Transcription
2014 Basic Plus Formulary ListThe 2014 Basic Plus Formulary drug list is shown below. The formulary is the list of drugs included inyour prescription drug benefit plan. Inclusion on the list does not guarantee coverage.Please note: Brand-name drugs may move to non-formulary status if a generic version becomesavailable during the year. Not all of the drugs listed are covered by all prescription drug benefitprograms; check our benefit materials for the specific drugs covered and the copayments for yourprescription drug benefit program. For specific questions about your coverage, please call thephone number printed on your member ID card.PLEASE NOTE: This drug list is subject to change so please visit the WellDyneRx website atemhp.welldynerx.com for the most current list and program criteria.Key[INJ]-Injectable Drug[SP]- Specialty Drug[PA]- Prior Authorization[QLL]- Quantity Level Limits[ST]- Step TherapyBrand Name drugs are listed in CAPITAL letters.Example: CELEBREXGeneric drugs are listed in lower-case letters.Example: ibuprofenFor the member: Generic medicationscontain the same active ingredients as their corresponding brand-name medications, although they may lookdifferent in color or shape. They have been FDA-approved under strict standards.For the physician: Please prescribe preferred products and allow generic substitutions when medicallyappropriate.AAvacavir [SP]ABELCET [INJ]ABILIFY [QLL]ABILIFY DISCMELT [QLL]ABILIFY MAINTENA [INJ] [QLL]ABRAXANE [INJ] [SP]Acamprosate delatyed-releaseACANYAacaraboseACCU-CHEK FASTCLIX LANCETACCU-CHEK MULTICLIX LANCETSACCU-CHEK SOLFCLIX n/phenloloxamine citrateext-releaseacetazolamideacetazolamide [INJ]acetazolamide ext-releaseacetic acid ear solutionacetic acid irrigation solutionacetic acid/aluminum acetate earsolutionacetic acid/hydrocortisone ear solutionacetic acid/oxyquinolineacetylcsteine [INJ]acitetinACETEMRA [INJ] [SP] [PA]ACTHAR H.P. [INJ] [SP] [PA]ACTHIB [INJ]ACTHREL [INJ]ACTIMMUNE [INJ] [SP]ACTIVASE [INJ]ACTONEL [QLL] [ST]ACTOPLUS MET XR [QLL]acycloviracyclovir [INJ]ADCETRIS [INJ] [SP]ADCIRCA [SA] [PA] [QLL]ADDAMEL N [INJ]adefoviradenosine [INJ]ADVAI DISKUS/HFA [QLL]advanced am/pmADVATE [INJ] [SP]ADVATE H [INJ] [SP]ADVATE L [INJ] [SP]ADVATE N [INJ] [SP]ADVATE SH [INJ] [SP]ADVATE UH [INJ] [SP]AFINITOR [SP] [QLL]AFINITOR DISPERZ [SP] [QLL]AFLURIA [INJ]AGGRASTAT [INJ]AGGRENOX [QLL]ALBENZAalbumin human [INJ]albuterolalbuterol ext-releasealbuterol nebulization solutionalclometasoneALDURAZYME [INJ] [SP]alendronate sodiumalfentanil [INJ]ALFERON N [INJ]alfuzonsin ext-releaseALIMTA [INJ]ALINIA [QLL]ALKERAN TABLETSallopurinolallopurinol sodium [INJ]ALOXI [INJ]ALPHAGAN P 0.1%ALPHANATE [INJ] [SP]ALPHANINE SD [INJ] [SP]alphaquin hpalprazolamalprazolam ext-releasealprazolam orally disintegrating tabletsalprostadil [INJ]ALREXaltaveraaluminum chloride 20% topical solutionalyacenamantadineAMBISOME [INJ]amcinonideamethiaamethia loamethystamifostine [INJ]amikacin [INJ]amilorideamiloride/hydrochlorothiazideamino acids [INJ]aminocaproic acidaminocaproic acid [INJ]aminophylline [INJ]AMINOSYN [INJ]amiodaroneamiodarone [INJ]AMITIZA [QLL]amitriptylineamitriptyline/chlordiazepoxide
prilAMMONIUM CHLORIDE [INJ]ammonium lactate 12% topicalAMMONUL [INJ]amoxapineamoxicillinamoxicillin/potassium clavulanateamphetamine salt comboamphetamine salt combo ext-releaseamphotericin [INJ]ampicillinampicillin [INJ]ampicillin/sulbactam [INJ]AMPYRA [SP] [PA] [QLL]AMTURNIDE [QLL]AMYTAL [INJ]anagrelideANALPRAM 2.5% LOTIONANALPRAM ADVANCED CREAM KITANALPRAM HC 1% CREAM SINGLESanastrozoleANDRODERMANDROGELanectine [INJ]ANGIOMAX [INJ]anthralinantipyrine/benzocaine ear solutionantipyrine/benzocaine/polycosanol earsolutionAPLISOL [INJ]APOKYN[INJ] [SP]apraclonidine eye solutionapriAPTIVUS [SP] [QLL]ap-zelAQUASOL A [INJ]ARALAST NP [INJ] [SP]aranelleARANESP [INJ] [SP]arbinoxaARCALYST [INJ] [SP]ARCAPTAARGATROBAN [INJ]ARISTOSPAN [INJ]ARMOUR THYROIDARANON [INJ] [SP]ARZERRA [INJ] [SP]ASACOL HD [QLL]ascorbic acid [INJ]ASMANEX [QLL]aspirin delayed-release 975mgASTEPRO [QLL]ATELVIA [QLL] [ST]atenololatenolol/chlorthalidoneATGAM A [SP] [QLL]atropine sulfate [INJ]atropine sulfate eye ointmentatropine sulfate eye solutionATROVENT HFA [QLL]ATRYN [INJ]aubraAUGMENTIN 125-31.25 MG/MLAVASTIN [INJ] [SP]AVELOXAVELOX ABC PACKAVELOX IN [INJ]avianeavo creamAVONEX [INJ] [SP] [PA] [QLL]AXIRON [ST]azacitidine [INJ] [SP]AZACTAM-ISO-OSMOTIC DEXTROSE[INJ]AZASANAZASITEazathioprine [SP]azathioprine sodium [INJ] [SP]azelastine eye solutionazelastine nasal sprayAZILECT [QLL]azithromycinazithromycin [INJ]AZOR [QLL]aztreonam [INJ]azuretteBbleomycin [INJ]BONIVA [INJ] [SP] [QLL]BOOSTRIX [INJ]BOSULIF [SP] [QLL]BOTOX [INJ] [SP] [PA]bp vit 3b-plex plusBREO ELLIPTA [QLL]BEVITAL [INJ]briellynBRILINTA [QLL]brimonidine eye solutionBROMDAYbromfenac eye codeinebudesonide delayd-releasebudesonide nebulization suspensionbumetanidebumetanide [INJ]BUPHENYL TABLETSbupivacaine [INJ]bupivacaine/dextrose [INJ]bupivacaine/epinephrine [INJ]buprenorphinebuprenorphine [INJ]buprenorphine/naloxonebupropionbupropion ext-release (12 hour)bupropion ext-release (24 hour)buspironeBUSULFEX affeine/codeinebutorphanol [INJ] [QLL]butorphanol nasalBUTRANS [QLL]BYDUREON [INJ] [QLL]BYETTA [INJ] [QLL]BYSTOLIC [QLL]Cbacitracin [INJ]bacitracin eye ointmentbacitracin/polymyxin eye ointmentbaclofenBAL IN OIL [INJ]balanced salt eye irrigation solutionbal-care dha prenatal vitaminsbalsalazidebalzivaBANZEL [QLL]BARACLUDE [QLL]b-complex [INJ]BEBULIN [INJ] [SP]BEBULIN VH IMMUNO [INJ] IX [INJ] [SP]BENICAR [QLL]BENICAR HCT [QLL]BENLYSTA [INJ] [SP] [PA]benoxinate/fluescein eye solutionBENZACLIN PUMPbenzocaine ear solutionbenzonatatebenzoyl peroxidebenzphetaminebenztropinebenztropine [INJ]BEPREVEBESIVANCEbetamethasone acetate/betamethasonesodium phosphate [INJ]betamethasone dipropionatebetamethasone dipropionateaugmentedbetamethasone valeratebetaxololbetaxolol eye solutionbethanecholBETOPTIC SBEXXAR [INJ]BEYAZbicalutamideBICILLIN C- [INJ]BICILLIN L-A [INJ]BICNU golinecaffeine citratedcaffeine citrated [INJ]caffeine/sodium benzoate [INJ]calcipotrienecalcitonin salmon nasalcalcitriolcalcitriol [INJ]calcium acetatecalcium chloride [INJ]calcium folinate [INJ]calcium gluconate {INJ]calcium-folic acid plus dCALDOLOR [INJ]camilacamresecamrese loCANASACANCIDAS [INJ]candesartan [QLL]candesartan/hydrochlorothiazidecandida albicans skin test [INJ]CAPASTAT SULFATE [INJ]CAPRELSA [SP] afate suspensioncarbachol [INJ]CARBAGLU [SP]carbamazepinecarbamazepine ext-releasecarbidopa/levodopacarbidopa/levodopa ext-releasecarbidopa/levodopa orallydisintegrating ARBOCAINE 2% [INJ]carboplatin [INJ]carteolol eye solutioncarvedilolCATHFLO ACTIVASE [INJ]cavan-alpha kit prenatal vitaminscavan-ec sod dha prenatal vitaminsCAVERJECT [INJ]CAYSTON [SP] [QLL]casiant
CEENUcefaclorcefadroxilcefazolin [INJ]cefazolin/dextrose [INJ]cefdinircefditorencefepime [INJ]cefepime/dextrose [INJ]cefotaxime [INJ]cefotetan [INJ]cefoxitin [INJ]cefoxitin/dextrose [INJ]cefpodoximecefprozilceftazidime [INJ]CEFTAZIDIME/DEXTROSE [INJ]cetibutenceftriaxone [INJ]ceftriaxone/dextrose [INJ]cefuroxime axetilcefuroxime sodium [INJ]CEFUROXIME SODIUM 75 G [INJ]cefuroxime/dextrose [INJ]CELEBREX [QLL] [ST]CELLCEPT [INJ] [SP]CELLCEPT SUSPENSION [SP]CELONTINCENESTINCENOLATE [INJ]centratexcephalexinCEPROTIN [INJ] [SP]CEREZYME [INJ] [SP]CERVARIX [INJ]cetirizine syrupCETROTIDE [INJ] [SP]cevimelinechatealCHEMETCHENODAL [SP]chloramphenicol rhexidine gluconatechloroprocaine [INJ]chloroquine phosphatechlorothiazidechlorothiazide sodium [INJ]chloroxylenol/benzocaine/hydrocortisone acetateear suspensionchlropheniramine promazine [INJ]chlorthalidonechlorzoxazonechoice-ob dha prenatal vitaminschoice-tabscholestryraminecholestryramine lightcholine salicylate/magnesium salicylateliquidchorionic gonadotropin [INJ] [SP]chromium chloride [INJ]CIALIS [QLL]ciclopiroxciclostazolcidofovir [INJ]cimetidineCINRYZE [INJ] [SP]CIPRO SUSPENSIONCIPRODEXciprofloxacinciprofloxacin ear solutionciprofloxacin ext-releaseciprofloxacin eye solutionciprofloxacin lactate [INJ]ciprofloxacin/dextrose [INJ]cisplatin [INJ]citalopram [QLL]citra-3citric acid/sodium citratecladribine [INJ]clarithromycinclarithromycin ext-releaseclemastineCLEVIPREX [INJ]clindamycin hclclindamycin palmitateclindamycin phosphate [INJ]clindamycin phosphate topicalclindamycin phosphate vaginalclindamycin phosphate/benzoylperoxideclindamycin phosphate/dextrose [INJ]CLINIMIX [INJ]CLINIMIX E [INJ]clobetasol propionateclobetasol propionate/emollientCLOLAR [INJ]clomiphene citrateclomipramineclonazepamclonazepam orally disintegrating tabletsclonidineclonidine [INJ]clonidine ext-releaseclonidine ateclotrimazole topicalclotrimazole neclozapine orally disintegrating tabletsc-nate dha prenatal vitaminsCOARTEMcocaine topical solutioncodeine imethate [INJ]COMBIGANCOMBIPATCHCOMBIVENT RESPIMAT [QLL]COMPLERAcomplete natal dha prenatal vitaminscompletenate prenatal vitamins]CONCEPTION KITCOPAXONE [INJ] [SP] [PA] [QLL]copper chloride [INJ]COREG CR [QLL]CORIFACT [INJ] [SP]CORTIFOAMcortisone acetatecorvitacosyntropin [INJ]COUMADIN [INJ]CREONCRESTOR [QLL[]CRINONECRIXIVAN [SP] [QLL]CROFAB [INJ]cromolyn sodium eye solutioncromolyn sodium nebulization solutioncromolyn sodium oral solutioncryselleCUBICAN [INJ]CUPRIC SULFATE [INJ]CUPIMINEcyanocobalamin [INJ]cyclafemcyclobenzaprinecyclopentolate eye solutioncyclophosphamidecyclophosphamide [INJ]cyclosporine [SP]cyclosporine [INJ] [SP]cyclosporine modified [SP]CYMBALTA [QLL]cyproheptadineCYSTADANE [SP]CYSTAGON [SP]CYSTARAN [SP] [QLL]cytarabine [INJ]CYTOGRAM [INJ] [SP]Ddacabazine [INJ]dactinomycin [INJ]dailyvite with zineDALIRESP [QLL]danazoldantrolenedantrolene [INJ]DAPACEL [INJ]DAPSONEDARAPRIMdasettadaunorubicin [INJ]DAUNOXOME [INJ]dayseeDAYTRANA [QLL]decitabine [INJ] [SP]deferoxamine [INJ]delflex with dextrose [INJ]DELZICOL [QLL]demeclocyclineDEMSERDENAVIRDEPOCYT [INJ]DEPO-ESTRADIOL [INJ]DEPO-MEDROL 20 MG/ML [INJ]DEPO-PROVERA 400 MG/ML [INJ]desipraminedesloratadine [QLL]desloratadine orally disintegratingtablets [QLL]desmopressin acetate [INJ] [SP]desmopressin acetate nasal [SP]desonidedesoximetasoneDETROL LA [QLL]dexamethasonedexamethasone sodium phosphate[INJ]dexamethasone sodium phosphateeye solutiondexchlorpheniramine ext-releasedexferrum [INJ]dexmethylphenidatedexpanthenol [INJ]dexrazoxane [INJ]dextroamphetaminedextroamphetamine niraminedextrose/lactated ringers [INJ]dextrose/sodium chloride [INJ]dextrose/water [INJ]dialyvite/zincediazepamdiazepam [INJ]diazepam rectal gelDIBENZYLINEdiclofenac eye solutiondiclofenac potassiumdiclofenac sodium delayed-releasediclofenac sodium delayedrelease/misoprostoldicloxacillindicyclomine hcldidanosine delayed-release [SP]diethylpropion [PA]diethylpropion ext-releaseDIFFERIN 0.3% GEL, 0.1% LOTIONdifil-gdiflorasone
diflorasone diacetatediflorasone diacetate/emollientdiflunisaldigoxindigoxin odeine/aspirin/caffeinedihydroergotamine [INJ]dihydroergotamine nasalDILANTIN 30 MG CAPSULESDILARATE-SRDILAUDID-HP 250 MG [INJ]diltiazemdiltiazem [INJ]diltiazem ext-release (12 hour)diltiazem ext-release (24 hour)dimenhydrinate [INJ]DIOVANdiphenhydraminediphenhydramine [INJ]diphenoylate/atropinedipyridamole [INJ]divalproex sodiumdivalproex sodium delayed-releasedivalproex sodium ext-releaseDIVIGELdobutamine [INJ]dobutamine/dextrose [INJ]DOCEFREZ [INJ]docetaxel [INJ]donepezildonepezil orally disintegrating tabletsdopamine [INJ]dopamine/dextrose [INJ]DORIBAX [INJ]dorzolamide eye solutiondorzolamide/timolol eye solutiondoxazosindoxepindoxepin creamDOXIL [INJ]doxorubicin [INJ]doxorubicin/liposomal [INJ]doxycycline hyclatedoxycycline hyclate [INJ]doxycycline hyclate delayed-releasedoxycycline monohydratedoxylamine succinate solutiondronabinol [QLL]droperidol [INJ]DROXIADULERA [QLL]DUREZOLdyphyllineEeconazoleEDECRIN SODIUM [INJ]edrophonium [INJ]EDURANT [SP] [QLL]EFFIENT [QLL]EGRIFTA [INJ] [SP] [PA] [QLL]ELAPRASE [INJ] [SP]electrolyte-48 solution/dextrose [INJ]ELELYSO [INJ] [SP]eletoneELIDELELIGARD [INJ] [SP] [QLL]elinesteliphosELIQUIS [QLL]elite ob dha prenatal vitaminsELITEK [INJ]elite-ob 400 prenatal vitaminselite-ob prenatal vitaminsELMIRONELSPAR [INJ]EMCYTEMEND [QLL]EMEND [INJ] [QLL]emoquetteEMTRIVA [SP] [QLL]emulsion t [INJ]ENBREL [INJ] [SP] [PA]ENDOMETRINENGERIX-N [INJ]ENJUVIAenoxaparin [INJ] [SP]enpresseenskyceentacaponeEOVIST [INJ]ephedrine [INJ]EPIDUOepinastine eye solutionepinephrine [INJ] [QLL]epinephrine auto-injector [INJ]EPIPEN [INJ] [QLL]EPIPEN JR. [INJ] [QLL]epirubicin [INJ]EPIVIR HBV [QLL]EPIVIR SOLUTIONeplerenoneepoprostenol [INJ] [SP]epoprostnol diluent [INJ] [SP]eprosartanEPZICOM [SP] [QLL]ERAXIS [INJ]ERBITUX [INJ] [SP]ergocalciferolergoloid mesylatesergotamine/caffeineergotamine/caffeine suppositoriesERIVEDGE [SP] [QLL]errinERYTHROCIN [INJ]erythromycinerythromycin delayed-releaseerythromycin ethylsuccinateerythromycin eye ointmenterythromycin stearateerythromycin topicalerythromycin/ benzoyl peroxideerythromycin/ ens/methyltestosteroneESTRACE CREAMestradiolestradiol patchesestradiol valerate [INJ]estradiol/ norethindrone acetateestrazolamESTRING [QLL]estropipateethambutolETHAMOLIN [INJ]ethosuximideethyl alcohol [INJ]ethyl chloride sprayetidronateetodolacetodolac ext-releaseetomidate [INJ]ETOPOPHOS [INJ]etoposideetoposide [INJ]EUFLEXXA [INJ] [SP] [PA] [QLL]EURAXEVAMISTEVISTA [QLL]EXELON PATCHES [QLL]EXELON SOLUTIONexemestaneEXFORGE [QLL]EXFORGE HCT [QLL]EXJADE [SP]EXTAVIA [INJ] [SP] [PA]EXTRANEAL ICODEXTRIN DIALYSISSOLUTIONEYLEA [INJ] [SP]FfabbFABRAZYME [INJ] [SP]falminafamciclovirfamotidinefamotidine [INJ]famotidine/sodium chloride [INJ]FARESTONFASLODEX [INJ]fe 90 plusfe cFEIBA [INJ] [SP]felbamateflodipine ext-releaseFEMCAPfenofibratefenofibrate micronized [QLL]fenofibric acid [QLL]fenofibric acid delayed-releasefenprofenfentanyl [INJ] {QLL]fentanyl citrate [QLL]fentanyl citrate lozenges [QLL]fentanyl patchesFENTORA [QLL]FERAHEME [INJ]feroconferotrinsicferraplus 90ferrex 150 forteferrex 150 forte plusferrex 28FERRIPROX [SP]ferocite plusferrogels forteFINACEAFINACEA PLUSfinasterideFIRAZYR [INJ] [SP]FIRST-BXNFIRST-LANSOPRAZOLEFIRST-MOUTHWASH BLMFIRST-OMEPRAZOLEflavoxateflecainidefloxuridine [INJ]FLUARIX [INJ]fluconazolefluconazole/dextrose [INJ]fluconazole/normal saline [INJ]flucytosinefludarabine [INJ]fludrocortisone acetateFLULAVAL [INJ]flumazenil [INJ]FLUMISTflunisolide nasal sprayfluocinolineflucinolone acetonide oil ear ein eye stripsflurometholone eye suspensionfluorouracil [INJ]fluorouracil topicalfluoxaminefluoxetinefluoxetine delayed-releasefluoxymesteronefluphenazine decanoate [INJ]fluphenazine hclfluphenazine hcl [INJ]flurazepam
flurbiprofenflubiprofen eye solutionflutamidefluticasone nasal sprayfluticasone topicalfluvastatinFLUVIRIN [INJ]fluvoxamine ext-releaseFLUZONE [INJ]FML S.O.P.FOCALIN XR [QLL]folbfolbecal prenatal vitaminsfolbeefolbee plusfolbicfolcal dha prenatal vitaminsfolcapsfolcaps omega-s prenatal vitaminsfolic acidfolic acid [INJ]folic acid/cyanocobalamin/pyridoxinefolinatal plus b prenatal vitaminsfolivane-ffolivane-ob prenatal vitaminsfolivane-plusfolivane-prx dha nf pernatal vitaminsFOLLISTIM AQ [INJ] [SP]FOLOTYN [INJ] [SP]folplex 2.2foltanxfomepizole [INJ]fondaparinux [INJ] [SP]FOR A LANCING DEVICEFORACARE 30G LANCETSFORADIL [QLL]FORTAZ-ISO-OSMOTIC [INJ]FORTEO [INJ] [SP]FORTESTA [ST]foscarnet enytoin [INJ]FOSRENOLFRAGMIN [INJ] [SP] [QLL]freamine [INJ]FREAMINE HBC [INJ]FRESSTYLE INSULINX TEST STRIPSFREESTYLE LITE TEST STRIPSFREESTYLE TEST STRIPSfurosemidefurosemide [INJ]FUSILEV [INJ]FUZEON [INJ] [SP] [QLL]GgabapentinGABITRIL 12 MG, 16 MGGABLOFEN [INJ]galantaminegalantamine ext-releaseGAMASTAN S-D [INJ] [SP]GAMMAGARD LIQUID [INJ] [SP]GAMMAGARD S-D [INJ] [SP]GAMUNEX [INJ] [SP]GAMUNEX-C [INJ] [SP]ganciclovir [INJ]GANIRELIX ACETATE [INJ] [SP]GARDASIL [INJ]gatifloxacin eye solutionGELNIQUEgemcitabine [INJ]gemfibrozilGENOTROPIN [INJ] [SP] [PA]gentamicin [INJ]gentamicin eye ointmentgentamicin eye solutiongentamicin topicalgentamicin/normal saline [INJ]GENTAMICIN/ NORMAL SALINE100MG/50ML [INJ]gianvigildagiagildessgildess feGILENYA [SP] [PA] [QLL]GILOTRIF [SP] [PA] [QLL]GLEEVEC [SP] [QLL]glimepirideglipizideglipizide ext-releaseGLUCAGEN [INJ] [QLL]GLUCAGON [INJ]glyburideglyburide micronizedglyburide/metforminglycine irrigation solutionGLYCOPHOS [INJ]glycopyrrolateglycopyrrolate [INJ]GRALISE [QLL]granisetrongranisetron [INJ]griseofulvin microsizegriseofulvin neHHALAVEN [INJ] [SP]HALFLTELY-BISACODYLhalobetasolhalobetasol ammonium lactate combopackhaloperidolhaloperidol decanoate [INJ]haloperidol lactatehaloperidol lactate [INJ]HAVRIX [INJ]heatherHECTOROLHECTOROL [INJ]HELIXATE FS [INJ] [SP]HEMABATE [INJ]hematinic plus hematinic with folic acidhematogenhematogen fahematogen fortehemenatal ob dha prenatal vitaminshemenatal ob prenatal vitaminshemetabHEPAGAM B [INJ]heparin lock flush [INJ]heparin sodium [INJ]heparin sodium/dextrose [INJ]heparin sodium/sodium chloride [INJ]HEPATAMINE [INJ]HEPATASOL [INJ]HERCEPTIN [INJ] [SP]hetastarch/normal saline [INJ]HEXALENHEXTEND LACTATED ELECTROLYE [INJ]HIZENTRA [INJ] [SP]homatropine eye solutionhpr emollient foamhpr plusHUMALOG [INJ]HUMATE-P [INJ] [SP]HUMATROPE [INJ] [SP] [PA]HUMIRA [INJ] [SP] [PA]HUMULIN [INJ]HUMULIN R 500 UNITS [INJ]HYCAMTIN CAPSULES aminophenhydrocodone/ ydrocodone/ibuprofenhydrocortisonehydrocortisone acetate suppositorieshydrocortisone acetate topicalhydrocortisone acetate/lidocainehydrocortisone acetate/pramoxinehydrocortisone butyratehydrocortisone butyrate/emollienthydrocortisone enemahydrocortisone sodium succinate [INJ]hydrocortisone topicalhydrocortisone amoxinehydrocortisone/parmoxine ear solutionhydrocortisone/pramoxine/chloroxylenol ear solutionhydromorphonehydromophone [INJ]hydromorphone suppositorieshydroquinonehydroquinone ext-releasehydroxocobalamin [INJ]hydroxychloroquine sulfatehydroxyureahydroxyzine hclhydroxyzine hcl [INJ]hydroxyzine pamoatehyophenhyoscyaminehyoscyamine ext-releasehyoscyamine orally YPERHEP B S-D [INJ]HYPERRAB S-D [INJ]HYPERRHO S-D [INJ]HYPERTET S-D [INJ]Iibandronateibuprofenibutilide [INJ]ICLUSIG [SP] [QLL]idarubicin [INJ]iferex 150 forteifosfamide [INJ]ifosfamide/mesna [INJ]ILARIS [INJ] [SP]ILEVROimipenem/cilastatin [INJ]imipramine hclimipramine pamoateimiquimodIMOGAM RABIES-HT [INJ]IMOVAX RABIES VACCINE [INJ]IMPLANON [SP]inatal advance prenatal vitaminsinatal gt prenatal vitaminsinatal ultra prenatal vitaminsINCIVEK [SP] [PA] [QLL]INCRELEX [INJ] [SP] [PA]indapamideindomethacinindomethacin ext-releaseindomethacin sodium [INJ]INFANRIX [INJ]infed [INJ]INFERGEN [INJ] [SP] [QLL]INFUMORPH [INJ]INFUVITE [INJ]INLYTA [SP] [QLL]INTEGRILIN [INJ]INTELENCE [SP] [QLL]intralipid 20% [INJ]INTRON A [INJ] [SP]introvaleINTUNIV [QLL]INVANZ [INJ]INVIRASE [SP] [QLL]INVOKANA [QLL]
IODOPEN [INJ]IONOSOL [INJ]IPOL [INJ]ipratropium bromide nasal sprayipratropium bromide nebulizationsolutionipratropium/albuterol sulfatenebulization inotecan [INJ]ISENTRESS [SP] [QLL]ISOLYTE nisoniazidisoniazid [INJ]ISOPTO CARBACHOL 1.5%isosorbide dinitrateisosorbide dinitrate ext-releaseisosorbide mononitrateisosorbide mononitrate ext-releaseisotretinoin [PA]ISOVUE [INJ]ISOVUE-M [INJ]isoxsuprineisradipineISTODAX [INJ] [SP]itraconazole [PA]IXEMPRA [INJ] [SP]IXIARO [INJ]JJAKAFI [SP] [QLL]JANUMET [QLL]JANUMET XR [QLL]JANUVIA [QLL]jencyclaJETREA [INJ] [SP]JEVTANA [INJ] [SP]jolessajolivettejuneljunel feJUVISYNC [QLL]JUXTAPID [SP] [PA] [QLL]KKADCYLA [INJ] [SP]KALBITOR [INJ] [SP]KALETRA [SP] [QLL]KALYDECO [SP] [PA] [QLL]kanamycinkarivakelnor 1-35KENALOG 10 MG/ML [INJ]KEPTIVANCE [INJ] [SP]ketamine [INJ]ketoconazoleketoconazole topicalketoprofen eye solutionketorolacketorolac [INJ]ketorolac eye solutionKINEVAC [INJ]KOATE-DVI [INJ] [SP]KOMBIGLYZE XR [QLL]k-phos neutralK-PHOS ORIGINALKRISTALOSEKRYSTEXXA [INJ] [SP]kurveloKUVAN [SP]KYPROLIS [INJ] [SP]Llabetalollabetalol [INJ]lactic acid 10% topicallactuloseLAMICTAL ODT [QLL]LAMICTAL XR STARTER KITSLAMISIL GRANULESlamivudine [SP] [QLL]lamivudine/zidovudine [SP]lamotriginelamotrigine ext-releaseLANOXIN PEDIATRIC [INJ]lansoprazole delayed-releaselansoprazole delayed-release amoxicillin clarithromycinLANTUS [INJ]LANTUS SOLOSTAR [INJ]latanoprost eye solutionLATUDA [QLL]l-cysteine [INJ]leenaleflunomidelessinaLETAIRIS [SP] [PA] [QLL]letrozoleleucovorinleucovorin [INJ]LEUKERANLEUKINE [INJ] [SP] [QLL]leuprolide [INJ]levalbuterolLEVEMIR [INJ]LEVEMIR FLEXPEN [INJ]levetiracetamlevetiracetam [INJ]levetiracetam ext-releaselevobunolol eye solutionlevocarnitinelevocarnitine [INJ]levocetirizinelevofloxacinlevofloxacin [INJ]levofloxacin eye solutionlevofloxacin/dextrose [INJ]levonorgestrellevoralevorphanollevothyroxine solutionLEVOTHYROXINE SODIUM [INJ]LEVSIN [INJ]LEXISCAN [INJ]LEXIVA [SP] [QLL]LIALDAlidocaine [INJ]lidocaine jellylidocaine patch [PA]lidocaine topicallidocaine viscouslidocaine/dextrose [INJ]lidocaine/epinephrine [INJ]lidocaine/prilocainelindaneLINZESS [QLL]LIORESAL [INJ]liothyronineliothyronine [INJ]LIPOFEN [QLL]liposyn III zidelithium carbonatelithium carbonate ext-releaselithium citratel-methylfolate calciumLO LOESTRIN FELO MINASTRIN FELODOSYNLOESTRIN 24 FELOMUSTINEloperamidelorazepamlorazepam EMAXLOTRONEX [QLL]lovastatin [QLL]LOVAZA [QLL]low-ogestrelloxapineLUCENTIS [INJ] [SP]LUMIGANLUMIZYME [INJ] [SP]LUNESTA [QLL] [ST]LUPRON DEPOT 3/75 MG, 11.25 MG[INJ] [SP] [QLL]LUPRON DEPOT-PED [INJ] [SP] [QLL]luteraLYRICA [QLL]LYSODRENlyzaMm.v.i.audit [INJ]M.V.I. PEDIATRIC [INJ]M.V.I.-12 [INJ]macnatal cn dha prenatal vitaminsmafenidemagnesium chloride [INJ]magnesium sulfate [INJ]MAGNESIUM-D5W 1GM/100 ML [INJ]MAGNEVIST [INJ]MAKENA [INJ] [SP]malathionmanganese chloride [INJ]manganese sulfate [INJ]mannitol [INJ]maprotilinemarlissaMARQIBO KIT [INJ]maternity prenatal vitaminsMATULANE [SP]mb hydrogelmd-gasroviewmeclizine rone [contraceptive)[INJ]mefenamic acidmefloquinemegestrolMEKINIST [SP] [PA] [QLL]meloxicammelphalan [INJ]MENACTRA [INJ]MENOMUNE-A-C-Y-Q-135 [INJ]MENOPUR [INJ] [SP]meperidine [INJ]MEPHYTONmepivacaine [INJ]MEPRONmercaptopurinemeropenem [INJ]mesalaminemesna [INJ]MESNEX TABLETSMESTINON SYRUPMESTINON TIMESPANmetafolbicmetafolbic plusmetaproterenolmetaxalonemetforminmetformin ext-releasemethadonemethadone [INJ]methamphetaminemethazolamidemethenamine hippuratemethenamine mandelatemethimazoleMETHITEST
methocarbamolmethotrexatemethotrexate orothiazidemethyldopate [INJ]methylene blue [INJ]methylergonovinemethylergonovine [INJ]methylphenidate [QLL]methylphenidate ext-release [QLL]methylprednisolonemethylprednisolone acetate [INJ]methylprednisolone sodium succinate[INJ]metipranolol eye solutionmetoclopramidemetoclopramide [INJ]metolazonemetoprolol succinate ext-releasemetoprolol tartratemetoprolol tartrate ronidazole [INJ]metronidazole topicalmetronidazole vaginalmetronidazole/sodium chloride [INJ]mexiletineMIACALCIN [INJ]miconazole vaginalmicrogestinmicrogestin FEmidazolammidazolam [INJ]midodrinemilrinone [INJ]milrinone/dextrose [INJ]MINASTRIN 24 FEMINIMED INFUSION SETMINIMED RESERVOIRMINIVELLEMINOCIN [INJ]minocyclineminocycline ext-releaseminoxidilmi-omega nfMIRAPEX ER [QLL]mirtazapinemirtazapine orally disintegrating tabletsmisoprostolmitomycin [INJ]mitoxantrone [INJ] [SP] [PA]M-M-R IImodafinil nemono-linyahmononessaMONONINE [INJ] [SP]montelukastmorphine sulfate [QLL]morphine sulfate [INJ]morphine sulfate ext-releasemorphine sulfate suppositoriesMOVIPREPMOXEZAMOZOBIL [INJ] [SP] [QLL]multigenmultigen folicmultigen plusMULTITRACE-4 [INJ]multitrace-4 ped [INJ]MULTITRACE-5 ironmupirocinMUSE [QLL]MUSTARGEN [INJ]MYCAMINE [INJ]MYCOBUTINmycophenolate mofetil [SP]MYFORTIC [SP]MYLERANmynatal advance prenatal vitaminsmynatal plus prenatal vitaminsmynatal prental vitaminsmynatal ultracap prental vitaminsmynatal-z prenatal vitaminsmynate 90 plus prenatal vitaminsmynephrocapsMYOBLOC [INJ] [SP] [PA]MYOZYME [INJ] [SP]MYRBETRIQ hiazidenafcillin [INJ]nafcillin/dextrose [INJ]NAGLAZYME [INJ] [SP]nalbuphine [INJ]naloxone [INJ]NAMENDA [QLL]NAMENDA XR [QLL]naphazoline eye solutionnaproxennaproxen delayed-releasenaproxen sodiumnaratriptanNAROPIN [INJ]NASONEX [QLL]NATACYNnatal-v rx prenatal vitaminsnatalvirt 90 dha prenatal vitaminsnatalvirt ca prenatal vitaminsnatalvirt fltNATAZIAnateglinideNATRECOR [INJ]NEBUPENTneconNEMBUTOL [INJ]neomycinneomycin/bacitracin/poylmyxin isone eye ointmentneomycin/polymyxin irrigation solutionneomycin/polymyxin/dexamethasoneeye ointmentneomycin/polymyxin/dexamethasoneeye solutionneomycin/polymyxin/gramicidin eyesolutionneomycin/polymyxin/hydrocortisoneear solutionneomycin/polymyxin/hydrocortisoneear suspensionneomycin/polymyxin/hydrocortisoneeye solutionNEOPROFEN [INJ]neostigmine [INJ]nephplex rxNEPHRAMINE INJ]nephron-vite rxNESACAINE 1% [INJ]NEULASTA [INJ] [SP] [QLL]NEUMEGA [INJ] [SP]NEUPOGEN [INJ] [SP] [QLL]NEUT [INJ]NEVANACnevirapine [SP]NEXAVAR [SP] [QLL]NEXIUM [QLL]NEXIUM [INJ] [QLL]NEXPLANON [SP]NEXTERONE [INJ]niacin ext-releasenicardipinenicardipine [INJ]nifedipine ext-releaseNILANDRONnimodipinenisoldipine ext-releasenitrofurantoinnitrofurantoin nitroglycerin [INJ]nitroglycerin ext-releasenitroglycerin ointmentnitroglycerin patchesnitroglycerin translingual spraynitroglycerin/dextrose [INJ]NITROLINGUAL PUMPSPRAYNITROSTATnizatidinenora-beNORDITROPIN [INJ] [SP] [PA]norepinephrine [INJ]norethindrone acetatenorethindrone acetate/ethinyl estradiolNORMOSOL-M AND DEXTROSE [INJ]NORMOSOL-R PH 7.4 [INJ]NORMOSOL-R-DEXTROSE [INJ]nortrelnortiptylineNORVIR [SP] [QLL]NOVOFINE 30G, 32G NEEDLESNOVOFINE AUTOCOVERNOVOLOG [INJ]NOVOSEVEN RT [INJ] [SP]NOXAFILNPLATE [INJ] [SP]NUCYNTA [QLL]NUCYNTA ER [QLL]NUEDEXTA [QLL]NULOJIX [INJ] [SP]nuquin hpnutrilyte [INJ]nutrilyte II [INJ]nutria-lab ob prenatal vitaminsNUVARING [QL]nystatinnystatin topicalnystatin/triamcinoloneOobstretrix dha prenatal vitaminsocellaoctreotide [INJ] [SP]ocudox kitOFIRMEV [INJ]ofloxacinofloxacin ear solutionofloxacin eye solutionogestrelolanzapineolanzapine [INJ]olanzapine orally disintegrating tabletsolanzapine/fluoxetineomeprazole delayed-releaseomeprazole/sodium bicarbonateOMNIPAQUE [INJ]ONCASPAR [INJ]ondansetronondansetron [INJ]ondansetron orally disintegratingtabletsondansetron/dextrose [INJ]ondansetron/sodium chloride [INJ]ONTOUCH ULTRA TEST STRIPSONTOUCH VERIO TEST STRIPSONFIONGLYZAONTAK [INJ]OPANA ER [QLL]
opium tinctureopium/belladonna alkaloidssuppositoriesORACEA [QLL]ORENCIA [INJ] [S] [PA] [ST]OFADIN [SP]orphenadrine [INJ]orphenadrine THOVISC [INJ] [SP] [PA] [QLL]oxacillin [INJ]oxacillin/dextrose [INJ]oxaliplatin RALENOXSORALEN-ULTRAoxybutyninoxybutynin ne/aspirinoxycodone/ibuprofen [QLL]OXYCONTIN [QLL]oxymorphoneoxymorphone ext-releaseoxytocin [INJ]OXYTROL [QLL]Ppaclitaxel [INJ]pamidronate [INJ]pancrelipase delayed-release 5000 unitsPANHEMATIN [INJ]pantoprazole delayed-releasepapaverinepapaverine [INJ]PARADIGM INFUSION SETSPARADIGM RESERVOIRSPARADIGM SILHOUETTE xetine ext-releasePATADAYPATANOLPEDIARIX [INJ]PEDITRACE [INJ]peg 3350/electrolytes powder for 4000ml solutionPEGANONEPEGASYS [INJ] [SP]PEGASYS PROCLICK [INJ] [SP]penicillin g potassium [INJ]penicillin g procaine [INJ]penicillin g sodium [INJ]PENICILLIN GK/DEXTROSE [INJ]penicillin v potassiumPENTASApentoxifylline ext-releasePERFORMISTperindoprilPERJETA [INJ] arbitalphendimetrazine [PA]phendimetrazine ext-releasephenelzinephenobarbitalphenobarbital sodium ephentermine [PA]phentolamine mesylate [INJ]phenylbutyratephenylephrine [INJ]phenylephrine eye n sodium [INJ]phenytoin sodium extendedphilithphosphasalPHOSPHOLINE IODIDEPHOTOFRIN [INJ]physostigmine [INJ]phytonadione [INJ]PHYTONADIONE 1 MG/0.5ML [INJ]pilocarpinepilocarpine eye solutionPILOPINE litazone/metforminp
2014 Basic Plus Formulary List The 2014 Basic Plus Formulary drug list is shown below. The formulary is the list of drugs included in your prescription drug benefit plan.
