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Formulary04/01/2021INTRODUCTION . 4PREFACE . 4DRUG LIST PRODUCT DESCRIPTIONS . 4GENERIC SUBSTITUTION . 5LEGEND . 6NOTICE. 6ANALGESICS. 7NSAIDs . 7NSAIDs, COMBINATIONS . 7NSAIDs, TOPICAL . 7COX-2 INHIBITORS . 7GOUT . 7OPIOID ANALGESICS . 7VISCOSUPPLEMENTS . 8ANTI-INFECTIVES . 8ANTIBACTERIALS . 8ANTIFUNGALS . 9ANTIMALARIALS . 9ANTIRETROVIRAL AGENTS . 9ANTITUBERCULAR AGENTS . 10ANTIVIRALS. 10MISCELLANEOUS . 11ANTINEOPLASTIC AGENTS . 11ALKYLATING AGENTS . 11ANTIMETABOLITES . 11HORMONAL ANTINEOPLASTIC AGENTS . 12KINASE INHIBITORS . 12MULTIPLE MYELOMA . 12TOPOISOMERASE INHIBITORS . 12MISCELLANEOUS . 13CARDIOVASCULAR . 13ACE INHIBITORS . 13ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS . 13ACE INHIBITOR/DIURETIC COMBINATIONS . 13ADRENOLYTICS, CENTRAL. 13ALDOSTERONE RECEPTOR ANTAGONISTS . 14ALPHA BLOCKERS . 14ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS . 14ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS . 14ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS . 14ANTIARRHYTHMICS . 14ANTILIPEMICS. 15BETA-BLOCKERS . 15BETA-BLOCKER/DIURETIC COMBINATIONS . 16CALCIUM CHANNEL BLOCKERS . 16CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS . 16DIGITALIS GLYCOSIDES. 16DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS . 16DIURETICS . 16HEART FAILURE . 17NITRATES . 17PULMONARY ARTERIAL HYPERTENSION . 17MISCELLANEOUS . 17CENTRAL NERVOUS SYSTEM . 18ANTIANXIETY . 18ANTICONVULSANTS . 18ANTIDEMENTIA . 19ANTIDEPRESSANTS . 19ANTIPARKINSONIAN AGENTS . 201
ANTIPSYCHOTICS . 20ATTENTION DEFICIT HYPERACTIVITY DISORDER . 20FIBROMYALGIA . 21HYPNOTICS. 21MIGRAINE . 21MOOD STABILIZERS . 22MOVEMENT DISORDERS . 22MULTIPLE SCLEROSIS AGENTS . 22MUSCULOSKELETAL THERAPY AGENTS . 22MYASTHENIA GRAVIS . 22NARCOLEPSY . 22POSTHERPETIC NEURALGIA (PHN). 22PSYCHOTHERAPEUTIC-MISCELLANEOUS . 23ENDOCRINE AND METABOLIC . 23ACROMEGALY . 23ANDROGENS . 23ANTIDIABETICS . 23ANTIOBESITY . 25CALCIUM RECEPTOR ANTAGONISTS . 25CALCIUM REGULATORS . 25CARNITINE DEFICIENCY AGENTS . 25CONTRACEPTIVES . 26ENDOMETRIOSIS . 27FERTILITY REGULATORS. 27GAUCHER DISEASE . 27GLUCOCORTICOIDS . 27GLUCOSE ELEVATING AGENTS . 27HEREDITARY TYROSINEMIA TYPE 1 AGENTS . 27HUMAN GROWTH HORMONES. 27HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS . 27MENOPAUSAL SYMPTOM AGENTS . 27PHENYLKETONURIA TREATMENT AGENTS . 28PHOSPHATE BINDER AGENTS . 28POLYNEUROPATHY . 28POTASSIUM-REMOVING AGENTS. 28PROGESTINS . 28SELECTIVE ESTROGEN RECEPTOR MODULATORS . 28THYROID AGENTS . 28UTERINE FIBROIDS . 29VASOPRESSINS . 29MISCELLANEOUS . 29GASTROINTESTINAL . 29ANTIDIARRHEALS . 29ANTIEMETICS . 29ANTISPASMODICS .
The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner: Tier 1: Lowest plan member copayment: All generic drugs, including those on this Formulary. Tier 2: Intermediate plan member copayment: Preferred brand-name product
