH 4% 125
PERIDEX 100-101                                     piroxicam 10mg capsule 60-61
PERIOSTAT 43                                        piroxicam 20mg capsule 60-61
permethrin 5% cream 67                              PLAQUENIL 67
perphenazine 2mg tablet 74                          PLATINOL 64-65
perphenazine 4mg tablet 74                          PLAVIX 75MG TABLET 85
perphenazine 8mg tablet 74                          PLETAL 85
perphenazine 16mg tablet 74                         podofilox 0.5% top soln 106
perphenazine/amitrip 2/10 tab 52-53                 POLY VI FLOR 135
perphenazine/amitrip 2/25 tab 52-53                 POLY-VI-FLOR 135
perphenazine/amitrip 4/10 tab 52-53                 poly-vit-fluor-fe .5mg drops 135
perphenazine/amitrip 4/25 tab 52-53                 POLYCITRA-K 133-134
perphenazine/amitrip 4/50 tab 52-53                 polymyx/tmp o/s (gx polytrim) 123-124
PERSANTINE 85                                       POLYMYXIN B SULF 500,000 U 37
phenadoz 12.5mg supp 55                             POLYSPORIN 123
phenadoz 25mg supp 55                               POLYTRIM 123-124
phenazopyridine 200mg tablet 34                     portia-28 tab (gx nordette) 115
phenazopyridine plus tablet 34                      pot chloride 2omeq/10ml inj 134
phenelzine 15mg tablet 50                           potassium chl 10% sf liquid 134
PHENERGAN 55-56, 128                                potassium chl 20% sf liquid 134
PHENERGAN DM 132                                    potassium cit 5meq er tab 134
PHENERGAN VC 132                                    potassium cit 10meq er tab 134
PHENERGAN VC WITH CODEINE 132                       pramipexole 0.125mg tablet 68
PHENERGAN W/CODEINE 132                             pramipexole 0.25mg tablet 68
phenobarbital 16.2mg tablet 45                      pramipexole 0.5mg tablet 68
phenobarbital 20mg/5ml elixr 45                     pramipexole 1mg tablet 68
phenobarbital 30mg tab 45                           pramipexole 1.5mg tablet 68
phenobarbital 64.8mg tablet 45                      PRAVACHOL 94
phenobarbital 100mg tab 45                          pravastatin 10mg tab 94
phenytoin 50mg/ml inj 47                            pravastatin 10mg tablet 94


                                                    [23]                            2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                          Last Updated: July 1, 2011
                                           Formulary
                                      Alphabetical Drug List

pravastatin 20mg tablet 94                          PREZISTA 400MG TABLET 77
pravastatin 40mg tablet 94                          PREZISTA 600MG TAB 77
pravastatin 80mg tablet 94                          PRIFTIN 150MG TAB 63
prazosin 1mg capsule 87                             PRILOSEC 110
prazosin 2mg capsule 87                             PRIMAXIN 500MG IV INJ 39
prazosin 5mg capsule 87                             primidone 50mg tablet 45
PRECOSE 80, 82                                      primidone 250mg tablet 45
PRED FORTE 126                                      PRINCIPEN 40-41
PRED-G OPHTH OINT 124                               PRISTIQ 50MG ER TABLET 53
PRED-G OPHTH SUSP 124                               PRISTIQ 100MG ER TABLET 53
PRED MILD 0.12% OPHTH SUSP 126                      PRO-BANTHINE 80
prednisolone 1%(gx predforte 126                    PROAMATINE 86
prednisolone 5mg/5ml syrup 59                       probenecid 500mg tablet 57
prednisolone 6.75mg/5ml liq 59                      probenecid/colch 500/0.5 tab 57
prednisolone 15mg/5ml syrup 59                      PROCAINAMIDE 500MG/ML INJ 87
prednisolone 15mg/5ml(orapred 58-59                 PROCARDIA (NOT XL) 90-91
prednisolone sod 1% ophth sol 126                   prochlorper 5mg/ml inj mdv 55-56
PREDNISOLONE SOD 1% OPHTHSOL 126                    prochlorperazine 5mg tablt 55-56
prednisone 1mg tablet 58-59                         prochlorperazine 10mg tablt 55-56
prednisone 2.5mg tablet 58-59                       prochlorperazine 25mg supp 55-56
prednisone 5mg/5ml oral sol 59                      PROCRIT 2,000 U/ML INJ 85
                                                    PROCRIT 3,000 U/ML INJ 85
prednisone 5mg tablet 58-59                         PROCRIT 4,000 U/ML INJ 85
prednisone 10mg tablet 58-59                        PROCRIT 10,000 U/ML INJ 85
prednisone 20mg tablet 58-59                        PROCRIT 20,000 U/ML INJ 85
prednisone 50mg tablet 58-59                        PROCRIT 40,000 U/ML INJ 85
PRELONE 59                                          proctosol-hc 2.5% crm 103, 105
PREMARIN 0.3MG TABLET(GREEN) 116                    PRODIGY AUTOCODE TEST STRIPS 137
PREMARIN 0.45MG TABLET 116                          progesterone 50mg/ml mdv inj 116
PREMARIN 0.625MG TABLET 116                         PROGLYCEM 50MG/ML SUSP 80
PREMARIN 0.9MG TABLET(WHITE) 116                    PROGRAF 120-121
PREMARIN 1.25MG TAB (YELLOW) 116                    PROLASTIN 1000MG INJ 132
PREMARIN VAG CREAM W/APPL 116                       PROLEUKIN 22MIU INJ 65
PREMPHASE 0.625/5MG TABLET 116                      PROLIXIN 69-70, 73-74
PREMPRO 0.3MG/1.5MG TABLET 116                      PROMACTA 25MG TABLET 85
PREMPRO 0.45MG/1.5MG TABLET 116                     PROMACTA 50MG TABLET 85
PREMPRO 0.625MG/2.5MG TABLET 116                    prometh-vc syrup 132
PREMPRO 0.625MG/5MG TABLET 116                      prometh-vc w/codeine syrup 132
prenatal plus tablet 135                            prometh w/codeine syrup 132
PREVACID (NOT SOLUTAB) 110                          promethazine 6.25/5ml syrup 128
PREVIDENT 100-101                                   promethazine 12.5mg tablet 128
PREZISTA 75MG TABLET 77                             promethazine 25mg/ml inj amp 56
PREZISTA 150MG TABLET 77                            promethazine 25mg tab 128


                                                    [24]                         2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                       Last Updated: July 1, 2011
                                           Formulary
                                      Alphabetical Drug List

promethazine 25mg tablet 55-56                      PYRIDIUM PLUS 34
promethazine 50mg/ml inj sdv 56                     pyridostigmine br 60mg tab   80
promethazine 50mg supp 55-56
promethazine 50mg tablet 128                        Q
promethazine-dm syrup 132
propafenone 150mg tablet 87-88                      QUESTRAN 93-94
propafenone 225mg tablet 88                         QUESTRAN LIGHT 93-94
propafenone 300mg tablet 88                         QUINAGLUTE 88
propantheline 15mg tablet 80                        QUINIDEX 88
proparacaine 0.5% ophth soln 122                    quinidine er 300mg tablet 88
propoxy-n/apap 100/650 tablt 34, 36                 quinidine gluconate 324mg tab 88
propoxyphene 65mg capsule 34, 36                    quinidine sulfate 200mg tab 88
propranolol 1mg/ml inj sdv 89                       quinidine sulfate 300mg tab 88
propranolol 10mg tablet 89                          QUIXIN 0.5% OPHTH SOLUTION 124
propranolol 20mg tablet 89
propranolol 40mg tablet 89                          R
propranolol 60mg tablet 89
propranolol 80mg tablet 89                          r-tanna 4.5/5mg susp 128
propranolol hcl sol 20mg/5ml 89                     RABAVERT INJ 119
propranolol hcl sol 40mg/5ml 89                     ramipril 1.25mg capsule 94, 96
propranolol/hctz 40/25mg tab 89                     ramipril 2.5mg capsule 94, 96
propranolol/hctz 80/25 tab 89                       ramipril 5mg capsule 94, 96
propylthiouracil 50mg tablet 118                    ramipril 10mg capsule 95-96
PROQUAD INJ 119                                     RANEXA 500MG TABLET 137
PROSCAR 111                                         RANEXA 1000MG ER TABLET 137
PROTONIX 110                                        ranitidine 15mg/ml syrup 110
PROTONIX 40MG INJ 110                               ranitidine 150mg tablet 110
PROTONIX 40MG ORAL SUSP PCKT 110                    ranitidine 300mg tablet 110
protriptyline 5mg tablet 53-54                      RAPAMUNE 0.5MG TABLET 8 120
protriptyline 10mg tablet 53-54                     RAPAMUNE 1MG/ML SOLUTION 120
PROVENTIL 129-130                                   RAPAMUNE 1MG TABLET 120
PROVERA 114-116                                     RAPAMUNE 2MG TABLET 121
PROVIGIL 100MG TABLET 100                           RAZADYNE 48
PROVIGIL 200MG CAPLET 100                           RAZADYNE ER 48
PROZAC 52-53                                        REBETOL 77
PROZAC LIQ 52-53                                    REBIF 22MCG/0.5ML PFS INJ 121
prudoxin 5% cream 105                               REBIF 44MCG/0.5ML PFS INJ 121
PSORCON 103, 105                                    REBIF TITRATION PACK 121
PTU 118                                             RECOMBIVAX-HB 10MCG/ML INJ 119
PULMICORT RESPULES 129                              RECOMBIVAX-HB 40MCG/ML INJ 119
PURINETHOL 64                                       REGLAN 109
pyrazinamide 500mg tablet 63                        RELAFEN 61
PYRIDIUM 34                                         RELENZA DISKHALER 77


                                                    [25]                              2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                            Last Updated: July 1, 2011
                                          Formulary
                                     Alphabetical Drug List

REMERON 49                                         RISPERDAL CONSTA 50MG/2ML INJ 72
REMERON ODT 49                                     RISPERDAL-M 72
REMERON-ODT 49                                     RISPERDAL-M 0.5MG TAB 72
REMERON SOLU-TAB 49                                risperidone 0.25mg tablet 71-72
REMICADE 100MG INJ 121                             risperidone 0.5mg tablet 71-72
REQUIP 68-69                                       risperidone 1mg/ml oral soln 71-72
REQUIP XL 2MG TABLET 68                            risperidone 1mg tablet 72
REQUIP XL 4MG TABLET 69                            risperidone 2mg tablet 72
REQUIP XL 8MG TABLET 69                            risperidone 3mg tablet 72
RESCRIPTOR 100MG TAB 75                            risperidone 4mg tablet 72
RESCRIPTOR 200MG TABLET 75                         risperidone-m 1mg tablet 72
reserpine 0.1mg tablet 98                          risperidone-m 2mg tablet 72
reserpine 0.25mg tablet 98                         RITALIN (NOT LA) 99-100
RESOTRIL (NOT 7.5MG) 133                           RITALIN ER (NOT LA) 99-100
RESTASIS 0.05% OPHTH 122                           RITALIN SOLN 99-100
RESTORIL (NOT 7.5MG) 133                           RITUXAN 100MG VL INJ 65
RETIN A 106                                        ROBAXIN 133
RETINA 106                                         ROBINUL 108
RETROVIR 76                                        ROBINUL 0.2MG/ML INJ 108
RETROVIR 10MG/ML INJ 76                            ROBITUSSIN AC 131-132
REVATIO 20MG TABLET 132                            ROBITUSSIN DAC 131-132
REVIA 136                                          ROCALTROL 112
REVLIMID 5MG CAPSULE 121                           ROCEPHIN 38-39
REVLIMID 10MG CAPSULE 121                          ROCHEPIN 38-39
REVLIMID 15MG CAPSULE 121                          RONDEC DM 131-132
REVLIMID 25MG CAPSULE 121                          RONDEC DM SYRUP 131-132
REYATAZ 100MG CAP 77                               RONDEC DROPS 131-132
REYATAZ 150MG CAPSULE 77                           RONDEC-S 127-128
REYATAZ 200MG CAPSULE 77                           ropinirole 0.25mg tablet 68-69
REYATAZ 300MG CAPSULE 77                           ropinirole 0.5mg tablet 68-69
RHEUMATREX 120-121                                 ropinirole 1mg tablet 68-69
RHUEMATREX 120-121                                 ropinirole 2mg tablet 68-69
ribavirin 200mg capsule 77                         ropinirole 3mg tablet 68-69
RIFADIN 63                                         ropinirole 4mg tablet 68-69
rifampin 150mg capsule 63                          ropinirole 5mg tablet 68-69
rifampin 300mg capsule 63                          ROTATEQ SUSP 119
rifampin 600mg inj. 63                             ROWASA 122
RIFATER 63                                         ROXANOL 35-36
RILUTEK 50MG TABLET 100                            ROXICET 36
rimantadine 100mg tablet 77                        RYNATAN 128
ringers irrig soln 134                             RYTHMOL (NOT SR) 87-88
RISPERDAL 71-72
RISPERDAL CONSTA 25MG/2ML INJ   72


                                                   [26]                          2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                       Last Updated: July 1, 2011
                                         Formulary
                                    Alphabetical Drug List

S                                                 SEROQUEL-XR 400MG TABLET 73
                                                  SERPALAN 98
SABRIL 500MG ORAL SOLUTION 45                     sertraline 20mg/ml conc 54-55
SABRIL 500MG TABLET 45                            sertraline 25mg tablet 54-55
SAIZEN 5MG VIAL INJ 113                           sertraline 100mg tablet 54-55
SAIZEN 8.8MG CLICKEASY DEVICE 113                 SERZONE 52, 54
SALAGEN 80                                        SILVADENE 102
salsalate 500mg tablet 59, 61                     simvastatin 5mg tablet 94
salsalate 750mg tablet 59, 61                     simvastatin 10mg tablet 94
SANDOSTATIN 117                                   simvastatin 20mg tablet 94
SANDOSTATIN LAR 30MG KIT 117                      simvastatin 40mg tablet 94
SANTYL 250U/GM OINT 107                           simvastatin 80mg tablet 94
SAPHRIS 5MG S/L TABLET 72                         SINEMET 68-69
SAPHRIS 10MG S/L BLCK CHR TAB 72                  SINEMET CR 68-69
SAVELLA 12.5MG TABLET 53                          SINEQUAN 51, 54
SAVELLA 25MG TABLET 54                            SLOW-K 134
SAVELLA 50MG TABLET 54                            smz-tmp 200-40/5ml ped susp 42
SAVELLA 100MG TABLET 54                           SMZ-TMP 400-80/5 INJ 42
SAVELLA TITRATION PACK TAB 54                     smz-tmp 400/80 reg str tablt 42
SECTRAL 88-89                                     sod bicarb 8.4% inj 50ml sdv 134
selegiline 5mg capsule 67-68                      sod chloride 0.45% inj 1000ml 134
selegiline 5mg tablet 67-68                       sod chloride 0.9% inj 250ml 134
selenium sulfide 2.5% lotion 102                  sod fluoride 0.25mg chew tab 100-101
SELSUN 102                                        sod fluoride 0.5mg chew tab 101
SELZENTRY 300MG TAB 77                            sod fluoride 0.5mg/ml drop 135
SEMPREX-D CAPSULE 132                             sod fluoride 1mg chew tablet 101
SENSIPAR 30MG TABLET 112                          sod sulfacet sol 10% opth sol 123-124
SENSIPAR 60MG TABLET 112                          sodiphluor 0.5mg/ml drop 135
SENSIPAR 90MG TABLET 112                          SOLARAZE 3% GEL 106
SEPTRA 42                                         SOLTAMOX 10MG/5ML SOLN 118
SEPTRA DS 42                                      SOLU-CORTEF 58-59
SEREVENT DISKUS 130                               SOLU-CORTEF 100MG/2ML INJ 59
SEROMYCIN 250MG CAPSULE 63                        SOLU-CORTEF 1000MG INJ 59
SEROQUEL 25MG TABLET 72                           SOLU-MEDROL 58-59, 111
SEROQUEL 50MG TABLET 72                           SOLU-MEDROL 1000MG INJ 59
SEROQUEL 100MG TABLET 72                          SOMA (NOT 250MG) 133
SEROQUEL 200MG TABLET 72                          SOMAVERT 10MG INJ 117
SEROQUEL 300MG TABLET 72                          somnote 500mg cap(chloral hy) 133
SEROQUEL 400MG TABLET 72                          SONATA 133
SEROQUEL-XR 50MG TABLET 72                        SORBITRATE 97-98
SEROQUEL-XR 150MG TABLET 72                       sotalol hcl 80mg tablet 87-88
SEROQUEL-XR 200MG TABLET 73                       sotalol hcl 120mg tablet 87-88
SEROQUEL-XR 300MG TABLET 73                       sotalol hcl 160mg tablet 87-88


                                                  [27]                             2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                         Last Updated: July 1, 2011
                                            Formulary
                                       Alphabetical Drug List

sotalol hcl 240mg tablet 87-88                       sumatriptan 5mg nasal spry 62
SPECTAZOLE 102                                       SUMATRIPTAN 8MG/ML KIT 62
SPIRIVA HANDIHALER 129                               SUMATRIPTAN 12MG/ML KIT 62
spironolactone 25mg tablet 91, 93                    sumatriptan 20mg nasal spry 62
spironolactone 50mg tablet 91, 93                    sumatriptan 25mg tablet 62
spironolactone/hctz 25/25 tab 91, 93                 sumatriptan 50mg tablet 62
SPORANOX 57                                          sumatriptan 100mg tablet 62
SPORANOX 10MG/ML ORAL SOLN 57                        SUMYCIN 43
sprintec 28 day tablet 115-116                       SUPRAX 100MG/5ML SUSP 39
SPRYCEL 50MG TABLET 65                               SUPRAX 400MG TABLET 39
SPRYCEL 70MG TABLET 66                               SURMONTIL 25MG CAP 54
SPRYCEL 80MG TABLET 66                               SURMONTIL 50MG CAP 54
SPRYCEL 140MG TABLET 65                              SURMONTIL 100MG CAP 54
ssd cream 102                                        SUSTIVA 50MG CAPSULE 75
STARLIX 82                                           SUSTIVA 200MG CAPSULE 75
stavudine 1mg/ml oral soln 76                        SUSTIVA 600MG TABLET 75
stavudine 20mg capsule 76                            SUTENT 12.5MG CAPSULE 66
stavudine 30mg capsule 76                            SUTENT 25MG CAPSULE 66
stavudine 40mg capsule 76                            SUTENT 50MG CAPSULE 66
STELAZINE 74                                         SYMBICORT 80/4.5 INHALER 132
STRATTERA 10MG CAPSULE 100                           SYMBICORT 160/4.5 INHALER 132
STRATTERA 18MG CAPSULE 100                           SYMLIN 0.6MG/ML INJ 137
STRATTERA 25MG CAPSULE 100                           SYMLIN PEN 60 1000MCG/ML INJ 137
STRATTERA 40MG CAPSULE 100                           SYMMETREL 68-69, 77
STRATTERA 60MG CAPSULE 100                           SYNAGIS 50MG INJ 119
STRATTERA 80MG CAPSULE 100                           SYNAGIS 100MG INJ 119
STRATTERA 100MG CAPSULE 100                          SYNALAR 104-105
STROMECTOL 3MG TAB 67                                SYNAREL 2MG/ML NASAL SOLN 113
STUART NATAL PLUS 135                                SYNVISC (3X2ML) INJ 137
STUARTNATAL PLUS THREE 135                           SYPRINE 250MG CAPSULE 136
SUBOXONE 2MG/0.5MG SL FILM 100
SUBOXONE 2MG/0.5MG SL TAB 100                        T
SUBOXONE 8MG/2MG SL FILM 100
SUBOXONE 8MG/2MG SL TAB 100                          tacrolimus 0.5mg capsule 120-121
SUBUTEX 99-100                                       tacrolimus 1mg capsule 120-121
sucralfate 1gm tablet 111                            tacrolimus 5mg capsule 120-121
sulf/pred (gx vasocidin) drop 124                    TAGAMET 109-110
sulfacetamide 10% ophth oint 123-124                 TAGAMET LIQ 109-110
sulfadiazine 500mg tablet 42                         TAMBACOR 87-88
sulfamethox/trim 800/160 tab 42                      TAMBOCOR 87-88
sulfasalazine 500mg tablet 122                       tamoxifen 10mg tablet 118
sulindac 150mg tablet 59, 61                         tamoxifen 20mg tablet 118
sulindac 200mg tablet 59, 61                         tamsulosin 0.4mg capsule 111


                                                     [28]                               2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                              Last Updated: July 1, 2011
                                           Formulary
                                      Alphabetical Drug List

TAPAZOLE 118                                        TESSALON 131-132
TARCEVA 25MG TABLET 66                              TESTIM 1% GEL PACK 50MG/5GM 116
TARCEVA 100MG TABLET 66                             testost cyp 100mg/ml inj 114, 116
TARCEVA 150MG TABLET 66                             testosterone enan 200mg/mlinj 116
TARGRETIN 1% GEL 66                                 TETANUS TOX 5LF ADS INJ 119
TARGRETIN 75MG CAP 66                               tetracycline 250mg capsule 43
TASIGNA 200MG CAP 66                                tetracycline 500mg capsule 43
TAVIST 127-128                                      THALOMID 50MG CAPSULE 121
TAXOL 65                                            THALOMID 100MG CAPSULE 121
TAXOTERE 64-65                                      THALOMID 150MG CAPSULE 121
TAXOTERE 20MG/0.5ML INJ 65                          THALOMID 200MG CAPSULE 121
TAXOTERE 80MG/2ML INJ 65                            THEO-DUR 130
tazicef 1gm inj 38-39                               theophylline sr 100mg tablet 130
TEGRETOL (NOT XR) 47                                theophylline sr 200mg tablet 130
TEGRETOL SUSP 47                                    theophylline sr 300mg tablet 130
TEKTURNA 150MG TABLET 96                            theophylline sr 450mg tablet 130
TEKTURNA 300MG TABLET 96                            thermazene 1% crm 102
temazepam 15mg capsule 133                          THIOGUANINE 40MG TAB 64
temazepam 30mg capsule 133                          thioridazine 10mg tablet 73-74
TEMODAR 5MG CAPSULE 64                              thioridazine 25mg tablet 73-74
TEMODAR 20MG CAPSULE 64                             thioridazine 50mg tablet 73-74
TEMODAR 100MG CAPSULE 64                            thioridazine 100mg tablet 73-74
TEMODAR 140MG CAPSULE 64                            thiothixene 1mg capsule 73-74
TEMODAR 180MG CAPSULE 64                            thiothixene 2mg capsule 73-74
TEMODAR 250MG CAPSULE 64                            thiothixene 5mg capsule 74
TEMOVATE 103, 105                                   thiothixene 10mg capsule 74
TEMOVATE E 103, 105                                 THORAZINE 73-74
TEMOVATE SCALP 103, 105                             TICLID 85-86
TENEX 86                                            ticlopidine 250mg tablet 85-86
TENORMIN 88-89                                      TIGAN 56
TERAZOL 3 57                                        TIKOSYN 0.25MG CAPSULE 88
TERAZOL-3 SUPP 57                                   TIKOSYN 0.5MG CAPSULE 88
TERAZOL 7 57                                        timolol mal 0.25% gxtimoptic 126
terazosin 1mg cap(gx hytrin) 86-87                  timolol mal 0.5% (gxtimoptic) 126
terazosin 2mg cap(gx hytrin) 86-87                  TIMOPTIC 126
terazosin 5mg cap(gx hytrin) 86-87                  tizanidine 2mg tablet 133
terazosin 10mg cap(gx hytrin) 86-87                 tizanidine 4mg tablet 133
terbinafine 250mg tablet 57                         TOBI 300MG/5ML INH SOLN 137
terbutaline 2.5mg tablet 130                        TOBRADEX 124
terbutaline 5mg tablet 130                          TOBRADEX OPHTH OINT 124
terconazole 0.4% vag cream 57                       tobramyc/dexa 0.3/0.1% op sus 124
terconazole-3 0.8% vag cream 57                     tobramycin 0.3% ophth soln 124
terconazole 80mg vag supp 57                        tobramycin 40mg/ml inj mdv 37


                                                    [29]                         2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                       Last Updated: July 1, 2011
                                            Formulary
                                       Alphabetical Drug List

TOBREX 124                                           triamcinolone 0.1% cream 103, 105
TOBREX 0.3% OPHTH OINT 124                           triamcinolone 0.1% lotion 103, 105
TOFRANIL (NOT PM) 52, 54                             triamcinolone 0.1% ointment 103, 105
tolazamide 250mg tablet 82                           triamcinolone 0.5% cream 103, 105
tolazamide 500mg tablet 82                           triamcinolone 0.5% ointment 103, 105
tolbutamide 500mg tablet 82                          triamcinolone 55mcg nasal spr 132
TOLINASE 82                                          triamcinolone/orabase dnt pst 100-101
TOPAMAX 46-47                                        triamt/hctz 37.5/25 caps (nf 92-93
TOPAMAX SPRINKLE 46                                  triamt/hctz 37.5/25 tablet 92-93
TOPICORT 103, 105                                    triamt/hctz 75/50 tab(maxzid 92-93
topiramate 15mg sprk capsule 46                      TRICOR 48MG TABLET 94
topiramate 25mg sprk capsul 46                       TRICOR 145MG TABLET 94
topiramate 25mg tablet 46                            TRIDESILON 103, 105
topiramate 50mg tablet 46-47                         trifluoperazine 1mg tablet 74
topiramate 100mg tablet 46-47                        trifluoperazine 2mg tablet 74
topiramate 200mg tablet 46-47                        trifluoperazine 5mg tablet 74
TORADOL 60-61                                        trifluoperazine 10mg tablet 74
TRACLEER 62.5MG TAB 132                              trifluridine 1% ophth soln 127
TRACLEER 125MG TAB 132                               trihexyphenidyl 2mg/5ml elix 67-68
tramadol 50mg tab(gx ultram) 36                      trihexyphenidyl 2mg tablet 67-68
TRANDATE 89-90                                       trihexyphenidyl 5mg tablet 67-68
TRANXENE 78-79                                       TRILAFON 74
TRAVATAN 0.004% OPHTH SOLN 126                       TRILEPTAL 47
trazodone 50mg tablet 49                             TRILIFON 74
trazodone 100mg tablet 49                            TRILIPIX 45MG CAPSULE 94
trazodone 150mg tablet 49                            TRILIPIX 135MG CAPSULE 94
trazodone 300mg tablet 49                            TRILISATE 59, 61
TRECATOR 250MG TABLET 63                             trimethobenzamid 100mg/ml inj 56
TRENTAL 85-86                                        trimethobenzamide 300mg caps 56
tretinoin 0.01% gel 106                              trimethoprim 100mg tablet 43
tretinoin 0.025% cream 106                           TRIMPEX 43
tretinoin 0.025% gel 106                             trinate tablet 135
tretinoin 0.05% cream 106                            TRINSICON 134
tretinoin 0.1% cream 106                             TRIPEDIA INJ 119
tri-sprintec 28 day tablet 115-116                   TRIPHASIL 114, 116
TRI-VI-FLOR 135                                      TRISENOX 1MG/ML INJ 65
TRI-VI-FLOUR W/FE 135                                TRIZIVIR TABLET 76
tri-vit fluor 0.25mg drops 135                       tropicacyl 0.5% ophth soln 122
tri-vit fluor 0.5mg drops 135                        tropicacyl 1% ophth soln 122
tri-vit w/fl & fe 0.25mg drop 135                    TRUSOPT 125-126
triamcinolone 0.025% cream 103, 105                  TRUVADA TABLET 76
triamcinolone 0.025% lotion 103, 105                 TWINRIX INJ 119
triamcinolone 0.025% oint 103, 105                   TYGACIL 50MG INJ 37


                                                     [30]                             2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                            Last Updated: July 1, 2011
                                          Formulary
                                     Alphabetical Drug List

TYKERB 250MG TABLET 66                             VELCADE 3.5MG INJ 65
TYLENOL #2 34, 36                                  venlafaxine 25mg tablet 51, 54
TYLENOL #3 34, 36                                  venlafaxine 37.5mg tablet 51, 54
TYLENOL #4 34, 36                                  venlafaxine 50mg tablet 51, 54
TYLENOL WITH CODIENE 34, 36                        venlafaxine 75mg tablet 51, 54
TYLOX 36                                           venlafaxine 100mg tablet 51, 54
TYPHIM VI INJ 120                                  venlafaxine-er 37.5mg capsle 51, 54
TYZEKA 600MG TAB 77                                venlafaxine-er 75mg capsule 51, 54
TYZINE 0.1% NASAL SOLUTION 132                     venlafaxine-er 150mg capsule 51, 54
                                                   VENTOLIN HFA AER INHALER 130
U                                                  VEPESID 67
                                                   verapamil 2.5mg/ml inj 91
ULTRAM (NOT ER) 36                                 verapamil 40mg tablet 90-91
UNASYN 40-41                                       verapamil 80mg tablet 90-91
urea 40% crm 106                                   verapamil 120mg tablet white 90-91
URECHOLINE 80                                      verapamil ext rel 120mg tab 90-91
URISPAS 111                                        verapamil ext rel 180mg tab 90-91
UROCIT-K 134                                       verapamil ext rel 240mg tab 90-91
UROQID-ACID NO.2 TAB 134                           VERMOX 67
ursodiol 300mg capsule 108-109                     VIBRA TABS 43
                                                   VIBRAMYCIN 43
V                                                  VICODIN 34-36
                                                   VICODIN-ES 35-36
valacyclovir 1gm tablet 75                         VICODIN HP 34, 36
valacyclovir 500mg tablet 75                       VIDAZA 100MG INJ 65
VALCYTE 50MG/ML SOLN 78                            VIDEX 4GM SOLN 76
VALCYTE 450MG TABLET 78                            VIDEX EC 75-76
VALISONE 103, 105                                  VIDEX EC 125MG CAPSULE 76
VALIUM 78-79                                       VIGAMOX 0.5% OPHTH SOLN 124
VALIUM SOLN 78-79                                  VIIBRYD 10MG TABLET 49
valproate sod 100mg/ml inj 44-45                   VIIBRYD 20MG TABLET 49
valproic acid 250mg/5ml syrp 44-45                 VIIBRYD 40MG TABLET 49
valproic acid 250mg capsule 44-45                  VIMPAT 10MG/ML INJ 47
VALTREX 75                                         VIMPAT 10MG/ML SOLN 47
vancomycin 500mg inj 37                            VIMPAT 50MG TABLET 48
vancomycin 1000mg inj 37                           VIMPAT 100MG TABLET 47
VANDETANIB 100MG TABLET 66                         VIMPAT 150MG TABLET 47
VANDETANIB 300MG TABLET 66                         VIMPAT 200MG TABLET 47
VAQTA 50U/ML INJ 120                               vincristine 1mg/ml inj 65
VARIVAX INJ 120                                    VIOKASE-16 TABLET 107
VASOCIDIN 124                                      VIRACEPT 50MG/GM POWDER 77
vasolex ointment 107                               VIRACEPT 250MG TABLET 77
VASOTEC 95-96                                      VIRACEPT 625MG TABLET 77


                                                   [31]                            2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                         Last Updated: July 1, 2011
                                          Formulary
                                     Alphabetical Drug List

VIRAMUNE 50MG/5ML SUSP 75                          XYLOCAINE 36, 101
VIRAMUNE 200MG TABLET 75                           XYREM 500MG/ML SOL     137
VIRAMUNE XR 400MG TABLET 75
VIREAD 300MG TABLET 77                             Y
VIROPTIC 127
VISTARIL 79                                        YAZ 115-116
vitamin d 50000iu capsule 135                      YELLOW FEVER VAC INJ   120
vitaplex plus tablet 134-135
VIVACTIL 53-54                                     Z
VIVAGLOBIN 160MG/ML INJ 120
VOLTAREN 59, 62                                    zafirlukast 10mg tablet 128
VOLTAREN (NOT XR) 59, 62                           zafirlukast 20mg tablet 128
VOSOL 127                                          zaleplon 5mg capsule 133
VOTRIENT 200MG TABLET 66                           zaleplon 10mg capsule 133
                                                   ZANAFLEX 133
W                                                  ZANTAC 110
                                                   ZANTAC 25MG/ML INJ 110
warfarin sodium 1mg tablet 83-84                   ZARONTIN 43
warfarin sodium 2 mg tablet 83-84                  ZAROXOLYN 92-93
warfarin sodium 2.5mg tablet 83-84                 ZAVESCA 100MG CAP 107
warfarin sodium 3mg tablet 83-84                   ZEMPLAR 1MCG CAPSULE 112
warfarin sodium 4mg tablet 83-84                   ZEMPLAR 2MCG CAPSULE 112
warfarin sodium 5mg tablet 83-84                   ZENPEP 5000UN CAPSULE 107
warfarin sodium 6mg tablet 83-84                   ZENPEP 10,000UN CAPSULE 107
warfarin sodium 7.5mg tablet 83-84                 ZENPEP 15,000UN CAPSULE 107
warfarin sodium 10mg tablet 83-84                  ZENPEP 20,000UN CAPSULE 108
WELLBUTRIN 48-50                                   ZERIT 76
WELLBUTRIN SR (NOT 200MG) 48-50                    ZESTRIL 95-96
WELLBUTRIN XL 48-50                                ZETIA 10MG TABLET 94
WELLCOVORIN 66                                     ZIAGEN 20MG/ML SOLN 76
WYCILLIN 41                                        ZIAGEN 300MG TABLET 76
                                                   zidovudine 50mg/5ml syrup 76
X                                                  zidovudine 300mg tablet 76
                                                   ZINACEF 38-39
x-viate 40% lotion 106                             ZITHROMAX 41-42
XALATAN 125-126                                    ZOCOR 94
XANAX 78-79                                        ZOFRAN 55-56
XANAX (NOT XR) 78-79                               ZOFRAN ODT 55-56
XELODA 150MG TABLET 64                             ZOLINZA 100MG CAP 66
XELODA 500MG TABLET 64                             ZOLOFT 54-55
XENADERM 107                                       zolpidem 5mg tablet 132-133
XENAZINE 25MG TABLET 137                           zolpidem 10mg tablet 132-133
XOLAIR 150MG INJ 132                               ZOMETA 4MG/5ML INJ 112


                                                   [32]                           2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                                        Last Updated: July 1, 2011
                                             Formulary
                                        Alphabetical Drug List

ZONALON 105
ZONEGRAN 43-44
zonisamide 25mg capsule 43
zonisamide 50mg capsule 43-44
zonisamide 100mg capsule 43-44
ZORTRESS 0.25MG TABLET 121
ZORTRESS 0.5MG TABLET 121
ZORTRESS 0.75MG TABLET 121
ZOSTAVAX INJ 120
ZOSYN 2 GM-0.25 GM VIAL INJ 41
zovia 1/50 (generic demulen) 114, 116
ZOVIRAX 75, 106
ZOVIRAX 5% OINT 106
ZOVIRAX SUSP 75
ZYLOPRIM 57
ZYPREXA 2.5MG TABLET 73
ZYPREXA 5MG TABLET 73
ZYPREXA 7.5MG TABLET 73
ZYPREXA 10MG TABLET 73
ZYPREXA 15MG TABLET 73
ZYPREXA 20MG TABLET 73
ZYPREXA IM 10MG INJ 73
ZYPREXA ZYDIS 5MG TABLET 73
ZYTIGA 250MG TABLET 66
ZYVOX 2MG/ML INJ 37
ZYVOX 100MG/5ML SUSPENSION 37
ZYVOX 600MG TABLET 37




                                                      [33]       2011 Commercial Drug Formulary
27-921/01-01/06 Rev. 01-11                                       Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
                               Analgesics - Non-Opiod Analgesics
phenazopyridine 200mg tablet   PYRIDIUM                                                2       Available via Mail Order
phenazopyridine plus tablet    PYRIDIUM PLUS                                           2       Available via Mail Order
PYRIDIUM                       phenazopyridine 200mg tablet                                    Only Generic Covered
PYRIDIUM PLUS                  phenazopyridine plus tablet                                     Only Generic Covered
                               Analgesics - Opioid Analgesics
apap w/codeine elixir          TYLENOL WITH CODIENE                                    2       Available via Mail Order
apap/codeine (#2) 300/15 tab   TYLENOL #2                                              2       Available via Mail Order
apap/codeine (#3) 300/30 tab   TYLENOL #3                                              2       Available via Mail Order
apap/codeine (#4) 300/60 tab   TYLENOL #4                                              2       Available via Mail Order
apap/hydrocod 500/ 5 tablet    VICODIN                                                 2       Available via Mail Order
apap/hydrocodone 660/10 tab    VICODIN HP                                              2       Available via Mail Order
asa/but/caff/cod cap           FIORINAL WITH CODEINE                                   2
codeine sulf 30mg tab                                                                  2       Available via Mail Order
DARVOCET N-100                 propoxy-n/apap 100/650 tablt                                    Only Generic Covered
DARVON                         propoxyphene 65mg capsule                                       Only Generic Covered
DEMEROL                        meperidine 50mg tablet                                          Only Generic Covered
DEMEROL                        meperidine 100mg tablet                                         Only Generic Covered
DEMEROL 50MG/ML INJ 10X1ML                                                             5
DILAUDID                       hydromorphone 2mg tablet                                        Only Generic Covered
DILAUDID                       hydromorphone 4mg tablet                                        Only Generic Covered
DILAUDID                       hydromorphone 8mg tablet                                        Only Generic Covered
DILAUDID-5 1MG/ML LIQUID                                                               3       Available via Mail Order
DOLOPHINE                      methadone 5mg tablet                                            Only Generic Covered
DOLOPHINE                      methadone (methadose)10mg tab                                   Only Generic Covered
DOLOPHINE                      methadone 5mg/5ml solution                                      Only Generic Covered
DOLOPHINE                      methadose conc 10mg/ml soln                                     Only Generic Covered
DURAGESIC                      fentanyl 12mcg/hr patch                                         Only Generic Covered
DURAGESIC                      fentanyl 25mcg/hr patch                                         Only Generic Covered
DURAGESIC                      fentanyl 50mcg/hr patch                                         Only Generic Covered
DURAGESIC                      fentanyl 75mcg/hr patch                                         Only Generic Covered
DURAGESIC                      fentanyl 100mcg/hr patch                                        Only Generic Covered
fentanyl 12mcg/hr patch        DURAGESIC                                               2       Prior Auth Required
                                                                                               Available via Mail Order
fentanyl 25mcg/hr patch        DURAGESIC                                               2       Prior Auth Required
                                                                                               Available via Mail Order

27-921/01-01/06 Rev 01-11                                           [ 34]                      2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
fentanyl 50mcg/hr patch         DURAGESIC                                             2       Prior Auth Required
                                                                                              Available via Mail Order
fentanyl 75mcg/hr patch         DURAGESIC                                             2       Prior Auth Required
                                                                                              Available via Mail Order
fentanyl cit 0.05mg/ml inj                                                            5
fentanyl 100mcg/hr patch        DURAGESIC                                             2       Prior Auth Required
                                                                                              Available via Mail Order
FIORINAL WITH CODEINE           asa/but/caff/cod cap                                          Only Generic Covered
hydrocodone/apap 7.5/750 tab    VICODIN-ES                                            2       Available via Mail Order
hydromorphone 2mg tablet        DILAUDID                                              2       Available via Mail Order
hydromorphone 4mg tablet        DILAUDID                                              2       Available via Mail Order
hydromorphone 8mg tablet        DILAUDID                                              2       Available via Mail Order
meperidine 50mg tablet          DEMEROL                                               2       Available via Mail Order
meperidine 100mg tablet         DEMEROL                                               2       Available via Mail Order
methadone 5mg tablet            DOLOPHINE                                             2       Available via Mail Order
methadone (methadose)10mg tab   DOLOPHINE                                             2       Available via Mail Order
methadone 5mg/5ml solution      DOLOPHINE                                             2       Available via Mail Order
methadose conc 10mg/ml soln     DOLOPHINE                                             2       Available via Mail Order
MORPHINE SULF 10MG/ 5ML SOLN    MS IR ORAL SOLN                                       2       Available via Mail Order
MORPHINE SULF 20MG/ 5ML SOLN    MS IR ORAL SOLN                                       2       Available via Mail Order
morphine sulf 20mg/ml soln      ROXANOL                                               2       Available via Mail Order
morphine sulf er 15mg tablt     MS CONTIN                                             2       Available via Mail Order
morphine sulf er 30mg tablt     MS CONTIN                                             2       Available via Mail Order
morphine sulf er 60mg tablt     MS CONTIN                                             2       Available via Mail Order
morphine sulf er 100mg tablt    MS CONTIN                                             2       Available via Mail Order
morphine sulf er 200mg tablt    MS CONTIN                                             2       Available via Mail Order
morphine sulf ir 15mg tablet    MS IR                                                 2       Available via Mail Order
morphine sulf ir 30mg tablet    MS IR                                                 2       Available via Mail Order
MS CONTIN                       morphine sulf er 15mg tablt                                   Only Generic Covered
MS CONTIN                       morphine sulf er 30mg tablt                                   Only Generic Covered
MS CONTIN                       morphine sulf er 60mg tablt                                   Only Generic Covered
MS CONTIN                       morphine sulf er 100mg tablt                                  Only Generic Covered
MS CONTIN                       morphine sulf er 200mg tablt                                  Only Generic Covered
MS IR                           morphine sulf ir 15mg tablet                                  Only Generic Covered
MS IR                           morphine sulf ir 30mg tablet                                  Only Generic Covered
MS IR ORAL SOLN                 MORPHINE SULF 10MG/ 5ML SOLN                                  Only Generic Covered


27-921/01-01/06 Rev 01-11                                          [ 35]                      2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
MS IR ORAL SOLN                 MORPHINE SULF 20MG/ 5ML SOLN                                     Only Generic Covered
oxycod/apap 5-325mg/5ml soln    ROXICET                                                  2       Available via Mail Order
oxycodone/apap 5/325 tablet     PERCOCET 5 ONLY                                          2       Available via Mail Order
oxycodone/apap 5/500 capsle     TYLOX                                                    2       Available via Mail Order
PERCOCET 5 ONLY                 oxycodone/apap 5/325 tablet                                      Only Generic Covered
propoxy-n/apap 100/650 tablt    DARVOCET N-100                                           2       Available via Mail Order
propoxyphene 65mg capsule       DARVON                                                   2       Available via Mail Order
ROXANOL                         morphine sulf 20mg/ml soln                                       Only Generic Covered
ROXICET                         oxycod/apap 5-325mg/5ml soln                                     Only Generic Covered
tramadol 50mg tab(gx ultram)    ULTRAM (NOT ER)                                          2       Available via Mail Order
TYLENOL #2                      apap/codeine (#2) 300/15 tab                                     Only Generic Covered
TYLENOL #3                      apap/codeine (#3) 300/30 tab                                     Only Generic Covered
TYLENOL #4                      apap/codeine (#4) 300/60 tab                                     Only Generic Covered
TYLENOL WITH CODIENE            apap w/codeine elixir                                            Only Generic Covered
TYLOX                           oxycodone/apap 5/500 capsle                                      Only Generic Covered
ULTRAM (NOT ER)                 tramadol 50mg tab(gx ultram)                                     Only Generic Covered
VICODIN                         apap/hydrocod 500/ 5 tablet                                      Only Generic Covered
VICODIN HP                      apap/hydrocodone 660/10 tab                                      Only Generic Covered
VICODIN-ES                      hydrocodone/apap 7.5/750 tab                                     Only Generic Covered
                                Anesthetics
lidocaine 1% 10mg/ml inj mdv    XYLOCAINE                                                5
lidocaine 1% 10mg/ml inj sdpf                                                            5
XYLOCAINE                       lidocaine 1% 10mg/ml inj mdv                                     Only Generic Covered
                                Antibacterials - Antibacterials, Other
amikacin 250mg/ml inj           AMIKIN                                                   5
AMIKIN                          amikacin 250mg/ml inj                                            Only Generic Covered
CLEOCIN (150MG ONLY)            clindamycin 150mg capsule                                        Only Generic Covered
CLEOCIN 900MG INJ                                                                        5
CLEOCIN INJ                     clindamycin 150mg/ml inj                                         Only Generic Covered
CLEOCIN VAGINAL                 clindamax 2% vaginal crm                                         Only Generic Covered
clindamax 2% vaginal crm        CLEOCIN VAGINAL                                          2       Quantity Limits Apply
clindamycin 150mg capsule       CLEOCIN (150MG ONLY)                                     2
clindamycin 150mg/ml inj        CLEOCIN INJ                                              5
colistimethate 150mg inj        COLY-MYCIN M                                             5
COLY-MYCIN M                    colistimethate 150mg inj                                         Only Generic Covered
CUBICIN 500MG VIAL IV INJ                                                                5
27-921/01-01/06 Rev 01-11                                                [ 36]                   2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
FLAGYL                          metronidazole 250mg tablet                                    Only Generic Covered
FLAGYL (NOT ER)                 metronidazole 500mg tablet                                    Only Generic Covered
FLAGYL INJ                      metronidazole 500mg/100ml inj                                 Only Generic Covered
gentamicin 10mg/ml inj                                                                5
gentamicin 80mg/2ml inj                                                               5
MACROBID                        nitrofurantoin bid 100mg cap                                  Only Generic Covered
MACRODANTIN                     nitrofurantoin 50mg capsle                                    Only Generic Covered
MACRODANTIN                     nitrofurantoin 100mg capsul                                   Only Generic Covered
METROGEL-VAGINAL GEL            metronidazole 0.75% vag gel                                   Only Generic Covered
metronidazole 0.75% vag gel     METROGEL-VAGINAL GEL                                  2       Quantity Limits Apply
metronidazole 250mg tablet      FLAGYL                                                2
metronidazole 500mg tablet      FLAGYL (NOT ER)                                       2
metronidazole 500mg/100ml inj   FLAGYL INJ                                            5
neomycin 500mg tablet                                                                 2
nitrofurantoin 50mg capsle      MACRODANTIN                                           2
nitrofurantoin 100mg capsul     MACRODANTIN                                           2
nitrofurantoin bid 100mg cap    MACROBID                                              2
POLYMYXIN B SULF 500,000 U                                                            5
tobramycin 40mg/ml inj mdv                                                            5
TYGACIL 50MG INJ                                                                      5
vancomycin 500mg inj                                                                  5
vancomycin 1000mg inj                                                                 5
ZYVOX 100MG/5ML SUSPENSION                                                            3       Prior Auth Required
ZYVOX 2MG/ML INJ                                                                      5
ZYVOX 600MG TABLET                                                                    3       Prior Auth Required
                                Antibacterials - Beta-Lactam, Cephalosporins
ANCEF                           cefazolin 1gm inj                                             Only Generic Covered
CECLOR                          cefaclor 250mg cap gxceclor                                   Only Generic Covered
CECLOR                          cefaclor 500mg cap gxceclor                                   Only Generic Covered
CECLOR SUSP                     cefaclor 125mg/5ml(gx ceclor)                                 Only Generic Covered
CECLOR SUSP                     cefaclor 250mg/5ml(gx ceclor)                                 Only Generic Covered
CECLOR SUSP                     cefaclor 375mg/5ml(gx ceclor)                                 Only Generic Covered
cefaclor 250mg cap gxceclor     CECLOR                                                2
cefaclor 500mg cap gxceclor     CECLOR                                                2
cefaclor 125mg/5ml(gx ceclor)   CECLOR SUSP                                           2       Quantity Limits Apply
cefaclor 250mg/5ml(gx ceclor)   CECLOR SUSP                                           2       Quantity Limits Apply
27-921/01-01/06 Rev 01-11                                               [ 37]                 2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
cefaclor 375mg/5ml(gx ceclor)   CECLOR SUSP                                             2       Quantity Limits Apply
cefadroxil 250mg/5ml susp       DURICEF                                                 2       Quantity Limits Apply
cefadroxil 500mg/5ml susp       DURICEF                                                 2       Quantity Limits Apply
cefazolin 1gm inj               ANCEF                                                   5
cefdinir 125mg/5ml susp         OMNICEF                                                 2       Quantity Limits Apply
cefdinir 250mg/5ml susp         OMNICEF                                                 2       Quantity Limits Apply
cefdinir 300mg cap              OMNICEF                                                 2
cefepime 1gm inj                MAXIPIME                                                5
cefprozil 125mg/5ml susp        CEFZIL                                                  2       Quantity Limits Apply
cefprozil 250mg tablet          CEFZIL                                                  2
cefprozil 250mg/5ml susp        CEFZIL                                                  2       Quantity Limits Apply
cefprozil 500mg tab             CEFZIL                                                  2
CEFTIN                          cefuroxime 250mg tablet                                         Only Generic Covered
CEFTIN                          cefuroxime 500mg tablet                                         Only Generic Covered
ceftriaxone 1gm inj             ROCEPHIN                                                5
ceftriaxone 250mg inj           ROCHEPIN                                                5
ceftriaxone 2gm inj             ROCEPHIN                                                5
ceftriaxone 500mg inj           ROCEPHIN                                                5
cefuroxime 1.5gm inj            ZINACEF                                                 5
cefuroxime 250mg tablet         CEFTIN                                                  2
cefuroxime 500mg tablet         CEFTIN                                                  2
CEFZIL                          cefprozil 125mg/5ml susp                                        Only Generic Covered
CEFZIL                          cefprozil 250mg tablet                                          Only Generic Covered
CEFZIL                          cefprozil 250mg/5ml susp                                        Only Generic Covered
CEFZIL                          cefprozil 500mg tab                                             Only Generic Covered
cephalexin 250mg capsule        KEFLEX                                                  2
cephalexin 500mg capsule        KEFLEX                                                  2
cephalexin 125mg/5ml susp       KEFLEX                                                  2       Quantity Limits Apply
cephalexin 250mg/5ml susp       KEFLEX                                                  2       Quantity Limits Apply
DURICEF                         cefadroxil 250mg/5ml susp                                       Only Generic Covered
DURICEF                         cefadroxil 500mg/5ml susp                                       Only Generic Covered
FORTAZ                          tazicef 1gm inj                                                 Only Generic Covered
KEFLEX                          cephalexin 250mg capsule                                        Only Generic Covered
KEFLEX                          cephalexin 500mg capsule                                        Only Generic Covered
KEFLEX                          cephalexin 125mg/5ml susp                                       Only Generic Covered
KEFLEX                          cephalexin 250mg/5ml susp                                       Only Generic Covered
27-921/01-01/06 Rev 01-11                                            [ 38]                      2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
MAXIPIME                        cefepime 1gm inj                                                Only Generic Covered
MAXIPIME 1GM INJ                                                                        5
OMNICEF                         cefdinir 125mg/5ml susp                                         Only Generic Covered
OMNICEF                         cefdinir 250mg/5ml susp                                         Only Generic Covered
OMNICEF                         cefdinir 300mg cap                                              Only Generic Covered
ROCEPHIN                        ceftriaxone 1gm inj                                             Only Generic Covered
ROCEPHIN                        ceftriaxone 2gm inj                                             Only Generic Covered
ROCEPHIN                        ceftriaxone 500mg inj                                           Only Generic Covered
ROCHEPIN                        ceftriaxone 250mg inj                                           Only Generic Covered
SUPRAX 100MG/5ML SUSP                                                                   4       Quantity Limits Apply
SUPRAX 400MG TABLET                                                                     4
tazicef 1gm inj                 FORTAZ                                                  5
ZINACEF                         cefuroxime 1.5gm inj                                            Only Generic Covered
                                Antibacterials - Beta-Lactam, Other
INVANZ 1GM INJ                                                                          5
PRIMAXIN 500MG IV INJ                                                                   5
                                Antibacterials - Beta-Lactam, Penicillins
amox/clav pot 1000/62.5mg tab   AUGMENTIN XR                                            2
amox/clav pot 200/5ml susp      AUGMENTIN                                               2       Quantity Limits Apply
amox/clav pot 250/125mg tab     AUGMENTIN                                               2
amox/clav pot 250/5ml susp      AUGMENTIN                                               2       Quantity Limits Apply
amox/clav pot 400/5ml susp      AUGMENTIN                                               2       Quantity Limits Apply
amox/clav pot 500/125mg tab     AUGMENTIN                                               2
amox/clav pot 600/5ml es sus    AUGMENTIN                                               2       Quantity Limits Apply
amox/clav pot 875/125mg tab     AUGMENTIN                                               2
amox/clav pot chew 200mg tab    AUGMENTIN                                               2
amox/clav pot chew 400mg tab    AUGMENTIN                                               2
amoxicillin 250mg capsule       AMOXIL                                                  2
amoxicillin 500mg capsule       AMOXIL                                                  2
amoxicillin 875mg tablet        AMOXIL                                                  2
amoxicillin 125mg/5ml susp      AMOXIL                                                  2       Quantity Limits Apply
amoxicillin 200mg/5ml susp      AMOXIL                                                  2       Quantity Limits Apply
amoxicillin 250mg/5ml susp      AMOXIL                                                  2       Quantity Limits Apply
amoxicillin 400mg/5ml susp      AMOXIL                                                  2       Quantity Limits Apply
amoxicillin chewable 125mg      AMOXIL                                                  2
amoxicillin chewable 200mg      AMOXIL                                                  2
27-921/01-01/06 Rev 01-11                                                   [ 39]               2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                        DRUG CATEGORY - DRUG CLASS
DRUG NAME                                              BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
amoxicillin chewable 250mg     AMOXIL                                                2
amoxicillin chewable 400mg     AMOXIL                                                2
AMOXIL                         amoxicillin 250mg capsule                                     Only Generic Covered
AMOXIL                         amoxicillin 500mg capsule                                     Only Generic Covered
AMOXIL                         amoxicillin 875mg tablet                                      Only Generic Covered
AMOXIL                         amoxicillin 125mg/5ml susp                                    Only Generic Covered
AMOXIL                         amoxicillin 200mg/5ml susp                                    Only Generic Covered
AMOXIL                         amoxicillin 250mg/5ml susp                                    Only Generic Covered
AMOXIL                         amoxicillin 400mg/5ml susp                                    Only Generic Covered
AMOXIL                         amoxicillin chewable 125mg                                    Only Generic Covered
AMOXIL                         amoxicillin chewable 200mg                                    Only Generic Covered
AMOXIL                         amoxicillin chewable 250mg                                    Only Generic Covered
AMOXIL                         amoxicillin chewable 400mg                                    Only Generic Covered
ampicil/sulbac 1.5gm inj vl    UNASYN                                                5
ampicillin 125mg/5ml susp      PRINCIPEN                                             2       Quantity Limits Apply
ampicillin 250mg cap(princip   PRINCIPEN                                             2
ampicillin 250mg/5ml susp      PRINCIPEN                                             2       Quantity Limits Apply
ampicillin 2gm inj             PRINCIPEN                                             5
ampicillin 500mg cap(princip   PRINCIPEN                                             2
AUGMENTIN                      amox/clav pot 200/5ml susp                                    Only Generic Covered
AUGMENTIN                      amox/clav pot 250/125mg tab                                   Only Generic Covered
AUGMENTIN                      amox/clav pot 250/5ml susp                                    Only Generic Covered
AUGMENTIN                      amox/clav pot 400/5ml susp                                    Only Generic Covered
AUGMENTIN                      amox/clav pot 500/125mg tab                                   Only Generic Covered
AUGMENTIN                      amox/clav pot 600/5ml es sus                                  Only Generic Covered
AUGMENTIN                      amox/clav pot 875/125mg tab                                   Only Generic Covered
AUGMENTIN                      amox/clav pot chew 200mg tab                                  Only Generic Covered
AUGMENTIN                      amox/clav pot chew 400mg tab                                  Only Generic Covered
AUGMENTIN XR                   amox/clav pot 1000/62.5mg tab                                 Only Generic Covered
BICILLIN L-A 2.4MMU/4ML INJ                                                          5
BICILLIN L-A 600MU/ML INJ                                                            5
dicloxacillin 250mg capsule    DYNAPEN                                               2
dicloxacillin 500mg capsule    DYNAPEN                                               2
DYNAPEN                        dicloxacillin 250mg capsule                                   Only Generic Covered
DYNAPEN                        dicloxacillin 500mg capsule                                   Only Generic Covered
OXACILLIN 1GM INJ                                                                    5
27-921/01-01/06 Rev 01-11                                         [ 40]                      2011 Commercial Drug Formulary
                                                                                                   Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
PEN G PROC 600000 U/ML INJ     WYCILLIN                                               5
PEN VEE K                      penicillin vk 250mg tablet                                     Only Generic Covered
PEN VEE K                      penicillin vk 500mg tablet                                     Only Generic Covered
PEN VEE K                      penicillin vk 125mg/5ml susp                                   Only Generic Covered
PEN VEE K                      penicillin vk 250mg/5ml susp                                   Only Generic Covered
penicillin g pot 5mmu inj                                                             5
penicillin vk 250mg tablet     PEN VEE K                                              2
penicillin vk 500mg tablet     PEN VEE K                                              2
penicillin vk 125mg/5ml susp   PEN VEE K                                              2       Quantity Limits Apply
penicillin vk 250mg/5ml susp   PEN VEE K                                              2       Quantity Limits Apply
PRINCIPEN                      ampicillin 125mg/5ml susp                                      Only Generic Covered
PRINCIPEN                      ampicillin 250mg cap(princip                                   Only Generic Covered
PRINCIPEN                      ampicillin 250mg/5ml susp                                      Only Generic Covered
PRINCIPEN                      ampicillin 2gm inj                                             Only Generic Covered
PRINCIPEN                      ampicillin 500mg cap(princip                                   Only Generic Covered
UNASYN                         ampicil/sulbac 1.5gm inj vl                                    Only Generic Covered
WYCILLIN                       PEN G PROC 600000 U/ML INJ                                     Only Generic Covered
ZOSYN 2 GM-0.25 GM VIAL INJ                                                           5
                               Antibacterials - Macrolides
azithromycin 500mg inj         ZITHROMAX                                              5
azithromycin 100mg/5ml susp    ZITHROMAX                                              2       Quantity Limits Apply
azithromycin 200mg/5ml susp    ZITHROMAX                                              2       Quantity Limits Apply
azithromycin 250mg 3x6 tablt   ZITHROMAX                                              2
azithromycin 500mg tablet      ZITHROMAX                                              2
azithromycin 600mg tablet      ZITHROMAX                                              2
BIAXIN                         clarithromycin 125mg/5ml sus                                   Only Generic Covered
BIAXIN                         clarithromycin 250mg/5ml sus                                   Only Generic Covered
BIAXIN (NOT XL)                clarithromycin 250mg tablet                                    Only Generic Covered
BIAXIN (NOT XL)                clarithromycin 500mg tablet                                    Only Generic Covered
clarithromycin 125mg/5ml sus   BIAXIN                                                 2       Quantity Limits Apply
clarithromycin 250mg tablet    BIAXIN (NOT XL)                                        2
clarithromycin 250mg/5ml sus   BIAXIN                                                 2       Quantity Limits Apply
clarithromycin 500mg tablet    BIAXIN (NOT XL)                                        2
ees 400 tablet                                                                        2
ERY-C                          erythromycin-dr 250mg capsle                                   Only Generic Covered
erythrocin 250mg tablet                                                               2
27-921/01-01/06 Rev 01-11                                          [ 41]                      2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
erythrocin 500mg tablet                                                                  2
ERYTHROCIN LAC 500MG INJ                                                                 5
erythromycin-dr 250mg capsle   ERY-C                                                     2
ZITHROMAX                      azithromycin 500mg inj                                            Only Generic Covered
ZITHROMAX                      azithromycin 100mg/5ml susp                                       Only Generic Covered
ZITHROMAX                      azithromycin 200mg/5ml susp                                       Only Generic Covered
ZITHROMAX                      azithromycin 250mg 3x6 tablt                                      Only Generic Covered
ZITHROMAX                      azithromycin 500mg tablet                                         Only Generic Covered
ZITHROMAX                      azithromycin 600mg tablet                                         Only Generic Covered
                               Antibacterials - Quinolones
CIPRO 400MG INJ                                                                          5
CIPRO (NOT XR, NOT SUSP)       ciprofloxacin 250mg tablet                                        Only Generic Covered
CIPRO (NOT XR, NOT SUSP)       ciprofloxacin 500mg tablet                                        Only Generic Covered
CIPRO (NOT XR, NOT SUSP)       ciprofloxacin 750mg tablet                                        Only Generic Covered
ciprofloxacin 250mg tablet     CIPRO (NOT XR, NOT SUSP)                                  2
ciprofloxacin 500mg tablet     CIPRO (NOT XR, NOT SUSP)                                  2
ciprofloxacin 750mg tablet     CIPRO (NOT XR, NOT SUSP)                                  2
LEVAQUIN                       levofloxacin 500mg tablet                                         Only Generic Covered
LEVAQUIN                       levofloxacin 750mg tablet                                         Only Generic Covered
LEVAQUIN 5MG/ML 100ML IV BAG                                                             5
LEVAQUIN 250MG TABLET                                                                    4
LEVAQUIN 25MG/ML SOLN                                                                    4
levofloxacin 500mg tablet      LEVAQUIN                                                  2
levofloxacin 750mg tablet      LEVAQUIN                                                  2
                               Antibacterials - Sulfonamides
ees/sulfisoxazole 200/600      PEDIAZOLE                                                 2       Quantity Limits Apply
PEDIAZOLE                      ees/sulfisoxazole 200/600                                         Only Generic Covered
SEPTRA                         smz-tmp 200-40/5ml ped susp                                       Only Generic Covered
SEPTRA                         SMZ-TMP 400-80/5 INJ                                              Only Generic Covered
SEPTRA                         smz-tmp 400/80 reg str tablt                                      Only Generic Covered
SEPTRA DS                      sulfamethox/trim 800/160 tab                                      Only Generic Covered
smz-tmp 200-40/5ml ped susp    SEPTRA                                                    2
SMZ-TMP 400-80/5 INJ           SEPTRA                                                    5
smz-tmp 400/80 reg str tablt   SEPTRA                                                    2
sulfadiazine 500mg tablet                                                                2
sulfamethox/trim 800/160 tab   SEPTRA DS                                                 2
27-921/01-01/06 Rev 01-11                                             [ 42]                      2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
trimethoprim 100mg tablet      TRIMPEX                                                2
TRIMPEX                        trimethoprim 100mg tablet                                      Only Generic Covered
                               Antibacterials - Tetracyclines
doxycycline 20mg tablet        PERIOSTAT                                              2
doxycycline 50mg capsule       VIBRAMYCIN                                             2
doxycycline 100mg capsule      VIBRAMYCIN                                             2
doxycycline 100mg tablet       VIBRA TABS                                             2
doxycycline hyc 100mg inj                                                             5
MINOCIN                        minocycline 50mg capsule                                       Only Generic Covered
MINOCIN                        minocycline 100mg capsule                                      Only Generic Covered
minocycline 50mg capsule       MINOCIN                                                2
minocycline 100mg capsule      MINOCIN                                                2
PERIOSTAT                      doxycycline 20mg tablet                                        Only Generic Covered
SUMYCIN                        tetracycline 250mg capsule                                     Only Generic Covered
SUMYCIN                        tetracycline 500mg capsule                                     Only Generic Covered
tetracycline 250mg capsule     SUMYCIN                                                2
tetracycline 500mg capsule     SUMYCIN                                                2
VIBRA TABS                     doxycycline 100mg tablet                                       Only Generic Covered
VIBRAMYCIN                     doxycycline 50mg capsule                                       Only Generic Covered
VIBRAMYCIN                     doxycycline 100mg capsule                                      Only Generic Covered
                               Anti-Convulsants - Calcium Channel Modifying Agents
BANZEL 40MG/ML SUSP                                                                   4       Prior Auth Required
                                                                                              Available via Mail Order
BANZEL 200MG TABLET                                                                   4       Prior Auth Required
                                                                                              Available via Mail Order
BANZEL 400MG TABLET                                                                   4       Prior Auth Required
                                                                                              Available via Mail Order
CELONTIN 300MG CAPSULE                                                                4       Available via Mail Order
ethosuximide 250mg capsule     ZARONTIN                                               2       Available via Mail Order
ethosuximide 250mg/5ml syrup   ZARONTIN                                               2       Available via Mail Order
ZARONTIN                       ethosuximide 250mg capsule                                     Only Generic Covered
ZARONTIN                       ethosuximide 250mg/5ml syrup                                   Only Generic Covered
ZONEGRAN                       zonisamide 25mg capsule                                        Only Generic Covered
ZONEGRAN                       zonisamide 50mg capsule                                        Only Generic Covered
ZONEGRAN                       zonisamide 100mg capsule                                       Only Generic Covered
zonisamide 25mg capsule        ZONEGRAN                                               2       Available via Mail Order


27-921/01-01/06 Rev 01-11                                             [ 43]                   2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                        DRUG CATEGORY - DRUG CLASS
DRUG NAME                                              BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
zonisamide 50mg capsule        ZONEGRAN                                              2       Available via Mail Order
zonisamide 100mg capsule       ZONEGRAN                                              2       Available via Mail Order
                               Anti-Convulsants - GABA Augmenting Agents
DEPAKENE                       valproate sod 100mg/ml inj                                    Only Generic Covered
DEPAKENE                       valproic acid 250mg capsule                                   Only Generic Covered
DEPAKENE                       valproic acid 250mg/5ml syrp                                  Only Generic Covered
DEPAKOTE                       divalproex 125mg dr tablet                                    Only Generic Covered
DEPAKOTE                       divalproex 250mg dr tablet                                    Only Generic Covered
DEPAKOTE                       divalproex 500mg dr tablet                                    Only Generic Covered
DEPAKOTE ER                    divalproex er 250mg tablet                                    Only Generic Covered
DEPAKOTE ER                    divalproex er 500mg tablet                                    Only Generic Covered
DEPAKOTE SPRINKLE              divalproex spr 125mg capsule                                  Only Generic Covered
divalproex 125mg dr tablet     DEPAKOTE                                              2       Available via Mail Order
divalproex 250mg dr tablet     DEPAKOTE                                              2       Available via Mail Order
divalproex 500mg dr tablet     DEPAKOTE                                              2       Available via Mail Order
divalproex er 250mg tablet     DEPAKOTE ER                                           2       Available via Mail Order
divalproex er 500mg tablet     DEPAKOTE ER                                           2       Available via Mail Order
divalproex spr 125mg capsule   DEPAKOTE SPRINKLE                                     2       Available via Mail Order
gabapentin 100mg capsule       NEURONTIN                                             2       Available via Mail Order
gabapentin 250mg/5ml soln      NEURONTIN                                             2       Available via Mail Order
gabapentin 300mg capsule       NEURONTIN                                             2       Available via Mail Order
gabapentin 400mg capsule       NEURONTIN                                             2       Available via Mail Order
gabapentin 600mg tablet        NEURONTIN                                             2       Available via Mail Order
gabapentin 800mg tablet        NEURONTIN                                             2       Available via Mail Order
GABITRIL 2MG TABLET                                                                  4       Available via Mail Order
GABITRIL 4MG TABLET                                                                  4       Available via Mail Order
GABITRIL 16MG TABLET                                                                 4       Available via Mail Order
LYRICA 25MG CAPSULE                                                                  4       Prior Auth Required
                                                                                             Quantity Limits Apply
                                                                                             Available via Mail Order
LYRICA 50MG CAPSULE                                                                  4       Prior Auth Required
                                                                                             Quantity Limits Apply
                                                                                             Available via Mail Order
LYRICA 75MG CAPSULE                                                                  4       Prior Auth Required
                                                                                             Quantity Limits Apply
                                                                                             Available via Mail Order



27-921/01-01/06 Rev 01-11                                           [ 44]                    2011 Commercial Drug Formulary
                                                                                                   Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
LYRICA 100MG CAPSULE                                                                   4       Prior Auth Required
                                                                                               Quantity Limits Apply
                                                                                               Available via Mail Order
LYRICA 150MG CAPSULE                                                                   4       Prior Auth Required
                                                                                               Quantity Limits Apply
                                                                                               Available via Mail Order
LYRICA 200MG CAPSULE                                                                   4       Prior Auth Required
                                                                                               Quantity Limits Apply
                                                                                               Available via Mail Order
LYRICA 225MG CAPSULE                                                                   4       Prior Auth Required
                                                                                               Quantity Limits Apply
                                                                                               Available via Mail Order
LYRICA 300MG CAPSULE                                                                   4       Prior Auth Required
                                                                                               Quantity Limits Apply
                                                                                               Available via Mail Order
MYSOLINE                       primidone 250mg tablet                                          Only Generic Covered
MYSOLINE                       primidone 50mg tablet                                           Only Generic Covered
NEURONTIN                      gabapentin 100mg capsule                                        Only Generic Covered
NEURONTIN                      gabapentin 250mg/5ml soln                                       Only Generic Covered
NEURONTIN                      gabapentin 300mg capsule                                        Only Generic Covered
NEURONTIN                      gabapentin 400mg capsule                                        Only Generic Covered
NEURONTIN                      gabapentin 600mg tablet                                         Only Generic Covered
NEURONTIN                      gabapentin 800mg tablet                                         Only Generic Covered
phenobarbital 100mg tab                                                                2       Available via Mail Order
phenobarbital 16.2mg tablet                                                            2       Available via Mail Order
phenobarbital 20mg/5ml elixr                                                           2       Available via Mail Order
phenobarbital 30mg tab                                                                 2       Available via Mail Order
phenobarbital 32.4mg tab                                                               2       Available via Mail Order
phenobarbital 64.8mg tablet                                                            2       Available via Mail Order
primidone 250mg tablet         MYSOLINE                                                2       Available via Mail Order
primidone 50mg tablet          MYSOLINE                                                2       Available via Mail Order
SABRIL 500MG ORAL SOLUTION                                                             4       Prior Auth Required
                                                                                               Available via Mail Order
SABRIL 500MG TABLET                                                                    4       Prior Auth Required
                                                                                               Available via Mail Order
valproate sod 100mg/ml inj     DEPAKENE                                                5
valproic acid 250mg capsule    DEPAKENE                                                2       Available via Mail Order
valproic acid 250mg/5ml syrp   DEPAKENE                                                2       Available via Mail Order
                               Anti-Convulsants - Glutamate Reducing Agents

27-921/01-01/06 Rev 01-11                                             [ 45]                    2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
FELBATOL 400MG TABLET                                                                    4       Available via Mail Order
FELBATOL 600MG TABLET                                                                    4       Available via Mail Order
FELBATOL 600MG/5ML SUSP                                                                  4       Available via Mail Order
KEPPRA                         levetiracetam 500/5ml inj                                         Only Generic Covered
KEPPRA (NOT XR)                levetiracetam 250mg tablet                                        Only Generic Covered
KEPPRA (NOT XR)                levetiracetam 500mg tablet                                        Only Generic Covered
KEPPRA (NOT XR)                levetiracetam 750mg tablet                                        Only Generic Covered
KEPPRA (NOT XR)                levetiracetam 1000mg tablet                                       Only Generic Covered
KEPPRA (NOT XR)                levetiracetam 100mg/ml soln                                       Only Generic Covered
LAMICTAL (NOT XR & ODT)        lamotrigine 5mg chew tab                                          Only Generic Covered
LAMICTAL (NOT XR & ODT)        lamotrigine 25mg chew tablt                                       Only Generic Covered
LAMICTAL (NOT XR & ODT)        lamotrigine 100mg tablet                                          Only Generic Covered
LAMICTAL (NOT XR & ODT)        lamotrigine 150mg tablet                                          Only Generic Covered
LAMICTAL (NOT XR & ODT)        lamotrigine 200mg tablet                                          Only Generic Covered
LAMICTAL (NOT XR & ODT)        lamotrigine 25mg tablet                                           Only Generic Covered
lamotrigine 5mg chew tab       LAMICTAL (NOT XR & ODT)                                   2       Available via Mail Order
lamotrigine 25mg chew tablt    LAMICTAL (NOT XR & ODT)                                   2       Available via Mail Order
lamotrigine 100mg tablet       LAMICTAL (NOT XR & ODT)                                   2       Available via Mail Order
lamotrigine 150mg tablet       LAMICTAL (NOT XR & ODT)                                   2       Available via Mail Order
lamotrigine 200mg tablet       LAMICTAL (NOT XR & ODT)                                   2       Available via Mail Order
lamotrigine 25mg tablet        LAMICTAL (NOT XR & ODT)                                   2       Available via Mail Order
levetiracetam 250mg tablet     KEPPRA (NOT XR)                                           2       Available via Mail Order
levetiracetam 500mg tablet     KEPPRA (NOT XR)                                           2       Available via Mail Order
levetiracetam 750mg tablet     KEPPRA (NOT XR)                                           2       Available via Mail Order
levetiracetam 1000mg tablet    KEPPRA (NOT XR)                                           2       Available via Mail Order
levetiracetam 100mg/ml soln    KEPPRA (NOT XR)                                           2       Available via Mail Order
levetiracetam 500/5ml inj      KEPPRA                                                    5
TOPAMAX                        topiramate 25mg tablet                                            Only Generic Covered
TOPAMAX                        topiramate 50mg tablet                                            Only Generic Covered
TOPAMAX                        topiramate 100mg tablet                                           Only Generic Covered
TOPAMAX                        topiramate 200mg tablet                                           Only Generic Covered
TOPAMAX SPRINKLE               topiramate 15mg sprk capsule                                      Only Generic Covered
TOPAMAX SPRINKLE               topiramate 25mg sprk capsul                                       Only Generic Covered
topiramate 15mg sprk capsule   TOPAMAX SPRINKLE                                          2       Available via Mail Order
topiramate 25mg tablet         TOPAMAX                                                   2       Available via Mail Order
topiramate 25mg sprk capsul    TOPAMAX SPRINKLE                                          2       Available via Mail Order
27-921/01-01/06 Rev 01-11                                             [ 46]                      2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                        DRUG CATEGORY - DRUG CLASS
DRUG NAME                                              BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
topiramate 50mg tablet         TOPAMAX                                               2       Available via Mail Order
topiramate 100mg tablet        TOPAMAX                                               2       Available via Mail Order
topiramate 200mg tablet        TOPAMAX                                               2       Available via Mail Order
                               Anti-Convulsants - Sodium Channel Inhibitors
carbamazepine 100mg chewable   TEGRETOL (NOT XR)                                     2       Available via Mail Order
carbamazepine 100mg/5ml susp   TEGRETOL SUSP                                         2       Available via Mail Order
carbamazepine 200mg tablet     TEGRETOL (NOT XR)                                     2       Available via Mail Order
DILANTIN                       phenytoin 50mg/ml inj                                         Only Generic Covered
DILANTIN                       phenytoin 100mg er capsule                                    Only Generic Covered
DILANTIN                       phenytoin 125mg/5ml susp                                      Only Generic Covered
DILANTIN 30MG CAPSULE                                                                3       Available via Mail Order
DILANTIN 50MG CHW INFATABS                                                           3       Available via Mail Order
oxcarbazepine 150mg tablet     TRILEPTAL                                             2       Available via Mail Order
oxcarbazepine 300mg tablet     TRILEPTAL                                             2       Available via Mail Order
oxcarbazepine 300mg/5ml susp   TRILEPTAL                                             2       Available via Mail Order
oxcarbazepine 600mg tablet     TRILEPTAL                                             2       Available via Mail Order
PEGANONE 250MG TABLET                                                                4       Available via Mail Order
phenytoin 50mg/ml inj          DILANTIN                                              5
phenytoin 100mg er capsule     DILANTIN                                              2       Available via Mail Order
phenytoin 125mg/5ml susp       DILANTIN                                              2       Available via Mail Order
TEGRETOL (NOT XR)              carbamazepine 100mg chewable                                  Only Generic Covered
TEGRETOL (NOT XR)              carbamazepine 200mg tablet                                    Only Generic Covered
TEGRETOL SUSP                  carbamazepine 100mg/5ml susp                                  Only Generic Covered
TRILEPTAL                      oxcarbazepine 150mg tablet                                    Only Generic Covered
TRILEPTAL                      oxcarbazepine 300mg tablet                                    Only Generic Covered
TRILEPTAL                      oxcarbazepine 300mg/5ml susp                                  Only Generic Covered
TRILEPTAL                      oxcarbazepine 600mg tablet                                    Only Generic Covered
VIMPAT 100MG TABLET                                                                  4       Prior Auth Required
                                                                                             Available via Mail Order
VIMPAT 10MG/ML INJ                                                                   5
VIMPAT 10MG/ML SOLN                                                                  4       Prior Auth Required
                                                                                             Available via Mail Order
VIMPAT 150MG TABLET                                                                  4       Prior Auth Required
                                                                                             Available via Mail Order
VIMPAT 200MG TABLET                                                                  4       Prior Auth Required
                                                                                             Available via Mail Order


27-921/01-01/06 Rev 01-11                                             [ 47]                  2011 Commercial Drug Formulary
                                                                                                   Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
VIMPAT 50MG TABLET                                                                      4       Prior Auth Required
                                                                                                Available via Mail Order
                                Antidementia Agents - Antidementia Agents, Other
ergoloid mesylates 1mg oral     HYDERGINE                                               2       Available via Mail Order
HYDERGINE                       ergoloid mesylates 1mg oral                                     Only Generic Covered
                                Antidementia Agents - Cholinesterase Inhibitors
ARICEPT                         donepezil hcl 5mg tablet                                        Only Generic Covered
ARICEPT                         donepezil hcl 10mg tablet                                       Only Generic Covered
ARICEPT                         donepezil hcl odt 5mg tablt                                     Only Generic Covered
ARICEPT                         donepezil hcl odt 10mg tablt                                    Only Generic Covered
donepezil hcl 5mg tablet        ARICEPT                                                 2       Available via Mail Order
donepezil hcl 10mg tablet       ARICEPT                                                 2       Available via Mail Order
donepezil hcl odt 5mg tablt     ARICEPT                                                 2       Available via Mail Order
donepezil hcl odt 10mg tablt    ARICEPT                                                 2       Available via Mail Order
galantamine 4mg tablet          RAZADYNE                                                2       Available via Mail Order
galantamine 8mg tablet          RAZADYNE                                                2       Available via Mail Order
galantamine 12mg tablet         RAZADYNE                                                2       Available via Mail Order
galantamine 4mg/ml soln         RAZADYNE                                                2       Available via Mail Order
galantamine er 8mg capsule      RAZADYNE ER                                             2       Available via Mail Order
galantamine er 16mg capsule     RAZADYNE ER                                             2       Available via Mail Order
galantamine er 24mg capsule     RAZADYNE ER                                             2       Available via Mail Order
RAZADYNE                        galantamine 4mg tablet                                          Only Generic Covered
RAZADYNE                        galantamine 8mg tablet                                          Only Generic Covered
RAZADYNE                        galantamine 12mg tablet                                         Only Generic Covered
RAZADYNE                        galantamine 4mg/ml soln                                         Only Generic Covered
RAZADYNE ER                     galantamine er 8mg capsule                                      Only Generic Covered
RAZADYNE ER                     galantamine er 16mg capsule                                     Only Generic Covered
RAZADYNE ER                     galantamine er 24mg capsule                                     Only Generic Covered
                                Antidementia Agents - Glutamate Pathway Modifiers
NAMENDA 5MG TABLET                                                                      3       Available via Mail Order
NAMENDA 10MG TABLET                                                                     3       Available via Mail Order
NAMENDA 10MG/5ML ORAL SOLN                                                              3       Available via Mail Order
NAMENDA 5/10MG TAB TITRA PACK                                                           3       Available via Mail Order
                                Antidepressants - Antidepressants, Other
budeprion 150mg sr tab          WELLBUTRIN SR (NOT 200MG)                               2       Available via Mail Order
budeprion xl 150mg tab          WELLBUTRIN XL                                           2       Available via Mail Order

27-921/01-01/06 Rev 01-11                                                  [ 48]                2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                        DRUG CATEGORY - DRUG CLASS
DRUG NAME                                              BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
bupropion 100mg er tablet    WELLBUTRIN SR (NOT 200MG)                               2       Available via Mail Order
bupropion 300mg xl tablet    WELLBUTRIN XL                                           2       Available via Mail Order
bupropion hcl 75mg tablet    WELLBUTRIN                                              2       Available via Mail Order
bupropion hcl 100mg tablet   WELLBUTRIN                                              2       Available via Mail Order
DESYREL                      trazodone 50mg tablet                                           Only Generic Covered
DESYREL                      trazodone 100mg tablet                                          Only Generic Covered
DESYREL                      trazodone 150mg tablet                                          Only Generic Covered
DESYREL                      trazodone 300mg tablet                                          Only Generic Covered
LUDIOMIL                     maprotiline 25mg tablet                                         Only Generic Covered
LUDIOMIL                     maprotiline 50mg tablet                                         Only Generic Covered
LUDIOMIL                     maprotiline 75mg tablet                                         Only Generic Covered
maprotiline 25mg tablet      LUDIOMIL                                                2       Available via Mail Order
maprotiline 50mg tablet      LUDIOMIL                                                2       Available via Mail Order
maprotiline 75mg tablet      LUDIOMIL                                                2       Available via Mail Order
mirtazapine 7.5mg tablet     REMERON                                                 2       Available via Mail Order
mirtazapine 15mg tablet      REMERON                                                 2       Available via Mail Order
mirtazapine 15mg tab (odt)   REMERON SOLU-TAB                                        2       Available via Mail Order
mirtazapine 30mg tablet      REMERON                                                 2       Available via Mail Order
mirtazapine 30mg tab (odt)   REMERON ODT                                             2       Available via Mail Order
mirtazapine 45mg tablet      REMERON                                                 2       Available via Mail Order
mirtazapine 45mg tab (odt)   REMERON-ODT                                             2       Available via Mail Order
REMERON                      mirtazapine 7.5mg tablet                                        Only Generic Covered
REMERON                      mirtazapine 15mg tablet                                         Only Generic Covered
REMERON                      mirtazapine 30mg tablet                                         Only Generic Covered
REMERON                      mirtazapine 45mg tablet                                         Only Generic Covered
REMERON ODT                  mirtazapine 30mg tab (odt)                                      Only Generic Covered
REMERON SOLU-TAB             mirtazapine 15mg tab (odt)                                      Only Generic Covered
REMERON-ODT                  mirtazapine 45mg tab (odt)                                      Only Generic Covered
trazodone 50mg tablet        DESYREL                                                 1       Available via Mail Order
trazodone 100mg tablet       DESYREL                                                 1       Available via Mail Order
trazodone 150mg tablet       DESYREL                                                 2       Available via Mail Order
trazodone 300mg tablet       DESYREL                                                 2       Available via Mail Order
VIIBRYD 10MG TABLET                                                                  4       Available via Mail Order
VIIBRYD 20MG TABLET                                                                  4       Available via Mail Order
VIIBRYD 40MG TABLET                                                                  4       Available via Mail Order
WELLBUTRIN                   bupropion hcl 75mg tablet                                       Only Generic Covered
27-921/01-01/06 Rev 01-11                                         [ 49]                      2011 Commercial Drug Formulary
                                                                                                   Last Updated: July 1, 2011
                                                       DRUG CATEGORY - DRUG CLASS
DRUG NAME                                             BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
WELLBUTRIN                   bupropion hcl 100mg tablet                                     Only Generic Covered
WELLBUTRIN SR (NOT 200MG)    budeprion 150mg sr tab                                         Only Generic Covered
WELLBUTRIN SR (NOT 200MG)    bupropion 100mg er tablet                                      Only Generic Covered
WELLBUTRIN XL                budeprion xl 150mg tab                                         Only Generic Covered
WELLBUTRIN XL                bupropion 300mg xl tablet                                      Only Generic Covered
                             Antidepressants - MAO Inhibitors
EMSAM 6MG/24HR PATCH                                                                4       Prior Auth Required
                                                                                            Quantity Limits Apply
                                                                                            Available via Mail Order
EMSAM 9MG/24HR PATCH                                                                4       Prior Auth Required
                                                                                            Quantity Limits Apply
                                                                                            Available via Mail Order
MARPLAN 10MG TABLET                                                                 4       Available via Mail Order
NARDIL                       phenelzine 15mg tablet                                         Only Generic Covered
PARNATE 10MG TABLET                                                                 4       Available via Mail Order
phenelzine 15mg tablet       NARDIL                                                 2       Available via Mail Order
                             Antidepressants - Re-Uptake Inhibitors
amitriptyline 10mg tablet    ELAVIL                                                 1       Available via Mail Order
amitriptyline 25mg tablet    ELAVIL                                                 1       Available via Mail Order
amitriptyline 50mg tablet    ELVIL                                                  1       Available via Mail Order
amitriptyline 75mg tablet    ELAVIL                                                 1       Available via Mail Order
amitriptyline 100mg tablet   ELAVIL                                                 1       Available via Mail Order
amitriptyline 150mg tablet   ELAVIL                                                 2       Available via Mail Order
amoxapine 25mg tablet        ASENDIN                                                2       Available via Mail Order
amoxapine 50mg tablet        ASENDIN                                                2       Available via Mail Order
amoxapine 100mg tablet       ASENDIN                                                2       Available via Mail Order
amoxapine 150mg tablet       ASENDIN                                                2       Available via Mail Order
ANAFRANIL                    clomipramine hcl 25mg capsle                                   Only Generic Covered
ANAFRANIL                    clomipramine hcl 50mg capsle                                   Only Generic Covered
ANAFRANIL                    clomipramine hcl 75mg capsle                                   Only Generic Covered
ASENDIN                      amoxapine 25mg tablet                                          Only Generic Covered
ASENDIN                      amoxapine 50mg tablet                                          Only Generic Covered
ASENDIN                      amoxapine 100mg tablet                                         Only Generic Covered
ASENDIN                      amoxapine 150mg tablet                                         Only Generic Covered
CELEXA                       citalopram 10mg tablet                                         Only Generic Covered
CELEXA                       citalopram 10mg/5ml oral soln                                  Only Generic Covered
CELEXA                       citalopram 20mg tablet                                         Only Generic Covered

27-921/01-01/06 Rev 01-11                                             [ 50]                 2011 Commercial Drug Formulary
                                                                                                  Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
CELEXA                          citalopram 40mg tablet                                           Only Generic Covered
citalopram 10mg tablet          CELEXA                                                   1       Available via Mail Order
citalopram 10mg/5ml oral soln   CELEXA                                                   1       Available via Mail Order
citalopram 20mg tablet          CELEXA                                                   1       Available via Mail Order
citalopram 40mg tablet          CELEXA                                                   1       Available via Mail Order
clomipramine hcl 25mg capsle    ANAFRANIL                                                2       Available via Mail Order
clomipramine hcl 50mg capsle    ANAFRANIL                                                2       Available via Mail Order
clomipramine hcl 75mg capsle    ANAFRANIL                                                2       Available via Mail Order
CYMBALTA 20MG CAPSULE                                                                    4       Available via Mail Order
CYMBALTA 30MG CAPSULE                                                                    4       Available via Mail Order
CYMBALTA 60MG CAPSULE                                                                    4       Available via Mail Order
desipramine 10mg tablet         NORPRAMIN                                                2       Available via Mail Order
desipramine 25mg tablet         NORPRAMIN                                                2       Available via Mail Order
desipramine 50mg tablet         NORPRAMIN                                                2       Available via Mail Order
desipramine 75mg tablet         NORPRAMIN                                                2       Available via Mail Order
desipramine 100mg tablet        NORPRAMIN                                                2       Available via Mail Order
desipramine 150mg tablet        NORPRAMIN                                                2       Available via Mail Order
doxepin 10mg capsule            SINEQUAN                                                 1       Available via Mail Order
doxepin 25mg capsule            SINEQUAN                                                 1       Available via Mail Order
doxepin 50mg capsule            SINEQUAN                                                 1       Available via Mail Order
doxepin 75mg capsule            SINEQUAN                                                 2       Available via Mail Order
doxepin hcl 10mg/ml conc        SINEQUAN                                                 2       Available via Mail Order
doxepin 100mg capsule           SINEQUAN                                                 2       Available via Mail Order
doxepin 150mg capsule           SINEQUAN                                                 2       Available via Mail Order
EFFEXOR                         venlafaxine 25mg tablet                                          Only Generic Covered
EFFEXOR                         venlafaxine 37.5mg tablet                                        Only Generic Covered
EFFEXOR                         venlafaxine 50mg tablet                                          Only Generic Covered
EFFEXOR                         venlafaxine 75mg tablet                                          Only Generic Covered
EFFEXOR                         venlafaxine 100mg tablet                                         Only Generic Covered
EFFEXOR-XR                      venlafaxine-er 150mg capsule                                     Only Generic Covered
EFFEXOR-XR                      venlafaxine-er 37.5mg capsle                                     Only Generic Covered
EFFEXOR-XR                      venlafaxine-er 75mg capsule                                      Only Generic Covered
ELAVIL                          amitriptyline 10mg tablet                                        Only Generic Covered
ELAVIL                          amitriptyline 25mg tablet                                        Only Generic Covered
ELAVIL                          amitriptyline 75mg tablet                                        Only Generic Covered
ELAVIL                          amitriptyline 100mg tablet                                       Only Generic Covered
27-921/01-01/06 Rev 01-11                                             [ 51]                      2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                       DRUG CATEGORY - DRUG CLASS
DRUG NAME                                             BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
ELAVIL                        amitriptyline 150mg tablet                                    Only Generic Covered
ELVIL                         amitriptyline 50mg tablet                                     Only Generic Covered
ETRAFON                       perphenazine/amitrip 2/10 tab                                 Only Generic Covered
ETRAFON                       perphenazine/amitrip 2/25 tab                                 Only Generic Covered
ETRAFON                       perphenazine/amitrip 4/10 tab                                 Only Generic Covered
ETRAFON                       perphenazine/amitrip 4/25 tab                                 Only Generic Covered
ETRAFON                       perphenazine/amitrip 4/50 tab                                 Only Generic Covered
fluoxetine 20mg/5ml liquid    PROZAC LIQ                                            2       Available via Mail Order
fluoxetine hcl 10mg capsule   PROZAC                                                1       Available via Mail Order
fluoxetine hcl 20mg capsule   PROZAC                                                1       Available via Mail Order
fluvoxamine 25mg tablet       LUVOX (NOT CR)                                        2       Available via Mail Order
fluvoxamine 50mg tablet       LUVOX (NOT CR)                                        2       Available via Mail Order
fluvoxamine 100mg tablet      LUVOX (NOT CR)                                        2       Available via Mail Order
imipramine 10mg tablet        TOFRANIL (NOT PM)                                     2       Available via Mail Order
imipramine 25mg tablet        TOFRANIL (NOT PM)                                     2       Available via Mail Order
imipramine 50mg tablet        TOFRANIL (NOT PM)                                     2       Available via Mail Order
LEXAPRO 5MG TABLET                                                                  3       Available via Mail Order
LEXAPRO 10MG TABLET                                                                 3       Available via Mail Order
LEXAPRO 20MG TABLET                                                                 3       Available via Mail Order
LEXAPRO 5MG/5ML ORAL SOLN                                                           3       Available via Mail Order
LUVOX (NOT CR)                fluvoxamine 25mg tablet                                       Only Generic Covered
LUVOX (NOT CR)                fluvoxamine 50mg tablet                                       Only Generic Covered
LUVOX (NOT CR)                fluvoxamine 100mg tablet                                      Only Generic Covered
nefazodone 50mg tablet        SERZONE                                               2       Available via Mail Order
nefazodone 100mg tablet       SERZONE                                               2       Available via Mail Order
nefazodone 150mg tablet       SERZONE                                               2       Available via Mail Order
nefazodone 200mg tablet       SERZONE                                               2       Available via Mail Order
nefazodone 250mg tablet       SERZONE                                               2       Available via Mail Order
NORPRAMIN                     desipramine 10mg tablet                                       Only Generic Covered
NORPRAMIN                     desipramine 25mg tablet                                       Only Generic Covered
NORPRAMIN                     desipramine 50mg tablet                                       Only Generic Covered
NORPRAMIN                     desipramine 75mg tablet                                       Only Generic Covered
NORPRAMIN                     desipramine 100mg tablet                                      Only Generic Covered
NORPRAMIN                     desipramine 150mg tablet                                      Only Generic Covered
nortriptyline 10mg/5ml soln   PAMELOR                                               2       Available via Mail Order
nortriptyline 10mg capsule    PAMELOR                                               1       Available via Mail Order
27-921/01-01/06 Rev 01-11                                        [ 52]                      2011 Commercial Drug Formulary
                                                                                                  Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
nortriptyline 25mg capsule      PAMELOR                                               1       Available via Mail Order
nortriptyline 50mg capsule      PAMELOR                                               2       Available via Mail Order
nortriptyline 75mg capsule      PAMELOR                                               2       Available via Mail Order
PAMELOR                         nortriptyline 10mg/5ml soln                                   Only Generic Covered
PAMELOR                         nortriptyline 10mg capsule                                    Only Generic Covered
PAMELOR                         nortriptyline 25mg capsule                                    Only Generic Covered
PAMELOR                         nortriptyline 50mg capsule                                    Only Generic Covered
PAMELOR                         nortriptyline 75mg capsule                                    Only Generic Covered
paroxetine hcl 10mg tablet      PAXIL                                                 2       Available via Mail Order
paroxetine hcl 12.5mg er tab    PAXIL CR                                              2       Available via Mail Order
paroxetine hcl 20mg tablet      PAXIL                                                 2       Available via Mail Order
paroxetine hcl 25mg er tab      PAXIL CR                                              2       Available via Mail Order
paroxetine hcl 30mg tablet      PAXIL                                                 2       Available via Mail Order
paroxetine hcl 37.5mg er tab    PAXIL CR                                              2       Available via Mail Order
paroxetine hcl 40mg tablet      PAXIL                                                 2       Available via Mail Order
PAXIL                           paroxetine hcl 10mg tablet                                    Only Generic Covered
PAXIL                           paroxetine hcl 20mg tablet                                    Only Generic Covered
PAXIL                           paroxetine hcl 30mg tablet                                    Only Generic Covered
PAXIL                           paroxetine hcl 40mg tablet                                    Only Generic Covered
PAXIL 10MG/5ML SUSP                                                                   4       Available via Mail Order
PAXIL CR                        paroxetine hcl 12.5mg er tab                                  Only Generic Covered
PAXIL CR                        paroxetine hcl 25mg er tab                                    Only Generic Covered
PAXIL CR                        paroxetine hcl 37.5mg er tab                                  Only Generic Covered
perphenazine/amitrip 2/10 tab   ETRAFON                                               2       Available via Mail Order
perphenazine/amitrip 2/25 tab   ETRAFON                                               2       Available via Mail Order
perphenazine/amitrip 4/10 tab   ETRAFON                                               2       Available via Mail Order
perphenazine/amitrip 4/25 tab   ETRAFON                                               2       Available via Mail Order
perphenazine/amitrip 4/50 tab   ETRAFON                                               2       Available via Mail Order
PRISTIQ 50MG ER TABLET                                                                3       Available via Mail Order
PRISTIQ 100MG ER TABLET                                                               3       Available via Mail Order
protriptyline 5mg tablet        VIVACTIL                                              2       Available via Mail Order
protriptyline 10mg tablet       VIVACTIL                                              2       Available via Mail Order
PROZAC                          fluoxetine hcl 10mg capsule                                   Only Generic Covered
PROZAC                          fluoxetine hcl 20mg capsule                                   Only Generic Covered
PROZAC LIQ                      fluoxetine 20mg/5ml liquid                                    Only Generic Covered
SAVELLA 12.5MG TABLET                                                                 4       Available via Mail Order
27-921/01-01/06 Rev 01-11                                          [ 53]                      2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
SAVELLA 25MG TABLET                                                                      4       Available via Mail Order
SAVELLA 50MG TABLET                                                                      4       Available via Mail Order
SAVELLA TITRATION PACK TAB                                                               4       Quantity Limits Apply
                                                                                                 Available via Mail Order
SAVELLA 100MG TABLET                                                                     4       Available via Mail Order
sertraline 25mg tablet         ZOLOFT                                                    2       Available via Mail Order
sertraline 100mg tablet        ZOLOFT                                                    2       Available via Mail Order
sertraline 20mg/ml conc        ZOLOFT                                                    2       Available via Mail Order
SERZONE                        nefazodone 50mg tablet                                            Only Generic Covered
SERZONE                        nefazodone 100mg tablet                                           Only Generic Covered
SERZONE                        nefazodone 150mg tablet                                           Only Generic Covered
SERZONE                        nefazodone 200mg tablet                                           Only Generic Covered
SERZONE                        nefazodone 250mg tablet                                           Only Generic Covered
SINEQUAN                       doxepin 10mg capsule                                              Only Generic Covered
SINEQUAN                       doxepin 25mg capsule                                              Only Generic Covered
SINEQUAN                       doxepin 50mg capsule                                              Only Generic Covered
SINEQUAN                       doxepin 75mg capsule                                              Only Generic Covered
SINEQUAN                       doxepin hcl 10mg/ml conc                                          Only Generic Covered
SINEQUAN                       doxepin 100mg capsule                                             Only Generic Covered
SINEQUAN                       doxepin 150mg capsule                                             Only Generic Covered
SURMONTIL 25MG CAP                                                                       4       Available via Mail Order
SURMONTIL 50MG CAP                                                                       4       Available via Mail Order
SURMONTIL 100MG CAP                                                                      4       Available via Mail Order
TOFRANIL (NOT PM)              imipramine 10mg tablet                                            Only Generic Covered
TOFRANIL (NOT PM)              imipramine 25mg tablet                                            Only Generic Covered
TOFRANIL (NOT PM)              imipramine 50mg tablet                                            Only Generic Covered
venlafaxine 25mg tablet        EFFEXOR                                                   2       Available via Mail Order
venlafaxine 37.5mg tablet      EFFEXOR                                                   2       Available via Mail Order
venlafaxine 50mg tablet        EFFEXOR                                                   2       Available via Mail Order
venlafaxine 75mg tablet        EFFEXOR                                                   2       Available via Mail Order
venlafaxine 100mg tablet       EFFEXOR                                                   2       Available via Mail Order
venlafaxine-er 150mg capsule   EFFEXOR-XR                                                2       Available via Mail Order
venlafaxine-er 37.5mg capsle   EFFEXOR-XR                                                2       Available via Mail Order
venlafaxine-er 75mg capsule    EFFEXOR-XR                                                2       Available via Mail Order
VIVACTIL                       protriptyline 5mg tablet                                          Only Generic Covered
VIVACTIL                       protriptyline 10mg tablet                                         Only Generic Covered

27-921/01-01/06 Rev 01-11                                             [ 54]                      2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
ZOLOFT                          sertraline 25mg tablet                                          Only Generic Covered
ZOLOFT                          sertraline 100mg tablet                                         Only Generic Covered
ZOLOFT                          sertraline 20mg/ml conc                                         Only Generic Covered
                                Antiemetics
ALOXI 0.25MG/5ML SDV INJ                                                                5
ANZEMET 20MG/ML SDV INJ                                                                 5
COMPAZINE                       prochlorper 5mg/ml inj mdv                                      Only Generic Covered
COMPAZINE                       prochlorperazine 5mg tablt                                      Only Generic Covered
COMPAZINE                       prochlorperazine 10mg tablt                                     Only Generic Covered
COMPAZINE                       prochlorperazine 25mg supp                                      Only Generic Covered
diphenhydramine 50mg/ml inj                                                             5
dronabinol 10mg capsule         MARINOL                                                 2       Prior Auth Required
                                                                                                Quantity Limits Apply
dronabinol 2.5mg cap            MARINOL                                                 2       Prior Auth Required
                                                                                                Quantity Limits Apply
dronabinol 5mg capsule          MARINOL                                                 2       Prior Auth Required
                                                                                                Quantity Limits Apply
EMEND 125-80MG CAPSULE                                                                  5       Prior Auth Required
EMEND 40MG CAPSULE                                                                      5       Prior Auth Required
EMEND 80MG CAPSULE                                                                      5       Prior Auth Required
MARINOL                         dronabinol 10mg capsule                                         Only Generic Covered
MARINOL                         dronabinol 2.5mg cap                                            Only Generic Covered
MARINOL                         dronabinol 5mg capsule                                          Only Generic Covered
metoclopramide 5mg/ml inj sdv                                                           5
ondansetron 4mg/5ml soln        ZOFRAN                                                  2       Quantity Limits Apply
ondansetron 2mg/ml inj sdv      ZOFRAN                                                  5
ondansetron 4mg tablet          ZOFRAN                                                  2       Quantity Limits Apply
ondansetron 8mg tablet          ZOFRAN                                                  2       Quantity Limits Apply
ondansetron odt 4mg tablet      ZOFRAN ODT                                              2       Quantity Limits Apply
ondansetron odt 8mg tablet      ZOFRAN ODT                                              2       Quantity Limits Apply
phenadoz 12.5mg supp            PHENERGAN                                               2       Quantity Limits Apply
phenadoz 25mg supp              PHENERGAN                                               2       Quantity Limits Apply
PHENERGAN                       phenadoz 12.5mg supp                                            Only Generic Covered
PHENERGAN                       phenadoz 25mg supp                                              Only Generic Covered
PHENERGAN                       promethazine 25mg tablet                                        Only Generic Covered
PHENERGAN                       promethazine 50mg supp                                          Only Generic Covered


27-921/01-01/06 Rev 01-11                                            [ 55]                      2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
PHENERGAN                       promethazine 25mg/ml inj amp                                     Only Generic Covered
prochlorper 5mg/ml inj mdv      COMPAZINE                                                5
prochlorperazine 5mg tablt      COMPAZINE                                                2       Available via Mail Order
prochlorperazine 10mg tablt     COMPAZINE                                                2       Available via Mail Order
prochlorperazine 25mg supp      COMPAZINE                                                2       Quantity Limits Apply
promethazine 25mg tablet        PHENERGAN                                                2
promethazine 50mg supp          PHENERGAN                                                2       Quantity Limits Apply
promethazine 25mg/ml inj amp    PHENERGAN                                                5
promethazine 50mg/ml inj sdv                                                             5
TIGAN                           trimethobenzamid 100mg/ml inj                                    Only Generic Covered
TIGAN                           trimethobenzamide 300mg caps                                     Only Generic Covered
trimethobenzamid 100mg/ml inj   TIGAN                                                    5
trimethobenzamide 300mg caps    TIGAN                                                    2
ZOFRAN                          ondansetron 4mg/5ml soln                                         Only Generic Covered
ZOFRAN                          ondansetron 2mg/ml inj sdv                                       Only Generic Covered
ZOFRAN                          ondansetron 4mg tablet                                           Only Generic Covered
ZOFRAN                          ondansetron 8mg tablet                                           Only Generic Covered
ZOFRAN ODT                      ondansetron odt 4mg tablet                                       Only Generic Covered
ZOFRAN ODT                      ondansetron odt 8mg tablet                                       Only Generic Covered
                                Antifungals
ANCOBON 250MG CAP                                                                        4
ANCOBON 500MG CAP                                                                        4
CANCIDAS 50MG INJ                                                                        5
DIFLUCAN                        fluconazole 50mg tablet                                          Only Generic Covered
DIFLUCAN                        fluconazole 100mg tablet                                         Only Generic Covered
DIFLUCAN                        fluconazole 10mg/ml oral susp                                    Only Generic Covered
DIFLUCAN                        fluconazole 150mg tablet                                         Only Generic Covered
DIFLUCAN                        fluconazole 40mg/ml susp                                         Only Generic Covered
DIFLUCAN IV                     fluconazole/dex 2mg/ml inj                                       Only Generic Covered
ERAXIS 50MG INJ                                                                          5
fluconazole 50mg tablet         DIFLUCAN                                                 2
fluconazole 100mg tablet        DIFLUCAN                                                 2
fluconazole 10mg/ml oral susp   DIFLUCAN                                                 2       Quantity Limits Apply
fluconazole 150mg tablet        DIFLUCAN                                                 2       Quantity Limits Apply
fluconazole 200mg tablet                                                                 2
fluconazole 40mg/ml susp        DIFLUCAN                                                 2       Quantity Limits Apply
27-921/01-01/06 Rev 01-11                                             [ 56]                      2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
fluconazole/dex 2mg/ml inj     DIFLUCAN IV                                              5
GRIFULVIN V SUSP               griseofulvin 125mg/5ml susp                                      Only Generic Covered
GRIFULVIN V SUSP               griseofulvin 125mg/5ml susp                                      Only Generic Covered
griseofulvin 125mg/5ml susp    GRIFULVIN V SUSP                                         2
griseofulvin 125mg/5ml susp    GRIFULVIN V SUSP                                         2
GYNAZOLE-1 2% VAG CRM                                                                   4       Quantity Limits Apply
itraconazole 100mg capsule     SPORANOX                                                 2       Prior Auth Required
ketoconazole 200mg tablet      NIZORAL                                                  2
LAMISIL                        terbinafine 250mg tablet                                         Only Generic Covered
MYCOSTATIN                     nystatin 100m un/ml susp                                         Only Generic Covered
MYCOSTATIN                     nystatin 500,000 units oral                                      Only Generic Covered
NIZORAL                        ketoconazole 200mg tablet                                        Only Generic Covered
nystatin 100m un/ml susp       MYCOSTATIN                                               2
nystatin 500,000 units oral    MYCOSTATIN                                               2
SPORANOX                       itraconazole 100mg capsule                                       Only Generic Covered
SPORANOX 10MG/ML ORAL SOLN                                                              4       Prior Auth Required
TERAZOL 3                      terconazole-3 0.8% vag cream                                     Only Generic Covered
TERAZOL 7                      terconazole 0.4% vag cream                                       Only Generic Covered
TERAZOL-3 SUPP                 terconazole 80mg vag supp                                        Only Generic Covered
terbinafine 250mg tablet       LAMISIL                                                  2
terconazole 0.4% vag cream     TERAZOL 7                                                2       Quantity Limits Apply
terconazole 80mg vag supp      TERAZOL-3 SUPP                                           2       Quantity Limits Apply
terconazole-3 0.8% vag cream   TERAZOL 3                                                2       Quantity Limits Apply
                               Antigout Agents
allopurinol 100mg tablet       ZYLOPRIM                                                 1       Available via Mail Order
allopurinol 300mg tablet       ZYLOPRIM                                                 1       Available via Mail Order
BENEMID                        probenecid 500mg tablet                                          Only Generic Covered
COLBENEMID                     probenecid/colch 500/0.5 tab                                     Only Generic Covered
colchicine 0.6mg tablet                                                                 2       Available via Mail Order
COLCRYS 0.6MG TABLET                                                                    4       Quantity Limits Apply
                                                                                                Available via Mail Order
probenecid 500mg tablet        BENEMID                                                  2       Available via Mail Order
probenecid/colch 500/0.5 tab   COLBENEMID                                               2       Available via Mail Order
ZYLOPRIM                       allopurinol 100mg tablet                                         Only Generic Covered
ZYLOPRIM                       allopurinol 300mg tablet                                         Only Generic Covered
                               Anti-Inflammatories - Glucocorticoids

27-921/01-01/06 Rev 01-11                                              [ 57]                    2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
a-hydrocort 100mg inj           SOLU-CORTEF                                             5
DECADRON                        dexamethasone 0.5mg tablet                                      Only Generic Covered
DECADRON                        dexamethasone 0.75mg tablet                                     Only Generic Covered
DECADRON                        dexamethasone 1.5mg tablet                                      Only Generic Covered
DECADRON                        dexamethasone 1mg tab                                           Only Generic Covered
DECADRON                        DEXAMETHASONE 1MG/ML CONC                                       Only Generic Covered
DECADRON                        dexamethasone 4mg tablet                                        Only Generic Covered
DECADRON                        dexamethasone 4mg/ml inj                                        Only Generic Covered
DECADRON ELIXIR                 dexamethasone 0.5/5ml elix                                      Only Generic Covered
DECADRON ELIXIR                 dexamethasone 0.5/5ml soln                                      Only Generic Covered
DELTASONE                       prednisone 1mg tablet                                           Only Generic Covered
DELTASONE                       prednisone 2.5mg tablet                                         Only Generic Covered
DELTASONE                       prednisone 5mg tablet                                           Only Generic Covered
DELTASONE                       prednisone 10mg tablet                                          Only Generic Covered
DELTASONE                       prednisone 20mg tablet                                          Only Generic Covered
DELTASONE                       prednisone 50mg tablet                                          Only Generic Covered
DEPO-MEDROL                     methylprednis acet 40mg/mlinj                                   Only Generic Covered
DEPO-MEDROL                     methylprednis acet 80mg/mlinj                                   Only Generic Covered
dexamethasone 0.5/5ml elix      DECADRON ELIXIR                                         2       Available via Mail Order
dexamethasone 0.5/5ml soln      DECADRON ELIXIR                                         2       Available via Mail Order
dexamethasone 0.5mg tablet      DECADRON                                                2       Available via Mail Order
dexamethasone 0.75mg tablet     DECADRON                                                2       Available via Mail Order
dexamethasone 1.5mg tablet      DECADRON                                                2       Available via Mail Order
dexamethasone 1mg tab           DECADRON                                                2       Available via Mail Order
DEXAMETHASONE 1MG/ML CONC       DECADRON                                                2       Quantity Limits Apply
                                                                                                Available via Mail Order
dexamethasone 4mg tablet        DECADRON                                                2       Available via Mail Order
dexamethasone 4mg/ml inj        DECADRON                                                5
MEDROL                          methylprednisolone 4mg tab                                      Only Generic Covered
MEDROL                          methylprednisolone 4mg dospak                                   Only Generic Covered
methylpred ss 125mg vial        SOLU-MEDROL                                             5
methylprednis acet 40mg/mlinj   DEPO-MEDROL                                             5
methylprednis acet 80mg/mlinj   DEPO-MEDROL                                             5
methylprednisolone 4mg tab      MEDROL                                                  2       Available via Mail Order
methylprednisolone 4mg dospak   MEDROL                                                  2       Available via Mail Order
ORAPRED (NOT ODT)               prednisolone 15mg/5ml(orapred                                   Only Generic Covered

27-921/01-01/06 Rev 01-11                                            [ 58]                      2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
PEDIAPRED                       prednisolone 6.75mg/5ml liq                                    Only Generic Covered
prednisolone 5mg/5ml syrup      PRELONE                                                2       Available via Mail Order
prednisolone 6.75mg/5ml liq     PEDIAPRED                                              2       Available via Mail Order
prednisolone 15mg/5ml syrup     PRELONE                                                2       Available via Mail Order
prednisolone 15mg/5ml(orapred   ORAPRED (NOT ODT)                                      2       Available via Mail Order
prednisone 5mg/5ml oral sol     PRELONE                                                2       Available via Mail Order
prednisone 1mg tablet           DELTASONE                                              2       Available via Mail Order
prednisone 2.5mg tablet         DELTASONE                                              2       Available via Mail Order
prednisone 5mg tablet           DELTASONE                                              2       Available via Mail Order
prednisone 10mg tablet          DELTASONE                                              2       Available via Mail Order
prednisone 20mg tablet          DELTASONE                                              2       Available via Mail Order
prednisone 50mg tablet          DELTASONE                                              2       Available via Mail Order
PRELONE                         prednisolone 5mg/5ml syrup                                     Only Generic Covered
PRELONE                         prednisolone 15mg/5ml syrup                                    Only Generic Covered
PRELONE                         prednisone 5mg/5ml oral sol                                    Only Generic Covered
SOLU-CORTEF                     a-hydrocort 100mg inj                                          Only Generic Covered
SOLU-CORTEF 1000MG INJ                                                                 5
SOLU-CORTEF 100MG/2ML INJ                                                              5
SOLU-MEDROL                     methylpred ss 125mg vial                                       Only Generic Covered
SOLU-MEDROL 1000MG INJ                                                                 5
                                Anti-Inflammatories - NSAIDS
ANAPROX DS                      naproxen sodium-ds 550mg tab                                   Only Generic Covered
choline mag/tris 1000mg tab     TRILISATE                                              2       Available via Mail Order
choline mag/trisal 500mg tab    TRILISATE                                              2       Available via Mail Order
choline mag/trisal 750mg tab    TRILISATE                                              2       Available via Mail Order
CLINORIL                        sulindac 150mg tablet                                          Only Generic Covered
CLINORIL                        sulindac 200mg tablet                                          Only Generic Covered
DAYPRO                          oxaprozin 600mg tablet                                         Only Generic Covered
diclofenac sod 25mg tablet      VOLTAREN (NOT XR)                                      2       Available via Mail Order
diclofenac sod 50mg tablet      VOLTAREN (NOT XR)                                      2       Available via Mail Order
diclofenac sod 75mg tablet      VOLTAREN (NOT XR)                                      2       Available via Mail Order
DISALCID                        salsalate 500mg tablet                                         Only Generic Covered
DISALCID                        salsalate 750mg tablet                                         Only Generic Covered
etodolac 200mg cap(gx lodine    LODINE                                                 2       Available via Mail Order
etodolac 300mg cap(gx lodine    LODINE                                                 2       Available via Mail Order
etodolac 400mg tab (gxlodine)   LODINE                                                 2       Available via Mail Order
27-921/01-01/06 Rev 01-11                                           [ 59]                      2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
etodolac 500mg tab (gxlodine)   LODINE                                                   2       Available via Mail Order
etodolac er 400mg tablet        LODINE XL                                                2       Available via Mail Order
etodolac er 500mg tablet        LODINE XL                                                2       Available via Mail Order
etodolac er 600mg tablet        LODINE XL                                                2       Available via Mail Order
FELDENE                         piroxicam 10mg capsule                                           Only Generic Covered
FELDENE                         piroxicam 20mg capsule                                           Only Generic Covered
fenoprofen 600mg tablet         NALFON                                                   2       Available via Mail Order
ibuprofen 400mg tablet          MOTRIN                                                   1       Available via Mail Order
ibuprofen 600mg tablet          MOTRIN                                                   1       Available via Mail Order
ibuprofen 800mg tablet          MOTRIN                                                   1       Available via Mail Order
INDOCIN                         indomethacin 25mg capsule                                        Only Generic Covered
INDOCIN                         indomethacin 50mg capsule                                        Only Generic Covered
INDOCIN SR                      indomethacin-er 75mg capsule                                     Only Generic Covered
indomethacin 25mg capsule       INDOCIN                                                  2       Available via Mail Order
indomethacin 50mg capsule       INDOCIN                                                  2       Available via Mail Order
indomethacin-er 75mg capsule    INDOCIN SR                                               2       Available via Mail Order
ketoprofen 50mg capsule         ORUDIS                                                   2       Available via Mail Order
ketoprofen 75mg capsule         ORUDIS                                                   2       Available via Mail Order
ketorolac 10mg tablet           TORADOL                                                  2       Quantity Limits Apply
ketorolac 30mg/ml inj 1ml       TORADOL                                                  5
ketorolac 60mg/2ml inj          TORADOL                                                  5
LODINE                          etodolac 200mg cap(gx lodine                                     Only Generic Covered
LODINE                          etodolac 300mg cap(gx lodine                                     Only Generic Covered
LODINE                          etodolac 400mg tab (gxlodine)                                    Only Generic Covered
LODINE                          etodolac 500mg tab (gxlodine)                                    Only Generic Covered
LODINE XL                       etodolac er 400mg tablet                                         Only Generic Covered
LODINE XL                       etodolac er 500mg tablet                                         Only Generic Covered
LODINE XL                       etodolac er 600mg tablet                                         Only Generic Covered
meclofenamate 50mg capsule      MECLOMEN                                                 2       Available via Mail Order
meclofenamate 100mg capsule     MECLOMEN                                                 2       Available via Mail Order
MECLOMEN                        meclofenamate 50mg capsule                                       Only Generic Covered
MECLOMEN                        meclofenamate 100mg capsule                                      Only Generic Covered
meloxicam 7.5mg tablet          MOBIC                                                    1       Available via Mail Order
meloxicam 7.5mg/5ml susp        MOBIC                                                    2       Quantity Limits Apply
                                                                                                 Available via Mail Order
meloxicam 15mg tablet           MOBIC                                                    1       Available via Mail Order

27-921/01-01/06 Rev 01-11                                             [ 60]                      2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
MOBIC                          meloxicam 7.5mg tablet                                          Only Generic Covered
MOBIC                          meloxicam 7.5mg/5ml susp                                        Only Generic Covered
MOBIC                          meloxicam 15mg tablet                                           Only Generic Covered
MOTRIN                         ibuprofen 400mg tablet                                          Only Generic Covered
MOTRIN                         ibuprofen 600mg tablet                                          Only Generic Covered
MOTRIN                         ibuprofen 800mg tablet                                          Only Generic Covered
nabumetone 500mg tablet        RELAFEN                                                 2       Available via Mail Order
nabumetone 750mg tablet        RELAFEN                                                 2       Available via Mail Order
NALFON                         fenoprofen 600mg tablet                                         Only Generic Covered
NAPROSYN                       naproxen 125mg/5ml susp                                         Only Generic Covered
NAPROSYN                       naproxen 250mg tablet                                           Only Generic Covered
NAPROSYN                       naproxen 375mg tablet                                           Only Generic Covered
NAPROSYN                       naproxen 500mg tablet                                           Only Generic Covered
naproxen 125mg/5ml susp        NAPROSYN                                                2       Available via Mail Order
naproxen 250mg tablet          NAPROSYN                                                2       Available via Mail Order
naproxen 375mg tablet          NAPROSYN                                                1       Available via Mail Order
naproxen 500mg tablet          NAPROSYN                                                1       Available via Mail Order
naproxen sodium-ds 550mg tab   ANAPROX DS                                              2
ORUDIS                         ketoprofen 50mg capsule                                         Only Generic Covered
ORUDIS                         ketoprofen 75mg capsule                                         Only Generic Covered
oxaprozin 600mg tablet         DAYPRO                                                  2       Available via Mail Order
piroxicam 10mg capsule         FELDENE                                                 2       Available via Mail Order
piroxicam 20mg capsule         FELDENE                                                 1       Available via Mail Order
RELAFEN                        nabumetone 500mg tablet                                         Only Generic Covered
RELAFEN                        nabumetone 750mg tablet                                         Only Generic Covered
salsalate 500mg tablet         DISALCID                                                2       Available via Mail Order
salsalate 750mg tablet         DISALCID                                                2       Prior Auth Required
                                                                                               Available via Mail Order
sulindac 150mg tablet          CLINORIL                                                2       Available via Mail Order
sulindac 200mg tablet          CLINORIL                                                2       Available via Mail Order
TORADOL                        ketorolac 10mg tablet                                           Only Generic Covered
TORADOL                        ketorolac 30mg/ml inj 1ml                                       Only Generic Covered
TORADOL                        ketorolac 60mg/2ml inj                                          Only Generic Covered
TRILISATE                      choline mag/tris 1000mg tab                                     Only Generic Covered
TRILISATE                      choline mag/trisal 500mg tab                                    Only Generic Covered
TRILISATE                      choline mag/trisal 750mg tab                                    Only Generic Covered

27-921/01-01/06 Rev 01-11                                           [ 61]                      2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
VOLTAREN (NOT XR)               diclofenac sod 25mg tablet                                       Only Generic Covered
VOLTAREN (NOT XR)               diclofenac sod 50mg tablet                                       Only Generic Covered
VOLTAREN (NOT XR)               diclofenac sod 75mg tablet                                       Only Generic Covered
                                Antimigraine Agents - Abortive
asa/but/caff(gx fiorinal) tab   FIORINAL                                                 2
butal/apap/caff (gx fioricet)   FIORICET                                                 2
CAFERGOT                        ergotamine/caff 1-100mg tab                                      Only Generic Covered
CAFERGOT                        migergot supp (gx cafergot)                                      Only Generic Covered
D.H.E-45                        dihydroergotam mes 1mg/ml inj                                    Only Generic Covered
dihydroergotam mes 1mg/ml inj   D.H.E-45                                                 5
epidrin cap (gx midrin)         MIDRIN                                                   2
ergotamine/caff 1-100mg tab     CAFERGOT                                                 2
FIORICET                        butal/apap/caff (gx fioricet)                                    Only Generic Covered
FIORINAL                        asa/but/caff(gx fiorinal) tab                                    Only Generic Covered
IMITREX                         sumatriptan 5mg nasal spry                                       Only Generic Covered
IMITREX                         sumatriptan 20mg nasal spry                                      Only Generic Covered
IMITREX                         sumatriptan 100mg tablet                                         Only Generic Covered
IMITREX                         sumatriptan 25mg tablet                                          Only Generic Covered
IMITREX                         sumatriptan 50mg tablet                                          Only Generic Covered
IMITREX                         SUMATRIPTAN 8MG/ML KIT                                           Only Generic Covered
IMITREX                         SUMATRIPTAN 12MG/ML KIT                                          Only Generic Covered
MAXALT 5MG TABLET                                                                        3       Quantity Limits Apply
MAXALT 10MG TABLET                                                                       3       Quantity Limits Apply
MAXALT-MLT 5MG (4X3) TABLET                                                              3       Quantity Limits Apply
MAXALT-MLT 10MG (4X3) TABLET                                                             3       Quantity Limits Apply
MIDRIN                          epidrin cap (gx midrin)                                          Only Generic Covered
migergot supp (gx cafergot)     CAFERGOT                                                 2       Quantity Limits Apply
sumatriptan 5mg nasal spry      IMITREX                                                  2       Quantity Limits Apply
sumatriptan 20mg nasal spry     IMITREX                                                  2       Quantity Limits Apply
sumatriptan 100mg tablet        IMITREX                                                  2       Quantity Limits Apply
sumatriptan 25mg tablet         IMITREX                                                  2       Quantity Limits Apply
sumatriptan 50mg tablet         IMITREX                                                  2       Quantity Limits Apply
SUMATRIPTAN 8MG/ML KIT          IMITREX                                                  2       Quantity Limits Apply
SUMATRIPTAN 12MG/ML KIT         IMITREX                                                  2       Quantity Limits Apply
                                Antimycobacterials - Antimycobacterials, Other
DAPSONE 25MG TABLET                                                                      4
27-921/01-01/06 Rev 01-11                                               [ 62]                    2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
DAPSONE 100MG TABLET                                                                   4
MYCOBUTIN 150MG CAPSULE                                                                3
                               Antimycobacterials - Antituberculars
CAPASTAT 1 GM INJ                                                                      5
ethambutol 100mg tablet        MYAMBUTOL                                               2
ethambutol 400mg tablet        MYAMBUTOL                                               2
isoniazid 100mg tablet         LANIAZID                                                2
isoniazid 300mg tablet         LANIAZID                                                2
LANIAZID                       isoniazid 100mg tablet                                          Only Generic Covered
LANIAZID                       isoniazid 300mg tablet                                          Only Generic Covered
MYAMBUTOL                      ethambutol 100mg tablet                                         Only Generic Covered
MYAMBUTOL                      ethambutol 400mg tablet                                         Only Generic Covered
PASER 4 GM GRANULES                                                                    4
PRIFTIN 150MG TAB                                                                      4
pyrazinamide 500mg tablet      RIFATER                                                 2
RIFADIN                        rifampin 150mg capsule                                          Only Generic Covered
RIFADIN                        rifampin 300mg capsule                                          Only Generic Covered
rifampin 150mg capsule         RIFADIN                                                 2
rifampin 300mg capsule         RIFADIN                                                 2
rifampin 600mg inj.                                                                    5
RIFATER                        pyrazinamide 500mg tablet                                       Only Generic Covered
SEROMYCIN 250MG CAPSULE                                                                4
TRECATOR 250MG TABLET                                                                  4
                               Antineoplastics - Alkylating Agents
ALKERAN 2MG TABLET                                                                     5
CEENU 10MG CAPSULE                                                                     3
CEENU 40MG CAPSULE                                                                     3
cyclophosphamide 25mg tablet   CYTOXAN                                                 2
cyclophosphamide 50mg tablet   CYTOXAN                                                 2
CYTOXAN                        cyclophosphamide 25mg tablet                                    Only Generic Covered
CYTOXAN                        cyclophosphamide 50mg tablet                                    Only Generic Covered
EMCYT 140MG CAPSULE                                                                    3
HEXALEN 50MG CAPSULE                                                                   3
LEUKERAN 2MG TABLET                                                                    3
MATULANE 50MG CAP                                                                      3
MITOMYCIN 20MG INJ                                                                     5
27-921/01-01/06 Rev 01-11                                             [ 63]                    2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
MYLERAN 2MG TABLET                                                                       5
TEMODAR 5MG CAPSULE                                                                      5
TEMODAR 20MG CAPSULE                                                                     5
TEMODAR 100MG CAPSULE                                                                    5
TEMODAR 140MG CAPSULE                                                                    5
TEMODAR 180MG CAPSULE                                                                    5
TEMODAR 250MG CAPSULE                                                                    5
                                Antineoplastics - Antimetabolites
ADRUCIL                         fluorouracil 50mg/ml inj                                         Only Generic Covered
ADRUCIL                         fluorouracil 50mg/ml inj                                         Only Generic Covered
DROXIA 200MG CAPSULE                                                                     3
fluorouracil 50mg/ml inj        ADRUCIL                                                  5
fluorouracil 50mg/ml inj        ADRUCIL                                                  5
fluorouracil 50mg/ml inj        ADRUCIL                                                  5
HYDREA                          hydroxyurea 500mg capsule                                        Only Generic Covered
hydroxyurea 500mg capsule       HYDREA                                                   2
mercaptopurine 50mg tablet      PURINETHOL                                               2
methotrexate 25mg/ml 2ml sdv                                                             5
methotrexate 25mg/ml 10ml mdv                                                            5
PURINETHOL                      mercaptopurine 50mg tablet                                       Only Generic Covered
THIOGUANINE 40MG TAB                                                                     3
XELODA 150MG TABLET                                                                      5
XELODA 500MG TABLET                                                                      5
                                Antineoplastics - Antineoplastics, Other
adriamycin 50mg sdv inj                                                                  5
ALIMTA 500MG INJ                                                                         6       Prior Auth Required
AVASTIN 25MG/ML INJ                                                                      6       Prior Auth Required
bleomycin 30 unit inj                                                                    5
CAMPATH 30MG/ML INJ                                                                      5       Prior Auth Required
carboplatin 50mg/5ml inj        PARAPLATIN                                               5
carboplatin 150mg/15ml inj      PARAPLATIN                                               5
carboplatin 450mg/45ml inj      PARAPLATIN                                               5
cisplatin 50mg inj              PLATINOL                                                 5
DOCETAXEL 10MG/ML INJ           TAXOTERE                                                 5
ELOXATIN 100MG INJ                                                                       5
mitoxantrone 2mg/ml inj mdv     NOVANTRONE                                               5
27-921/01-01/06 Rev 01-11                                                  [ 64]                 2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
NOVANTRONE                    mitoxantrone 2mg/ml inj mdv                                     Only Generic Covered
ONCOVORIN                     vincristine 1mg/ml inj                                          Only Generic Covered
paclitaxel 100mg/16.7ml inj   TAXOL                                                   5
paclitaxel 300mg/50ml inj     TAXOL                                                   5
paclitaxel 300mg/50ml inj     TAXOL                                                   5
paclitaxel 30mg/5ml inj       TAXOL                                                   5
PARAPLATIN                    carboplatin 50mg/5ml inj                                        Only Generic Covered
PARAPLATIN                    carboplatin 150mg/15ml inj                                      Only Generic Covered
PARAPLATIN                    carboplatin 450mg/45ml inj                                      Only Generic Covered
PLATINOL                      cisplatin 50mg inj                                              Only Generic Covered
RITUXAN 100MG VL INJ                                                                  6
TAXOL                         paclitaxel 100mg/16.7ml inj                                     Only Generic Covered
TAXOL                         paclitaxel 300mg/50ml inj                                       Only Generic Covered
TAXOL                         paclitaxel 300mg/50ml inj                                       Only Generic Covered
TAXOL                         paclitaxel 30mg/5ml inj                                         Only Generic Covered
TAXOTERE                      DOCETAXEL 10MG/ML INJ                                           Only Generic Covered
TAXOTERE 20MG/0.5ML INJ                                                               5
TAXOTERE 80MG/2ML INJ                                                                 5
TRISENOX 1MG/ML INJ                                                                   5       Prior Auth Required
VELCADE 3.5MG INJ                                                                     6       Prior Auth Required
VIDAZA 100MG INJ                                                                      6
vincristine 1mg/ml inj        ONCOVORIN                                               5
                              Antineoplastics - Immune Modulators and Vaccines
ONTAK 150MCG/ML INJ                                                                   6       Prior Auth Required
PROLEUKIN 22MIU INJ                                                                   6
                              Antineoplastics - Molecular Target Inhibitors
AFINITOR 2.5MG TABLET                                                                 6
AFINITOR 5MG TABLET                                                                   6
AFINITOR 10MG TABLET                                                                  6
GLEEVEC 100MG TABLET                                                                  3
GLEEVEC 400MG TABLET                                                                  3
IRESSA 250MG TABLET                                                                   6
NEXAVAR 200MG TABLET                                                                  6
PANRETIN 0.1% GEL                                                                     3
SPRYCEL 140MG TABLET                                                                  6
SPRYCEL 50MG TABLET                                                                   6
27-921/01-01/06 Rev 01-11                                              [ 65]                  2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
SPRYCEL 70MG TABLET                                                                     6
SPRYCEL 80MG TABLET                                                                     6
SUTENT 12.5MG CAPSULE                                                                   6
SUTENT 25MG CAPSULE                                                                     6
SUTENT 50MG CAPSULE                                                                     6
TARCEVA 25MG TABLET                                                                     6
TARCEVA 100MG TABLET                                                                    6
TARCEVA 150MG TABLET                                                                    6
TARGRETIN 1% GEL                                                                        6       Quantity Limits Apply
TARGRETIN 75MG CAP                                                                      6
TASIGNA 200MG CAP                                                                       4       Prior Auth Required
TYKERB 250MG TABLET                                                                     4       Prior Auth Required
VANDETANIB 100MG TABLET                                                                 5
VANDETANIB 300MG TABLET                                                                 5
VOTRIENT 200MG TABLET                                                                   6
ZOLINZA 100MG CAP                                                                       3       Prior Auth Required
ZYTIGA 250MG TABLET                                                                     6       Prior Auth Required
                                Antineoplastics - Nucleoside Analogs
cladribine 1mg/ml inj           LEUSTATIN                                               5
FLUDARA 50MG INJ                                                                        5
LEUSTATIN                       cladribine 1mg/ml inj                                           Only Generic Covered
                                Antineoplastics - Protective Agents
leucovorin ca 100mg inj         WELLCOVORIN                                             5
leucovorin ca 200mg inj         WELLCOVORIN                                             5
leucovorin calcium 10mg tab     WELLCOVORIN                                             2
leucovorin calcium 15mg tablt   WELLCOVORIN                                             2
leucovorin calcium 5mg tablt    WELLCOVORIN                                             2
mesna 1gm inj                                                                           5
MESNEX 400MG TAB                                                                        4
WELLCOVORIN                     leucovorin ca 100mg inj                                         Only Generic Covered
WELLCOVORIN                     leucovorin ca 200mg inj                                         Only Generic Covered
WELLCOVORIN                     leucovorin calcium 10mg tab                                     Only Generic Covered
WELLCOVORIN                     leucovorin calcium 15mg tablt                                   Only Generic Covered
WELLCOVORIN                     leucovorin calcium 5mg tablt                                    Only Generic Covered
                                Antineoplastics - Topoisomerse Inhibitors
CAMPTOSAR                       irinotecan 20mg/ml sdv inj                                      Only Generic Covered
27-921/01-01/06 Rev 01-11                                                   [ 66]               2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
etoposide 20mg/ml mdv inj      VEPESID                                                  5
etoposide 50mg capsule         VEPESID                                                  5
irinotecan 20mg/ml sdv inj     CAMPTOSAR                                                5
VEPESID                        etoposide 20mg/ml mdv inj                                        Only Generic Covered
VEPESID                        etoposide 50mg capsule                                           Only Generic Covered
                               Antiparasitics - Anthelmetics
mebendazole 100mg chew tab     VERMOX                                                   2
STROMECTOL 3MG TAB                                                                      4       Quantity Limits Apply
VERMOX                         mebendazole 100mg chew tab                                       Only Generic Covered
                               Antiparasitics - Antiprotozoals
ARALEN                         chloroquine 500mg tablet                                         Only Generic Covered
chloroquine 500mg tablet       ARALEN                                                   2
DARAPRIM 25MG TABLET                                                                    4
hydroxychloroquine 200mg tab   PLAQUENIL                                                2       Available via Mail Order
LARIUM                         mefloquine 250mg tablet                                          Only Generic Covered
mefloquine 250mg tablet        LARIUM                                                   2
MEPRON 750MG/5ML SUSP                                                                   3
PLAQUENIL                      hydroxychloroquine 200mg tab                                     Only Generic Covered
                               Antiparasitics - Pediculicides/Scabicides
ELIMITE                        permethrin 5% cream                                              Only Generic Covered
malathion 0.5% lotion          OVIDE                                                    2       Quantity Limits Apply
OVIDE                          malathion 0.5% lotion                                            Only Generic Covered
permethrin 5% cream            ELIMITE                                                  2       Quantity Limits Apply
                               Antiparkinson Agents - Antiparkinson Agents, Other
APOKYN 10MG/ML INJ                                                                      6       Prior Auth Required
ARTANE                         trihexyphenidyl 2mg/5ml elix                                     Only Generic Covered
ARTANE                         trihexyphenidyl 2mg tablet                                       Only Generic Covered
ARTANE                         trihexyphenidyl 5mg tablet                                       Only Generic Covered
benztropine 0.5mg tablet       COGENTIN                                                 2       Available via Mail Order
benztropine 1.0mg tablet       COGENTIN                                                 2       Available via Mail Order
benztropine 2.0mg tablet       COGENTIN                                                 2       Available via Mail Order
COGENTIN                       benztropine 0.5mg tablet                                         Only Generic Covered
COGENTIN                       benztropine 1.0mg tablet                                         Only Generic Covered
COGENTIN                       benztropine 2.0mg tablet                                         Only Generic Covered
ELDEPRYL                       selegiline 5mg tablet                                            Only Generic Covered
ELEDPRYL                       selegiline 5mg capsule                                           Only Generic Covered
27-921/01-01/06 Rev 01-11                                                  [ 67]                2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
selegiline 5mg tablet           ELDEPRYL                                                 2       Available via Mail Order
selegiline 5mg capsule          ELEDPRYL                                                 2       Available via Mail Order
trihexyphenidyl 2mg/5ml elix    ARTANE                                                   2       Available via Mail Order
trihexyphenidyl 2mg tablet      ARTANE                                                   2       Available via Mail Order
trihexyphenidyl 5mg tablet      ARTANE                                                   2       Available via Mail Order
                                Antiparkinson Agents - COMT Inhibitors
COMTAN 200MG TABLET                                                                      3       Available via Mail Order
                                Antiparkinson Agents - Dopamine Agonists
amantadine 100mg capsule        SYMMETREL                                                2
bromocriptine 2.5mg tablet      PARLODEL                                                 2       Available via Mail Order
bromocriptine 5mg capsule       PARLODEL                                                 2       Available via Mail Order
carbidopa/levo er 25/100 tab    SINEMET                                                  2       Available via Mail Order
carbidopa/levo er 50/200 tab    SINEMET CR                                               2       Available via Mail Order
carbidopa/levodopa 10/100 tab   SINEMET                                                  2       Available via Mail Order
carbidopa/levodopa 25/100 tab   SINEMET                                                  2       Available via Mail Order
carbidopa/levodopa 25/250 tab   SINEMET                                                  2       Available via Mail Order
MIRAPEX (NOT ER)                pramipexole 0.125mg tablet                                       Only Generic Covered
MIRAPEX (NOT ER)                pramipexole 0.25mg tablet                                        Only Generic Covered
MIRAPEX (NOT ER)                pramipexole 0.5mg tablet                                         Only Generic Covered
MIRAPEX (NOT ER)                pramipexole 1.5mg tablet                                         Only Generic Covered
MIRAPEX (NOT ER)                pramipexole 1mg tablet                                           Only Generic Covered
PARLODEL                        bromocriptine 2.5mg tablet                                       Only Generic Covered
PARLODEL                        bromocriptine 5mg capsule                                        Only Generic Covered
pramipexole 0.125mg tablet      MIRAPEX (NOT ER)                                         2       Available via Mail Order
pramipexole 0.25mg tablet       MIRAPEX (NOT ER)                                         2       Available via Mail Order
pramipexole 0.5mg tablet        MIRAPEX (NOT ER)                                         2       Available via Mail Order
pramipexole 1.5mg tablet        MIRAPEX (NOT ER)                                         2       Available via Mail Order
pramipexole 1mg tablet          MIRAPEX (NOT ER)                                         2       Available via Mail Order
REQUIP                          ropinirole 0.25mg tablet                                         Only Generic Covered
REQUIP                          ropinirole 0.5mg tablet                                          Only Generic Covered
REQUIP                          ropinirole 1mg tablet                                            Only Generic Covered
REQUIP                          ropinirole 2mg tablet                                            Only Generic Covered
REQUIP                          ropinirole 3mg tablet                                            Only Generic Covered
REQUIP                          ropinirole 4mg tablet                                            Only Generic Covered
REQUIP                          ropinirole 5mg tablet                                            Only Generic Covered
REQUIP XL 2MG TABLET                                                                     3       Available via Mail Order
27-921/01-01/06 Rev 01-11                                                [ 68]                   2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
REQUIP XL 4MG TABLET                                                                  3       Available via Mail Order
REQUIP XL 8MG TABLET                                                                  3       Available via Mail Order
ropinirole 0.25mg tablet      REQUIP                                                  2       Available via Mail Order
ropinirole 0.5mg tablet       REQUIP                                                  2       Available via Mail Order
ropinirole 1mg tablet         REQUIP                                                  2       Available via Mail Order
ropinirole 2mg tablet         REQUIP                                                  2       Available via Mail Order
ropinirole 3mg tablet         REQUIP                                                  2       Available via Mail Order
ropinirole 4mg tablet         REQUIP                                                  2       Available via Mail Order
ropinirole 5mg tablet         REQUIP                                                  2       Available via Mail Order
SINEMET                       carbidopa/levo er 25/100 tab                                    Only Generic Covered
SINEMET                       carbidopa/levodopa 10/100 tab                                   Only Generic Covered
SINEMET                       carbidopa/levodopa 25/100 tab                                   Only Generic Covered
SINEMET                       carbidopa/levodopa 25/250 tab                                   Only Generic Covered
SINEMET CR                    carbidopa/levo er 50/200 tab                                    Only Generic Covered
SYMMETREL                     amantadine 100mg capsule                                        Only Generic Covered
                              Antipsychotics - Non-Phenothiazines
fluphenazine 1mg tablet       PROLIXIN                                                2       Available via Mail Order
fluphenazine 5mg tab          PROLIXIN                                                2       Available via Mail Order
fluphenazine 10mg tablet      PROLIXIN                                                2       Available via Mail Order
HALDOL                        haloperidol 2mg/ml conc liq                                     Only Generic Covered
HALDOL                        haloperidol 0.5mg tablet                                        Only Generic Covered
HALDOL                        haloperidol 1mg tablet                                          Only Generic Covered
HALDOL                        haloperidol 2mg tablet                                          Only Generic Covered
HALDOL                        haloperidol 5mg tablet                                          Only Generic Covered
HALDOL                        haloperidol dec 50mg/ml inj                                     Only Generic Covered
HALDOL                        haloperidol 10mg tablet                                         Only Generic Covered
HALDOL                        haloperidol 20mg tablet                                         Only Generic Covered
haloperidol 2mg/ml conc liq   HALDOL                                                  2       Available via Mail Order
haloperidol 0.5mg tablet      HALDOL                                                  2       Available via Mail Order
haloperidol 1mg tablet        HALDOL                                                  2       Available via Mail Order
haloperidol 2mg tablet        HALDOL                                                  2       Available via Mail Order
haloperidol 5mg tablet        HALDOL                                                  2       Available via Mail Order
haloperidol dec 50mg/ml inj   HALDOL                                                  5
haloperidol lact 5mg/ml inj                                                           5
haloperidol 10mg tablet       HALDOL                                                  2       Available via Mail Order
haloperidol 20mg tablet       HALDOL                                                  2       Available via Mail Order
27-921/01-01/06 Rev 01-11                                           [ 69]                     2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                       DRUG CATEGORY - DRUG CLASS
DRUG NAME                                             BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
loxapine 5mg capsule        LOXITANE                                                2       Available via Mail Order
loxapine 10mg capsule       LOXITANE                                                2       Available via Mail Order
loxapine 25mg capsule       LOXITANE                                                2       Available via Mail Order
loxapine 50mg capsule       LOXITANE                                                2       Available via Mail Order
LOXITANE                    loxapine 5mg capsule                                            Only Generic Covered
LOXITANE                    loxapine 10mg capsule                                           Only Generic Covered
LOXITANE                    loxapine 25mg capsule                                           Only Generic Covered
LOXITANE                    loxapine 50mg capsule                                           Only Generic Covered
ORAP 1MG TABLET                                                                     4       Available via Mail Order
ORAP 2MG TABLET                                                                     4       Available via Mail Order
PROLIXIN                    fluphenazine 1mg tablet                                         Only Generic Covered
PROLIXIN                    fluphenazine 5mg tab                                            Only Generic Covered
PROLIXIN                    fluphenazine 10mg tablet                                        Only Generic Covered
                            Antipsychotics - Non-Phenothiazines, Atypicals
ABILIFY 1MG/ML SOLN                                                                 4       Prior Auth Required
                                                                                            Available via Mail Order
ABILIFY 2MG TABLET                                                                  4       Prior Auth Required
                                                                                            Available via Mail Order
ABILIFY 5MG TABLET                                                                  4       Prior Auth Required
                                                                                            Available via Mail Order
ABILIFY ODT 10MG TAB                                                                4       Prior Auth Required
                                                                                            Available via Mail Order
ABILIFY ODT 15MG TAB                                                                4       Prior Auth Required
                                                                                            Available via Mail Order
ABILIFY 10MG TABLET                                                                 4       Prior Auth Required
                                                                                            Available via Mail Order
ABILIFY 15MG TABLET                                                                 4       Prior Auth Required
                                                                                            Available via Mail Order
ABILIFY 20MG TABLET                                                                 4       Prior Auth Required
                                                                                            Available via Mail Order
ABILIFY 30MG TABLET                                                                 4       Prior Auth Required
                                                                                            Available via Mail Order
ABILIFY 9.75MG INJ                                                                  5
clozapine 25mg tab          CLOZARIL                                                2       Available via Mail Order
clozapine 50mg tab          CLOZARIL                                                2       Available via Mail Order
clozapine 100mg tablet      CLOZARIL                                                2       Available via Mail Order
clozapine 100mg tab         CLOZARIL                                                2       Available via Mail Order
CLOZARIL                    clozapine 25mg tab                                              Only Generic Covered

27-921/01-01/06 Rev 01-11                                            [ 70]                  2011 Commercial Drug Formulary
                                                                                                  Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
CLOZARIL                      clozapine 50mg tab                                               Only Generic Covered
CLOZARIL                      clozapine 100mg tablet                                           Only Generic Covered
CLOZARIL                      clozapine 100mg tab                                              Only Generic Covered
FANAPT 1MG TABLET                                                                      4       Prior Auth Required
                                                                                               Available via Mail Order
FANAPT 2MG TABLET                                                                      4       Prior Auth Required
                                                                                               Available via Mail Order
FANAPT 4MG TABLET                                                                      4       Prior Auth Required
                                                                                               Available via Mail Order
FANAPT 6MG TABLET                                                                      4       Prior Auth Required
                                                                                               Available via Mail Order
FANAPT 8MG TABLET                                                                      4       Prior Auth Required
                                                                                               Available via Mail Order
FANAPT 10MG TABLET                                                                     4       Prior Auth Required
                                                                                               Available via Mail Order
FANAPT 12MG TABLET                                                                     4       Prior Auth Required
                                                                                               Available via Mail Order
FAZACLO 25MG TABLET                                                                    4       Available via Mail Order
FAZACLO 100MG TABLET                                                                   4       Available via Mail Order
GEODON 20MG INJ                                                                        5       Prior Auth Required
GEODON 20MG CAPSULE                                                                    4       Prior Auth Required
                                                                                               Available via Mail Order
GEODON 40MG CAPSULE                                                                    4       Prior Auth Required
                                                                                               Available via Mail Order
GEODON 60MG CAPSULE                                                                    4       Prior Auth Required
                                                                                               Available via Mail Order
GEODON 80MG CAPSULE                                                                    4       Prior Auth Required
                                                                                               Available via Mail Order
INVEGA 3MG TABLET                                                                      3       Available via Mail Order
INVEGA 6MG TABLET                                                                      3       Available via Mail Order
INVEGA 9MG TABLET                                                                      3       Available via Mail Order
INVEGA SUST 39MG/0.25ML INJ                                                            5
LATUDA 40MG TABLET                                                                     4       Prior Auth Required
                                                                                               Available via Mail Order
LATUDA 80MG TABLET                                                                     4       Prior Auth Required
                                                                                               Available via Mail Order
RISPERDAL                     risperidone 1mg/ml oral soln                                     Only Generic Covered
RISPERDAL                     risperidone 0.25mg tablet                                        Only Generic Covered
RISPERDAL                     risperidone 0.5mg tablet                                         Only Generic Covered


27-921/01-01/06 Rev 01-11                                           [ 71]                      2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
RISPERDAL                       risperidone 1mg tablet                                           Only Generic Covered
RISPERDAL                       risperidone 2mg tablet                                           Only Generic Covered
RISPERDAL                       risperidone 3mg tablet                                           Only Generic Covered
RISPERDAL                       risperidone 4mg tablet                                           Only Generic Covered
RISPERDAL CONSTA 25MG/2ML INJ                                                            5
RISPERDAL CONSTA 50MG/2ML INJ                                                            5
RISPERDAL-M                     risperidone-m 1mg tablet                                         Only Generic Covered
RISPERDAL-M                     risperidone-m 2mg tablet                                         Only Generic Covered
RISPERDAL-M 0.5MG TAB                                                                    3       Available via Mail Order
risperidone 1mg/ml oral soln    RISPERDAL                                                2       Available via Mail Order
risperidone 0.25mg tablet       RISPERDAL                                                2       Available via Mail Order
risperidone 0.5mg tablet        RISPERDAL                                                2       Available via Mail Order
risperidone 1mg tablet          RISPERDAL                                                2       Available via Mail Order
risperidone 2mg tablet          RISPERDAL                                                2       Available via Mail Order
risperidone 3mg tablet          RISPERDAL                                                2       Available via Mail Order
risperidone 4mg tablet          RISPERDAL                                                2       Available via Mail Order
risperidone-m 1mg tablet        RISPERDAL-M                                              2       Available via Mail Order
risperidone-m 2mg tablet        RISPERDAL-M                                              2       Available via Mail Order
SAPHRIS 10MG S/L BLCK CHR TAB                                                            4       Prior Auth Required
                                                                                                 Available via Mail Order
SAPHRIS 5MG S/L TABLET                                                                   4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL 25MG TABLET                                                                     4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL 50MG TABLET                                                                     4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL 100MG TABLET                                                                    4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL 200MG TABLET                                                                    4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL 300MG TABLET                                                                    4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL 400MG TABLET                                                                    4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL-XR 50MG TABLET                                                                  4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL-XR 150MG TABLET                                                                 4       Prior Auth Required
                                                                                                 Available via Mail Order


27-921/01-01/06 Rev 01-11                                             [ 72]                      2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
SEROQUEL-XR 200MG TABLET                                                                 4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL-XR 300MG TABLET                                                                 4       Prior Auth Required
                                                                                                 Available via Mail Order
SEROQUEL-XR 400MG TABLET                                                                 4       Prior Auth Required
                                                                                                 Available via Mail Order
ZYPREXA 2.5MG TABLET                                                                     4       Prior Auth Required
                                                                                                 Available via Mail Order
ZYPREXA 5MG TABLET                                                                       4       Prior Auth Required
                                                                                                 Available via Mail Order
ZYPREXA 7.5MG TABLET                                                                     4       Prior Auth Required
                                                                                                 Available via Mail Order
ZYPREXA 10MG TABLET                                                                      4       Prior Auth Required
                                                                                                 Available via Mail Order
ZYPREXA 15MG TABLET                                                                      4       Prior Auth Required
                                                                                                 Available via Mail Order
ZYPREXA 20MG TABLET                                                                      4       Prior Auth Required
                                                                                                 Available via Mail Order
ZYPREXA IM 10MG INJ                                                                      5       Prior Auth Required
ZYPREXA ZYDIS 5MG TABLET                                                                 4       Prior Auth Required
                                                                                                 Available via Mail Order
                                Antipsychotics - Phenothiazines
chlorpromazine 10mg tablet      THORAZINE                                                2       Available via Mail Order
chlorpromazine 25mg tablet      THORAZINE                                                2       Available via Mail Order
chlorpromazine 50mg tablet      THORAZINE                                                2       Available via Mail Order
chlorpromazine 100mg tablet     THORAZINE                                                2       Available via Mail Order
chlorpromazine 200mg tablet     THORAZINE                                                2       Available via Mail Order
chlorpromazine 25mg/ml inj      THORAZINE                                                5
fluphenazine 2.5mg tablet       PROLIXIN                                                 2       Available via Mail Order
fluphenazine 5mg tablet         PROLIXIN                                                 2       Available via Mail Order
fluphenazine 2.5mg/5ml elixir   PROLIXIN                                                 2       Available via Mail Order
FLUPHENAZINE 2.5MG/ML INJ                                                                5
fluphenazine dec 25mg/ml inj    PROLIXIN                                                 5
MELLARIL                        thioridazine 10mg tablet                                         Only Generic Covered
MELLARIL                        thioridazine 25mg tablet                                         Only Generic Covered
MELLARIL                        thioridazine 50mg tablet                                         Only Generic Covered
MELLARIL                        thioridazine 100mg tablet                                        Only Generic Covered
NAVANE                          thiothixene 1mg capsule                                          Only Generic Covered
NAVANE                          thiothixene 2mg capsule                                          Only Generic Covered
27-921/01-01/06 Rev 01-11                                             [ 73]                      2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
NAVANE                        thiothixene 5mg capsule                                         Only Generic Covered
NAVANE                        thiothixene 10mg capsule                                        Only Generic Covered
perphenazine 2mg tablet       TRILAFON                                                2       Available via Mail Order
perphenazine 4mg tablet       TRILIFON                                                2       Available via Mail Order
perphenazine 8mg tablet       TRILIFON                                                2       Available via Mail Order
perphenazine 16mg tablet      TRILAFON                                                2       Available via Mail Order
PROLIXIN                      fluphenazine 2.5mg tablet                                       Only Generic Covered
PROLIXIN                      fluphenazine 5mg tablet                                         Only Generic Covered
PROLIXIN                      fluphenazine 2.5mg/5ml elixir                                   Only Generic Covered
PROLIXIN                      fluphenazine dec 25mg/ml inj                                    Only Generic Covered
STELAZINE                     trifluoperazine 1mg tablet                                      Only Generic Covered
STELAZINE                     trifluoperazine 2mg tablet                                      Only Generic Covered
STELAZINE                     trifluoperazine 5mg tablet                                      Only Generic Covered
STELAZINE                     trifluoperazine 10mg tablet                                     Only Generic Covered
thioridazine 10mg tablet      MELLARIL                                                2       Available via Mail Order
thioridazine 25mg tablet      MELLARIL                                                2       Available via Mail Order
thioridazine 50mg tablet      MELLARIL                                                2       Available via Mail Order
thioridazine 100mg tablet     MELLARIL                                                2       Available via Mail Order
thiothixene 1mg capsule       NAVANE                                                  2       Available via Mail Order
thiothixene 2mg capsule       NAVANE                                                  2       Available via Mail Order
thiothixene 5mg capsule       NAVANE                                                  2       Available via Mail Order
thiothixene 10mg capsule      NAVANE                                                  2       Available via Mail Order
THORAZINE                     chlorpromazine 10mg tablet                                      Only Generic Covered
THORAZINE                     chlorpromazine 25mg tablet                                      Only Generic Covered
THORAZINE                     chlorpromazine 50mg tablet                                      Only Generic Covered
THORAZINE                     chlorpromazine 100mg tablet                                     Only Generic Covered
THORAZINE                     chlorpromazine 200mg tablet                                     Only Generic Covered
THORAZINE                     chlorpromazine 25mg/ml inj                                      Only Generic Covered
trifluoperazine 1mg tablet    STELAZINE                                               2       Available via Mail Order
trifluoperazine 2mg tablet    STELAZINE                                               2       Available via Mail Order
trifluoperazine 5mg tablet    STELAZINE                                               2       Available via Mail Order
trifluoperazine 10mg tablet   STELAZINE                                               2       Available via Mail Order
TRILAFON                      perphenazine 2mg tablet                                         Only Generic Covered
TRILAFON                      perphenazine 16mg tablet                                        Only Generic Covered
TRILIFON                      perphenazine 4mg tablet                                         Only Generic Covered
TRILIFON                      perphenazine 8mg tablet                                         Only Generic Covered
27-921/01-01/06 Rev 01-11                                          [ 74]                      2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT                           TIER*   NOTES
                                Antivirals - Antiherpetic Agents
acyclovir 200mg/5ml susp        ZOVIRAX SUSP                                                                    2
acyclovir 200mg capsule         ZOVIRAX                                                                         2
acyclovir 400mg tablet          ZOVIRAX                                                                         2
acyclovir 800mg tablet          ZOVIRAX                                                                         2
valacyclovir 1gm tablet         VALTREX                                                                         2
valacyclovir 500mg tablet       VALTREX                                                                         2
VALTREX                         valacyclovir 1gm tablet                                                                 Only Generic Covered
VALTREX                         valacyclovir 500mg tablet                                                               Only Generic Covered
ZOVIRAX                         acyclovir 200mg capsule                                                                 Only Generic Covered
ZOVIRAX                         acyclovir 400mg tablet                                                                  Only Generic Covered
ZOVIRAX                         acyclovir 800mg tablet                                                                  Only Generic Covered
ZOVIRAX SUSP                    acyclovir 200mg/5ml susp                                                                Only Generic Covered
                                Antivirals - Anti-HIV Agents, Fusion Inhibitors
FUZEON KIT                                                                                                      3
                                Antivirals - Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors
NORVIR 100MG SOFT GEL CAPSULE                                                                                   3
NORVIR 100MG TABLET                                                                                             3
NORVIR 80MG/ML SOLN                                                                                             3
RESCRIPTOR 100MG TAB                                                                                            3
RESCRIPTOR 200MG TABLET                                                                                         3
SUSTIVA 200MG CAPSULE                                                                                           3
SUSTIVA 50MG CAPSULE                                                                                            3
SUSTIVA 600MG TABLET                                                                                            3
VIRAMUNE 200MG TABLET                                                                                           3
VIRAMUNE 50MG/5ML SUSP                                                                                          3
VIRAMUNE XR 400MG TABLET                                                                                        3
                                Antivirals - Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase
                                Inhibitors’
ATRIPLA TABLET                                                                                                  3
COMBIVIR TABLET                                                                                                 3
didanosine 200mg capsule        VIDEX EC                                                                        2
didanosine 250mg capsule        VIDEX EC                                                                        2
didanosine 400mg capsule        VIDEX EC                                                                        2
EMTRIVA 10MG/ML SOLN                                                                                            3
EMTRIVA 200MG CAPSULE                                                                                           3

27-921/01-01/06 Rev 01-11                                                [ 75]                                          2011 Commercial Drug Formulary
                                                                                                                              Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
EPIVIR 10MG/ML ORAL SOLUTION                                                           3
EPIVIR 150MG TABLET                                                                    3
EPIVIR 300MG TABLET                                                                    3
EPZICOM TABLET                                                                         3
RETROVIR                       zidovudine 50mg/5ml syrup                                       Only Generic Covered
RETROVIR                       zidovudine 300mg tablet                                         Only Generic Covered
RETROVIR 10MG/ML INJ                                                                   5
stavudine 1mg/ml oral soln     ZERIT                                                   2
stavudine 20mg capsule         ZERIT                                                   2
stavudine 30mg capsule         ZERIT                                                   2
stavudine 40mg capsule         ZERIT                                                   2
TRIZIVIR TABLET                                                                        3
TRUVADA TABLET                                                                         3
VIDEX 4GM SOLN                                                                         3
VIDEX EC                       didanosine 200mg capsule                                        Only Generic Covered
VIDEX EC                       didanosine 250mg capsule                                        Only Generic Covered
VIDEX EC                       didanosine 400mg capsule                                        Only Generic Covered
VIDEX EC 125MG CAPSULE                                                                 3
ZERIT                          stavudine 1mg/ml oral soln                                      Only Generic Covered
ZERIT                          stavudine 20mg capsule                                          Only Generic Covered
ZERIT                          stavudine 30mg capsule                                          Only Generic Covered
ZERIT                          stavudine 40mg capsule                                          Only Generic Covered
ZIAGEN 20MG/ML SOLN                                                                    3
ZIAGEN 300MG TABLET                                                                    3
zidovudine 50mg/5ml syrup      RETROVIR                                                2
zidovudine 300mg tablet        RETROVIR                                                2
                               Antivirals - Anti-HIV Agents, Protease Inhibitors
APTIVUS 100MG/ML SOLN                                                                  3
APTIVUS 250MG CAPSULE                                                                  3
CRIXIVAN 100MG CAPSULE                                                                 3
CRIXIVAN 200MG CAPSULE                                                                 3
CRIXIVAN 333MG CAPSULE                                                                 3
CRIXIVAN 400MG CAPSULE                                                                 3
INVIRASE 200MG CAPSULE                                                                 3
INVIRASE 500MG TABLET                                                                  3
KALETRA 200MG/50MG TABLET                                                              3
27-921/01-01/06 Rev 01-11                                                [ 76]                 2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                       DRUG CATEGORY - DRUG CLASS
DRUG NAME                                             BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
KALETRA ORAL SOLUTION                                                               3
LEXIVA 50MG/ML SUSP                                                                 3
LEXIVA 700MG TABLET                                                                 3
PREZISTA 75MG TABLET                                                                3
PREZISTA 150MG TABLET                                                               3
PREZISTA 400MG TABLET                                                               3
PREZISTA 600MG TAB                                                                  3
REYATAZ 100MG CAP                                                                   3
REYATAZ 150MG CAPSULE                                                               3
REYATAZ 200MG CAPSULE                                                               3
REYATAZ 300MG CAPSULE                                                               3
VIRACEPT 50MG/GM POWDER                                                             3
VIRACEPT 250MG TABLET                                                               3
VIRACEPT 625MG TABLET                                                               3
VIREAD 300MG TABLET                                                                 3
                            Antivirals - Anti-Influenza Agents
amantadine 50mg/5ml syrup   SYMMETREL                                               2
FLUMADINE                   rimantadine 100mg tablet                                        Only Generic Covered
RELENZA DISKHALER                                                                   4
rimantadine 100mg tablet    FLUMADINE                                               2
SYMMETREL                   amantadine 50mg/5ml syrup                                       Only Generic Covered
                            Antivirals - Antivirals, Other
BARACLUDE 0.5MG TABLET                                                              3
BARACLUDE 1MG TABLET                                                                3
EPIVIR HBV 100MG TABLET                                                             3
HEPSERA 10MG TABLET                                                                 6       Prior Auth Required
INTELENCE 100MG TAB                                                                 3
INTELENCE 200MG TAB                                                                 3
ISENTRESS 400MG TABLET                                                              3
REBETOL                     ribavirin 200mg capsule                                         Only Generic Covered
ribavirin 200mg capsule     REBETOL                                                 5
SELZENTRY 300MG TAB                                                                 3
TYZEKA 600MG TAB                                                                    4       Prior Auth Required
                            Antivirals - CMV Agents
CYTOVENE                    ganciclovir 250mg capsule                                       Only Generic Covered
CYTOVENE                    ganciclovir 500mg capsule                                       Only Generic Covered
27-921/01-01/06 Rev 01-11                                        [ 77]                      2011 Commercial Drug Formulary
                                                                                                  Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
CYTOVENE                        ganciclovir 500mg inj                                          Only Generic Covered
ganciclovir 250mg capsule       CYTOVENE                                               2
ganciclovir 500mg capsule       CYTOVENE                                               2
ganciclovir 500mg inj           CYTOVENE                                               5
VALCYTE 450MG TABLET                                                                   3
VALCYTE 50MG/ML SOLN                                                                   3
                                Anxiolytics - Anxiolytics, Other
alprazolam 0.25mg tablet        XANAX                                                  2       Available via Mail Order
alprazolam 0.5mg tablet         XANAX (NOT XR)                                         2       Available via Mail Order
alprazolam 1mg tab(gx xanax)    XANAX (NOT XR)                                         2       Available via Mail Order
alprazolam 2mg tab(gx xanax)    XANAX (NOT XR)                                         2       Available via Mail Order
ATIVAN                          lorazepam 0.5mg tablet                                         Only Generic Covered
ATIVAN                          lorazepam 1.0mg tablet                                         Only Generic Covered
ATIVAN                          lorazepam 2.0mg tablet                                         Only Generic Covered
ATIVAN                          lorazepam 2mg/ml oral conc                                     Only Generic Covered
BUSPAR                          buspirone 5mg tab(gx buspar)                                   Only Generic Covered
BUSPAR                          buspirone 10mg tab(gx buspar)                                  Only Generic Covered
BUSPAR                          buspirone 15mg tab(gx buspar)                                  Only Generic Covered
buspirone 5mg tab(gx buspar)    BUSPAR                                                 2       Available via Mail Order
buspirone 10mg tab(gx buspar)   BUSPAR                                                 2       Available via Mail Order
buspirone 15mg tab(gx buspar)   BUSPAR                                                 2       Available via Mail Order
chlordiazepoxide 5mg capsule    LIBRIUM                                                2       Available via Mail Order
chlordiazepoxide 10mg capsul    LIBRIUM                                                2       Available via Mail Order
chlordiazepoxide 25mg capsul    LIBRIUM                                                2       Available via Mail Order
clonazepam 0.125mg odt tab      KLONOPIN ODT                                           2       Available via Mail Order
clonazepam 0.5mg tablet         KLONOPIN (NOT WAFERS)                                  2       Available via Mail Order
clonazepam 1mg tablet           KLONOPIN (NOT WAFERS)                                  2       Available via Mail Order
clonazepam 2mg tablet           KLONOPIN (NOT WAFERS)                                  2       Available via Mail Order
clorazepate 3.75mg tablet       TRANXENE                                               2       Available via Mail Order
clorazepate 7.5mg tablet        TRANXENE                                               2       Available via Mail Order
clorazepate 15mg tablet         TRANXENE                                               2       Available via Mail Order
diazepam 2mg tablet             VALIUM                                                 2       Available via Mail Order
diazepam 5mg tablet             VALIUM                                                 2       Available via Mail Order
diazepam 10mg tablet            VALIUM                                                 2       Available via Mail Order
DIAZEPAM 5MG/5ML ORAL SOLN      VALIUM SOLN                                            2       Available via Mail Order
EQUANIL                         meprobamate 200mg tablet                                       Only Generic Covered
27-921/01-01/06 Rev 01-11                                           [ 78]                      2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
EQUANIL                         meprobamate 400mg tablet                                        Only Generic Covered
hydroxyzine pamoate 25mg cap    VISTARIL                                                2
hydroxyzine pamoate 50mg cap    VISTARIL                                                2
hydroxyzine pamoate 100mg cap   VISTARIL                                                2
KLONOPIN (NOT WAFERS)           clonazepam 0.5mg tablet                                         Only Generic Covered
KLONOPIN (NOT WAFERS)           clonazepam 1mg tablet                                           Only Generic Covered
KLONOPIN (NOT WAFERS)           clonazepam 2mg tablet                                           Only Generic Covered
KLONOPIN ODT                    clonazepam 0.125mg odt tab                                      Only Generic Covered
LIBRIUM                         chlordiazepoxide 5mg capsule                                    Only Generic Covered
LIBRIUM                         chlordiazepoxide 10mg capsul                                    Only Generic Covered
LIBRIUM                         chlordiazepoxide 25mg capsul                                    Only Generic Covered
lorazepam 0.5mg tablet          ATIVAN                                                  2       Available via Mail Order
lorazepam 1.0mg tablet          ATIVAN                                                  2       Available via Mail Order
lorazepam 2.0mg tablet          ATIVAN                                                  2       Available via Mail Order
lorazepam 2mg/ml oral conc      ATIVAN                                                  2       Quantity Limits Apply
                                                                                                Available via Mail Order
meprobamate 200mg tablet        EQUANIL                                                 2       Available via Mail Order
meprobamate 400mg tablet        EQUANIL                                                 2       Available via Mail Order
TRANXENE                        clorazepate 3.75mg tablet                                       Only Generic Covered
TRANXENE                        clorazepate 7.5mg tablet                                        Only Generic Covered
TRANXENE                        clorazepate 15mg tablet                                         Only Generic Covered
VALIUM                          diazepam 2mg tablet                                             Only Generic Covered
VALIUM                          diazepam 5mg tablet                                             Only Generic Covered
VALIUM                          diazepam 10mg tablet                                            Only Generic Covered
VALIUM SOLN                     DIAZEPAM 5MG/5ML ORAL SOLN                                      Only Generic Covered
VISTARIL                        hydroxyzine pamoate 25mg cap                                    Only Generic Covered
VISTARIL                        hydroxyzine pamoate 50mg cap                                    Only Generic Covered
VISTARIL                        hydroxyzine pamoate 100mg cap                                   Only Generic Covered
XANAX                           alprazolam 0.25mg tablet                                        Only Generic Covered
XANAX (NOT XR)                  alprazolam 0.5mg tablet                                         Only Generic Covered
XANAX (NOT XR)                  alprazolam 1mg tab(gx xanax)                                    Only Generic Covered
XANAX (NOT XR)                  alprazolam 2mg tab(gx xanax)                                    Only Generic Covered
                                Autonomic Agents - Parasympatholytics
ATARAX                          hydroxyzine 50mg/ml inj                                         Only Generic Covered
atropine sul 0.1mg/ml inj syg                                                           5
hydroxyzine 50mg/ml inj         ATARAX                                                  5

27-921/01-01/06 Rev 01-11                                               [ 79]                   2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
PRO-BANTHINE                   propantheline 15mg tablet                                        Only Generic Covered
propantheline 15mg tablet      PRO-BANTHINE                                             2
                               Autonomic Agents - Parasympathomimetics
bethanechol 5mg tablet         URECHOLINE                                               2       Available via Mail Order
bethanechol 10mg tablet        URECHOLINE                                               2       Available via Mail Order
bethanechol 25mg tab           URECHOLINE                                               2       Available via Mail Order
bethanechol 50mg tab           URECHOLINE                                               2       Available via Mail Order
GUANIDINE 125MG TAB                                                                     4       Available via Mail Order
MESTINON                       pyridostigmine br 60mg tab                                       Only Generic Covered
MESTINON TIMESPAN 180MG TAB                                                             3       Available via Mail Order
pilocarpine 5mg tablet         SALAGEN                                                  2       Available via Mail Order
pyridostigmine br 60mg tab     MESTINON                                                 2       Available via Mail Order
SALAGEN                        pilocarpine 5mg tablet                                           Only Generic Covered
URECHOLINE                     bethanechol 5mg tablet                                           Only Generic Covered
URECHOLINE                     bethanechol 10mg tablet                                          Only Generic Covered
URECHOLINE                     bethanechol 25mg tab                                             Only Generic Covered
URECHOLINE                     bethanechol 50mg tab                                             Only Generic Covered
                               Autonomic Agents - Sympathomimetics
ADRENALIN                      epinephrine 0.1mg/ml inj                                         Only Generic Covered
epinephrine 0.1mg/ml inj       ADRENALIN                                                5
                               Bipolar Agents
ESKALITH                       lithium carbonate 150mg caps                                     Only Generic Covered
ESKALITH                       lithium carbonate 300mg caps                                     Only Generic Covered
ESKALITH CR                    lithium carb 450mg er tablet                                     Only Generic Covered
lithium carb 450mg er tablet   ESKALITH CR                                              2       Available via Mail Order
lithium carbonate 150mg caps   ESKALITH                                                 2       Available via Mail Order
lithium carbonate 300mg caps   ESKALITH                                                 1       Available via Mail Order
lithium citrate 8meq/5ml syr                                                            2       Available via Mail Order
                               Blood Glucose Regulators - Antihypoglycemics
GLUCAGON 1MG KIT                                                                        3       Quantity Limits Apply
                                                                                                Available via Mail Order
PROGLYCEM 50MG/ML SUSP                                                                  4       Available via Mail Order
                               Blood Glucose Regulators - Hypoglycemics, Oral
acarbose 25mg tablet           PRECOSE                                                  2       Available via Mail Order
acarbose 50mg tablet           PRECOSE                                                  2       Available via Mail Order
acarbose 100mg tablet          PRECOSE                                                  2       Available via Mail Order

27-921/01-01/06 Rev 01-11                                              [ 80]                    2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
AMARYL                          glimepiride 1mg tablet                                          Only Generic Covered
AMARYL                          glimepiride 2mg tablet                                          Only Generic Covered
AMARYL                          glimepiride 4mg tablet                                          Only Generic Covered
chlorpropamide 100mg tablet     DIABINESE                                               2       Available via Mail Order
chlorpropamide 250mg tablet     DIABINESE                                               2       Available via Mail Order
DIABETA                         glyburide 1.25mg tablet                                         Only Generic Covered
DIABETA                         glyburide 2.5mg (gx diabeta)                                    Only Generic Covered
DIABETA                         glyburide 5mg tab (gxdiabeta)                                   Only Generic Covered
DIABINESE                       chlorpropamide 100mg tablet                                     Only Generic Covered
DIABINESE                       chlorpropamide 250mg tablet                                     Only Generic Covered
glimepiride 1mg tablet          AMARYL                                                  1       Available via Mail Order
glimepiride 2mg tablet          AMARYL                                                  1       Available via Mail Order
glimepiride 4mg tablet          AMARYL                                                  1       Available via Mail Order
glipizide 5mg (gx glucotrol     GLUCOTROL (NOT XL)                                      1       Available via Mail Order
glipizide 10mg (gx glucotrol    GLUCOTROL (NOT XL)                                      1       Available via Mail Order
GLUCOPHAGE                      metformin hcl 500mg tablet                                      Only Generic Covered
GLUCOPHAGE                      metformin hcl 850mg tablet                                      Only Generic Covered
GLUCOPHAGE                      metformin hcl 1000mg tablet                                     Only Generic Covered
GLUCOPHAGE XR                   metformin-er 500mg tablet                                       Only Generic Covered
GLUCOPHAGE XR                   metformin-er 750mg tablet                                       Only Generic Covered
GLUCOTROL (NOT XL)              glipizide 5mg (gx glucotrol                                     Only Generic Covered
GLUCOTROL (NOT XL)              glipizide 10mg (gx glucotrol                                    Only Generic Covered
glyburide 1.25mg tablet         DIABETA                                                 2       Available via Mail Order
glyburide 2.5mg (gx diabeta)    DIABETA                                                 1       Available via Mail Order
glyburide 5mg tab (gxdiabeta)   DIABETA                                                 1       Available via Mail Order
GLYNASE                         micronized glyburide 3mg tab                                    Only Generic Covered
JANUVIA 25MG TABLET                                                                     4       Prior Auth Required
                                                                                                Quantity Limits Apply
                                                                                                Available via Mail Order
JANUVIA 50MG TABLET                                                                     4       Prior Auth Required
                                                                                                Quantity Limits Apply
                                                                                                Available via Mail Order
JANUVIA 100MG TABLET                                                                    4       Prior Auth Required
                                                                                                Quantity Limits Apply
                                                                                                Available via Mail Order
metformin hcl 500mg tablet      GLUCOPHAGE                                              1       Available via Mail Order
metformin hcl 850mg tablet      GLUCOPHAGE                                              1       Available via Mail Order


27-921/01-01/06 Rev 01-11                                            [ 81]                      2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT                TIER*   NOTES
metformin hcl 1000mg tablet    GLUCOPHAGE                                                            1       Available via Mail Order
metformin-er 500mg tablet      GLUCOPHAGE XR                                                         2       Available via Mail Order
metformin-er 750mg tablet      GLUCOPHAGE XR                                                         2       Available via Mail Order
micronized glyburide 3mg tab   GLYNASE                                                               2       Available via Mail Order
nateglinide 60mg tablet        STARLIX                                                               2       Available via Mail Order
nateglinide 120mg tablet       STARLIX                                                               2       Available via Mail Order
ONGLYZA 2.5MG TABLET                                                                                 4       Prior Auth Required
                                                                                                             Quantity Limits Apply
                                                                                                             Available via Mail Order
ONGLYZA 5MG TABLET                                                                                   4       Prior Auth Required
                                                                                                             Quantity Limits Apply
                                                                                                             Available via Mail Order
ORINASE                        tolbutamide 500mg tablet                                                      Only Generic Covered
PRECOSE                        acarbose 25mg tablet                                                          Only Generic Covered
PRECOSE                        acarbose 50mg tablet                                                          Only Generic Covered
PRECOSE                        acarbose 100mg tablet                                                         Only Generic Covered
STARLIX                        nateglinide 60mg tablet                                                       Only Generic Covered
STARLIX                        nateglinide 120mg tablet                                                      Only Generic Covered
tolazamide 250mg tablet        TOLINASE                                                              2       Available via Mail Order
tolazamide 500mg tablet        TOLINASE                                                              2       Available via Mail Order
tolbutamide 500mg tablet       ORINASE                                                               2       Available via Mail Order
TOLINASE                       tolazamide 250mg tablet                                                       Only Generic Covered
TOLINASE                       tolazamide 500mg tablet                                                       Only Generic Covered
                               Blood Glucose Regulators - Hypoglycemics, Oral-Step Therapy Applies
ACTOS 15MG TABLET                                                                                    4       Available via Mail Order
                                                                                                             Step Therapy Applies
ACTOS 30MG TABLET                                                                                    4       Available via Mail Order
                                                                                                             Step Therapy Applies
ACTOS 45MG TABLET                                                                                    4       Available via Mail Order
                                                                                                             Step Therapy Applies
AVANDIA 2MG TABLET                                                                                   3       Available via Mail Order
                                                                                                             Step Therapy Applies
AVANDIA 4MG TABLET                                                                                   3       Available via Mail Order
                                                                                                             Step Therapy Applies
AVANDIA 8MG TABLET                                                                                   3       Available via Mail Order
                                                                                                             Step Therapy Applies
                               Blood Glucose Regulators - Insulins
HUMULIN R 500U/ML INJ (CONC)                                                                         3       Quantity Limits Apply
                                                                                                             Available via Mail Order

27-921/01-01/06 Rev 01-11                                             [ 82]                                  2011 Commercial Drug Formulary
                                                                                                                   Last Updated: July 1, 2011
                                                       DRUG CATEGORY - DRUG CLASS
DRUG NAME                                             BRAND OR GENERIC EQUIVALENT          TIER*   NOTES
LANTUS 100U/ML INJ                                                                         4       Quantity Limits Apply
                                                                                                   Available via Mail Order
LEVEMIR 100U/ML INJ                                                                        3       Quantity Limits Apply
                                                                                                   Available via Mail Order
NOVOLIN 70/30 100U/ML INJ                                                                  3       Quantity Limits Apply
                                                                                                   Available via Mail Order
NOVOLIN N 100U/ML INJ                                                                      3       Quantity Limits Apply
                                                                                                   Available via Mail Order
NOVOLIN R 100U/ML INJ                                                                      3       Quantity Limits Apply
                                                                                                   Available via Mail Order
NOVOLOG 100U/ML INJ                                                                        3       Quantity Limits Apply
                                                                                                   Available via Mail Order
NOVOLOG MIX 70/30 INJ                                                                      3       Quantity Limits Apply
                                                                                                   Available via Mail Order
                              Blood Products/Modifiers/Volume Expanders - Anticoagulants
ARIXTRA 2.5MG/0.5ML INJ                                                                    5       Prior Auth Required
ARIXTRA 5MG/0.4ML INJ                                                                      6       Prior Auth Required
ARIXTRA 7.5MG/0.6ML INJ                                                                    6       Prior Auth Required
ARIXTRA 10MG/0.8ML INJ                                                                     6       Prior Auth Required
COUMADIN                      warfarin sodium 1mg tablet                                           Only Generic Covered
COUMADIN                      warfarin sodium 2 mg tablet                                          Only Generic Covered
COUMADIN                      warfarin sodium 2.5mg tablet                                         Only Generic Covered
COUMADIN                      warfarin sodium 3mg tablet                                           Only Generic Covered
COUMADIN                      warfarin sodium 4mg tablet                                           Only Generic Covered
COUMADIN                      warfarin sodium 5mg tablet                                           Only Generic Covered
COUMADIN                      warfarin sodium 6mg tablet                                           Only Generic Covered
COUMADIN                      warfarin sodium 7.5mg tablet                                         Only Generic Covered
COUMADIN                      warfarin sodium 10mg tablet                                          Only Generic Covered
enoxaparin 30mg/0.3ml inj     LOVENOX                                                      5       Quantity Limits Apply
enoxaparin 40mg/0.4ml inj     LOVENOX                                                      5       Quantity Limits Apply
enoxaparin 60mg/0.6ml inj     LOVENOX                                                      5       Quantity Limits Apply
enoxaparin 80mg/0.8ml inj     LOVENOX                                                      5       Quantity Limits Apply
enoxaparin 100mg/ml inj       LOVENOX                                                      5       Quantity Limits Apply
enoxaparin 120mg/0.8ml inj    LOVENOX                                                      5       Quantity Limits Apply
enoxaparin 150mg/ml inj       LOVENOX                                                      5       Quantity Limits Apply
heparin sod 1,000 u/ml inj                                                                 5
heparin sod 5,000 u/ml inj                                                                 5
heparin sod 10,000 u/ml inj                                                                5

27-921/01-01/06 Rev 01-11                                            [ 83]                         2011 Commercial Drug Formulary
                                                                                                         Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT                  TIER*   NOTES
heparin sod 20,000 u/ml inj                                                                            5
LOVENOX                         enoxaparin 30mg/0.3ml inj                                                      Only Generic Covered
LOVENOX                         enoxaparin 40mg/0.4ml inj                                                      Only Generic Covered
LOVENOX                         enoxaparin 60mg/0.6ml inj                                                      Only Generic Covered
LOVENOX                         enoxaparin 80mg/0.8ml inj                                                      Only Generic Covered
LOVENOX                         enoxaparin 100mg/ml inj                                                        Only Generic Covered
LOVENOX                         enoxaparin 120mg/0.8ml inj                                                     Only Generic Covered
LOVENOX                         enoxaparin 150mg/ml inj                                                        Only Generic Covered
LOVENOX 30MG/0.3ML INJ                                                                                 5
LOVENOX 40MG/0.4ML INJ                                                                                 5
LOVENOX 60MG/0.6ML INJ                                                                                 5
LOVENOX 80MG/0.8ML INJ                                                                                 5
LOVENOX 100MG/ML INJ                                                                                   5
LOVENOX 120MG/0.8ML INJ                                                                                5
LOVENOX 150MG/1ML INJ                                                                                  5
LOVENOX 300MG/3ML MDV 1X3MLVL                                                                          5
warfarin sodium 1mg tablet      COUMADIN                                                               2       Available via Mail Order
warfarin sodium 2 mg tablet     COUMADIN                                                               2       Available via Mail Order
warfarin sodium 2.5mg tablet    COUMADIN                                                               2       Available via Mail Order
warfarin sodium 3mg tablet      COUMADIN                                                               2       Available via Mail Order
warfarin sodium 4mg tablet      COUMADIN                                                               2       Available via Mail Order
warfarin sodium 5mg tablet      COUMADIN                                                               2       Available via Mail Order
warfarin sodium 6mg tablet      COUMADIN                                                               2       Available via Mail Order
warfarin sodium 7.5mg tablet    COUMADIN                                                               2       Available via Mail Order
warfarin sodium 10mg tablet     COUMADIN                                                               2       Available via Mail Order
                                Blood Products/Modifiers/Volume Expanders - Blood Formation Products
AGRYLIN                         anagrelide 0.5mg capsule                                                       Only Generic Covered
AGRYLIN                         anagrelide 1mg capsule                                                         Only Generic Covered
anagrelide 0.5mg capsule        AGRYLIN                                                                2       Available via Mail Order
anagrelide 1mg capsule          AGRYLIN                                                                2       Available via Mail Order
ARANESP 25MCG/ML INJ                                                                                   5
ARANESP 40MCG/0.4ML SURECLCK                                                                           5
ARANESP 40MCG/ML INJ                                                                                   5
ARANESP 60MCG/0.3ML INJ                                                                                6
ARANESP 60MCG/ML INJ                                                                                   6
ARANESP 100MCG/0.5ML SNGLJCT                                                                           6
27-921/01-01/06 Rev 01-11                                             [ 84]                                    2011 Commercial Drug Formulary
                                                                                                                     Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT                        TIER*   NOTES
ARANESP 100MCG/ML INJ                                                                                       6
ARANESP 200MCG/ML INJ                                                                                       6
ARANESP 300MCG/0.6ML INJ                                                                                    6
NEULASTA 6MG/0.6ML INJ                                                                                      6
NEUMEGA 5MG VIAL                                                                                            6
NEUPOGEN 300MCG/ML 1ML VIAL                                                                                 6
NEUPOGEN 480MCG/1.6ML VIAL                                                                                  6
PROCRIT 2,000 U/ML INJ                                                                                      5
PROCRIT 3,000 U/ML INJ                                                                                      5
PROCRIT 4,000 U/ML INJ                                                                                      5
PROCRIT 10,000 U/ML INJ                                                                                     5
PROCRIT 20,000 U/ML INJ                                                                                     5
PROCRIT 40,000 U/ML INJ                                                                                     5
PROMACTA 25MG TABLET                                                                                        6       Prior Auth Required
PROMACTA 50MG TABLET                                                                                        6       Prior Auth Required
                              Blood Products/Modifiers/Volume Expanders - Coagulants
amicar 250mg/ml syrup                                                                                       2
amicar 500mg tablet                                                                                         2
AMICAR 1000MG TABLET                                                                                        2
CYKLOKAPRON 100MG/ML INJ                                                                                    5
METHERGINE 0.2MG TABLET                                                                                     3
                              Blood Products/Modifiers/Volume Expanders - Platelet Aggregation Inhibitors
AGGRENOX 200/25MG CAPSULE                                                                                   3       Available via Mail Order
cilostazol 50mg tablet        PLETAL                                                                        2       Available via Mail Order
cilostazol 100mg tablet       PLETAL                                                                        2       Available via Mail Order
dipyridamole 25mg tablet      PERSANTINE                                                                    2       Available via Mail Order
dipyridamole 50mg tablet      PERSANTINE                                                                    2       Available via Mail Order
dipyridamole 75mg tablet      PERSANTINE                                                                    2       Available via Mail Order
pentoxifylline 400mg tablet   TRENTAL                                                                       2       Available via Mail Order
PERSANTINE                    dipyridamole 25mg tablet                                                              Only Generic Covered
PERSANTINE                    dipyridamole 50mg tablet                                                              Only Generic Covered
PERSANTINE                    dipyridamole 75mg tablet                                                              Only Generic Covered
PLAVIX 75MG TABLET                                                                                          3       Available via Mail Order
PLETAL                        cilostazol 50mg tablet                                                                Only Generic Covered
PLETAL                        cilostazol 100mg tablet                                                               Only Generic Covered
TICLID                        ticlopidine 250mg tablet                                                              Only Generic Covered
27-921/01-01/06 Rev 01-11                                             [ 85]                                         2011 Commercial Drug Formulary
                                                                                                                          Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT       TIER*   NOTES
ticlopidine 250mg tablet        TICLID                                                     2       Available via Mail Order
TRENTAL                         pentoxifylline 400mg tablet                                        Only Generic Covered
                                Cardiovascular Agents - Alpha-Adrenergic Agonists
ALDOMET                         methyldopa 250mg tablet                                            Only Generic Covered
ALDOMET                         methyldopa 500mg tablet                                            Only Generic Covered
CATAPRESS (NOT TTS)             clonidine 0.1mg tablet                                             Only Generic Covered
CATAPRESS (NOT TTS)             clonidine 0.2mg tablet                                             Only Generic Covered
CATAPRESS (NOT TTS)             clonidine 0.3mg tablet                                             Only Generic Covered
clonidine 0.1mg tablet          CATAPRESS (NOT TTS)                                        1       Available via Mail Order
clonidine 0.2mg tablet          CATAPRESS (NOT TTS)                                        1       Available via Mail Order
clonidine 0.3mg tablet          CATAPRESS (NOT TTS)                                        2       Available via Mail Order
guanfacine 1mg tablet           TENEX                                                      2       Available via Mail Order
guanfacine 2mg tablet           TENEX                                                      2       Available via Mail Order
methyldopa 250mg tablet         ALDOMET                                                    2       Available via Mail Order
methyldopa 500mg tablet         ALDOMET                                                    2       Available via Mail Order
midodrine 2.5mg tablet          PROAMATINE                                                 2
midodrine 5mg tablet            PROAMATINE                                                 2
midodrine 10mg tablet           PROAMATINE                                                 2
PROAMATINE                      midodrine 2.5mg tablet                                             Only Generic Covered
PROAMATINE                      midodrine 5mg tablet                                               Only Generic Covered
PROAMATINE                      midodrine 10mg tablet                                              Only Generic Covered
TENEX                           guanfacine 1mg tablet                                              Only Generic Covered
TENEX                           guanfacine 2mg tablet                                              Only Generic Covered
                                Cardiovascular Agents - Alpha-Adrenergic Blocking Agents
CARDURA (NOT XL)                doxazosin 1mg tab (gx cardura                                      Only Generic Covered
CARDURA (NOT XL)                doxazosin 2mg tab (gx cardura                                      Only Generic Covered
CARDURA (NOT XL)                doxazosin 4mg tab (gx cardura                                      Only Generic Covered
CARDURA (NOT XL)                doxazosin 8mg tab (gx cardura                                      Only Generic Covered
doxazosin 1mg tab (gx cardura   CARDURA (NOT XL)                                           1       Available via Mail Order
doxazosin 2mg tab (gx cardura   CARDURA (NOT XL)                                           1       Available via Mail Order
doxazosin 4mg tab (gx cardura   CARDURA (NOT XL)                                           1       Available via Mail Order
doxazosin 8mg tab (gx cardura   CARDURA (NOT XL)                                           1       Available via Mail Order
HYTRIN                          terazosin 1mg cap(gx hytrin)                                       Only Generic Covered
HYTRIN                          terazosin 2mg cap(gx hytrin)                                       Only Generic Covered
HYTRIN                          terazosin 5mg cap(gx hytrin)                                       Only Generic Covered
HYTRIN                          terazosin 10mg cap(gx hytrin)                                      Only Generic Covered
27-921/01-01/06 Rev 01-11                                              [ 86]                       2011 Commercial Drug Formulary
                                                                                                         Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
MINIPRESS                       prazosin 1mg capsule                                             Only Generic Covered
MINIPRESS                       prazosin 2mg capsule                                             Only Generic Covered
MINIPRESS                       prazosin 5mg capsule                                             Only Generic Covered
prazosin 1mg capsule            MINIPRESS                                                2       Available via Mail Order
prazosin 2mg capsule            MINIPRESS                                                2       Available via Mail Order
prazosin 5mg capsule            MINIPRESS                                                2       Available via Mail Order
terazosin 1mg cap(gx hytrin)    HYTRIN                                                   1       Available via Mail Order
terazosin 2mg cap(gx hytrin)    HYTRIN                                                   1       Available via Mail Order
terazosin 5mg cap(gx hytrin)    HYTRIN                                                   1       Available via Mail Order
terazosin 10mg cap(gx hytrin)   HYTRIN                                                   1       Available via Mail Order
                                Cardiovascular Agents - Antiarrhythmics
amiodarone 200mg tablet         CORDARONE                                                2       Available via Mail Order
amiodarone 50mg/ml inj sdv      CORDARONE                                                5
amiodarone 50mg/ml inj sdv      CORDARONE                                                5
BETAPACE                        sotalol hcl 80mg tablet                                          Only Generic Covered
BETAPACE                        sotalol hcl 120mg tablet                                         Only Generic Covered
BETAPACE                        sotalol hcl 160mg tablet                                         Only Generic Covered
BETAPACE                        sotalol hcl 240mg tablet                                         Only Generic Covered
CORDARONE                       amiodarone 200mg tablet                                          Only Generic Covered
CORDARONE                       amiodarone 50mg/ml inj sdv                                       Only Generic Covered
disopyramide 100mg capsule      NORPACE                                                  2       Available via Mail Order
disopyramide 150mg capsule      NORPACE                                                  2       Available via Mail Order
flecainide 50mg tablet          TAMBOCOR                                                 2       Available via Mail Order
flecainide 100mg tablet         TAMBACOR                                                 2       Available via Mail Order
flecainide 150mg tablet         TAMBOCOR                                                 2       Available via Mail Order
mexiletine 150mg capsule        MEXITIL                                                  2       Available via Mail Order
mexiletine 200mg capsule        MEXITIL                                                  2       Available via Mail Order
mexiletine 250mg capsule        MEXITIL                                                  2       Available via Mail Order
MEXITIL                         mexiletine 150mg capsule                                         Only Generic Covered
MEXITIL                         mexiletine 200mg capsule                                         Only Generic Covered
MEXITIL                         mexiletine 250mg capsule                                         Only Generic Covered
NORPACE                         disopyramide 100mg capsule                                       Only Generic Covered
NORPACE                         disopyramide 150mg capsule                                       Only Generic Covered
NORPACE CR 100MG CAPSULE                                                                 4       Available via Mail Order
PROCAINAMIDE 500MG/ML INJ                                                                5
propafenone 150mg tablet        RYTHMOL (NOT SR)                                         2       Available via Mail Order
27-921/01-01/06 Rev 01-11                                                 [ 87]                  2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                             DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                   BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
propafenone 225mg tablet        RYTHMOL (NOT SR)                                          2       Available via Mail Order
propafenone 300mg tablet        RYTHMOL (NOT SR)                                          2       Available via Mail Order
QUINAGLUTE                      quinidine gluconate 324mg tab                                     Only Generic Covered
QUINIDEX                        quinidine er 300mg tablet                                         Only Generic Covered
quinidine er 300mg tablet       QUINIDEX                                                  2       Available via Mail Order
quinidine gluconate 324mg tab   QUINAGLUTE                                                2       Available via Mail Order
quinidine sulfate 200mg tab                                                               2       Available via Mail Order
quinidine sulfate 300mg tab                                                               2       Available via Mail Order
RYTHMOL (NOT SR)                propafenone 150mg tablet                                          Only Generic Covered
RYTHMOL (NOT SR)                propafenone 225mg tablet                                          Only Generic Covered
RYTHMOL (NOT SR)                propafenone 300mg tablet                                          Only Generic Covered
sotalol hcl 80mg tablet         BETAPACE                                                  2       Available via Mail Order
sotalol hcl 120mg tablet        BETAPACE                                                  2       Available via Mail Order
sotalol hcl 160mg tablet        BETAPACE                                                  2       Available via Mail Order
sotalol hcl 240mg tablet        BETAPACE                                                  2       Available via Mail Order
TAMBACOR                        flecainide 100mg tablet                                           Only Generic Covered
TAMBOCOR                        flecainide 50mg tablet                                            Only Generic Covered
TAMBOCOR                        flecainide 150mg tablet                                           Only Generic Covered
TIKOSYN 0.25MG CAPSULE                                                                    4       Available via Mail Order
TIKOSYN 0.5MG CAPSULE                                                                     4       Available via Mail Order
                                Cardiovascular Agents - Beta-Adrenergic Blocking Agents
acebutolol hcl 200mg capsule    SECTRAL                                                   2       Available via Mail Order
acebutolol hcl 400mg capsule    SECTRAL                                                   2       Available via Mail Order
atenolol 25mg tablet            TENORMIN                                                  1       Available via Mail Order
atenolol 50mg tablet            TENORMIN                                                  1       Available via Mail Order
atenolol 100mg tablet           TENORMIN                                                  1       Available via Mail Order
carvedilol 3.125mg tablet       COREG                                                     1       Available via Mail Order
carvedilol 6.25mg tablet        COREG                                                     1       Available via Mail Order
carvedilol 12.5mg tablet        COREG                                                     1       Available via Mail Order
carvedilol 25mg tablet          COREG                                                     1       Available via Mail Order
COREG                           carvedilol 3.125mg tablet                                         Only Generic Covered
COREG                           carvedilol 6.25mg tablet                                          Only Generic Covered
COREG                           carvedilol 12.5mg tablet                                          Only Generic Covered
COREG                           carvedilol 25mg tablet                                            Only Generic Covered
COREG CR 10MG CAPSULE                                                                     3       Available via Mail Order
COREG CR 20MG CAPSULE                                                                     3       Available via Mail Order
27-921/01-01/06 Rev 01-11                                              [ 88]                      2011 Commercial Drug Formulary
                                                                                                        Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
COREG CR 40MG CAPSULE                                                                  3       Available via Mail Order
COREG CR 80MG CAPSULE                                                                  3       Available via Mail Order
INDERAL                        propranolol 1mg/ml inj sdv                                      Only Generic Covered
INDERAL (NOT LA)               propranolol 10mg tablet                                         Only Generic Covered
INDERAL (NOT LA)               propranolol 20mg tablet                                         Only Generic Covered
INDERAL (NOT LA)               propranolol 40mg tablet                                         Only Generic Covered
INDERAL (NOT LA)               propranolol 60mg tablet                                         Only Generic Covered
INDERAL (NOT LA)               propranolol 80mg tablet                                         Only Generic Covered
INDERAL SOLN                   propranolol hcl sol 20mg/5ml                                    Only Generic Covered
INDERAL SOLN                   propranolol hcl sol 40mg/5ml                                    Only Generic Covered
INDERIDE                       propranolol/hctz 40/25mg tab                                    Only Generic Covered
INDERIDE                       propranolol/hctz 80/25 tab                                      Only Generic Covered
labetalol hcl 100mg tablet     TRANDATE                                                2       Available via Mail Order
labetalol hcl 200mg tablet     TRANDATE                                                2       Available via Mail Order
labetalol hcl 300mg tablet     TRANDATE                                                2       Available via Mail Order
LOPRESSOR (NOT HCT)            metoprolol   50mg tablet                                        Only Generic Covered
LOPRESSOR (NOT HCT)            metoprolol 25mg tablet                                          Only Generic Covered
LOPRESSOR (NOT HCT)            metoprolol 100mg tablet                                         Only Generic Covered
metoprolol   50mg tablet       LOPRESSOR (NOT HCT)                                     1       Available via Mail Order
metoprolol 25mg tablet         LOPRESSOR (NOT HCT)                                     1       Available via Mail Order
metoprolol 100mg tablet        LOPRESSOR (NOT HCT)                                     1       Available via Mail Order
propranolol 10mg tablet        INDERAL (NOT LA)                                        1       Available via Mail Order
propranolol 1mg/ml inj sdv     INDERAL                                                 5
propranolol 20mg tablet        INDERAL (NOT LA)                                        1       Available via Mail Order
propranolol 40mg tablet        INDERAL (NOT LA)                                        1       Available via Mail Order
propranolol 60mg tablet        INDERAL (NOT LA)                                        1       Available via Mail Order
propranolol 80mg tablet        INDERAL (NOT LA)                                        1       Available via Mail Order
propranolol hcl sol 20mg/5ml   INDERAL SOLN                                            2       Available via Mail Order
propranolol hcl sol 40mg/5ml   INDERAL SOLN                                            2       Available via Mail Order
propranolol/hctz 40/25mg tab   INDERIDE                                                2       Available via Mail Order
propranolol/hctz 80/25 tab     INDERIDE                                                2       Available via Mail Order
SECTRAL                        acebutolol hcl 200mg capsule                                    Only Generic Covered
SECTRAL                        acebutolol hcl 400mg capsule                                    Only Generic Covered
TENORMIN                       atenolol 25mg tablet                                            Only Generic Covered
TENORMIN                       atenolol 50mg tablet                                            Only Generic Covered
TENORMIN                       atenolol 100mg tablet                                           Only Generic Covered
27-921/01-01/06 Rev 01-11                                           [ 89]                      2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT      TIER*   NOTES
TRANDATE                        labetalol hcl 100mg tablet                                        Only Generic Covered
TRANDATE                        labetalol hcl 200mg tablet                                        Only Generic Covered
TRANDATE                        labetalol hcl 300mg tablet                                        Only Generic Covered
                                Cardiovascular Agents - Calcium Channel Blocking Agents
ADALAT CC                       afeditab cr 30mg gx-adalat-cc                                     Only Generic Covered
ADALAT CC                       nifediac cc 60mg(gx adalat-cc                                     Only Generic Covered
ADALAT CC                       nifediac cc 90mg(gx adalat-cc                                     Only Generic Covered
afeditab cr 30mg gx-adalat-cc   ADALAT CC                                                 2       Available via Mail Order
amlodipine bes 2.5mg tablet     NORVASC                                                   2       Available via Mail Order
amlodipine bes 5mg tablet       NORVASC                                                   2       Available via Mail Order
amlodipine bes 10mg tablet      NORVASC                                                   2       Available via Mail Order
CALAN                           verapamil 40mg tablet                                             Only Generic Covered
CALAN                           verapamil 80mg tablet                                             Only Generic Covered
CALAN                           verapamil 120mg tablet white                                      Only Generic Covered
CALAN SR                        verapamil ext rel 120mg tab                                       Only Generic Covered
CALAN-SR                        verapamil ext rel 180mg tab                                       Only Generic Covered
CALAN-SR                        verapamil ext rel 240mg tab                                       Only Generic Covered
CARDIZEM (NOT SR)               diltiazem 30mg tablet                                             Only Generic Covered
CARDIZEM (NOT SR)               diltiazem 60mg tablet                                             Only Generic Covered
CARDIZEM (NOT SR)               diltiazem 90mg tablet                                             Only Generic Covered
CARDIZEM (NOT SR)               diltiazem 120mg tablet                                            Only Generic Covered
CARDIZEM CD                     diltiazem cd 120mg cap                                            Only Generic Covered
CARDIZEM CD                     diltiazem cd 300mg cap                                            Only Generic Covered
CARDIZEM CD                     diltiazem er 180mg capsule                                        Only Generic Covered
CARDIZEM CD                     diltiazem er 240mg capsule                                        Only Generic Covered
diltiazem 30mg tablet           CARDIZEM (NOT SR)                                         2       Available via Mail Order
diltiazem 60mg tablet           CARDIZEM (NOT SR)                                         2       Available via Mail Order
diltiazem 90mg tablet           CARDIZEM (NOT SR)                                         2       Available via Mail Order
diltiazem 120mg tablet          CARDIZEM (NOT SR)                                         2       Available via Mail Order
diltiazem cd 120mg cap          CARDIZEM CD                                               2       Available via Mail Order
diltiazem cd 300mg cap          CARDIZEM CD                                               2       Available via Mail Order
diltiazem er 180mg capsule      CARDIZEM CD                                               2       Available via Mail Order
diltiazem er 240mg capsule      CARDIZEM CD                                               2       Available via Mail Order
nifediac cc 60mg(gx adalat-cc   ADALAT CC                                                 2       Available via Mail Order
nifediac cc 90mg(gx adalat-cc   ADALAT CC                                                 2       Available via Mail Order
nifedipine 10mg capsule         PROCARDIA (NOT XL)                                        2       Available via Mail Order
27-921/01-01/06 Rev 01-11                                              [ 90]                      2011 Commercial Drug Formulary
                                                                                                        Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
nifedipine 20mg capsule         PROCARDIA (NOT XL)                                      2       Available via Mail Order
nimodipine 30mg capsule         NIMOTOP                                                 4       Available via Mail Order
NIMOTOP                         nimodipine 30mg capsule                                         Only Generic Covered
NORVASC                         amlodipine bes 2.5mg tablet                                     Only Generic Covered
NORVASC                         amlodipine bes 5mg tablet                                       Only Generic Covered
NORVASC                         amlodipine bes 10mg tablet                                      Only Generic Covered
PROCARDIA (NOT XL)              nifedipine 10mg capsule                                         Only Generic Covered
PROCARDIA (NOT XL)              nifedipine 20mg capsule                                         Only Generic Covered
verapamil 40mg tablet           CALAN                                                   2       Available via Mail Order
verapamil 80mg tablet           CALAN                                                   2       Available via Mail Order
verapamil ext rel 120mg tab     CALAN SR                                                2       Available via Mail Order
verapamil ext rel 180mg tab     CALAN-SR                                                2       Available via Mail Order
verapamil ext rel 240mg tab     CALAN-SR                                                2       Available via Mail Order
verapamil 120mg tablet white    CALAN                                                   2       Available via Mail Order
verapamil 2.5mg/ml inj                                                                  5
                                Cardiovascular Agents - Direct Cardiac Inotropics
digoxin 0.05mg/ml ped elixir    LANOXIN PED ELIX                                        2       Available via Mail Order
digoxin 0.25mg/ml inj           LANOXIN                                                 5
LANOXIN                         digoxin 0.25mg/ml inj                                           Only Generic Covered
LANOXIN 0.125 MG (YELLOW) TAB                                                           3       Available via Mail Order
LANOXIN 0.25MG (WHITE) TAB                                                              3       Available via Mail Order
LANOXIN PED ELIX                digoxin 0.05mg/ml ped elixir                                    Only Generic Covered
                                Cardiovascular Agents - Diuretics
ALDACTAZIDE                     spironolactone/hctz 25/25 tab                                   Only Generic Covered
ALDACTONE                       spironolactone 25mg tablet                                      Only Generic Covered
ALDACTONE                       spironolactone 50mg tablet                                      Only Generic Covered
amiloride 5mg tablet            MIDAMOR                                                 2       Available via Mail Order
amiloride/hctz 5/50mg tablet    MODURETIC                                               2       Available via Mail Order
bumetanide 0.25mg/ml inj        BUMEX                                                   5
bumetanide 0.5mg tablet         BUMEX                                                   1       Available via Mail Order
bumetanide 1mg tablet           BUMEX                                                   1       Available via Mail Order
bumetanide 2mg tablet           BUMEX                                                   2       Available via Mail Order
BUMEX                           bumetanide 0.25mg/ml inj                                        Only Generic Covered
BUMEX                           bumetanide 0.5mg tablet                                         Only Generic Covered
BUMEX                           bumetanide 1mg tablet                                           Only Generic Covered
BUMEX                           bumetanide 2mg tablet                                           Only Generic Covered
27-921/01-01/06 Rev 01-11                                                [ 91]                  2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
chlorothiazide 250mg tablet    DIURIL                                                 2       Available via Mail Order
chlorothiazide 500mg tablet    DIURIL                                                 2       Available via Mail Order
chlorthalidone 25mg tablet     HYGROTON                                               1       Available via Mail Order
chlorthalidone 50mg tablet     HYGROTON                                               1       Available via Mail Order
DIURIL                         chlorothiazide 250mg tablet                                    Only Generic Covered
DIURIL                         chlorothiazide 500mg tablet                                    Only Generic Covered
DIURIL SUSP 250MG/5ML                                                                 4       Available via Mail Order
DYAZIDE                        triamt/hctz 37.5/25 caps (nf                                   Only Generic Covered
EDECRIN 25MG TABLET                                                                   3       Available via Mail Order
ENDURON                        methyclothiazide 5mg tablet                                    Only Generic Covered
furosemide 10mg/ml inj sdv     LASIX                                                  5
furosemide 10mg/ml soln        LASIX                                                  2       Available via Mail Order
furosemide 40mg/5ml soln       LASIX                                                  2       Available via Mail Order
furosemide 20mg tablet         LASIX                                                  1       Available via Mail Order
furosemide 40mg tablet         LASIX                                                  1       Available via Mail Order
furosemide 80mg tablet         LASIX                                                  1       Available via Mail Order
hydrochlorothiazide 25mg tab   HYDRODIURIL                                            1       Available via Mail Order
hydrochlorothiazide 50mg tab   HYDRODIURIL                                            1       Available via Mail Order
HYDRODIURIL                    hydrochlorothiazide 25mg tab                                   Only Generic Covered
HYDRODIURIL                    hydrochlorothiazide 50mg tab                                   Only Generic Covered
HYGROTON                       chlorthalidone 25mg tablet                                     Only Generic Covered
HYGROTON                       chlorthalidone 50mg tablet                                     Only Generic Covered
LASIX                          furosemide 10mg/ml inj sdv                                     Only Generic Covered
LASIX                          furosemide 10mg/ml soln                                        Only Generic Covered
LASIX                          furosemide 40mg/5ml soln                                       Only Generic Covered
LASIX                          furosemide 20mg tablet                                         Only Generic Covered
LASIX                          furosemide 40mg tablet                                         Only Generic Covered
LASIX                          furosemide 80mg tablet                                         Only Generic Covered
MAXZIDE                        triamt/hctz 75/50 tab(maxzid                                   Only Generic Covered
MAXZIDE 25                     triamt/hctz 37.5/25 tablet                                     Only Generic Covered
methyclothiazide 5mg tablet    ENDURON                                                2       Available via Mail Order
metolazone 2.5mg tablet        ZAROXOLYN                                              2       Available via Mail Order
metolazone 5mg tablet          ZAROXOLYN                                              2       Available via Mail Order
metolazone 10mg tablet         ZAROXOLYN                                              2       Available via Mail Order
MIDAMOR                        amiloride 5mg tablet                                           Only Generic Covered
MODURETIC                      amiloride/hctz 5/50mg tablet                                   Only Generic Covered
27-921/01-01/06 Rev 01-11                                          [ 92]                      2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
spironolactone 25mg tablet      ALDACTONE                                                2       Available via Mail Order
spironolactone 50mg tablet      ALDACTONE                                                2       Available via Mail Order
spironolactone/hctz 25/25 tab   ALDACTAZIDE                                              2       Available via Mail Order
triamt/hctz 37.5/25 caps (nf    DYAZIDE                                                  1       Available via Mail Order
triamt/hctz 37.5/25 tablet      MAXZIDE 25                                               1       Available via Mail Order
triamt/hctz 75/50 tab(maxzid    MAXZIDE                                                  1       Available via Mail Order
ZAROXOLYN                       metolazone 2.5mg tablet                                          Only Generic Covered
ZAROXOLYN                       metolazone 5mg tablet                                            Only Generic Covered
ZAROXOLYN                       metolazone 10mg tablet                                           Only Generic Covered
                                Cardiovascular Agents - Dyslipidemics
cholestyramine 4gm pwd pckt     QUESTRAN                                                 2       Quantity Limits Apply
                                                                                                 Available via Mail Order
cholestyramine light powder     QUESTRAN LIGHT                                           2       Quantity Limits Apply
                                                                                                 Available via Mail Order
cholestyramine lite 4gm pwdpk   QUESTRAN LIGHT                                           2       Quantity Limits Apply
                                                                                                 Available via Mail Order
cholestyramine reg powder       QUESTRAN                                                 2       Quantity Limits Apply
                                                                                                 Available via Mail Order
CRESTOR 5MG TABLET                                                                       3       Available via Mail Order
CRESTOR 10MG TABLET                                                                      3       Available via Mail Order
CRESTOR 20MG TABLET                                                                      3       Available via Mail Order
CRESTOR 40MG TABLET                                                                      3       Available via Mail Order
gemfibrozil 600mg tablet        LOPID                                                    2       Available via Mail Order
LIPITOR 20MG TABLET                                                                      4       Quantity Limits Apply
                                                                                                 Available via Mail Order
LIPITOR 40MG TABLET                                                                      4       Quantity Limits Apply
                                                                                                 Available via Mail Order
LIPITOR 80MG TABLET                                                                      4       Available via Mail Order
LOPID                           gemfibrozil 600mg tablet                                         Only Generic Covered
lovastatin 10mg tablet          MEVACOR                                                  2       Available via Mail Order
lovastatin 20mg tablet          MEVACOR                                                  2       Available via Mail Order
lovastatin 40mg tablet          MEVACOR                                                  2       Available via Mail Order
LOVAZA 1GM CAPSULE                                                                       3       Available via Mail Order
MEVACOR                         lovastatin 10mg tablet                                           Only Generic Covered
MEVACOR                         lovastatin 20mg tablet                                           Only Generic Covered
MEVACOR                         lovastatin 40mg tablet                                           Only Generic Covered
NIASPAN 500MG ER TABLET                                                                  3       Available via Mail Order


27-921/01-01/06 Rev 01-11                                               [ 93]                    2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                       DRUG CATEGORY - DRUG CLASS
DRUG NAME                                             BRAND OR GENERIC EQUIVALENT                     TIER*   NOTES
NIASPAN 750MG ER TABLET                                                                               3       Available via Mail Order
NIASPAN 1000MG ER TABLET                                                                              3       Available via Mail Order
PRAVACHOL                   pravastatin 10mg tablet                                                           Only Generic Covered
PRAVACHOL                   pravastatin 10mg tab                                                              Only Generic Covered
PRAVACHOL                   pravastatin 20mg tablet                                                           Only Generic Covered
PRAVACHOL                   pravastatin 40mg tablet                                                           Only Generic Covered
PRAVACHOL                   pravastatin 80mg tablet                                                           Only Generic Covered
pravastatin 10mg tablet     PRAVACHOL                                                                 2       Quantity Limits Apply
                                                                                                              Available via Mail Order
pravastatin 10mg tab        PRAVACHOL                                                                 2       Available via Mail Order
pravastatin 20mg tablet     PRAVACHOL                                                                 2       Available via Mail Order
pravastatin 40mg tablet     PRAVACHOL                                                                 2       Available via Mail Order
pravastatin 80mg tablet     PRAVACHOL                                                                 2       Available via Mail Order
QUESTRAN                    cholestyramine 4gm pwd pckt                                                       Only Generic Covered
QUESTRAN                    cholestyramine reg powder                                                         Only Generic Covered
QUESTRAN LIGHT              cholestyramine light powder                                                       Only Generic Covered
QUESTRAN LIGHT              cholestyramine lite 4gm pwdpk                                                     Only Generic Covered
simvastatin 5mg tablet      ZOCOR                                                                     2       Available via Mail Order
simvastatin 10mg tablet     ZOCOR                                                                     2       Available via Mail Order
simvastatin 20mg tablet     ZOCOR                                                                     2       Available via Mail Order
simvastatin 40mg tablet     ZOCOR                                                                     2       Available via Mail Order
simvastatin 80mg tablet     ZOCOR                                                                     2       Available via Mail Order
TRICOR 48MG TABLET                                                                                    3       Available via Mail Order
TRICOR 145MG TABLET                                                                                   3       Available via Mail Order
TRILIPIX 135MG CAPSULE                                                                                3       Available via Mail Order
TRILIPIX 45MG CAPSULE                                                                                 3       Available via Mail Order
ZETIA 10MG TABLET                                                                                     3       Available via Mail Order
ZOCOR                       simvastatin 5mg tablet                                                            Only Generic Covered
ZOCOR                       simvastatin 10mg tablet                                                           Only Generic Covered
ZOCOR                       simvastatin 20mg tablet                                                           Only Generic Covered
ZOCOR                       simvastatin 40mg tablet                                                           Only Generic Covered
ZOCOR                       simvastatin 80mg tablet                                                           Only Generic Covered
                            Cardiovascular Agents - Renin-Angiotensin-Aldosterone System Inhibitors
ALTACE                      ramipril 1.25mg capsule                                                           Only Generic Covered
ALTACE                      ramipril 2.5mg capsule                                                            Only Generic Covered
ALTACE                      ramipril 5mg capsule                                                              Only Generic Covered

27-921/01-01/06 Rev 01-11                                           [ 94]                                     2011 Commercial Drug Formulary
                                                                                                                    Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
ALTACE                         ramipril 10mg capsule                                           Only Generic Covered
benazepril 5mg tablet          LOTENSIN (NOT HCT)                                      1       Available via Mail Order
benazepril 10mg tablet         LOTENSIN (NOT HCT)                                      1       Available via Mail Order
benazepril 10mg tab            LOTENSIN (NOT HCT)                                      1       Available via Mail Order
benazepril 20mg tablet         LOTENSIN (NOT HCT)                                      1       Available via Mail Order
benazepril 40mg tablet         LOTENSIN (NOT HCT)                                      1       Available via Mail Order
CAPOTEN                        captopril 12.5mg tablet                                         Only Generic Covered
CAPOTEN                        captopril 25mg tablet                                           Only Generic Covered
CAPOTEN                        captopril 50mg tablet                                           Only Generic Covered
CAPOTEN                        captopril 100mg tablet                                          Only Generic Covered
CAPOZIDE                       captopril/hctz 25/15mg tablt                                    Only Generic Covered
CAPOZIDE                       captopril/hctz 50/15mg tablt                                    Only Generic Covered
captopril 12.5mg tablet        CAPOTEN                                                 1       Available via Mail Order
captopril 25mg tablet          CAPOTEN                                                 1       Available via Mail Order
captopril 50mg tablet          CAPOTEN                                                 1       Available via Mail Order
captopril 100mg tablet         CAPOTEN                                                 1       Available via Mail Order
captopril/hctz 25/15mg tablt   CAPOZIDE                                                2       Available via Mail Order
captopril/hctz 50/15mg tablt   CAPOZIDE                                                2       Available via Mail Order
COZAAR                         losartan 25mg tablet                                            Only Generic Covered
COZAAR                         losartan 50mg tablet                                            Only Generic Covered
COZAAR                         losartan 100mg tablet                                           Only Generic Covered
DIOVAN 40MG TABLET                                                                     3       Available via Mail Order
DIOVAN 80MG TABLET                                                                     3       Available via Mail Order
DIOVAN 160MG TABLET                                                                    3       Available via Mail Order
DIOVAN 320MG TABLET                                                                    3       Available via Mail Order
enalapril 2.5mg tabgxvasotec   VASOTEC                                                 1       Available via Mail Order
enalapril 5mg tab gx vasotec   VASOTEC                                                 1       Available via Mail Order
enalapril 10mgtab gx vasotec   VASOTEC                                                 1       Available via Mail Order
enalapril 20mgtab gxvasotec    VASOTEC                                                 1       Available via Mail Order
fosinopril 10mg tablet         MONOPRIL (NOT HCT)                                      2       Available via Mail Order
fosinopril 20mg tablet         MONOPRIL (NOT HCT)                                      2       Available via Mail Order
fosinopril 40mg tablet         MONOPRIL (NOT HCT)                                      2       Available via Mail Order
lisinopril 2.5mg tablet        ZESTRIL                                                 1       Available via Mail Order
lisinopril 5mg tablet          ZESTRIL                                                 1       Available via Mail Order
lisinopril 10mg tablet         ZESTRIL                                                 1       Available via Mail Order
lisinopril 20mg tablet         ZESTRIL                                                 1       Available via Mail Order
27-921/01-01/06 Rev 01-11                                           [ 95]                      2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                       DRUG CATEGORY - DRUG CLASS
DRUG NAME                                             BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
lisinopril 30mg tablet      ZESTRIL                                                 2       Available via Mail Order
lisinopril 40mg tablet      ZESTRIL                                                 1       Available via Mail Order
losartan 25mg tablet        COZAAR                                                  2       Available via Mail Order
losartan 50mg tablet        COZAAR                                                  2       Available via Mail Order
losartan 100mg tablet       COZAAR                                                  2       Available via Mail Order
LOTENSIN (NOT HCT)          benazepril 5mg tablet                                           Only Generic Covered
LOTENSIN (NOT HCT)          benazepril 10mg tablet                                          Only Generic Covered
LOTENSIN (NOT HCT)          benazepril 10mg tab                                             Only Generic Covered
LOTENSIN (NOT HCT)          benazepril 20mg tablet                                          Only Generic Covered
LOTENSIN (NOT HCT)          benazepril 40mg tablet                                          Only Generic Covered
MICARDIS 20MG TABLET                                                                3       Available via Mail Order
MICARDIS 40MG TABLET                                                                3       Available via Mail Order
MICARDIS 80MG TABLET                                                                3       Available via Mail Order
MONOPRIL (NOT HCT)          fosinopril 10mg tablet                                          Only Generic Covered
MONOPRIL (NOT HCT)          fosinopril 20mg tablet                                          Only Generic Covered
MONOPRIL (NOT HCT)          fosinopril 40mg tablet                                          Only Generic Covered
ramipril 1.25mg capsule     ALTACE                                                  2       Available via Mail Order
ramipril 2.5mg capsule      ALTACE                                                  2       Available via Mail Order
ramipril 5mg capsule        ALTACE                                                  2       Available via Mail Order
ramipril 10mg capsule       ALTACE                                                  2       Available via Mail Order
TEKTURNA 150MG TABLET                                                               4       Available via Mail Order
                                                                                            Step Therapy Applies
TEKTURNA 300MG TABLET                                                               4       Available via Mail Order
                                                                                            Step Therapy Applies
VASOTEC                     enalapril 2.5mg tabgxvasotec                                    Only Generic Covered
VASOTEC                     enalapril 5mg tab gx vasotec                                    Only Generic Covered
VASOTEC                     enalapril 10mgtab gx vasotec                                    Only Generic Covered
VASOTEC                     enalapril 20mgtab gxvasotec                                     Only Generic Covered
ZESTRIL                     lisinopril 2.5mg tablet                                         Only Generic Covered
ZESTRIL                     lisinopril 5mg tablet                                           Only Generic Covered
ZESTRIL                     lisinopril 10mg tablet                                          Only Generic Covered
ZESTRIL                     lisinopril 20mg tablet                                          Only Generic Covered
ZESTRIL                     lisinopril 30mg tablet                                          Only Generic Covered
ZESTRIL                     lisinopril 40mg tablet                                          Only Generic Covered
                            Cardiovascular Agents - Vasodilators
APRESOLINE                  hydralazine 10mg tablet                                         Only Generic Covered

27-921/01-01/06 Rev 01-11                                          [ 96]                    2011 Commercial Drug Formulary
                                                                                                  Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
APRESOLINE                    hydralazine 25mg tablet                                          Only Generic Covered
APRESOLINE                    hydralazine 50mg tablet                                          Only Generic Covered
APRESOLINE                    hydralazine 100mg tablet                                         Only Generic Covered
APRESOLINE                    hydralazine 20mg/ml inj                                          Only Generic Covered
hydralazine 10mg tablet       APRESOLINE                                               2       Available via Mail Order
hydralazine 25mg tablet       APRESOLINE                                               2       Available via Mail Order
hydralazine 50mg tablet       APRESOLINE                                               2       Available via Mail Order
hydralazine 100mg tablet      APRESOLINE                                               2       Available via Mail Order
hydralazine 20mg/ml inj       APRESOLINE                                               5
IMDUR                         isosorbide mon er 30mg tab                                       Only Generic Covered
IMDUR                         isosorbide mon er 60mg tab                                       Only Generic Covered
IMDUR                         isosorbide mon er 120mg tab                                      Only Generic Covered
ISORDIL                       isosorbide 2.5mg sl tablet                                       Only Generic Covered
ISORDIL                       isosorbide 5mg sl tablet                                         Only Generic Covered
ISORDIL                       isosorbide 5mg oral tablet                                       Only Generic Covered
ISORDIL                       isosorbide 10mg oral tablet                                      Only Generic Covered
ISORDIL                       isosorbide 20mg oral tablet                                      Only Generic Covered
ISORDIL                       isosorbide 30mg oral tablet                                      Only Generic Covered
isosorbide 2.5mg sl tablet    ISORDIL                                                  2       Available via Mail Order
isosorbide 5mg sl tablet      ISORDIL                                                  2       Available via Mail Order
isosorbide 5mg oral tablet    ISORDIL                                                  2       Available via Mail Order
isosorbide mon er 30mg tab    IMDUR                                                    2       Available via Mail Order
isosorbide mon er 60mg tab    IMDUR                                                    2       Available via Mail Order
isosorbide mon er 120mg tab   IMDUR                                                    2       Available via Mail Order
isosorbide 10mg oral tablet   ISORDIL                                                  2       Available via Mail Order
isosorbide 20mg oral tablet   ISORDIL                                                  2       Available via Mail Order
isosorbide 30mg oral tablet   ISORDIL                                                  2       Available via Mail Order
isosorbide-er 40mg tablet     SORBITRATE                                               2       Available via Mail Order
LONITEN                       minoxidil 2.5mg tablet                                           Only Generic Covered
LONITEN                       minoxidil 10mg tablet                                            Only Generic Covered
minoxidil 2.5mg tablet        LONITEN                                                  2       Available via Mail Order
minoxidil 10mg tablet         LONITEN                                                  2       Available via Mail Order
NITRO DUR                     nitroglycerin 0.2mg/hr patch                                     Only Generic Covered
NITRO DUR                     nitroglycerin 0.4mg/hr patch                                     Only Generic Covered
nitro-bid 2% ointment                                                                  2       Quantity Limits Apply
                                                                                               Available via Mail Order

27-921/01-01/06 Rev 01-11                                           [ 97]                      2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
NITRO-DUR                       nitroglycerin 0.1mg/hr patch                                    Only Generic Covered
NITRO-DUR                       nitroglycerin 0.6mg/hr patch                                    Only Generic Covered
nitroglycerin 0.1mg/hr patch    NITRO-DUR                                               2       Available via Mail Order
nitroglycerin 0.2mg/hr patch    NITRO DUR                                               2       Available via Mail Order
nitroglycerin 0.4mg/hr patch    NITRO DUR                                               2       Available via Mail Order
nitroglycerin 0.6mg/hr patch    NITRO-DUR                                               2       Available via Mail Order
nitroglycerin 2.5mg capsule                                                             2       Available via Mail Order
nitroglycerin 6.5mg capsule                                                             2       Available via Mail Order
nitroglycerin 9mg capsule                                                               2       Available via Mail Order
nitroglycerin s/l 0.3mg tablt   NITROSTAT                                               2       Available via Mail Order
nitroglycerin s/l 0.4mg tablt   NITROSTAT                                               1       Available via Mail Order
nitroglycerin s/l 0.6mg tablt   NITROSTAT                                               2       Available via Mail Order
nitroquick 0.4mg sl tab         NITROSTAT                                               2       Available via Mail Order
NITROSTAT                       nitroglycerin s/l 0.3mg tablt                                   Only Generic Covered
NITROSTAT                       nitroglycerin s/l 0.4mg tablt                                   Only Generic Covered
NITROSTAT                       nitroglycerin s/l 0.6mg tablt                                   Only Generic Covered
NITROSTAT                       nitroquick 0.4mg sl tab                                         Only Generic Covered
NITROSTAT 0.3MG SUBLING                                                                 3       Available via Mail Order
NITROSTAT 0.4MG SUBLING                                                                 3       Available via Mail Order
NITROSTAT 0.6MG SUBLING                                                                 3       Available via Mail Order
papaverine 150mg capsule        PAVABID                                                 2       Available via Mail Order
PAVABID                         papaverine 150mg capsule                                        Only Generic Covered
reserpine 0.1mg tablet          SERPALAN                                                2       Available via Mail Order
reserpine 0.25mg tablet         SERPALAN                                                2       Available via Mail Order
SERPALAN                        reserpine 0.1mg tablet                                          Only Generic Covered
SERPALAN                        reserpine 0.25mg tablet                                         Only Generic Covered
SORBITRATE                      isosorbide-er 40mg tablet                                       Only Generic Covered
                                Central Nervous System Agents - Amphetamines
adderall xr 5mg capsule                                                                 2       Quantity Limits Apply
                                                                                                Available via Mail Order
adderall xr 10mg capsule                                                                2       Quantity Limits Apply
                                                                                                Available via Mail Order
adderall xr 15mg capsule                                                                2       Quantity Limits Apply
                                                                                                Available via Mail Order
adderall xr 20mg capsule                                                                2       Quantity Limits Apply
                                                                                                Available via Mail Order


27-921/01-01/06 Rev 01-11                                             [ 98]                     2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                        DRUG CATEGORY - DRUG CLASS
DRUG NAME                                              BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
adderall xr 25mg capsule                                                             2       Quantity Limits Apply
                                                                                             Available via Mail Order
adderall xr 30mg capsule                                                             2       Quantity Limits Apply
                                                                                             Available via Mail Order
DEXEDRINE                       dextroamphetamine 5mg tablet                                 Only Generic Covered
DEXEDRINE CR                    dextroamphetamine cr 5mg cap                                 Only Generic Covered
DEXEDRINE CR                    dextroamphetamine cr 10mg cap                                Only Generic Covered
DEXEDRINE CR                    dextroamphetamine cr 15mg cap                                Only Generic Covered
dextroamphetamine 10mg tablet   DEXTROSTAT                                           2       Available via Mail Order
dextroamphetamine 5mg tablet    DEXEDRINE                                            2       Available via Mail Order
dextroamphetamine cr 5mg cap    DEXEDRINE CR                                         2       Available via Mail Order
dextroamphetamine cr 10mg cap   DEXEDRINE CR                                         2       Available via Mail Order
dextroamphetamine cr 15mg cap   DEXEDRINE CR                                         2       Available via Mail Order
DEXTROSTAT                      dextroamphetamine 10mg tablet                                Only Generic Covered
                                Central Nervous System Agents - Non-Amphetamines
buprenorphine 2mg sl tablet     SUBUTEX                                              2       Prior Auth Required
buprenorphine 8mg sl tablet     SUBUTEX                                              2       Prior Auth Required
CONCERTA                        methylphenidate er 18mg tab                                  Only Generic Covered
CONCERTA                        methylphenidate er 27mg tab                                  Only Generic Covered
CONCERTA                        methylphenidate er 36mg tab                                  Only Generic Covered
CONCERTA                        methylphenidate er 54mg tab                                  Only Generic Covered
METADATE CD 10MG CAPSULE                                                             3       Quantity Limits Apply
                                                                                             Available via Mail Order
METADATE CD 20MG CAPSULE                                                             3       Quantity Limits Apply
                                                                                             Available via Mail Order
METADATE CD 30MG CAPSULE                                                             3       Quantity Limits Apply
                                                                                             Available via Mail Order
METADATE CD 40MG CAPSULE                                                             3       Quantity Limits Apply
                                                                                             Available via Mail Order
METADATE CD 50MG CAPSULE                                                             3       Quantity Limits Apply
                                                                                             Available via Mail Order
METADATE CD 60MG CAPSULE                                                             3       Quantity Limits Apply
                                                                                             Available via Mail Order
methylin 5mg tablet             RITALIN (NOT LA)                                     2       Available via Mail Order
methylin 10mg tablet            RITALIN (NOT LA)                                     2       Available via Mail Order
methylin 20mg tablet            RITALIN (NOT LA)                                     2       Available via Mail Order
methylin er 20mg tablet         RITALIN ER (NOT LA)                                  2       Available via Mail Order
methylphenidate 10mg/5ml soln   RITALIN SOLN                                         2       Available via Mail Order

27-921/01-01/06 Rev 01-11                                            [ 99]                   2011 Commercial Drug Formulary
                                                                                                   Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
methylphenidate er 18mg tab     CONCERTA                                                2       Quantity Limits Apply
                                                                                                Available via Mail Order
methylphenidate er 27mg tab     CONCERTA                                                2       Quantity Limits Apply
                                                                                                Available via Mail Order
methylphenidate er 36mg tab     CONCERTA                                                2       Quantity Limits Apply
                                                                                                Available via Mail Order
methylphenidate er 54mg tab     CONCERTA                                                2       Quantity Limits Apply
                                                                                                Available via Mail Order
PROVIGIL 100MG TABLET                                                                   4       Prior Auth Required
                                                                                                Quantity Limits Apply
PROVIGIL 200MG CAPLET                                                                   4       Prior Auth Required
                                                                                                Quantity Limits Apply
RILUTEK 50MG TABLET                                                                     3       Prior Auth Required
RITALIN (NOT LA)                methylin 5mg tablet                                             Only Generic Covered
RITALIN (NOT LA)                methylin 10mg tablet                                            Only Generic Covered
RITALIN (NOT LA)                methylin 20mg tablet                                            Only Generic Covered
RITALIN ER (NOT LA)             methylin er 20mg tablet                                         Only Generic Covered
RITALIN SOLN                    methylphenidate 10mg/5ml soln                                   Only Generic Covered
STRATTERA 10MG CAPSULE                                                                  3       Available via Mail Order
STRATTERA 18MG CAPSULE                                                                  3       Available via Mail Order
STRATTERA 25MG CAPSULE                                                                  3       Available via Mail Order
STRATTERA 40MG CAPSULE                                                                  3       Available via Mail Order
STRATTERA 60MG CAPSULE                                                                  3       Available via Mail Order
STRATTERA 80MG CAPSULE                                                                  3       Available via Mail Order
STRATTERA 100MG CAPSULE                                                                 3       Available via Mail Order
SUBOXONE 2MG/0.5MG SL TAB                                                               4       Prior Auth Required
SUBOXONE 2MG/0.5MG SL FILM                                                              4       Prior Auth Required
                                                                                                Quantity Limits Apply
SUBOXONE 8MG/2MG SL TAB                                                                 4       Prior Auth Required
SUBOXONE 8MG/2MG SL FILM                                                                4       Prior Auth Required
                                                                                                Quantity Limits Apply
SUBUTEX                         buprenorphine 2mg sl tablet                                     Only Generic Covered
SUBUTEX                         buprenorphine 8mg sl tablet                                     Only Generic Covered
                                Dental and Oral Agents
chlorhexidine gluc 0.12% soln   PERIDEX                                                 2       Quantity Limits Apply
dentagel 1.1% gel               PREVIDENT                                               2       Quantity Limits Apply
KENALOG                         triamcinolone/orabase dnt pst                                   Only Generic Covered
LURIDE                          sod fluoride 0.25mg chew tab                                    Only Generic Covered

27-921/01-01/06 Rev 01-11                                            [ 100]                     2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
LURIDE                          sod fluoride 0.5mg chew tab                                     Only Generic Covered
LURIDE                          sod fluoride 1mg chew tablet                                    Only Generic Covered
PERIDEX                         chlorhexidine gluc 0.12% soln                                   Only Generic Covered
PREVIDENT                       dentagel 1.1% gel                                               Only Generic Covered
sod fluoride 0.25mg chew tab    LURIDE                                                  2       Available via Mail Order
sod fluoride 0.5mg chew tab     LURIDE                                                  2       Available via Mail Order
sod fluoride 1mg chew tablet    LURIDE                                                  2       Available via Mail Order
triamcinolone/orabase dnt pst   KENALOG                                                 2
                                Dermatological Agents - Dermatological Anesthetics
EMLA                            lido/prilocaine 2.5% cream                                      Only Generic Covered
lido/prilocaine 2.5% cream      EMLA                                                    2       Quantity Limits Apply
lidocaine 5% ointment           XYLOCAINE                                               2       Quantity Limits Apply
lidocaine viscous 2% soln       XYLOCAINE                                               2       Quantity Limits Apply
LIDODERM 5% PATCH                                                                       4       Prior Auth Required
XYLOCAINE                       lidocaine 5% ointment                                           Only Generic Covered
XYLOCAINE                       lidocaine viscous 2% soln                                       Only Generic Covered
                                Dermatological Agents - Dermatological Antibacterials
A/T/S                           erythromycin 2% topical soln                                    Only Generic Covered
ALCOHOL PREP PADS                                                                       3       Available via Mail Order
BACTROBAN                       mupirocin 2% ointment                                           Only Generic Covered
BACTROBAN 2% CREAM                                                                      3       Quantity Limits Apply
CORTISPORIN CREAM                                                                       3       Quantity Limits Apply
CORTISPORIN OINTMENT                                                                    3       Quantity Limits Apply
erythromycin 2% topical soln    A/T/S                                                   2       Quantity Limits Apply
GARAMYCIN                       gentamicin 0.1% ointment                                        Only Generic Covered
GARAMYCIN                       gentamicin 0.1% cream                                           Only Generic Covered
gentamicin 0.1% ointment        GARAMYCIN                                               2       Quantity Limits Apply
gentamicin 0.1% cream           GARAMYCIN                                               2       Quantity Limits Apply
METROCREAM                      metronidazole 0.75% cream                                       Only Generic Covered
METROGEL                        metronidazole 0.75% gel                                         Only Generic Covered
METROGEL 1% GEL                                                                         3       Quantity Limits Apply
METROLOTION                     metronidazole 0.75% lotion                                      Only Generic Covered
metronidazole 0.75% cream       METROCREAM                                              2       Quantity Limits Apply
metronidazole 0.75% gel         METROGEL                                                2       Quantity Limits Apply
metronidazole 0.75% lotion      METROLOTION                                             2       Quantity Limits Apply
mupirocin 2% ointment           BACTROBAN                                               2       Quantity Limits Apply
27-921/01-01/06 Rev 01-11                                               [ 101]                  2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT        TIER*   NOTES
SILVADENE                      thermazene 1% crm                                                   Only Generic Covered
thermazene 1% crm              SILVADENE                                                   2
                               Dermatological Agents - Dermatological Antifungals
ciclopirox 0.77% cream         LOPROX (NOT SHAMPOO)                                        2       Quantity Limits Apply
ciclopirox 0.77% gel           LOPROX                                                      2       Quantity Limits Apply
ciclopirox 0.77% susp          LOPROX (NOT SHAMPOO)                                        2       Quantity Limits Apply
ciclopirox 8% soln             PENLAC                                                      2       Quantity Limits Apply
clotrim/betam dip/0.05% crm    LOTRISONE                                                   2       Quantity Limits Apply
clotrim/betam dip/0.05% lot    LOTRISONE                                                   2       Quantity Limits Apply
econazole nitrate 1% cream     SPECTAZOLE                                                  2       Quantity Limits Apply
ketoconazole 2% cream          NIZORAL                                                     2       Quantity Limits Apply
LOPROX                         ciclopirox 0.77% gel                                                Only Generic Covered
LOPROX (NOT SHAMPOO)           ciclopirox 0.77% cream                                              Only Generic Covered
LOPROX (NOT SHAMPOO)           ciclopirox 0.77% susp                                               Only Generic Covered
LOTRISONE                      clotrim/betam dip/0.05% crm                                         Only Generic Covered
LOTRISONE                      clotrim/betam dip/0.05% lot                                         Only Generic Covered
MYCOLOG II                     nystatin/triamcinolone cream                                        Only Generic Covered
MYCOLOG II                     nystatin/triamcinolone oint                                         Only Generic Covered
MYCOSTATIN                     nystatin cream                                                      Only Generic Covered
MYCOSTATIN                     nystatin ointment                                                   Only Generic Covered
MYCOSTATIN                     nystatin 100m un/ml susp                                            Only Generic Covered
NIZORAL                        ketoconazole 2% cream                                               Only Generic Covered
nystatin cream                 MYCOSTATIN                                                  2       Quantity Limits Apply
nystatin ointment              MYCOSTATIN                                                  2       Quantity Limits Apply
nystatin 100m un/ml susp       MYCOSTATIN                                                  2
nystatin/triamcinolone cream   MYCOLOG II                                                  2       Quantity Limits Apply
nystatin/triamcinolone oint    MYCOLOG II                                                  2       Quantity Limits Apply
OXISTAT 1% CREAM                                                                           3       Quantity Limits Apply
OXISTAT 1% LOTION                                                                          3       Quantity Limits Apply
PENLAC                         ciclopirox 8% soln                                                  Only Generic Covered
selenium sulfide 2.5% lotion   SELSUN                                                      2       Quantity Limits Apply
SELSUN                         selenium sulfide 2.5% lotion                                        Only Generic Covered
SILVADENE                      ssd cream                                                           Only Generic Covered
SPECTAZOLE                     econazole nitrate 1% cream                                          Only Generic Covered
ssd cream                      SILVADENE                                                   2
                               Dermatological Agents - Dermatological Antiinflammatories
27-921/01-01/06 Rev 01-11                                             [ 102]                       2011 Commercial Drug Formulary
                                                                                                         Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
ANUSOL HC                       proctosol-hc 2.5% crm                                           Only Generic Covered
ARISOCORT                       triamcinolone 0.5% cream                                        Only Generic Covered
ARISOTCORT                      triamcinolone 0.1% cream                                        Only Generic Covered
ARISTOCORT                      triamcinolone 0.025% cream                                      Only Generic Covered
ARISTOCORT                      triamcinolone 0.025% lotion                                     Only Generic Covered
ARISTOCORT                      triamcinolone 0.025% oint                                       Only Generic Covered
ARISTOCORT                      triamcinolone 0.1% lotion                                       Only Generic Covered
ARISTOCORT                      triamcinolone 0.1% ointment                                     Only Generic Covered
ARISTOCORT                      triamcinolone 0.5% ointment                                     Only Generic Covered
betamethasone diprop .05% crm   DIPROSONE                                               2       Quantity Limits Apply
betamethasone diprop .05% lot   DIPROSONE                                               2       Quantity Limits Apply
betamethasone diprop.05% oint   DIPROSONE                                               2       Quantity Limits Apply
betamethasone val 0.1% cream    VALISONE                                                2       Quantity Limits Apply
betamethasone val 0.1% oint     VALISONE                                                2       Quantity Limits Apply
betamethasone val 0.1% lotion   VALISONE                                                2       Quantity Limits Apply
clobetasol e 0.05% cream        TEMOVATE E                                              2       Quantity Limits Apply
clobetasol prop. 0.05% gel      TEMOVATE                                                2       Quantity Limits Apply
clobetasol prop. 0.05% soln     TEMOVATE SCALP                                          2       Quantity Limits Apply
clobetasol prop. 0.05% cream    TEMOVATE                                                2       Quantity Limits Apply
clobetasol prop. 0.05% oint     TEMOVATE                                                2       Quantity Limits Apply
CORDRAN TAPE LARGE                                                                      3       Quantity Limits Apply
CUTIVATE                        fluticasone 0.005% ointment                                     Only Generic Covered
CUTIVATE                        fluticasone 0.05% cream                                         Only Generic Covered
CUTIVATE 0.05%       LOTION                                                             4       Quantity Limits Apply
desonide 0.05% cream            TRIDESILON                                              2       Quantity Limits Apply
desonide 0.05% lotion           DESOWEN                                                 2       Quantity Limits Apply
desonide 0.05% ointment         TRIDESILON                                              2       Quantity Limits Apply
DESOWEN                         desonide 0.05% lotion                                           Only Generic Covered
desoximetasone 0.05% cream      TOPICORT                                                2       Quantity Limits Apply
desoximetasone 0.05% gel        TOPICORT                                                2       Quantity Limits Apply
desoximetasone 0.25% cream      TOPICORT                                                2       Quantity Limits Apply
desoximetasone 0.25% ointment   TOPICORT                                                2       Quantity Limits Apply
diflorasone diac 0.05% cream    PSORCON                                                 2       Quantity Limits Apply
diflorasone diac 0.05% oint     PSORCON                                                 2       Quantity Limits Apply
DIPROSONE                       betamethasone diprop .05% crm                                   Only Generic Covered
DIPROSONE                       betamethasone diprop .05% lot                                   Only Generic Covered
27-921/01-01/06 Rev 01-11                                            [ 103]                     2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
DIPROSONE                       betamethasone diprop.05% oint                                   Only Generic Covered
ELIDEL 1% CREAM                                                                         4       Quantity Limits Apply
ELOCON                          mometasone 0.1% cream                                           Only Generic Covered
ELOCON                          mometasone 0.1% ointment                                        Only Generic Covered
ELOCON                          mometasone 0.1% soln                                            Only Generic Covered
fluocinolone 0.01% cream        SYNALAR                                                 2       Quantity Limits Apply
fluocinolone 0.01% soln         SYNALAR                                                 2       Quantity Limits Apply
fluocinolone 0.025% cream       SYNALAR                                                 2       Quantity Limits Apply
fluocinolone 0.025% oint        SYNALAR                                                 2       Quantity Limits Apply
fluocinonide 0.05% cream        LIDEX                                                   2       Quantity Limits Apply
fluocinonide 0.05% gel          LIDEX                                                   2       Quantity Limits Apply
fluocinonide 0.05% ointment     LIDEX                                                   2       Quantity Limits Apply
fluocinonide 0.05% soln         LIDEX                                                   2       Quantity Limits Apply
fluocinonide-e 0.05% cream      LIDEX -E                                                2       Quantity Limits Apply
fluticasone 0.005% ointment     CUTIVATE                                                2       Quantity Limits Apply
fluticasone 0.05% cream         CUTIVATE                                                2       Quantity Limits Apply
hydrocortisone 2.5% cream       HYTONE                                                  2       Quantity Limits Apply
hydrocortisone 2.5% lotion      HYTONE                                                  2       Quantity Limits Apply
hydrocortisone 2.5% ointment    HYTONE                                                  2       Quantity Limits Apply
hydrocortisone but 0.1% oint    LOCOID                                                  2       Quantity Limits Apply
hydrocortisone but 0.1% soln    LOCOID                                                  2       Quantity Limits Apply
hydrocortisone but 0.1% cream   LOCOID                                                  2       Quantity Limits Apply
HYTONE                          hydrocortisone 2.5% cream                                       Only Generic Covered
HYTONE                          hydrocortisone 2.5% lotion                                      Only Generic Covered
HYTONE                          hydrocortisone 2.5% ointment                                    Only Generic Covered
LIDEX                           fluocinonide 0.05% cream                                        Only Generic Covered
LIDEX                           fluocinonide 0.05% gel                                          Only Generic Covered
LIDEX                           fluocinonide 0.05% ointment                                     Only Generic Covered
LIDEX                           fluocinonide 0.05% soln                                         Only Generic Covered
LIDEX -E                        fluocinonide-e 0.05% cream                                      Only Generic Covered
LOCOID                          hydrocortisone but 0.1% oint                                    Only Generic Covered
LOCOID                          hydrocortisone but 0.1% soln                                    Only Generic Covered
LOCOID                          hydrocortisone but 0.1% cream                                   Only Generic Covered
mometasone 0.1% cream           ELOCON                                                  2       Quantity Limits Apply
mometasone 0.1% ointment        ELOCON                                                  2       Quantity Limits Apply
mometasone 0.1% soln            ELOCON                                                  2       Quantity Limits Apply
27-921/01-01/06 Rev 01-11                                            [ 104]                     2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
proctosol-hc 2.5% crm         ANUSOL HC                                                2       Quantity Limits Apply
                                                                                               Available via Mail Order
PSORCON                       diflorasone diac 0.05% cream                                     Only Generic Covered
PSORCON                       diflorasone diac 0.05% oint                                      Only Generic Covered
SYNALAR                       fluocinolone 0.01% cream                                         Only Generic Covered
SYNALAR                       fluocinolone 0.01% soln                                          Only Generic Covered
SYNALAR                       fluocinolone 0.025% cream                                        Only Generic Covered
SYNALAR                       fluocinolone 0.025% oint                                         Only Generic Covered
TEMOVATE                      clobetasol prop. 0.05% gel                                       Only Generic Covered
TEMOVATE                      clobetasol prop. 0.05% cream                                     Only Generic Covered
TEMOVATE                      clobetasol prop. 0.05% oint                                      Only Generic Covered
TEMOVATE E                    clobetasol e 0.05% cream                                         Only Generic Covered
TEMOVATE SCALP                clobetasol prop. 0.05% soln                                      Only Generic Covered
TOPICORT                      desoximetasone 0.05% cream                                       Only Generic Covered
TOPICORT                      desoximetasone 0.05% gel                                         Only Generic Covered
TOPICORT                      desoximetasone 0.25% cream                                       Only Generic Covered
TOPICORT                      desoximetasone 0.25% ointment                                    Only Generic Covered
triamcinolone 0.025% cream    ARISTOCORT                                               2       Quantity Limits Apply
triamcinolone 0.025% lotion   ARISTOCORT                                               2       Quantity Limits Apply
triamcinolone 0.025% oint     ARISTOCORT                                               2       Quantity Limits Apply
triamcinolone 0.1% lotion     ARISTOCORT                                               2       Quantity Limits Apply
triamcinolone 0.1% cream      ARISOTCORT                                               2       Quantity Limits Apply
triamcinolone 0.1% ointment   ARISTOCORT                                               2       Quantity Limits Apply
triamcinolone 0.5% cream      ARISOCORT                                                2       Quantity Limits Apply
triamcinolone 0.5% ointment   ARISTOCORT                                               2       Quantity Limits Apply
TRIDESILON                    desonide 0.05% cream                                             Only Generic Covered
TRIDESILON                    desonide 0.05% ointment                                          Only Generic Covered
VALISONE                      betamethasone val 0.1% cream                                     Only Generic Covered
VALISONE                      betamethasone val 0.1% oint                                      Only Generic Covered
VALISONE                      betamethasone val 0.1% lotion                                    Only Generic Covered
                              Dermatological Agents - Dermatological Antipruritic
prudoxin 5% cream             ZONALON                                                  2       Quantity Limits Apply
ZONALON                       prudoxin 5% cream                                                Only Generic Covered
                              Dermatological Agents - Dermatological Antivirals
aldara 5% cream                                                                        2       Quantity Limits Apply
DENAVIR 1% CREAM                                                                       4       Quantity Limits Apply

27-921/01-01/06 Rev 01-11                                             [ 105]                   2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                        DRUG CATEGORY - DRUG CLASS
DRUG NAME                                              BRAND OR GENERIC EQUIVALENT            TIER*   NOTES
ZOVIRAX 5% OINT                                                                               3       Quantity Limits Apply
                            Dermatological Agents - Dermatological Keratolytics
CARMOL                      urea 40% crm                                                              Only Generic Covered
CARMOL                      x-viate 40% lotion                                                        Only Generic Covered
SOLARAZE 3% GEL                                                                               3       Prior Auth Required
                                                                                                      Quantity Limits Apply
urea 40% crm                CARMOL                                                            2       Quantity Limits Apply
x-viate 40% lotion          CARMOL                                                            2       Quantity Limits Apply
                            Dermatological Agents - Dermatological Mitotic Inhibitors
CONDYLOX                    podofilox 0.5% top soln                                                   Only Generic Covered
EFUDEX                      fluorouracil 2% top soln                                                  Only Generic Covered
EFUDEX                      fluorouracil 5% cream                                                     Only Generic Covered
EFUDEX 5% SOLN              fluorouracil 5% top soln                                                  Only Generic Covered
fluorouracil 2% top soln    EFUDEX                                                            2       Quantity Limits Apply
fluorouracil 5% cream       EFUDEX                                                            2       Quantity Limits Apply
fluorouracil 5% top soln    EFUDEX 5% SOLN                                                    2       Quantity Limits Apply
podofilox 0.5% top soln     CONDYLOX                                                          2       Quantity Limits Apply
                            Dermatological Agents - Dermatological Photochemotherapy Agents
OXSORALEN 1% LOTION                                                                           3       Quantity Limits Apply
OXSORALEN ULTRA 10MG CAP                                                                      3
                            Dermatological Agents - Dermatological Retinoids
RETIN A                     tretinoin 0.01% gel                                                       Only Generic Covered
RETIN A                     tretinoin 0.025% gel                                                      Only Generic Covered
RETIN A                     tretinoin 0.025% cream                                                    Only Generic Covered
RETIN A                     tretinoin 0.05% cream                                                     Only Generic Covered
RETINA                      tretinoin 0.1% cream                                                      Only Generic Covered
tretinoin 0.01% gel         RETIN A                                                           2       Prior Auth Required
                                                                                                      Quantity Limits Apply
tretinoin 0.025% gel        RETIN A                                                           2       Prior Auth Required
                                                                                                      Quantity Limits Apply
tretinoin 0.025% cream      RETIN A                                                           2       Prior Auth Required
                                                                                                      Quantity Limits Apply
tretinoin 0.05% cream       RETIN A                                                           2       Prior Auth Required
                                                                                                      Quantity Limits Apply
tretinoin 0.1% cream        RETINA                                                            2       Prior Auth Required
                                                                                                      Quantity Limits Apply
                            Dermatological Agents - Dermatological Vitamin D Analogs


27-921/01-01/06 Rev 01-11                                           [ 106]                            2011 Commercial Drug Formulary
                                                                                                            Last Updated: July 1, 2011
                                                        DRUG CATEGORY - DRUG CLASS
DRUG NAME                                              BRAND OR GENERIC EQUIVALENT      TIER*   NOTES
calcipotriene 0.005% oint    DOVONEX                                                    2       Quantity Limits Apply
calcipotriene 0.005% soln    DOVONEX                                                    2       Quantity Limits Apply
DOVONEX                      calcipotriene 0.005% oint                                          Only Generic Covered
DOVONEX                      calcipotriene 0.005% soln                                          Only Generic Covered
DOVONEX 0.005% CREAM                                                                    4       Quantity Limits Apply
                             Dermatological Agents - Dermatological Wound Care Agents
collodion (flexible) liq                                                                2
SANTYL 250U/GM OINT                                                                     4       Quantity Limits Apply
vasolex ointment             XENADERM                                                   2       Quantity Limits Apply
XENADERM                     vasolex ointment                                                   Only Generic Covered
                             Deterents/Replacements - Alcohol Deterents
ANTABUSE                     disulfiram 250mg tablet                                            Only Generic Covered
ANTABUSE 500MG TAB                                                                      4
CAMPRAL 333MG TAB                                                                       4
disulfiram 250mg tablet      ANTABUSE                                                   2
                             Enzyme Replacements/Modifiers
ADAGEN 250U/ML INJ                                                                      6       Prior Auth Required
ALDURAZYME 2.9MG/5ML INJ                                                                6       Prior Auth Required
CEREDASE 80U/ML INJECTABLE                                                              6       Prior Auth Required
CEREZYME 200U INJ                                                                       6       Prior Auth Required
CREON CAPSULE 6OOO UNITS                                                                3       Available via Mail Order
CREON CAPSULE 12000 UNITS                                                               3       Available via Mail Order
CREON CAPSULE 24000 UNITS                                                               3       Available via Mail Order
ELAPRASE 6MG/3ML INJ                                                                    6       Prior Auth Required
ELITEK 1.5MG INJ                                                                        6       Prior Auth Required
FABRAZYME 5MG INJ                                                                       6       Prior Auth Required
KUVAN 100MG TABLET                                                                      6       Prior Auth Required
NAGLAZYME 1MG/ML INJ                                                                    6       Prior Auth Required
ORFADIN 10MG CAP                                                                        6       Prior Auth Required
PANCREAZE 10,500UN CAPSULE                                                              3       Available via Mail Order
PANCREAZE 21,000UN CAPSULE                                                              3       Available via Mail Order
VIOKASE-16 TABLET                                                                       4       Available via Mail Order
ZAVESCA 100MG CAP                                                                       4       Prior Auth Required
ZENPEP 5000UN CAPSULE                                                                   4       Available via Mail Order
ZENPEP 10,000UN CAPSULE                                                                 4       Available via Mail Order
ZENPEP 15,000UN CAPSULE                                                                 4       Available via Mail Order
27-921/01-01/06 Rev 01-11                                           [ 107]                      2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT         TIER*   NOTES
ZENPEP 20,000UN CAPSULE                                                                      4       Available via Mail Order
                                Gastrointestinal Agents - Antispasmodics, Gastrointestinal
bell al/phen tab(gx donnatal)   DONNATAL                                                     2
bella/pb elix                   DONNATAL                                                     2
BENTYL                          dicyclomine 10mg capsule                                             Only Generic Covered
BENTYL                          dicyclomine 20mg tab                                                 Only Generic Covered
BENTYL 10MG/5ML SYRUP                                                                        4
dicyclomine 10mg capsule        BENTYL                                                       2
dicyclomine 20mg tab            BENTYL                                                       2
DONNATAL                        bell al/phen tab(gx donnatal)                                        Only Generic Covered
DONNATAL                        bella/pb elix                                                        Only Generic Covered
glycopyrrolate 0.2mg/ml inj     ROBINUL                                                      5
glycopyrrolate 1mg tablet       ROBINUL                                                      2
glycopyrrolate 2mg tablet       ROBINUL                                                      2
hyomax 0.125mg tab              LEVSIN                                                       2
hyomax-sl 0.125mg subl tab      LEVSIN S/L                                                   2
hyomax-sr 0.375mg tab           LEVBID                                                       2
hyoscyamine 0.125/5ml elixir    LEVSIN                                                       2
hyoscyamine 0.125mg/ml drop     LEVSIN DROPS                                                 2       Quantity Limits Apply
hyoscyamine 0.375mg er tab      LEVBID                                                       2
hyoscyamine-sr 0.375mg caps     LEVSINEX                                                     2
LEVBID                          hyomax-sr 0.375mg tab                                                Only Generic Covered
LEVBID                          hyoscyamine 0.375mg er tab                                           Only Generic Covered
LEVSIN                          hyomax 0.125mg tab                                                   Only Generic Covered
LEVSIN                          hyoscyamine 0.125/5ml elixir                                         Only Generic Covered
LEVSIN DROPS                    hyoscyamine 0.125mg/ml drop                                          Only Generic Covered
LEVSIN S/L                      hyomax-sl 0.125mg subl tab                                           Only Generic Covered
LEVSINEX                        hyoscyamine-sr 0.375mg caps                                          Only Generic Covered
paregoric 2mg/5ml elixer                                                                     2
ROBINUL                         glycopyrrolate 0.2mg/ml inj                                          Only Generic Covered
ROBINUL                         glycopyrrolate 1mg tablet                                            Only Generic Covered
ROBINUL                         glycopyrrolate 2mg tablet                                            Only Generic Covered
ROBINUL 0.2MG/ML INJ                                                                         5
                                Gastrointestinal Agents - Gastrointestinal Agents, Other
ACTIGALL                        ursodiol 300mg capsule                                               Only Generic Covered


27-921/01-01/06 Rev 01-11                                                [ 108]                      2011 Commercial Drug Formulary
                                                                                                           Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
anucort-hc 25mg supp            ANUSOL HC                                               2       Quantity Limits Apply
                                                                                                Available via Mail Order
ANUSOL HC                       anucort-hc 25mg supp                                            Only Generic Covered
calcium acetate 667mg gel cap   PHOSLO                                                  2
colocort 100mg/60ml enema                                                               2       Available via Mail Order
COMPAZINE SUPP                  compro 25mg rectal supp                                         Only Generic Covered
compro 25mg rectal supp         COMPAZINE SUPP                                          2       Quantity Limits Apply
diphenoxylate/atropine liq      LOMOTIL LIQ                                             2
diphenoxylate/atropine tablt    LOMOTIL                                                 2
ENULOSE                         lactulose 10gm/15ml syrup                                       Only Generic Covered
FOSRENOL 500MG CHEW TAB                                                                 4       Prior Auth Required
FOSRENOL 750MG CHEW TAB                                                                 4       Prior Auth Required
FOSRENOL 1000MG CHEW TAB                                                                4       Prior Auth Required
GASTROCROM 100MG/5ML CONC.                                                              4
golytely                                                                                2       Quantity Limits Apply
golytely powder                                                                         2       Quantity Limits Apply
IMODIUM                         loperamide 2mg cap                                              Only Generic Covered
KAYEXALATE                      kionex 15gm/60ml susp                                           Only Generic Covered
KAYEXALATE                      kionex powder                                                   Only Generic Covered
kionex 15gm/60ml susp           KAYEXALATE                                              2
kionex powder                   KAYEXALATE                                              2
lactulose 10gm/15ml syrup       ENULOSE                                                 2       Quantity Limits Apply
LOMOTIL                         diphenoxylate/atropine tablt                                    Only Generic Covered
LOMOTIL LIQ                     diphenoxylate/atropine liq                                      Only Generic Covered
loperamide 2mg cap              IMODIUM                                                 2
metoclopramide 5mg tablet       REGLAN                                                  2       Available via Mail Order
metoclopramide 10mg tablet      REGLAN                                                  1       Available via Mail Order
metoclopramide 5mg/5ml syrup    REGLAN                                                  2       Available via Mail Order
PHOSLO                          calcium acetate 667mg gel cap                                   Only Generic Covered
REGLAN                          metoclopramide 5mg tablet                                       Only Generic Covered
REGLAN                          metoclopramide 10mg tablet                                      Only Generic Covered
REGLAN                          metoclopramide 5mg/5ml syrup                                    Only Generic Covered
ursodiol 300mg capsule          ACTIGALL                                                2       Available via Mail Order
                                Gastrointestinal Agents - H2 Blocking Agents
cimetidine 300mg tablet         TAGAMET                                                 2       Available via Mail Order
cimetidine 300mg/5ml liquid     TAGAMET LIQ                                             2       Available via Mail Order

27-921/01-01/06 Rev 01-11                                               [ 109]                  2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT      TIER*   NOTES
cimetidine 400mg tablet        TAGAMET                                                     2       Available via Mail Order
cimetidine 800mg tablet        TAGAMET                                                     2       Available via Mail Order
ranitidine 150mg tablet        ZANTAC                                                      1       Available via Mail Order
ranitidine 15mg/ml syrup       ZANTAC                                                      2       Available via Mail Order
ranitidine 300mg tablet        ZANTAC                                                      1       Available via Mail Order
TAGAMET                        cimetidine 300mg tablet                                             Only Generic Covered
TAGAMET                        cimetidine 400mg tablet                                             Only Generic Covered
TAGAMET                        cimetidine 800mg tablet                                             Only Generic Covered
TAGAMET LIQ                    cimetidine 300mg/5ml liquid                                         Only Generic Covered
ZANTAC                         ranitidine 150mg tablet                                             Only Generic Covered
ZANTAC                         ranitidine 15mg/ml syrup                                            Only Generic Covered
ZANTAC                         ranitidine 300mg tablet                                             Only Generic Covered
ZANTAC 25MG/ML INJ                                                                         5
                               Gastrointestinal Agents - Irritable Bowel Syndrome Agents
chlordiaz/clid 5mg-2.5mg cap   LIBRAX                                                      2
LIBRAX                         chlordiaz/clid 5mg-2.5mg cap                                        Only Generic Covered
LOTRONEX 0.5MG TABLET                                                                      3       Prior Auth Required
                                                                                                   Available via Mail Order
LOTRONEX 1MG TABLET                                                                        3       Prior Auth Required
                                                                                                   Available via Mail Order
                               Gastrointestinal Agents - PPIs
lansoprazole 15mg capsule      PREVACID (NOT SOLUTAB)                                      2       Available via Mail Order
lansoprazole 30mg capsule      PREVACID (NOT SOLUTAB)                                      2       Available via Mail Order
omeprazole dr 10mg capsule     PRILOSEC                                                    2       Available via Mail Order
omeprazole dr 20mg capsule     PRILOSEC                                                    2       Available via Mail Order
pantoprazole 20mg tablet       PROTONIX                                                    2       Available via Mail Order
pantoprazole 40mg tablet       PROTONIX                                                    2       Available via Mail Order
PREVACID (NOT SOLUTAB)         lansoprazole 15mg capsule                                           Only Generic Covered
PREVACID (NOT SOLUTAB)         lansoprazole 30mg capsule                                           Only Generic Covered
PRILOSEC                       omeprazole dr 10mg capsule                                          Only Generic Covered
PRILOSEC                       omeprazole dr 20mg capsule                                          Only Generic Covered
PROTONIX                       pantoprazole 20mg tablet                                            Only Generic Covered
PROTONIX                       pantoprazole 40mg tablet                                            Only Generic Covered
PROTONIX 40MG INJ                                                                          5
PROTONIX 40MG ORAL SUSP PCKT                                                               3       Available via Mail Order
                               Gastrointestinal Agents - Protectants

27-921/01-01/06 Rev 01-11                                              [ 110]                      2011 Commercial Drug Formulary
                                                                                                         Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT                            TIER*   NOTES
CARAFATE                       sucralfate 1gm tablet                                                                   Only Generic Covered
CARAFATE SUSP 1GM/10ML                                                                                         3       Available via Mail Order
CYTOTEC                        misoprostol 100mcg tablet                                                               Only Generic Covered
CYTOTEC                        misoprostol 200mcg tablet                                                               Only Generic Covered
misoprostol 100mcg tablet      CYTOTEC                                                                         2       Available via Mail Order
misoprostol 200mcg tablet      CYTOTEC                                                                         2       Available via Mail Order
sucralfate 1gm tablet          CARAFATE                                                                        2       Available via Mail Order
                               Genitourinary Agents - Antispasmodics, Urinary
DITROPAN (NOT XL)              oxybutynin 5mg tablet                                                                   Only Generic Covered
DITROPAN SYRUP (NOT XL)        oxybutynin 5mg/5ml syrup                                                                Only Generic Covered
flavoxate 100mg tablet         URISPAS                                                                         2       Available via Mail Order
oxybutynin 5mg tablet          DITROPAN (NOT XL)                                                               2       Available via Mail Order
oxybutynin 5mg/5ml syrup       DITROPAN SYRUP (NOT XL)                                                         2       Available via Mail Order
URISPAS                        flavoxate 100mg tablet                                                                  Only Generic Covered
                               Genitourinary Agents - Benign Prostatic Hypertrophy Agents
AVODART 0.5MG CAPSULE                                                                                          3
finasteride 5mg tablet         PROSCAR                                                                         2
FLOMAX                         tamsulosin 0.4mg capsule                                                                Only Generic Covered
PROSCAR                        finasteride 5mg tablet                                                                  Only Generic Covered
tamsulosin 0.4mg capsule       FLOMAX                                                                          2       Available via Mail Order
                               Hormonal Agents, Stimulant/Replacement/Modifying - Adrenal
a-methapred 125mg vial         SOLU-MEDROL                                                                     5
CORTEF                         hydrocortisone 5mg tablet                                                               Only Generic Covered
CORTEF                         hydrocortisone 10mg tablet                                                              Only Generic Covered
CORTEF                         hydrocortisone 20mg tablet                                                              Only Generic Covered
FLORINEF                       fludrocortisone 0.1mg tablet                                                            Only Generic Covered
fludrocortisone 0.1mg tablet   FLORINEF                                                                        2       Available via Mail Order
hydrocortisone 5mg tablet      CORTEF                                                                          2       Available via Mail Order
hydrocortisone 10mg tablet     CORTEF                                                                          2       Available via Mail Order
hydrocortisone 20mg tablet     CORTEF                                                                          2       Available via Mail Order
MEDROL 16MG TABLET                                                                                             4       Available via Mail Order
SOLU-MEDROL                    a-methapred 125mg vial                                                                  Only Generic Covered
                               Hormonal Agents, Stimulant/Replacement/Modifying - Parathyroid/Metabolic Bone
                               Disease Agents
alendronate 5mg tablet         FOSAMAX                                                                         2       Available via Mail Order
alendronate 10mg tablet        FOSAMAX                                                                         2       Available via Mail Order

27-921/01-01/06 Rev 01-11                                             [ 111]                                           2011 Commercial Drug Formulary
                                                                                                                             Last Updated: July 1, 2011
                                                             DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                   BRAND OR GENERIC EQUIVALENT        TIER*   NOTES
alendronate 70mg tablet         FOSAMAX                                                        2       Available via Mail Order
alendronate 70mg tab            FOSAMAX                                                        2       Quantity Limits Apply
                                                                                                       Available via Mail Order
AREDIA 90MG INJ                                                                                6
BONIVA 3MG/3ML INJ KIT                                                                         5       Prior Auth Required
calcitonin-salmon 200u/inh ns   MIACALCIN                                                      2       Quantity Limits Apply
                                                                                                       Available via Mail Order
calcitriol 0.25mcg capsule      ROCALTROL                                                      2       Available via Mail Order
calcitriol 0.5mcg capsule       ROCALTROL                                                      2       Available via Mail Order
calcitriol 1mcg/ml soln         ROCALTROL                                                      2       Available via Mail Order
EVISTA 60MG TABLET                                                                             3       Available via Mail Order
FORTEO 600MCG/2.4ML INJ PEN                                                                    6       Prior Auth Required
FOSAMAX                         alendronate 5mg tablet                                                 Only Generic Covered
FOSAMAX                         alendronate 10mg tablet                                                Only Generic Covered
FOSAMAX                         alendronate 70mg tablet                                                Only Generic Covered
FOSAMAX                         alendronate 70mg tab                                                   Only Generic Covered
MIACALCIN                       calcitonin-salmon 200u/inh ns                                          Only Generic Covered
ROCALTROL                       calcitriol 0.25mcg capsule                                             Only Generic Covered
ROCALTROL                       calcitriol 0.5mcg capsule                                              Only Generic Covered
ROCALTROL                       calcitriol 1mcg/ml soln                                                Only Generic Covered
SENSIPAR 30MG TABLET                                                                           3       Prior Auth Required
SENSIPAR 60MG TABLET                                                                           3       Prior Auth Required
SENSIPAR 90MG TABLET                                                                           3       Prior Auth Required
ZEMPLAR 1MCG CAPSULE                                                                           4       Prior Auth Required
                                                                                                       Available via Mail Order
ZEMPLAR 2MCG CAPSULE                                                                           4       Prior Auth Required
                                                                                                       Available via Mail Order
ZOMETA 4MG/5ML INJ                                                                             5
                                Hormonal Agents, Stimulant/Replacement/Modifying - Pituitary
DDAVP                           desmopressin 0.01mg/inh n.s.                                           Only Generic Covered
DDAVP                           desmopressin 0.01mg/inh n.s.                                           Only Generic Covered
DDAVP                           desmopressin 0.1mg tablet                                              Only Generic Covered
DDAVP                           desmopressin 0.2mg tablet                                              Only Generic Covered
desmopressin 0.01mg/inh n.s.    DDAVP                                                          2       Quantity Limits Apply
desmopressin 0.01mg/inh n.s.    DDAVP                                                          2       Quantity Limits Apply
desmopressin 0.1mg tablet       DDAVP                                                          2
desmopressin 0.2mg tablet       DDAVP                                                          2

27-921/01-01/06 Rev 01-11                                              [ 112]                          2011 Commercial Drug Formulary
                                                                                                             Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT                         TIER*   NOTES
GENOTROPIN 0.8MG INJ                                                                                        6       Prior Auth Required
GENOTROPIN 1.2MG INJ                                                                                        6       Prior Auth Required
GENOTROPIN 1.4MG INJ                                                                                        6       Prior Auth Required
GENOTROPIN 1.6MG INJ                                                                                        6       Prior Auth Required
GENOTROPIN 13.8MG INJ                                                                                       6       Prior Auth Required
GENOTROPIN 1MG INJ                                                                                          6       Prior Auth Required
GENOTROPIN 5.8MG INJ                                                                                        6       Prior Auth Required
HUMATROPE 5MG/VIAL INJ                                                                                      6       Prior Auth Required
HUMATROPE 12MG CARTRIDGE KIT                                                                                6       Prior Auth Required
HUMATROPE 24MG CARTRIDGE KIT                                                                                6       Prior Auth Required
INCRELEX 40MG/4ML INJ                                                                                       6       Prior Auth Required
NORDITROPIN CART 15MG/1.5ML                                                                                 6       Prior Auth Required
NORDITROPIN NRDFLEX 5MG/1.5ML                                                                               6       Prior Auth Required
NORDITROPIN NRDFLX 10MG/1.5ML                                                                               6       Prior Auth Required
NUTROPIN 10MG INJ                                                                                           6       Prior Auth Required
NUTROPIN AQ 5MG/ML INJ                                                                                      6       Prior Auth Required
OMNITROPE 5.8MG INJ                                                                                         6       Prior Auth Required
SAIZEN 5MG VIAL INJ                                                                                         6       Prior Auth Required
SAIZEN 8.8MG CLICKEASY DEVICE                                                                               6       Prior Auth Required
SYNAREL 2MG/ML NASAL SOLN                                                                                   4       Prior Auth Required
                                                                                                                    Quantity Limits Apply
                                Hormonal Agents, Stimulant/Replacement/Modifying - Sex Hormones/Modifiers
ALESSE                          aviane-28 tablet                                                                    Only Generic Covered
ANADROL-50 TABLET                                                                                           4       Prior Auth Required
ANDRODERM 2.5MG/24HR PATCH                                                                                  4
ANDRODERM 5MG/24HR PATCH                                                                                    4
apri tablet (gx desogen)        DESOGEN                                                                     2       Available via Mail Order
aviane-28 tablet                ALESSE                                                                      2       Available via Mail Order
AYGESTIN                        norethindrone ace 5mg tablet                                                        Only Generic Covered
camila 0.35mgtab(gx micronor)   MICRONOR                                                                    2       Available via Mail Order
CLIMARA (NOT PRO)               estradiol 0.025mg/24hr patch                                                        Only Generic Covered
CLIMARA (NOT PRO)               estradiol 0.0375mg/24hr patch                                                       Only Generic Covered
CLIMARA (NOT PRO)               estradiol 0.05mg/24hr patch                                                         Only Generic Covered
CLIMARA (NOT PRO)               estradiol 0.06mg/24hr patch                                                         Only Generic Covered
CLIMARA (NOT PRO)               estradiol 0.075mg/24hr patch                                                        Only Generic Covered
CLIMARA (NOT PRO)               estradiol 0.1mg/24hr patch                                                          Only Generic Covered

27-921/01-01/06 Rev 01-11                                             [ 113]                                        2011 Commercial Drug Formulary
                                                                                                                          Last Updated: July 1, 2011
                                                             DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                   BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
cryselle-28 tab (gx lo/ovral)   LO-OVRAL                                                  2       Available via Mail Order
DELESTROGEN                     estradiol val 20mg/ml inj                                         Only Generic Covered
DELESTROGEN 10MG/ML INJ                                                                   5
DELESTROGEN 20MG/ML INJ                                                                   5
DELESTROGEN 40MG/ML INJ                                                                   5
DEMULEN                         kelnor 1/35 tab (gx demulen)                                      Only Generic Covered
DEMULEN                         zovia 1/50 (generic demulen)                                      Only Generic Covered
DEPO-ESTRAD 5MG/ML INJ                                                                    5
DEPO-PROVERA                    medroxyprog 150mg/ml sdv inj                                      Only Generic Covered
DEPO-TESTOST 100MG/ML INJ                                                                 5
DEPO-TESTOSTERONE               testost cyp 100mg/ml inj                                          Only Generic Covered
DESOGEN                         apri tablet (gx desogen)                                          Only Generic Covered
enpresse-28 tab(gx triphasil)   TRIPHASIL                                                 2       Available via Mail Order
ESTRA-TEST                      estrogen/me-test ds tablet                                        Only Generic Covered
ESTRACE                         estradiol 0.5mg (gx estrace)                                      Only Generic Covered
ESTRACE                         estradiol 1mg (gx estrace)                                        Only Generic Covered
ESTRACE                         estradiol 2mg (gx estrace)                                        Only Generic Covered
ESTRACE VAG CREAM 0.1MG/GM                                                                4       Quantity Limits Apply
                                                                                                  Available via Mail Order
estradiol 0.025mg/24hr patch    CLIMARA (NOT PRO)                                         2       Available via Mail Order
estradiol 0.0375mg/24hr patch   CLIMARA (NOT PRO)                                         2       Available via Mail Order
estradiol 0.05mg/24hr patch     CLIMARA (NOT PRO)                                         2       Available via Mail Order
estradiol 0.06mg/24hr patch     CLIMARA (NOT PRO)                                         2       Available via Mail Order
estradiol 0.075mg/24hr patch    CLIMARA (NOT PRO)                                         2       Available via Mail Order
estradiol 0.1mg/24hr patch      CLIMARA (NOT PRO)                                         2       Available via Mail Order
estradiol 0.5mg (gx estrace)    ESTRACE                                                   1       Available via Mail Order
estradiol 1mg (gx estrace)      ESTRACE                                                   1       Available via Mail Order
estradiol 2mg (gx estrace)      ESTRACE                                                   1       Available via Mail Order
estradiol val 20mg/ml inj       DELESTROGEN                                               5
ESTRATEST HS                    estrogen/me-test hs tablet                                        Only Generic Covered
estrogen/me-test ds tablet      ESTRA-TEST                                                2       Available via Mail Order
estrogen/me-test hs tablet      ESTRATEST HS                                              2       Available via Mail Order
estropipate 0.625mg (gx ogen)   OGEN                                                      2       Available via Mail Order
estropipate 1.25mg (gx ogen)    OGEN                                                      2       Available via Mail Order
estropipate 2.5mg (gx ogen)     OGEN                                                      2       Available via Mail Order
fluoxymesterone 10mg tablet     HALOTESTIN                                                2

27-921/01-01/06 Rev 01-11                                              [ 114]                     2011 Commercial Drug Formulary
                                                                                                        Last Updated: July 1, 2011
                                                             DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                   BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
gianvi-28 3-0.02mg tablet      YAZ                                                        2       Available via Mail Order
HALOTESTIN                     fluoxymesterone 10mg tablet                                        Only Generic Covered
kelnor 1/35 tab (gx demulen)   DEMULEN                                                    2       Available via Mail Order
LEVORA-28 TAB (GX NORDETTE)    NORDETTE                                                   2       Available via Mail Order
LO-OVRAL                       cryselle-28 tab (gx lo/ovral)                                      Only Generic Covered
medroxyprog 150mg/ml sdv inj   DEPO-PROVERA                                               2       Quantity Limits Apply
medroxyprogesterone 2.5mgtab   PROVERA                                                    1       Available via Mail Order
medroxyprogesterone 5mg tab    PROVERA                                                    1       Available via Mail Order
medroxyprogesterone 10mg tab   PROVERA                                                    1       Available via Mail Order
MEGACE                         megestrol 40mg/ml susp                                             Only Generic Covered
MEGACE                         megestrol acetate 20mg tablt                                       Only Generic Covered
MEGACE                         megestrol acetate 40mg tablt                                       Only Generic Covered
megestrol 40mg/ml susp         MEGACE                                                     2
megestrol acetate 20mg tablt   MEGACE                                                     2
megestrol acetate 40mg tablt   MEGACE                                                     2
MICRONOR                       camila 0.35mgtab(gx micronor)                                      Only Generic Covered
MODICON                        nortrel 0.5/35-28 tablet                                           Only Generic Covered
necon 1/35-28 tab                                                                         2       Available via Mail Order
necon 1/50-28 tablet           ORTHO NOVUM                                                2       Available via Mail Order
necon 10/11-28                 ORTHO NOVUM                                                2       Available via Mail Order
NORDETTE                       LEVORA-28 TAB (GX NORDETTE)                                        Only Generic Covered
NORDETTE                       portia-28 tab (gx nordette)                                        Only Generic Covered
norethindrone ace 5mg tablet   AYGESTIN                                                   2       Available via Mail Order
nortrel 0.5/35-28 tablet       MODICON                                                    2       Available via Mail Order
NOVAREL 10000U IM INJ                                                                     5
OGEN                           estropipate 0.625mg (gx ogen)                                      Only Generic Covered
OGEN                           estropipate 1.25mg (gx ogen)                                       Only Generic Covered
OGEN                           estropipate 2.5mg (gx ogen)                                        Only Generic Covered
ogestrel-28 tab (gx ovral)     OVRAL                                                      2       Available via Mail Order
ORTHO NOVUM                    necon 1/50-28 tablet                                               Only Generic Covered
ORTHO NOVUM                    necon 10/11-28                                                     Only Generic Covered
ORTHO-CYCLEN                   sprintec 28 day tablet                                             Only Generic Covered
ORTHO-TRICYCLEN                tri-sprintec 28 day tablet                                         Only Generic Covered
OVRAL                          ogestrel-28 tab (gx ovral)                                         Only Generic Covered
OXANDRIN 2.5MG TABLET                                                                     3       Prior Auth Required
portia-28 tab (gx nordette)    NORDETTE                                                   2       Available via Mail Order
27-921/01-01/06 Rev 01-11                                              [ 115]                     2011 Commercial Drug Formulary
                                                                                                        Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT       TIER*   NOTES
PREMARIN 0.3MG TABLET(GREEN)                                                                 3       Available via Mail Order
PREMARIN 0.45MG TABLET                                                                       3       Available via Mail Order
PREMARIN 0.625MG TABLET                                                                      3       Available via Mail Order
PREMARIN 0.9MG TABLET(WHITE)                                                                 3       Available via Mail Order
PREMARIN 1.25MG TAB (YELLOW)                                                                 3       Available via Mail Order
PREMARIN VAG CREAM W/APPL                                                                    3       Quantity Limits Apply
                                                                                                     Available via Mail Order
PREMPHASE 0.625/5MG TABLET                                                                   3       Available via Mail Order
PREMPRO 0.3MG/1.5MG TABLET                                                                   3       Available via Mail Order
PREMPRO 0.45MG/1.5MG TABLET                                                                  3       Available via Mail Order
PREMPRO 0.625MG/2.5MG TABLET                                                                 3       Available via Mail Order
PREMPRO 0.625MG/5MG TABLET                                                                   3       Available via Mail Order
progesterone 50mg/ml mdv inj                                                                 9
PROVERA                         medroxyprogesterone 2.5mgtab                                         Only Generic Covered
PROVERA                         medroxyprogesterone 5mg tab                                          Only Generic Covered
PROVERA                         medroxyprogesterone 10mg tab                                         Only Generic Covered
sprintec 28 day tablet          ORTHO-CYCLEN                                                 2       Available via Mail Order
TESTIM 1% GEL PACK 50MG/5GM                                                                  4       Quantity Limits Apply
testost cyp 100mg/ml inj        DEPO-TESTOSTERONE                                            5
testosterone enan 200mg/mlinj                                                                5
tri-sprintec 28 day tablet      ORTHO-TRICYCLEN                                              2       Available via Mail Order
TRIPHASIL                       enpresse-28 tab(gx triphasil)                                        Only Generic Covered
YAZ                             gianvi-28 3-0.02mg tablet                                            Only Generic Covered
zovia 1/50 (generic demulen)    DEMULEN                                                      2       Available via Mail Order
                                Hormonal Agents, Stimulant/Replacement/Modifying - Thyroid
CYTOMEL                         liothyronine 5mcg tablet                                             Only Generic Covered
CYTOMEL                         liothyronine 25mcg tablet                                            Only Generic Covered
levoxyl 0.025mg tablet                                                                       2       Available via Mail Order
levoxyl 0.05mg tablet                                                                        2       Available via Mail Order
levoxyl 0.075mg tablet                                                                       2       Available via Mail Order
levoxyl 0.088mg tablet                                                                       2       Available via Mail Order
levoxyl 0.112mg tablet                                                                       2       Available via Mail Order
levoxyl 0.125mg tablet                                                                       2       Available via Mail Order
levoxyl 0.137mg tablet                                                                       2       Available via Mail Order
levoxyl 0.15mg tablet                                                                        2       Available via Mail Order
levoxyl 0.175mg tablet                                                                       2       Available via Mail Order

27-921/01-01/06 Rev 01-11                                             [ 116]                         2011 Commercial Drug Formulary
                                                                                                           Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
levoxyl 0.1mg tablet                                                                    2       Available via Mail Order
levoxyl 0.2mg tablet                                                                    2       Available via Mail Order
liothyronine 5mcg tablet       CYTOMEL                                                  2       Available via Mail Order
liothyronine 25mcg tablet      CYTOMEL                                                  2       Available via Mail Order
                               Hormonal Agents, Suppressant - Adrenal
LYSODREN 500MG TAB                                                                      3
                               Hormonal Agents, Suppressant - Pituitary
cabergoline 0.5mg tablet       DOSTINEX                                                 2       Available via Mail Order
DOSTINEX                       cabergoline 0.5mg tablet                                         Only Generic Covered
leuprolide 1mg/.2ml mdv inj    LUPRON                                                   5
LUPRON                         leuprolide 1mg/.2ml mdv inj                                      Only Generic Covered
LUPRON DEPOT 3.75MG INJ                                                                 5       Quantity Limits Apply
LUPRON DEPOT 3.75MG INJ                                                                 5
LUPRON DEPOT 7.5MG INJ                                                                  5
LUPRON DEPOT 11.25MG INJ                                                                5
LUPRON DEPOT 11.25MG PED INJ                                                            5
LUPRON DEPOT 15MG PED INJ                                                               5
LUPRON DEPOT 22.5MG INJ                                                                 9
octreotide 0.05mg/ml inj       SANDOSTATIN                                              5
octreotide 0.1mg/ml inj        SANDOSTATIN                                              6
octreotide 0.2mg/ml inj mdv    SANDOSTATIN                                              6
octreotide 0.5mg/ml inj        SANDOSTATIN                                              6
octreotide 1mg/ml inj mdv      SANDOSTATIN                                              6
SANDOSTATIN                    octreotide 0.05mg/ml inj                                         Only Generic Covered
SANDOSTATIN                    octreotide 0.1mg/ml inj                                          Only Generic Covered
SANDOSTATIN                    octreotide 0.2mg/ml inj mdv                                      Only Generic Covered
SANDOSTATIN                    octreotide 0.5mg/ml inj                                          Only Generic Covered
SANDOSTATIN                    octreotide 1mg/ml inj mdv                                        Only Generic Covered
SANDOSTATIN LAR 30MG KIT                                                                6
SOMAVERT 10MG INJ                                                                       6       Prior Auth Required
                               Hormonal Agents, Suppressant - Sex Hormones/Modifiers
anastrozole 1mg tablet         ARIMIDEX                                                 2
ARIMIDEX                       anastrozole 1mg tablet                                           Only Generic Covered
AROMASIN                       exemestane 25mg tablet                                           Only Generic Covered
bicalutamide 50mg tablet       CASODEX                                                  2
CASODEX                        bicalutamide 50mg tablet                                         Only Generic Covered
27-921/01-01/06 Rev 01-11                                               [ 117]                  2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
danazol 100mg capsule          DANOCRINE                                               2
danazol 200mg capsule          DANOCRINE                                               2
DANOCRINE                      danazol 100mg capsule                                           Only Generic Covered
DANOCRINE                      danazol 200mg capsule                                           Only Generic Covered
EULEXIN                        flutamide 125mg capsule                                         Only Generic Covered
exemestane 25mg tablet         AROMASIN                                                2
FARESTON 60MG TABLET                                                                   3
FASLODEX 50MG/ML INJ                                                                   5
FEMARA                         letrozole 2.5mg tablet                                          Only Generic Covered
flutamide 125mg capsule        EULEXIN                                                 2
letrozole 2.5mg tablet         FEMARA                                                  2
NILANDRON 150MG TABLET                                                                 3
NOLVADEX                       tamoxifen 10mg tablet                                           Only Generic Covered
NOLVADEX                       tamoxifen 20mg tablet                                           Only Generic Covered
SOLTAMOX 10MG/5ML SOLN                                                                 3
tamoxifen 10mg tablet          NOLVADEX                                                2
tamoxifen 20mg tablet          NOLVADEX                                                2
                               Hormonal Agents, Suppressant - Thyroid
methimazole 5mg tablet         TAPAZOLE                                                2
methimazole 10mg tablet        TAPAZOLE                                                2
propylthiouracil 50mg tablet   PTU                                                     2
PTU                            propylthiouracil 50mg tablet                                    Only Generic Covered
TAPAZOLE                       methimazole 5mg tablet                                          Only Generic Covered
TAPAZOLE                       methimazole 10mg tablet                                         Only Generic Covered
                               Immunological Agents - Immune Stimulants
ACT-HIB INJ                                                                            5
ACTIMMUNE 3MU/.5ML INJ                                                                 6       Prior Auth Required
ADACEL INJ                                                                             5
AVONEX ADMIN PACK 30MCG PFS                                                            6
AVONEX ADMIN PACK 33MCG VIAL                                                           6
BETASERON 0.3MG/VIAL INJ                                                               6
BOOSTRIX INJ (PF)                                                                      5
CERVARIX INJ PFS                                                                       5
COMVAX INJ                                                                             5
DAPTACEL INJ                                                                           5
DECAVAC ADULT 5-2LF                                                                    5
27-921/01-01/06 Rev 01-11                                               [ 118]                 2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                 DRUG CATEGORY - DRUG CLASS
DRUG NAME                       BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
DIP/TET TOXOID PED 6.7-5LF                                    5
ENGERIX-B 10MCG/.5ML INJ SYR                                  5
ENGERIX-B 20MCG/ML INJ SYRN                                   5
GAMMAGARD 1G/10ML INJ                                         5       Prior Auth Required
GARDASIL      INJ                                             5
HAVRIX (ADULT HEP A)INJ SYRN                                  5
HAVRIX (PED HEP A) INJ SYRN                                   5
HIZENTRA 200MG/ML INJ                                         5
IMOVAX RABIES VAC 2.5/ML INJ                                  5
INFANRIX INJ                                                  5
INTRON A 3MMU/0.2ML PEN INJ                                   5
INTRON A 10MMU INJ W/DIL                                      5
INTRON A 18MMU MDV(3MMU/.5ML)                                 5
INTRON A 50MMU INJ W/DIL                                      5
INTRON A HSAF 25MMU/2.5ML INJ                                 5
IPOL (POLIO VAC INACTIVATED)                                  5
JE-VAX     INJ                                                5
M-M-R II INJ LIVE                                             5
MENACTRA INJ                                                  5
MENOMUNE-A/C/Y/W-135 INJ                                      5
PEDVAXHIB INJ (10X0.5ML)                                      5
PEG-INTRON 50MCG/0.5ML KIT                                    6       Prior Auth Required
PEG-INTRON 80MCG REDIPEN KIT                                  6       Prior Auth Required
PEG-INTRON 120MCG REDIPEN KIT                                 6       Prior Auth Required
PEG-INTRON 150MCG REDIPEN KIT                                 6       Prior Auth Required
PEGASYS 180MCG/0.5ML KIT                                      6       Prior Auth Required
PROQUAD INJ                                                   5
RABAVERT INJ                                                  5
RECOMBIVAX-HB 10MCG/ML INJ                                    5
RECOMBIVAX-HB 40MCG/ML INJ                                    5
ROTATEQ SUSP                                                  5
SYNAGIS 100MG INJ                                             6
SYNAGIS 50MG INJ                                              6
TETANUS TOX 5LF ADS INJ                                       5
TRIPEDIA INJ                                                  5
TWINRIX INJ                                                   5
27-921/01-01/06 Rev 01-11                  [ 119]                     2011 Commercial Drug Formulary
                                                                            Last Updated: July 1, 2011
                                                              DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                    BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
TYPHIM VI INJ                                                                              5
VAQTA 50U/ML INJ                                                                           5
VARIVAX INJ                                                                                5
VIVAGLOBIN 160MG/ML INJ                                                                    5
YELLOW FEVER VAC INJ                                                                       5
ZOSTAVAX INJ                                                                               5
                                  Immunological Agents - Immune Suppressants
azathioprine 50mg tablet          IMURAN                                                   5       Available via Mail Order
CELLCEPT                          mycophenolate 250mg capsule                                      Only Generic Covered
CELLCEPT                          mycophenolate 500mg tablet                                       Only Generic Covered
CELLCEPT 200MG/ML SUSP                                                                     5       Available via Mail Order
CUPRIMINE 250MG CAPSULE                                                                    3
cyclosporine 25mg capsule         NEORAL                                                   5       Available via Mail Order
cyclosporine 50mg capsule                                                                  5       Available via Mail Order
cyclosporine 100mg capsule        NEORAL                                                   5       Available via Mail Order
cyclosporine 100mg/ml soln        NEORAL                                                   5       Available via Mail Order
ENBREL 25MG INJ VIAL KIT                                                                   6       Prior Auth Required
ENBREL 25MG/0.5ML INJ (PFS)                                                                6       Prior Auth Required
ENBREL 50MG/ML INJ (PFS)                                                                   6       Prior Auth Required
HUMIRA 40MG/0.8ML INJ KIT                                                                  6       Prior Auth Required
IMURAN                            azathioprine 50mg tablet                                         Only Generic Covered
methotrexate 2.5mg tablet         RHEUMATREX                                               2       Available via Mail Order
methotrexate 2.5mg tab            RHUEMATREX                                               2       Available via Mail Order
mycophenolate 250mg capsule       CELLCEPT                                                 5       Available via Mail Order
mycophenolate 500mg tablet        CELLCEPT                                                 5       Available via Mail Order
MYFORTIC 180MG TABLET                                                                      5       Available via Mail Order
MYFORTIC 360MG TABLET                                                                      5       Available via Mail Order
NEORAL                            cyclosporine 25mg capsule                                        Only Generic Covered
NEORAL                            cyclosporine 100mg capsule                                       Only Generic Covered
NEORAL                            cyclosporine 100mg/ml soln                                       Only Generic Covered
PROGRAF                           tacrolimus 0.5mg capsule                                         Only Generic Covered
PROGRAF                           tacrolimus 1mg capsule                                           Only Generic Covered
PROGRAF                           tacrolimus 5mg capsule                                           Only Generic Covered
RAPAMUNE 0.5MG TABLET         8                                                            5       Available via Mail Order
RAPAMUNE 1MG TABLET                                                                        5       Available via Mail Order
RAPAMUNE 1MG/ML SOLUTION                                                                   5       Available via Mail Order
27-921/01-01/06 Rev 01-11                                               [ 120]                     2011 Commercial Drug Formulary
                                                                                                         Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
RAPAMUNE 2MG TABLET                                                                     5       Available via Mail Order
REMICADE 100MG INJ                                                                      6       Prior Auth Required
RHEUMATREX                      methotrexate 2.5mg tablet                                       Only Generic Covered
RHUEMATREX                      methotrexate 2.5mg tab                                          Only Generic Covered
tacrolimus 0.5mg capsule        PROGRAF                                                 5       Available via Mail Order
tacrolimus 1mg capsule          PROGRAF                                                 5       Available via Mail Order
tacrolimus 5mg capsule          PROGRAF                                                 5       Available via Mail Order
ZORTRESS 0.25MG TABLET                                                                  5       Available via Mail Order
ZORTRESS 0.5MG TABLET                                                                   5       Available via Mail Order
ZORTRESS 0.75MG TABLET                                                                  5       Available via Mail Order
                                Immunological Agents - Immunomodulators
ARAVA                           leflunomide 10mg tablet                                         Only Generic Covered
ARAVA                           leflunomide 20mg tablet                                         Only Generic Covered
COPAXONE 20MG/ML P.F. SYRINGE                                                           6
KINERET 100MG/.67ML INJ                                                                 5       Prior Auth Required
leflunomide 10mg tablet         ARAVA                                                   2       Available via Mail Order
leflunomide 20mg tablet         ARAVA                                                   2       Available via Mail Order
ORENCIA 250MG INJ                                                                       6       Prior Auth Required
REBIF 22MCG/0.5ML PFS INJ                                                               6
REBIF 44MCG/0.5ML PFS INJ                                                               6
REBIF TITRATION PACK                                                                    6
REVLIMID 5MG CAPSULE                                                                    4       Prior Auth Required
REVLIMID 10MG CAPSULE                                                                   4       Prior Auth Required
REVLIMID 15MG CAPSULE                                                                   4       Prior Auth Required
REVLIMID 25MG CAPSULE                                                                   4       Prior Auth Required
THALOMID 50MG CAPSULE                                                                   3       Prior Auth Required
THALOMID 100MG CAPSULE                                                                  3       Prior Auth Required
THALOMID 150MG CAPSULE                                                                  3       Prior Auth Required
THALOMID 200MG CAPSULE                                                                  3       Prior Auth Required
                                Inflammatory Bowel Disease Agents - Glucocorticoids
ANUSOL-HC                       hydrocortisone 25mg supp                                        Only Generic Covered
cortisone ac 25mg tablet                                                                2       Available via Mail Order
ENTOCORT EC 3MG/24HR CAP                                                                4       Prior Auth Required
                                                                                                Available via Mail Order
hydrocortisone 25mg supp        ANUSOL-HC                                               2       Quantity Limits Apply
                                                                                                Available via Mail Order

27-921/01-01/06 Rev 01-11                                              [ 121]                   2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
                                Inflammatory Bowel Disease Agents - Salicylates
ASACOL 400MG TABLET                                                                    3       Available via Mail Order
ASACOL HD 800MG TABLET                                                                 3       Available via Mail Order
balsalazide 750mg capsule       COLAZAL                                                2       Available via Mail Order
CANASA 1000MG SUPP                                                                     3       Quantity Limits Apply
                                                                                               Available via Mail Order
COLAZAL                         balsalazide 750mg capsule                                      Only Generic Covered
DIPENTUM 250MG CAP                                                                     4       Available via Mail Order
mesalamine 4gm/60ml rec ene     ROWASA                                                 2       Quantity Limits Apply
                                                                                               Available via Mail Order
ROWASA                          mesalamine 4gm/60ml rec ene                                    Only Generic Covered
                                Inflammatory Bowel Disease Agents - Sulfonamides
AZULFADINE (NOT EN)             sulfasalazine 500mg tablet                                     Only Generic Covered
sulfasalazine 500mg tablet      AZULFADINE (NOT EN)                                    2       Available via Mail Order
                                Ophthalmic Agents - Ophthalmic Agents, Other
ALCAINE                         proparacaine 0.5% ophth soln                                   Only Generic Covered
atropine 1% ophth    soln       ISOPTO ATROPINE                                        2       Quantity Limits Apply
atropine 1% ophth ointment      ISOPTO ATROPINE                                        2       Quantity Limits Apply
CYCLOGYL                        cyclopentolate hcl 1% op soln                                  Only Generic Covered
CYCLOGYL 0.5% OPHTH SOLN                                                               2       Quantity Limits Apply
cyclopentolate hcl 1% op soln   CYCLOGYL                                               2       Quantity Limits Apply
ISO-HOMATROP 2% OPHTH SOLN                                                             2       Quantity Limits Apply
ISO-HOMATROP 5% OPHTH SOLN                                                             2       Quantity Limits Apply
ISOPTO ATROPINE                 atropine 1% ophth    soln                                      Only Generic Covered
ISOPTO ATROPINE                 atropine 1% ophth ointment                                     Only Generic Covered
LACRISERT      DIS OPHTHAL                                                             4       Available via Mail Order
MYDRIACYL                       tropicacyl 0.5% ophth soln                                     Only Generic Covered
proparacaine 0.5% ophth soln    ALCAINE                                                2       Quantity Limits Apply
RESTASIS 0.05% OPHTH                                                                   3       Quantity Limits Apply
                                                                                               Available via Mail Order
tropicacyl 0.5% ophth soln      MYDRIACYL                                              2       Quantity Limits Apply
tropicacyl 1% ophth soln                                                               2       Quantity Limits Apply
                                Ophthalmic Agents - Ophthalmic Anti-Allergy Agents
ALOMIDE 0.1% OPHTHALMIC SOLN                                                           3       Quantity Limits Apply
cromolyn sod 4% ophth soln      OPTICROM                                               2       Quantity Limits Apply
OPTICROM                        cromolyn sod 4% ophth soln                                     Only Generic Covered


27-921/01-01/06 Rev 01-11                                               [ 122]                 2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
                                Ophthalmic Agents - Ophthalmic Antibacterials
ak-poly-bac o/o gx polysporin   POLYSPORIN                                              2       Quantity Limits Apply
AK-TRACIN                       BACITRACIN OPHTH OINT                                           Only Generic Covered
AK-TRACIN                       bacitracin ophth oint                                           Only Generic Covered
bac/neo/poly o/o(gx neospor)    NEOSPORIN OPHTH                                         2       Quantity Limits Apply
BACITRACIN OPHTH OINT           AK-TRACIN                                               2       Quantity Limits Apply
bacitracin ophth oint           AK-TRACIN                                               2       Quantity Limits Apply
BLEPH-10                        sod sulfacet sol 10% opth sol                                   Only Generic Covered
BLEPH-10                        sulfacetamide 10% ophth oint                                    Only Generic Covered
BLEPHAMIDE OPHTH SUSP                                                                   3       Quantity Limits Apply
BLEPHAMIDE S.O.P. OINTMENT                                                              3       Quantity Limits Apply
CILOXAN                         ciprofloxacin 0.3% ophth soln                                   Only Generic Covered
CILOXAN 0.3% OPHTH OINT                                                                 3       Quantity Limits Apply
ciprofloxacin 0.3% ophth soln   CILOXAN                                                 2       Quantity Limits Apply
CORTISPORIN                     neo/poly b/hc o/s (gx cortis)                                   Only Generic Covered
CORTISPORIN                     neo/poly/bac/hc o/o(gxcortis)                                   Only Generic Covered
dex/neo/poly o/o (gxmaxitrol)   MAXITROL                                                2       Quantity Limits Apply
dex/neo/poly o/s (gxmaxitrol)   MAXITROL SUSP                                           2       Quantity Limits Apply
erythromycin ophth ointment     ILOTYCIN                                                2       Quantity Limits Apply
GARAMYCIN                       gentak 0.3% ophth ointment                                      Only Generic Covered
GARAMYCIN                       gentamicin 0.3% ophth soln                                      Only Generic Covered
gentak 0.3% ophth ointment      GARAMYCIN                                               2       Quantity Limits Apply
gentamicin 0.3% ophth soln      GARAMYCIN                                               2       Quantity Limits Apply
ILOTYCIN                        erythromycin ophth ointment                                     Only Generic Covered
MAXITROL                        dex/neo/poly o/o (gxmaxitrol)                                   Only Generic Covered
MAXITROL SUSP                   dex/neo/poly o/s (gxmaxitrol)                                   Only Generic Covered
MOXEZA 0.5% OPHTH SOLN                                                                  3       Quantity Limits Apply
neo/poly b/hc o/s (gx cortis)   CORTISPORIN                                             2       Quantity Limits Apply
neo/poly/bac/hc o/o(gxcortis)   CORTISPORIN                                             2       Quantity Limits Apply
NEOSPORIN                       ocutricin o/s (gx neosporin)                                    Only Generic Covered
NEOSPORIN OPHTH                 bac/neo/poly o/o(gx neospor)                                    Only Generic Covered
OCUFLOX                         ofloxacin 0.3% ophth soln                                       Only Generic Covered
ocutricin o/s (gx neosporin)    NEOSPORIN                                               2       Quantity Limits Apply
ofloxacin 0.3% ophth soln       OCUFLOX                                                 2       Quantity Limits Apply
polymyx/tmp o/s (gx polytrim)   POLYTRIM                                                2       Quantity Limits Apply
POLYSPORIN                      ak-poly-bac o/o gx polysporin                                   Only Generic Covered
27-921/01-01/06 Rev 01-11                                              [ 123]                   2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
POLYTRIM                        polymyx/tmp o/s (gx polytrim)                                  Only Generic Covered
PRED-G OPHTH OINT                                                                      3       Quantity Limits Apply
PRED-G OPHTH SUSP                                                                      3       Quantity Limits Apply
QUIXIN 0.5% OPHTH SOLUTION                                                             3       Quantity Limits Apply
sod sulfacet sol 10% opth sol   BLEPH-10                                               2       Quantity Limits Apply
sulf/pred (gx vasocidin) drop   VASOCIDIN                                              2       Quantity Limits Apply
sulfacetamide 10% ophth oint    BLEPH-10                                               2       Quantity Limits Apply
TOBRADEX                        tobramyc/dexa 0.3/0.1% op sus                                  Only Generic Covered
TOBRADEX OPHTH OINT                                                                    3       Quantity Limits Apply
tobramyc/dexa 0.3/0.1% op sus   TOBRADEX                                               2       Quantity Limits Apply
tobramycin 0.3% ophth soln      TOBREX                                                 2       Quantity Limits Apply
TOBREX                          tobramycin 0.3% ophth soln                                     Only Generic Covered
TOBREX 0.3% OPHTH OINT                                                                 3       Quantity Limits Apply
VASOCIDIN                       sulf/pred (gx vasocidin) drop                                  Only Generic Covered
VIGAMOX 0.5% OPHTH SOLN                                                                3       Quantity Limits Apply
                                Ophthalmic Agents - Ophthalmic Antifungals
NATACYN OPHTH SOLN                                                                     3       Quantity Limits Apply
                                Ophthalmic Agents - Ophthalmic Antiglaucoma Agents
acetazolamide 125mg tablet      DIAMOX                                                 2       Available via Mail Order
acetazolamide 250mg tablet      DIAMOX                                                 2       Available via Mail Order
acetazolamide er 500mg caps     DIAMOX SEQUELS                                         2       Available via Mail Order
ak-pentolate 1% ophth soln      CYCLOGYL                                               2       Quantity Limits Apply
ALPHAGAN (NOT P)                brimonidine tart 0.2% op soln                                  Only Generic Covered
apraclonidine 0.5% ophth sol    IOPIDINE                                               2       Quantity Limits Apply
                                                                                               Available via Mail Order
BETAGAN                         levobunolol (0.25%)gx betagan                                  Only Generic Covered
BETAGAN                         levobunolol 0.5% (gx betagan)                                  Only Generic Covered
betaxolol 0.5% ophth sol 10ml   BETOPTIC                                               2       Quantity Limits Apply
                                                                                               Available via Mail Order
BETOPTIC                        betaxolol 0.5% ophth sol 10ml                                  Only Generic Covered
BETOPTIC-S OPHTH SUSP                                                                  3       Quantity Limits Apply
                                                                                               Available via Mail Order
brimonidine tart 0.2% op soln   ALPHAGAN (NOT P)                                       2       Quantity Limits Apply
                                                                                               Available via Mail Order
carteolol hcl 1% ophth soln     OCUPRESS OPHTHALMIC SOLN                               2       Quantity Limits Apply
                                                                                               Available via Mail Order
COSOPT                          dorzolam/timolol 2-0.5% o/s                                    Only Generic Covered

27-921/01-01/06 Rev 01-11                                             [ 124]                   2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
CYCLOGYL                        ak-pentolate 1% ophth soln                                     Only Generic Covered
DIAMOX                          acetazolamide 125mg tablet                                     Only Generic Covered
DIAMOX                          acetazolamide 250mg tablet                                     Only Generic Covered
DIAMOX SEQUELS                  acetazolamide er 500mg caps                                    Only Generic Covered
dorzolam/timolol 2-0.5% o/s     COSOPT                                                 2       Quantity Limits Apply
                                                                                               Available via Mail Order
dorzolamide 2% ophth soln       TRUSOPT                                                2       Quantity Limits Apply
                                                                                               Available via Mail Order
IOPIDINE                        apraclonidine 0.5% ophth sol                                   Only Generic Covered
ISOPTO CARBA 1.5% OPHTH SOLN                                                           2       Quantity Limits Apply
ISOPTO CARBA 3% OPHTH SOLN                                                             2       Quantity Limits Apply
ISOPTO-CARPIN                   pilocarpine 0.5% (pilostat)                                    Only Generic Covered
ISOPTO-CARPIN                   pilocarpine 3% soln(pilostat)                                  Only Generic Covered
ISOPTO-CARPINE                  pilocarpine 1% soln(pilostat)                                  Only Generic Covered
ISOPTO-CARPINE                  pilocarpine 2% soln(pilostat)                                  Only Generic Covered
ISOPTO-CARPINE                  pilocarpine 4% ophth soln                                      Only Generic Covered
ISOPTO-CARPINE                  pilocarpine 6% ophth soln                                      Only Generic Covered
latanoprost 0.005% ophth sol    XALATAN                                                2       Quantity Limits Apply
                                                                                               Available via Mail Order
levobunolol (0.25%)gx betagan   BETAGAN                                                2       Quantity Limits Apply
                                                                                               Available via Mail Order
levobunolol 0.5% (gx betagan)   BETAGAN                                                1       Quantity Limits Apply
                                                                                               Available via Mail Order
methazolamide 25mg tablet       NEPTAZANE                                              2       Available via Mail Order
methazolamide 50mg tablet       NEPTAZANE                                              2       Available via Mail Order
NEPTAZANE                       methazolamide 25mg tablet                                      Only Generic Covered
NEPTAZANE                       methazolamide 50mg tablet                                      Only Generic Covered
OCUPRESS OPHTHALMIC SOLN        carteolol hcl 1% ophth soln                                    Only Generic Covered
PHOSPHOLINE SOL 0.125% O/S                                                             3
pilocarpine 0.5% (pilostat)     ISOPTO-CARPIN                                          2       Quantity Limits Apply
pilocarpine 1% soln(pilostat)   ISOPTO-CARPINE                                         2       Quantity Limits Apply
pilocarpine 2% soln(pilostat)   ISOPTO-CARPINE                                         2       Quantity Limits Apply
pilocarpine 3% soln(pilostat)   ISOPTO-CARPIN                                          2       Quantity Limits Apply
pilocarpine 4% ophth soln       ISOPTO-CARPINE                                         2       Quantity Limits Apply
pilocarpine 6% ophth soln       ISOPTO-CARPINE                                         2       Quantity Limits Apply
PILOPINE HS GEL OPTH 4%                                                                3       Quantity Limits Apply



27-921/01-01/06 Rev 01-11                                           [ 125]                     2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
timolol mal 0.25% gxtimoptic    TIMOPTIC                                              1       Quantity Limits Apply
                                                                                              Available via Mail Order
timolol mal 0.5% (gxtimoptic)   TIMOPTIC                                              1       Quantity Limits Apply
                                                                                              Available via Mail Order
TIMOPTIC                        timolol mal 0.25% gxtimoptic                                  Only Generic Covered
TIMOPTIC                        timolol mal 0.5% (gxtimoptic)                                 Only Generic Covered
TRAVATAN 0.004% OPHTH SOLN                                                            3       Quantity Limits Apply
                                                                                              Available via Mail Order
TRUSOPT                         dorzolamide 2% ophth soln                                     Only Generic Covered
XALATAN                         latanoprost 0.005% ophth sol                                  Only Generic Covered
                                Ophthalmic Agents - Ophthalmic Anti-Inflammatories
ACULAR                          ketorolac 0.5% ophth soln                                     Only Generic Covered
ACULAR LS                       ketorolac ls 0.4% ophth soln                                  Only Generic Covered
ALREX 0.2% OPHTH SUSP                                                                 4       Quantity Limits Apply
                                                                                              Available via Mail Order
DECADRON OPTH SOLN              dexameth 0.1% ophth soln                                      Only Generic Covered
dexameth 0.1% ophth soln        DECADRON OPTH SOLN                                    2       Quantity Limits Apply
diclofenac sod 0.1% ophth sol   VOLTAREN                                              2       Quantity Limits Apply
fluorometholone 0.1% o/s        FML                                                   2       Quantity Limits Apply
flurbiprofen 0.03% ophth sol    OCUFEN                                                2       Quantity Limits Apply
FML                             fluorometholone 0.1% o/s                                      Only Generic Covered
FML FORTE 0.25% OPHTH SUSP                                                            3       Quantity Limits Apply
FML OPHTH OINTMENT                                                                    3       Quantity Limits Apply
INFLAMASE FORTE                 PREDNISOLONE SOD 1% OPHTHSOL                                  Only Generic Covered
INFLAMASE FORTE                 prednisolone sod 1% ophth sol                                 Only Generic Covered
ketorolac 0.5% ophth soln       ACULAR                                                2       Quantity Limits Apply
ketorolac ls 0.4% ophth soln    ACULAR LS                                             2       Quantity Limits Apply
LOTEMAX 0.5% OPHTH SUSP                                                               4       Quantity Limits Apply
NEVANAC 0.1% OPHTH SUSP                                                               3       Quantity Limits Apply
OCUFEN                          flurbiprofen 0.03% ophth sol                                  Only Generic Covered
PRED FORTE                      prednisolone 1%(gx predforte                                  Only Generic Covered
PRED MILD 0.12% OPHTH SUSP                                                            3       Quantity Limits Apply
prednisolone 1%(gx predforte    PRED FORTE                                            2       Quantity Limits Apply
PREDNISOLONE SOD 1% OPHTHSOL    INFLAMASE FORTE                                       2       Quantity Limits Apply
prednisolone sod 1% ophth sol   INFLAMASE FORTE                                       2       Quantity Limits Apply
VOLTAREN                        diclofenac sod 0.1% ophth sol                                 Only Generic Covered
                                Ophthalmic Agents - Ophthalmic Antivirals

27-921/01-01/06 Rev 01-11                                              [ 126]                 2011 Commercial Drug Formulary
                                                                                                    Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
trifluridine 1% ophth soln      VIROPTIC                                                 2       Quantity Limits Apply
VIROPTIC                        trifluridine 1% ophth soln                                       Only Generic Covered
                                Otic Agents - Otic Antibacterials
acetic acid 2% otic soln        VOSOL                                                    2       Quantity Limits Apply
CIPRODEX OTIC SUSP                                                                       3       Quantity Limits Apply
CORTISPORIN                     cortomycin 1% otic sus                                           Only Generic Covered
CORTISPORIN                     neo/poly b/hc otic soln                                          Only Generic Covered
cortomycin 1% otic sus          CORTISPORIN                                              2       Quantity Limits Apply
neo/poly b/hc otic soln         CORTISPORIN                                              2       Quantity Limits Apply
VOSOL                           acetic acid 2% otic soln                                         Only Generic Covered
                                Otic Agents - Otic Anti-Inflammatories
a/a 2% & alum acet otic soln    DOMEBORO OTIC                                            2       Quantity Limits Apply
a/b otic sol                                                                             2       Quantity Limits Apply
DERMOTIC 0.01% OIL DROPS                                                                 3       Quantity Limits Apply
                                                                                                 Available via Mail Order
DOMEBORO OTIC                   a/a 2% & alum acet otic soln                                     Only Generic Covered
FLOXIN OTIC                     ofloxacin otic 0.3% soln                                         Only Generic Covered
ofloxacin otic 0.3% soln        FLOXIN OTIC                                              2       Quantity Limits Apply
                                Respiratory Tract Agents - Antihistamines
ALLEGRA                         fexofenadine 30mg tablet                                         Only Generic Covered
ALLEGRA                         fexofenadine 60mg tablet                                         Only Generic Covered
ALLEGRA                         fexofenadine 180mg tablet                                        Only Generic Covered
ALLEGRA 30MG/5ML SUSP                                                                    3       Quantity Limits Apply
ALLEGRA-D                       fexofenad/pse er 120/60mg tab                                    Only Generic Covered
ALLEGRA-D 180 (24HR)            fexofenad/pse er 180/240mgtab                                    Only Generic Covered
ATARAX                          hydroxyzine 10mg/5ml syrup                                       Only Generic Covered
ATARAX                          hydroxyzine hcl 10mg tablet                                      Only Generic Covered
ATARAX                          hydroxyzine hcl 25mg tablet                                      Only Generic Covered
ATARAX                          hydroxyzine hcl 50mg tablet                                      Only Generic Covered
c-phen 12.5-4mg/5ml syp         RONDEC-S                                                 2       Quantity Limits Apply
clemastine 0.67mg/5ml syrup     TAVIST                                                   2       Quantity Limits Apply
cyproheptadine 4mg tablet       PERIACTIN                                                2
cyproheptadine syrup 2mg/5ml    PERIACTIN                                                2       Quantity Limits Apply
fexofenad/pse er 120/60mg tab   ALLEGRA-D                                                2
fexofenad/pse er 180/240mgtab   ALLEGRA-D 180 (24HR)                                     2
fexofenadine 30mg tablet        ALLEGRA                                                  2

27-921/01-01/06 Rev 01-11                                                [ 127]                  2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT         TIER*   NOTES
fexofenadine 60mg tablet        ALLEGRA                                                       2
fexofenadine 180mg tablet       ALLEGRA                                                       2
HYCODAN                         hydrocod/hom syp (gx hycodan)                                         Only Generic Covered
hydrocod/hom syp (gx hycodan)   HYCODAN                                                       2       Quantity Limits Apply
hydroxyzine 10mg/5ml syrup      ATARAX                                                        2
hydroxyzine hcl 10mg tablet     ATARAX                                                        2
hydroxyzine hcl 25mg tablet     ATARAX                                                        2
hydroxyzine hcl 50mg tablet     ATARAX                                                        2
ny-tannic 9-25mg tablet         RYNATAN                                                       2
PATANASE 0.6% NASAL SPRAY                                                                     3       Quantity Limits Apply
PERIACTIN                       cyproheptadine 4mg tablet                                             Only Generic Covered
PERIACTIN                       cyproheptadine syrup 2mg/5ml                                          Only Generic Covered
PHENERGAN                       promethazine 12.5mg tablet                                            Only Generic Covered
PHENERGAN                       promethazine 25mg tab                                                 Only Generic Covered
PHENERGAN                       promethazine 50mg tablet                                              Only Generic Covered
PHENERGAN                       promethazine 6.25/5ml syrup                                           Only Generic Covered
promethazine 12.5mg tablet      PHENERGAN                                                     2
promethazine 25mg tab           PHENERGAN                                                     2
promethazine 50mg tablet        PHENERGAN                                                     2
promethazine 6.25/5ml syrup     PHENERGAN                                                     2       Quantity Limits Apply
r-tanna 4.5/5mg susp            RYNATAN                                                       2       Quantity Limits Apply
RONDEC-S                        c-phen 12.5-4mg/5ml syp                                               Only Generic Covered
RYNATAN                         ny-tannic 9-25mg tablet                                               Only Generic Covered
RYNATAN                         r-tanna 4.5/5mg susp                                                  Only Generic Covered
TAVIST                          clemastine 0.67mg/5ml syrup                                           Only Generic Covered
                                Respiratory Tract Agents - Antileukotrienes
ACCOLATE                        zafirlukast 10mg tablet                                               Only Generic Covered
ACCOLATE                        zafirlukast 20mg tablet                                               Only Generic Covered
zafirlukast 10mg tablet         ACCOLATE                                                      2       Available via Mail Order
zafirlukast 20mg tablet         ACCOLATE                                                      2       Available via Mail Order
                                Respiratory Tract Agents - Bronchodilators, Anticholinergic
ATROVENT HFA INHALER                                                                          3       Quantity Limits Apply
                                                                                                      Available via Mail Order
ATROVENT NASAL                  ipratropium 0.03% nasal spry                                          Only Generic Covered
ATROVENT NASAL                  ipratropium 0.06% nasal spry                                          Only Generic Covered
ATROVENT NEB                    ipratrop brom 0.02% neb soln                                          Only Generic Covered

27-921/01-01/06 Rev 01-11                                               [ 128]                        2011 Commercial Drug Formulary
                                                                                                            Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT               TIER*   NOTES
ipratrop brom 0.02% neb soln    ATROVENT NEB                                                      5       Available via Mail Order
ipratropium 0.03% nasal spry    ATROVENT NASAL                                                    2       Quantity Limits Apply
                                                                                                          Available via Mail Order
ipratropium 0.06% nasal spry    ATROVENT NASAL                                                    2       Quantity Limits Apply
                                                                                                          Available via Mail Order
SPIRIVA HANDIHALER                                                                                3       Quantity Limits Apply
                                                                                                          Available via Mail Order
                                Respiratory Tract Agents - Bronchodilators, Anti-Inflammatories
AEROBID INHALER                                                                                   4       Quantity Limits Apply
                                                                                                          Available via Mail Order
budesonide 0.25mg/2ml neb sus   PULMICORT RESPULES                                                5       Prior Auth Required
                                                                                                          Quantity Limits Apply
                                                                                                          Available via Mail Order
budesonide 0.5mg/2ml neb sus    PULMICORT RESPULES                                                5       Prior Auth Required
                                                                                                          Quantity Limits Apply
                                                                                                          Available via Mail Order
FLONASE                         fluticasone 50mcg nasal spry                                              Only Generic Covered
FLOVENT DISKUS 50MCG                                                                              3       Quantity Limits Apply
                                                                                                          Available via Mail Order
FLOVENT DISKUS 100MCG                                                                             3       Quantity Limits Apply
                                                                                                          Available via Mail Order
FLOVENT DISKUS 250MCG                                                                             3       Quantity Limits Apply
                                                                                                          Available via Mail Order
FLOVENT HFA 110MCG INHALER                                                                        3       Quantity Limits Apply
                                                                                                          Available via Mail Order
FLOVENT HFA 220MCG INHALER                                                                        3       Quantity Limits Apply
                                                                                                          Available via Mail Order
FLOVENT HFA 44MCG INHALER                                                                         3       Quantity Limits Apply
                                                                                                          Available via Mail Order
fluticasone 50mcg nasal spry    FLONASE                                                           2       Quantity Limits Apply
                                                                                                          Available via Mail Order
PULMICORT RESPULES              budesonide 0.25mg/2ml neb sus                                             Only Generic Covered
PULMICORT RESPULES              budesonide 0.5mg/2ml neb sus                                              Only Generic Covered
                                Respiratory Tract Agents - Bronchodilators, Sympathomimetic
albuterol 0.083% neb soln       PROVENTIL                                                         5       Quantity Limits Apply
                                                                                                          Available via Mail Order
albuterol 0.5% neb soln         PROVENTIL                                                         5       Quantity Limits Apply
                                                                                                          Available via Mail Order
albuterol 2mg tablet            PROVENTIL                                                         2       Available via Mail Order
albuterol 2mg/5ml syrup         PROVENTIL                                                         2       Available via Mail Order
albuterol 4mg tablet            PROVENTIL                                                         2       Available via Mail Order
27-921/01-01/06 Rev 01-11                                               [ 129]                            2011 Commercial Drug Formulary
                                                                                                                Last Updated: July 1, 2011
                                                            DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                  BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
ALUPENT                         metaproterenol 10mg tablet                                       Only Generic Covered
ALUPENT                         metaproterenol 20mg tablet                                       Only Generic Covered
ALUPENT                         metaproterenol 10mg/5ml syrup                                    Only Generic Covered
BRETHINE                        terbutaline 2.5mg tablet                                         Only Generic Covered
BRETHINE                        terbutaline 5mg tablet                                           Only Generic Covered
EPIPEN 0.3MG INJ                                                                         3       Quantity Limits Apply
EPIPEN-JR 0.15MG INJ                                                                     3       Quantity Limits Apply
metaproterenol 10mg tablet      ALUPENT                                                  2       Available via Mail Order
metaproterenol 20mg tablet      ALUPENT                                                  2       Available via Mail Order
metaproterenol 10mg/5ml syrup   ALUPENT                                                  2       Available via Mail Order
PROVENTIL                       albuterol 0.083% neb soln                                        Only Generic Covered
PROVENTIL                       albuterol 0.5% neb soln                                          Only Generic Covered
PROVENTIL                       albuterol 2mg tablet                                             Only Generic Covered
PROVENTIL                       albuterol 2mg/5ml syrup                                          Only Generic Covered
PROVENTIL                       albuterol 4mg tablet                                             Only Generic Covered
SEREVENT DISKUS                                                                          3       Available via Mail Order
terbutaline 2.5mg tablet        BRETHINE                                                 2       Available via Mail Order
terbutaline 5mg tablet          BRETHINE                                                 2       Available via Mail Order
VENTOLIN HFA AER INHALER                                                                 3       Quantity Limits Apply
                                                                                                 Available via Mail Order
                                Respiratory Tract Agents - Bronchodilators, Xanthines
aminophyllin 25mg/ml inj                                                                 5
aminophylline 100mg tablet                                                               2       Available via Mail Order
aminophylline 200mg tablet                                                               2       Available via Mail Order
dyphylline gg 200-200mg tab     LUFYLLIN-GG                                              2       Available via Mail Order
LUFYLLIN-GG                     dyphylline gg 200-200mg tab                                      Only Generic Covered
THEO-DUR                        theophylline sr 100mg tablet                                     Only Generic Covered
THEO-DUR                        theophylline sr 200mg tablet                                     Only Generic Covered
THEO-DUR                        theophylline sr 300mg tablet                                     Only Generic Covered
THEO-DUR                        theophylline sr 450mg tablet                                     Only Generic Covered
theophylline sr 100mg tablet    THEO-DUR                                                 2       Available via Mail Order
theophylline sr 200mg tablet    THEO-DUR                                                 2       Available via Mail Order
theophylline sr 300mg tablet    THEO-DUR                                                 2       Available via Mail Order
theophylline sr 450mg tablet    THEO-DUR                                                 2       Available via Mail Order
                                Respiratory Tract Agents - Mast Cell Stabilizers


27-921/01-01/06 Rev 01-11                                                [ 130]                  2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT        TIER*   NOTES
cromolyn solution 20mg/2ml      INTAL NEB                                                    2       Prior Auth Required
                                                                                                     Available via Mail Order
INTAL NEB                       cromolyn solution 20mg/2ml                                           Only Generic Covered
                                Respiratory Tract Agents - Mucolytics
acetylcysteine 10% soln         MUCOMYST                                                     5
acetylcysteine 20% soln         MUCOMYST                                                     5
MUCOMYST                        acetylcysteine 10% soln                                              Only Generic Covered
MUCOMYST                        acetylcysteine 20% soln                                              Only Generic Covered
                                Respiratory Tract Agents - Respiratory Tract Agents, Other
ADVAIR 100/50 DISKUS INH                                                                     4       Quantity Limits Apply
                                                                                                     Available via Mail Order
ADVAIR 250/50 DISKUS INH                                                                     4       Quantity Limits Apply
                                                                                                     Available via Mail Order
ADVAIR 500/50 DISKUS INH                                                                     4       Quantity Limits Apply
                                                                                                     Available via Mail Order
ADVAIR HFA 45/21MCG INHALER                                                                  4       Quantity Limits Apply
                                                                                                     Available via Mail Order
ADVAIR HFA 115/21MCG INHALER                                                                 4       Quantity Limits Apply
                                                                                                     Available via Mail Order
ADVAIR HFA 230/21MCG INHALER                                                                 4       Quantity Limits Apply
                                                                                                     Available via Mail Order
benzonatate 100mg capsule       TESSALON                                                     2
benzonatate 100mg cap           TESSALON                                                     2
benzonatate 200mg capsule       TESSALON                                                     2
benzonatate 200mg cap           TESSALON                                                     2
brometane dx (gx dimetane dx)   DIMETANE DX                                                  2       Quantity Limits Apply
c-phen 1mg-3.5mg/ml drops       RONDEC DROPS                                                 2       Quantity Limits Apply
c-phen dm 3.5-1-3mg/ml drops    RONDEC DM                                                    2       Quantity Limits Apply
c-phen dm syrup 15/12.5/4       RONDEC DM SYRUP                                              2       Quantity Limits Apply
cheratussin ac syrup            ROBITUSSIN AC                                                2       Quantity Limits Apply
cheratussin dac syp             ROBITUSSIN DAC                                               2       Quantity Limits Apply
DIMETANE DX                     brometane dx (gx dimetane dx)                                        Only Generic Covered
DULERA 100MCG/5MCG INHALER                                                                   4       Quantity Limits Apply
                                                                                                     Available via Mail Order
DULERA 200MCG/5MCG INHALER                                                                   4       Quantity Limits Apply
                                                                                                     Available via Mail Order
flunisolide 0.025% nasal spr    NASALIDE                                                     2       Quantity Limits Apply
                                                                                                     Available via Mail Order
NASALIDE                        flunisolide 0.025% nasal spr                                         Only Generic Covered
27-921/01-01/06 Rev 01-11                                               [ 131]                       2011 Commercial Drug Formulary
                                                                                                           Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
PHENERGAN DM                    promethazine-dm syrup                                           Only Generic Covered
PHENERGAN VC                    prometh-vc syrup                                                Only Generic Covered
PHENERGAN VC WITH CODEINE       prometh-vc w/codeine syrup                                      Only Generic Covered
PHENERGAN W/CODEINE             prometh w/codeine syrup                                         Only Generic Covered
PROLASTIN 1000MG INJ                                                                    5
prometh w/codeine syrup         PHENERGAN W/CODEINE                                     2       Quantity Limits Apply
prometh-vc syrup                PHENERGAN VC                                            2       Quantity Limits Apply
prometh-vc w/codeine syrup      PHENERGAN VC WITH CODEINE                               2       Quantity Limits Apply
promethazine-dm syrup           PHENERGAN DM                                            2       Quantity Limits Apply
REVATIO 20MG TABLET                                                                     6       Prior Auth Required
ROBITUSSIN AC                   cheratussin ac syrup                                            Only Generic Covered
ROBITUSSIN DAC                  cheratussin dac syp                                             Only Generic Covered
RONDEC DM                       c-phen dm 3.5-1-3mg/ml drops                                    Only Generic Covered
RONDEC DM SYRUP                 c-phen dm syrup 15/12.5/4                                       Only Generic Covered
RONDEC DROPS                    c-phen 1mg-3.5mg/ml drops                                       Only Generic Covered
SEMPREX-D CAPSULE                                                                       4
SYMBICORT 80/4.5 INHALER                                                                4       Quantity Limits Apply
                                                                                                Available via Mail Order
SYMBICORT 160/4.5 INHALER                                                               4       Quantity Limits Apply
                                                                                                Available via Mail Order
TESSALON                        benzonatate 100mg capsule                                       Only Generic Covered
TESSALON                        benzonatate 100mg cap                                           Only Generic Covered
TESSALON                        benzonatate 200mg capsule                                       Only Generic Covered
TESSALON                        benzonatate 200mg cap                                           Only Generic Covered
TRACLEER 125MG TAB                                                                      6       Prior Auth Required
TRACLEER 62.5MG TAB                                                                     6       Prior Auth Required
triamcinolone 55mcg nasal spr                                                           2       Quantity Limits Apply
                                                                                                Available via Mail Order
TYZINE 0.1% NASAL SOLUTION                                                              3       Quantity Limits Apply
XOLAIR 150MG INJ                                                                        6       Prior Auth Required
                                Sedatives/Hypnotics
AMBIEN (NOT CR)                 zolpidem 5mg tablet                                             Only Generic Covered
AMBIEN (NOT CR)                 zolpidem 10mg tablet                                            Only Generic Covered
chloral hydrate 500mg/5ml syp   NOCTEC                                                  2       Available via Mail Order
DALMANE                         flurazepam 15mg capsule                                         Only Generic Covered
DALMANE                         flurazepam 30mg capsule                                         Only Generic Covered


27-921/01-01/06 Rev 01-11                                            [ 132]                     2011 Commercial Drug Formulary
                                                                                                      Last Updated: July 1, 2011
                                                         DRUG CATEGORY - DRUG CLASS
DRUG NAME                                               BRAND OR GENERIC EQUIVALENT                   TIER*   NOTES
flurazepam 15mg capsule         DALMANE                                                               2
flurazepam 30mg capsule         DALMANE                                                               2
NOCTEC                          chloral hydrate 500mg/5ml syp                                                 Only Generic Covered
RESOTRIL (NOT 7.5MG)            temazepam 30mg capsule                                                        Only Generic Covered
RESTORIL (NOT 7.5MG)            temazepam 15mg capsule                                                        Only Generic Covered
somnote 500mg cap(chloral hy)                                                                         2       Available via Mail Order
SONATA                          zaleplon 5mg capsule                                                          Only Generic Covered
SONATA                          zaleplon 10mg capsule                                                         Only Generic Covered
temazepam 15mg capsule          RESTORIL (NOT 7.5MG)                                                  2
temazepam 30mg capsule          RESOTRIL (NOT 7.5MG)                                                  2
zaleplon 5mg capsule            SONATA                                                                2       Available via Mail Order
zaleplon 10mg capsule           SONATA                                                                2       Available via Mail Order
zolpidem 5mg tablet             AMBIEN (NOT CR)                                                       2       Available via Mail Order
zolpidem 10mg tablet            AMBIEN (NOT CR)                                                       2       Available via Mail Order
                                Skelatal Muscle Relaxants
baclofen 10mg tablet            LIORESAL                                                              2
baclofen 20mg tablet            LIORESAL                                                              2
BOTOX 100U INJ                                                                                        5       Prior Auth Required
carisoprodol 350mg tablet       SOMA (NOT 250MG)                                                      2
cyclobenzaprine 10mg tablet     FLEXERIL (NOT 5MG)                                                    2
DANTRIUM                        dantrolene 50mg cap                                                           Only Generic Covered
dantrolene 50mg cap             DANTRIUM                                                              2
FLEXERIL (NOT 5MG)              cyclobenzaprine 10mg tablet                                                   Only Generic Covered
LIORESAL                        baclofen 10mg tablet                                                          Only Generic Covered
LIORESAL                        baclofen 20mg tablet                                                          Only Generic Covered
methocarbamol 500mg tablet      ROBAXIN                                                               2
methocarbamol 750mg tablet      ROBAXIN                                                               2
ROBAXIN                         methocarbamol 500mg tablet                                                    Only Generic Covered
ROBAXIN                         methocarbamol 750mg tablet                                                    Only Generic Covered
SOMA (NOT 250MG)                carisoprodol 350mg tablet                                                     Only Generic Covered
tizanidine 2mg tablet           ZANAFLEX                                                              2
tizanidine 4mg tablet           ZANAFLEX                                                              2
ZANAFLEX                        tizanidine 2mg tablet                                                         Only Generic Covered
ZANAFLEX                        tizanidine 4mg tablet                                                         Only Generic Covered
                                Therapeutic Nutrients/Minerals/Electrolytes - Electrolytes/Minerals
cytra-k soln                    POLYCITRA-K                                                           2
27-921/01-01/06 Rev 01-11                                                [ 133]                               2011 Commercial Drug Formulary
                                                                                                                    Last Updated: July 1, 2011
                                                           DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                 BRAND OR GENERIC EQUIVALENT    TIER*   NOTES
dextrose 10% inj                                                                         5
dextrose 5% 20x4x100ml inj                                                               5
dextrose 5%-nacl 0.45% 1000ml                                                            5
dextrose 5%-nacl 0.9% 1000ml                                                             5
ferocon cap (gx trinsicon)      TRINSICON                                                2
K-LYTE                          k-vescent tab 25meq ef                                           Only Generic Covered
K-PHOS 500MG ORIGINAL TAB                                                                2
k-tab 10meq er tablet                                                                    1       Available via Mail Order
k-vescent   tab 25meq ef        K-LYTE                                                   2       Available via Mail Order
KCL/D5W/LR 0.15% INJ                                                                     5
klor-con 20meq pwd pack                                                                  2       Available via Mail Order
klor-con er 8meq tablet         SLOW-K                                                   1       Available via Mail Order
lactated ringer's 1000ml inj                                                             5
LACTATED RINGER'S 500ML INJ                                                              5
lactated ringer/d5w inj                                                                  5
magnesium sulfate 1gm/2ml inj                                                            5
phospha 250mg neutral tablet                                                             2
POLYCITRA-K                     cytra-k soln                                                     Only Generic Covered
pot chloride 2omeq/10ml inj                                                              5
potassium chl 10% sf liquid                                                              2       Available via Mail Order
potassium chl 20% sf liquid                                                              2       Available via Mail Order
potassium cit 5meq er tab       UROCIT-K                                                 2
potassium cit 10meq er tab      UROCIT-K                                                 2
ringers irrig soln                                                                       5
SLOW-K                          klor-con er 8meq tablet                                          Only Generic Covered
sod bicarb 8.4% inj 50ml sdv                                                             5
sod chloride 0.45% inj 1000ml                                                            5       Available via Mail Order
sod chloride 0.9% inj 250ml                                                              5
TRINSICON                       ferocon cap (gx trinsicon)                                       Only Generic Covered
UROCIT-K                        potassium cit 5meq er tab                                        Only Generic Covered
UROCIT-K                        potassium cit 10meq er tab                                       Only Generic Covered
UROQID-ACID NO.2 TAB                                                                     2
                                Therapeutic Nutrients/Minerals/Electrolytes - Vitamins
BEROCCA PLUS                    vitaplex plus tablet                                             Only Generic Covered
cyanocobalamin 1000mcg/ml inj                                                            2
folic acid 1mg tablet                                                                    2       Available via Mail Order
27-921/01-01/06 Rev 01-11                                               [ 134]                   2011 Commercial Drug Formulary
                                                                                                       Last Updated: July 1, 2011
                                                              DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                    BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
folic acid 5mg/ml inj                                                                      2
INTRALIPID 30% INJ                                                                         5
LURIDE                          sod fluoride 0.5mg/ml drop                                         Only Generic Covered
LURIDE                          sodiphluor 0.5mg/ml drop                                           Only Generic Covered
MEPHYTON 5MG TABLET                                                                        3
multi vita-bets/fl 0.5mg        POLY VI FLOR                                               2       Available via Mail Order
multi vita-bets/fl 1mg tablet   POLY VI FLOR                                               2       Available via Mail Order
multi-vit fl/fe 0.25mg drops    POLY-VI-FLOR                                               2       Quantity Limits Apply
                                                                                                   Available via Mail Order
multi-vit fluor 0.25mg drops    POLY-VI-FLOR                                               2       Quantity Limits Apply
                                                                                                   Available via Mail Order
phluorivit 0.5mg drops                                                                     2       Quantity Limits Apply
                                                                                                   Available via Mail Order
POLY VI FLOR                    multi vita-bets/fl 0.5mg                                           Only Generic Covered
POLY VI FLOR                    multi vita-bets/fl 1mg tablet                                      Only Generic Covered
POLY-VI-FLOR                    multi-vit fl/fe 0.25mg drops                                       Only Generic Covered
POLY-VI-FLOR                    multi-vit fluor 0.25mg drops                                       Only Generic Covered
poly-vit-fluor-fe .5mg drops                                                               2       Quantity Limits Apply
                                                                                                   Available via Mail Order
prenatal plus tablet            STUART NATAL PLUS                                          2       Available via Mail Order
sod fluoride 0.5mg/ml drop      LURIDE                                                     2       Available via Mail Order
sodiphluor 0.5mg/ml drop        LURIDE                                                     2       Quantity Limits Apply
                                                                                                   Available via Mail Order
STUART NATAL PLUS               prenatal plus tablet                                               Only Generic Covered
STUARTNATAL PLUS THREE          trinate tablet                                                     Only Generic Covered
tpn electrolytes inj                                                                       5
TRI-VI-FLOR                     tri-vit fluor 0.25mg drops                                         Only Generic Covered
TRI-VI-FLOR                     tri-vit fluor 0.5mg drops                                          Only Generic Covered
TRI-VI-FLOUR W/FE               tri-vit w/fl & fe 0.25mg drop                                      Only Generic Covered
tri-vit fluor 0.25mg drops      TRI-VI-FLOR                                                2       Quantity Limits Apply
                                                                                                   Available via Mail Order
tri-vit fluor 0.5mg    drops    TRI-VI-FLOR                                                2       Quantity Limits Apply
                                                                                                   Available via Mail Order
tri-vit w/fl & fe 0.25mg drop   TRI-VI-FLOUR W/FE                                          2       Quantity Limits Apply
                                                                                                   Available via Mail Order
trinate tablet                  STUARTNATAL PLUS THREE                                     2       Available via Mail Order
vitamin d 50000iu capsule                                                                  2       Available via Mail Order
vitaplex plus tablet            BEROCCA PLUS                                               2       Available via Mail Order

27-921/01-01/06 Rev 01-11                                               [ 135]                     2011 Commercial Drug Formulary
                                                                                                         Last Updated: July 1, 2011
                                                          DRUG CATEGORY - DRUG CLASS
DRUG NAME                                                BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
                                Toxicologic Agents
ANTIZOL 1GM/ML INJ                                                                     6       Prior Auth Required
BUPHENYL 500MG TAB                                                                     4       Prior Auth Required
CHEMET 100MG CAP                                                                       3
EXJADE 125MG TABLET                                                                    6       Prior Auth Required
EXJADE 250MG TABLET                                                                    6       Prior Auth Required
EXJADE 500MG TABLET                                                                    6       Prior Auth Required
naloxone 0.4mg/ml inj           NARCAN                                                 5
naltrexone 50mg tablet          REVIA                                                  2
NARCAN                          naloxone 0.4mg/ml inj                                          Only Generic Covered
REVIA                           naltrexone 50mg tablet                                         Only Generic Covered
SYPRINE 250MG CAPSULE                                                                  4
                                Unclassified
amifostine 500mg inj            ETHYOL                                                 5       Prior Auth Required
AMINOSYN/D25 II 3.5% INJ                                                               5
ARCALYST 220MG INJ                                                                     6       Prior Auth Required
ASCENSIA CONTOUR HIGH SOLN                                                             5
ASCENSIA CONTOUR LOW SOLN                                                              5
ASCENSIA CONTOUR NORM SOLN                                                             5
ASCENSIA ELITE HI/LO CTRL SOL                                                          5
ascensia elite test strips                                                             2       Available via Mail Order
breeze 2 ascensia test strip                                                           2       Available via Mail Order
BYETTA 10MCG/0.04ML INJ                                                                3       Prior Auth Required
                                                                                               Quantity Limits Apply
                                                                                               Available via Mail Order
BYETTA 5MCG/0.02ML INJ                                                                 3       Prior Auth Required
                                                                                               Quantity Limits Apply
                                                                                               Available via Mail Order
CYSTADANE POWD                                                                         4
CYSTAGON 150MG CAP                                                                     2
DIABETIC GAUZE PADS 2X2                                                                3       Quantity Limits Apply
                                                                                               Available via Mail Order
ETHYOL                          amifostine 500mg inj                                           Only Generic Covered
EUFLEXXA 10MG/ML (3X2ML) INJ                                                           5       Prior Auth Required
INS/SYG ULT-TH-II 0.5CC/29G                                                            3       Available via Mail Order
INS/SYG ULT-TH-II 1CC/29G                                                              3       Available via Mail Order
INS/SYG ULT-TH-II 3/10CC 29G                                                           3       Available via Mail Order

27-921/01-01/06 Rev 01-11                                           [ 136]                     2011 Commercial Drug Formulary
                                                                                                     Last Updated: July 1, 2011
                                 DRUG CATEGORY - DRUG CLASS
DRUG NAME                       BRAND OR GENERIC EQUIVALENT   TIER*   NOTES
INS/SYG ULT-TH-II 3/10CC 30G                                  3       Available via Mail Order
INS/SYG ULT-TH-II 3/10CC 31G                                  3       Available via Mail Order
INS/SYG ULT-TH-II-SHRT0.5/30G                                 3       Available via Mail Order
INS/SYG ULT-TH-II-SHRT0.5/31G                                 3       Available via Mail Order
INS/SYG ULT-TH-II-SHRT1CC/30G                                 3       Available via Mail Order
LEUKINE 250MCG INJ                                            6       Prior Auth Required
mpd lancets thin                                              5       Available via Mail Order
PRODIGY AUTOCODE TEST STRIPS                                  5       Available via Mail Order
RANEXA 1000MG ER TABLET                                       3       Prior Auth Required
                                                                      Available via Mail Order
RANEXA 500MG TABLET                                           3       Prior Auth Required
                                                                      Available via Mail Order
SYMLIN 0.6MG/ML INJ                                           3       Prior Auth Required
                                                                      Available via Mail Order
SYMLIN PEN 60 1000MCG/ML INJ                                  3       Prior Auth Required
                                                                      Available via Mail Order
SYNVISC (3X2ML) INJ                                           5       Prior Auth Required
TOBI 300MG/5ML INH SOLN                                       5       Prior Auth Required
XENAZINE 25MG TABLET                                          6       Prior Auth Required
XYREM 500MG/ML SOL                                            4




27-921/01-01/06 Rev 01-11                  [ 137]                     2011 Commercial Drug Formulary
                                                                            Last Updated: July 1, 2011
    DRUG CATEGORY – DRUG CLASS PAGE

A

Analgesics - Non-Opiod Analgesics 34
Analgesics - Opioid Analgesics 34
Anesthetics 36
Anti-Convulsants - Calcium Channel Modifying Agents 43
Anti-Convulsants - GABA Augmenting Agents 43
Anti-Convulsants - Glutamate Reducing Agents 45
Anti-Convulsants - Sodium Channel Inhibitors 47
Anti-Inflammatories - Glucocorticoids 57
Anti-Inflammatories - NSAIDS 59
Antibacterials - Antibacterials, Other 36
Antibacterials - Beta-Lactam, Cephalosporins 36
Antibacterials - Beta-Lactam, Other 36
Antibacterials - Beta-Lactam, Penicillins 39
Antibacterials - Macrolides 41
Antibacterials - Quinolones 41
Antibacterials - Sulfonamides 42
Antibacterials - Tetracyclines 42
Antidementia Agents - Antidementia Agents, Other 48
Antidementia Agents - Cholinesterase Inhibitors 48
Antidementia Agents - Glutamate Pathway Modifiers 48
Antidepressants - Antidepressants, Other 48
Antidepressants - MAO Inhibitors 50
Antidepressants - Re-Uptake Inhibitors 50
Antiemetics 55
Antifungals 56
Antigout Agents 57
Antimigraine Agents - Abortive 62
Antimycobacterials - Antimycobacterials, Other 62
Antimycobacterials - Antituberculars 62
Antineoplastics - Alkylating Agents 63
Antineoplastics - Antimetabolites 63
Antineoplastics - Antineoplastics, Other 63
Antineoplastics - Immune Modulators and Vaccines 64
Antineoplastics - Molecular Target Inhibitors 65
Antineoplastics - Nucleoside Analogs 65
Antineoplastics - Protective Agents 65
Antineoplastics - Topoisomerse Inhibitors 66
Antiparasitics - Anthelmetics 67
Antiparasitics - Antiprotozoals 67
Antiparasitics - Pediculicides/Scabicides 67
Antiparkinson Agents - Antiparkinson Agents, Other 67


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                                                                        Last Updated on July 1, 2011
    DRUG CATEGORY – DRUG CLASS PAGE

Antiparkinson Agents - COMT Inhibitors 67
Antiparkinson Agents - Dopamine Agonists 67
Antipsychotics - Non-Phenothiazines 69
Antipsychotics - Non-Phenothiazines, Atypicals 69
Antipsychotics - Phenothiazines 69
Antivirals - Anti-HIV Agents, Fusion Inhibitors 75
Antivirals - Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors 75
Antivirals - Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors’   75
Antivirals - Anti-HIV Agents, Protease Inhibitors 75
Antivirals - Anti-Influenza Agents 76
Antivirals - Antiherpetic Agents 75
Antivirals - Antivirals, Other 75
Antivirals - CMV Agents 76
Anxiolytics - Anxiolytics, Other 78
Autonomic Agents - Parasympatholytics 79
Autonomic Agents - Parasympathomimetics 79
Autonomic Agents - Sympathomimetics 79

B

Bipolar Agents 80
Blood Glucose Regulators - Antihypoglycemics 80
Blood Glucose Regulators – Hypoglycemics, Oral 80
Blood Glucose Regulators – Hypoglycemics, Oral-Step Therapy Applies 82
Blood Glucose Regulators - Insulins 82
Blood Products/Modifiers/Volume Expanders - Anticoagulants 83
Blood Products/Modifiers/Volume Expanders - Blood Formation Products 84
Blood Products/Modifiers/Volume Expanders - Coagulants 84
Blood Products/Modifiers/Volume Expanders - Platelet Aggregation Inhibitors       84

C

Cardiovascular Agents - Alpha-Adrenergic Agonists 86
Cardiovascular Agents - Alpha-Adrenergic Blocking Agents 86
Cardiovascular Agents - Antiarrhythmics 86
Cardiovascular Agents - Beta-Adrenergic Blocking Agents 88
Cardiovascular Agents - Calcium Channel Blocking Agents 90
Cardiovascular Agents - Direct Cardiac Inotropics 91
Cardiovascular Agents - Diuretics 91
Cardiovascular Agents - Dyslipidemics 93
Cardiovascular Agents - Renin-Angiotensin-Aldosterone System Inhibitors      94
Cardiovascular Agents - Vasodilators 96
Central Nervous System Agents - Amphetamines 98


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                                                                                                      Last Updated on July 1, 2011
    DRUG CATEGORY – DRUG CLASS PAGE

Central Nervous System Agents - Non-Amphetamines           98

D

Dental and Oral Agents 100
Dermatological Agents - Dermatological Anesthetics 101
Dermatological Agents - Dermatological Antibacterials 101
Dermatological Agents - Dermatological Antifungals 101
Dermatological Agents - Dermatological Antiinflammatories 102
Dermatological Agents - Dermatological Antipruritic 105
Dermatological Agents - Dermatological Antivirals 105
Dermatological Agents - Dermatological Keratolytics 105
Dermatological Agents - Dermatological Mitotic Inhibitors 105
Dermatological Agents - Dermatological Photochemotherapy Agents          105
Dermatological Agents - Dermatological Retinoids 105
Dermatological Agents - Dermatological Vitamin D Analogs 106
Dermatological Agents - Dermatological Wound Care Agents 106
Deterents/Replacements - Alcohol Deterents 107

E

Enzyme Replacements/Modifiers      107

G

Gastrointestinal Agents - Antispasmodics, Gastrointestinal 108
Gastrointestinal Agents - Gastrointestinal Agents, Other 108
Gastrointestinal Agents - H2 Blocking Agents 109
Gastrointestinal Agents - Irritable Bowel Syndrome Agents 109
Gastrointestinal Agents - PPIs 109
Gastrointestinal Agents - Protectants 110
Genitourinary Agents - Antispasmodics, Urinary 111
Genitourinary Agents - Benign Prostatic Hypertrophy Agents 111

H

Hormonal   Agents,   Stimulant/Replacement/Modifying   -   Adrenal 111
Hormonal   Agents,   Stimulant/Replacement/Modifying   -   Parathyroid/Metabolic Bone Disease Agents   111
Hormonal   Agents,   Stimulant/Replacement/Modifying   -   Pituitary 111
Hormonal   Agents,   Stimulant/Replacement/Modifying   -   Sex Hormones/Modifiers 112
Hormonal   Agents,   Stimulant/Replacement/Modifying   -   Thyroid 116
Hormonal   Agents,   Suppressant - Adrenal 116
Hormonal   Agents,   Suppressant - Pituitary 116


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                                                                                                                  Last Updated on July 1, 2011
    DRUG CATEGORY – DRUG CLASS PAGE

Hormonal Agents, Suppressant - Sex Hormones/Modifiers          116
Hormonal Agents, Suppressant - Thyroid 116

I

Immunological Agents - Immune Stimulants 118
Immunological Agents - Immune Suppressants 120
Immunological Agents - Immunomodulators 121
Inflammatory Bowel Disease Agents - Glucocorticoids 121
Inflammatory Bowel Disease Agents - Salicylates 121
Inflammatory Bowel Disease Agents - Sulfonamides 121

O

Ophthalmic Agents - Ophthalmic Agents, Other 122
Ophthalmic Agents - Ophthalmic Anti-Allergy Agents 122
Ophthalmic Agents - Ophthalmic Anti-Inflammatories 126
Ophthalmic Agents - Ophthalmic Antibacterials 122
Ophthalmic Agents - Ophthalmic Antifungals 124
Ophthalmic Agents - Ophthalmic Antiglaucoma Agents 124
Ophthalmic Agents - Ophthalmic Antivirals 126
Otic Agents - Otic Anti-Inflammatories 127
Otic Agents - Otic Antibacterials 127

R

Respiratory   Tract   Agents   - Antihistamines 127
Respiratory   Tract   Agents   - Antileukotrienes 128
Respiratory   Tract   Agents   – Bronchodilators, Anti-Inflammatories 128
Respiratory   Tract   Agents   – Bronchodilators, Anticholinergic 128
Respiratory   Tract   Agents   – Bronchodilators, Sympathomimetic 128
Respiratory   Tract   Agents   – Bronchodilators, Xanthines 129
Respiratory   Tract   Agents   - Mast Cell Stabilizers 130
Respiratory   Tract   Agents   - Mucolytics 130
Respiratory   Tract   Agents   - Respiratory Tract Agents, Other 130

S

Sedatives/Hypnotics 132
Skelatal Muscle Relaxants 133




27-921/01-01/06 Rev. 01-11                                                  [ [141]   2011 Commercial Drug Formulary
                                                                                           Last Updated on July 1, 2011
    DRUG CATEGORY – DRUG CLASS PAGE

T

Therapeutic Nutrients/Minerals/Electrolytes - Electrolytes/Minerals   133
Therapeutic Nutrients/Minerals/Electrolytes - Vitamins 133
Toxicologic Agents 136

U

Unclassified   136




27-921/01-01/06 Rev. 01-11                                              [ [142]   2011 Commercial Drug Formulary
                                                                                       Last Updated on July 1, 2011

								
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