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Friday Health plans of Colorado
is serviced by
TIER 1 PREFERRED GENERICS
2018
Page 1 of 54
Proprietary and Confidential
The following is a list of Tier 1 preferred generic drugs covered on the Friday Health Plans formulary. This list is subject to change as new drugs
become available.*
Restrictions
PA= Prior Authorization
ST= Step Therapy
Drug Name Formulary Tier Restrictions
ALTERNATIVE THERAPY
ALTERNATIVE THERAPY - ESTROGENIC AGENTS
VP-GSTN T1
ALTERNATIVE THERAPY - UNCLASSIFIED
epigallocatechin gallate(bulk) T1
ANALGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC
ANALGESIC - CENTRAL ALPHA-2 RECEPTOR AGONISTS
clonidine (pf) T1
ANALGESIC - NEUROLYSIS AGENTS
ethanol (ethyl alcohol) T1
ANALGESIC NARCOTIC AGONISTS
alfentanil T1
codeine sulfate T1
fentanyl T1
fentanyl citrate T1 PA
fentanyl citrate (pf) T1
fentanyl citrate-0.9%nacl (pf) T1
hydromorph(pf)-ropiv-0.9% nacl T1
hydromorphone T1
hydromorphone (pf) T1
hydromorphone (pf)-0.9% nacl T1
hydromorphone in 0.9 % nacl T1
levorphanol tartrate T1
meperidine T1
meperidine (pf) T1
meperidine (pf) in 0.9 % nacl T1
methadone T1
morphine T1
morphine (pf) T1
morphine (pf) in 0.9 % nacl T1
morphine (pf) in dextrose 5 % T1
Friday Health plans of Colorado
is serviced by
Page 2 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
morphine concentrate T1
morphine in 0.9 % nacl T1
oxycodone T1
oxymorphone T1
tramadol T1
ANALGESIC NARCOTIC CODEINE COMBINATIONS
acetaminophen-codeine T1
butalbital-acetaminop-caf-cod T1
ASCOMP WITH CODEINE T1
FIORINAL-CODEINE #3 T1
ANALGESIC NARCOTIC DIHYDROCODEINE COMBINATIONS
aspirin-caffeine-dihydrocodein T1
ANALGESIC NARCOTIC DIHYDROCODEINE, SALICYLATE ANALGESIC, XANTHINE COMB
aspirin-caffeine-dihydrocodein T1
ANALGESIC NARCOTIC FENTANYL COMBINATIONS
fentanyl (pf)-bupivacaine-nacl T1
ANALGESIC NARCOTIC HYDROCODONE AND NON-SALICYLATE COMBINATIONS
hydrocodone-acetaminophen T1
LORTAB ELIXIR T1
ANALGESIC NARCOTIC HYDROCODONE AND NSAID COMBINATIONS
hydrocodone-ibuprofen T1
ANALGESIC NARCOTIC HYDROCODONE COMBINATIONS
hydrocodone-acetaminophen T1
hydrocodone-ibuprofen T1
LORTAB ELIXIR T1
ANALGESIC NARCOTIC HYDROMORPHONE COMBINATIONS
hydromorphone-bupiv (pf)-nacl T1
ANALGESIC NARCOTIC OXYCODONE AND NON-SALICYLATE COMBINATIONS
oxycodone-acetaminophen T1
ENDOCET T1
ANALGESIC NARCOTIC OXYCODONE AND NSAID COMBINATIONS
ibuprofen-oxycodone T1
ANALGESIC NARCOTIC OXYCODONE AND SALICYLATE COMBINATIONS
oxycodone-aspirin T1
ANALGESIC NARCOTIC OXYCODONE COMBINATIONS
ibuprofen-oxycodone T1
oxycodone-acetaminophen T1
oxycodone-aspirin T1
ENDOCET T1
ANALGESIC NARCOTIC PARTIAL-MIXED AGONISTS
Friday Health plans of Colorado
is serviced by
Page 3 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
buprenorphine T1
buprenorphine hcl T1
butorphanol tartrate T1
pentazocine-naloxone T1
ANALGESIC NARCOTIC TRAMADOL AND NON-SALICYLATE COMBINATIONS
tramadol-acetaminophen T1
ANALGESIC NARCOTIC TRAMADOL COMBINATIONS
tramadol-acetaminophen T1
ANALGESIC OR ANTIPYRETIC NON-NARCOTIC/SEDATIVE COMBINATIONS
butalbital-acetaminophen T1
butalbital-acetaminophen-caff T1
FIORICET T1
DMARD - ANTIMALARIALS
hydroxychloroquine T1
DMARD - ANTIMETABOLITES
methotrexate sodium T1
DMARD - IMMUNOSUPPRESSIVES
azathioprine T1
cyclophosphamide T1
cyclosporine T1
cyclosporine modified T1
mycophenolate mofetil T1
DMARD - OTHER
minocycline T1
sulfasalazine T1
DMARD - PYRIMIDINE SYNTHESIS INHIBITORS
leflunomide T1
NSAID ANALGESIC AND TOPICAL IRRITANT COUNTER-IRRITANT COMBINATIONS
COMFORT PAC-IBUPROFEN T1
NSAID ANALGESIC, CYCLOOXYGENASE-2 (COX-2) SELECTIVE INHIBITORS
celecoxib T1
NSAID ANALGESICS (COX NON-SPECIFIC) - ANTHRANILIC ACID DERIVATIVES
meclofenamate T1
NSAID ANALGESICS (COX NON-SPECIFIC) - OTHER
ketorolac T1
nabumetone T1
sulindac T1
tolmetin T1
NSAID ANALGESICS (COX NON-SPECIFIC) - OXICAM DERIVATIVES
meloxicam T1
Friday Health plans of Colorado
is serviced by
Page 4 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
piroxicam T1
NSAID ANALGESICS (COX NON-SPECIFIC) - PROPIONIC ACID DERIVATIVES
fenoprofen T1
flurbiprofen T1
ibuprofen T1
ketoprofen T1
naproxen T1
naproxen sodium T1
oxaprozin T1
FENORTHO T1
NSAID ANALGESICS, (COX NON-SPECIFIC) - INDOLE ACETIC ACID DERIVATIVES
etodolac T1
indomethacin T1
SALICYLATE ANALGESIC AND SEDATIVE COMBINATIONS
butalbital-aspirin-caffeine T1
SALICYLATE ANALGESICS
diflunisal T1
salsalate T1
ANESTHETICS
GENERAL ANESTHETIC - INHALANT VOLATILE
isoflurane T1
sevoflurane T1
GENERAL ANESTHETIC - PARENTERAL, ARYLCYCLOHEXYLAMINES
ketamine T1
ketamine in 0.9 % sod chloride T1
GENERAL ANESTHETIC - PARENTERAL, BENZODIAZEPINES
midazolam T1
GENERAL ANESTHETIC - PARENTERAL, OTHERS
etomidate T1
GENERAL ANESTHETIC - PARENTERAL, PHENOL DERIVATIVES
propofol T1
GENERAL ANESTHETIC ADJUNCTS - NARCOTIC
fentanyl citrate (pf) T1
sufentanil citrate T1
GENERAL ANESTHETIC ADJUNCTS - NEUROLEPTIC, BUTYROPHENONE DERIVATIVE
droperidol T1
LOCAL ANESTHETIC - AMIDES
bupivacaine T1
bupivacaine (pf) T1
bupivacaine in nacl(pf) T1
Friday Health plans of Colorado
is serviced by
Page 5 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
bupivacaine-dextrose-water(pf) T1
lidocaine (pf) in d7.5w T1
lidocaine (pf) T1
lidocaine hcl T1
lidocaine hcl(pf) in 0.9% nacl T1
mepivacaine (pf) T1
ropivacaine (pf) T1
POLOCAINE-MPF T1
XYLOCAINE-MPF T1
LOCAL ANESTHETIC - ESTERS
tetracaine hcl (pf) T1
LOCAL ANESTHETIC - SYMPATHOMIMETIC COMBINATIONS
bupivacaine-epinephrine T1
bupivacaine-epinephrine (pf) T1
lidocaine-epinephrine T1
lidocaine-epinephrine bit T1
SENSORCAINE-MPF/EPINEPHRINE T1
ANORECTAL PREPARATIONS
ANORECTAL - GLUCOCORTICOIDS
hydrocortisone acetate T1
ANUCORT-HC T1
PROCTO-PAK T1
PROCTOZONE-HC T1
ANORECTAL - HEMORRHOIDAL RECTAL GLUCOCORTICOID-LOCAL ANESTHETIC COMB
hydrocortisone-pramoxine T1
lidocaine hcl-hydrocortison ac T1
lidocaine-hydrocortisone-aloe T1
ANTIDOTES AND OTHER REVERSAL AGENTS
ANTIDOTE - ACETAMINOPHEN POISONING
acetylcysteine T1
acetylcysteine (bulk) T1
ANTIDOTE - ALCOHOL DEHYDROGENASE ENZYME INHIBITOR
fomepizole T1
ANTIDOTE - ANTICHOLINESTERASE AGENTS
physostigmine salicylate T1
ANTIDOTE - CHOLINESTERASE REACTIVATING AGENT
pralidoxime T1
ANTIDOTE - CYANIDE POISONING
sodium nitrite T1
sodium thiosulfate T1
Friday Health plans of Colorado
is serviced by
Page 6 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
ANTIDOTE - METHEMOGLOBINEMIA
methylene blue (antidote) T1
BENZODIAZEPINE REVERSAL AGENTS - BENZODIAZEPINE ANTAGONISTS
flumazenil T1
CHELATING AGENTS - IRON
deferoxamine T1
CHELATING AGENTS - OTHERS
betadex (bulk) T1
EMETICS
ipecac T1
OPIATE/NARCOTIC REVERSAL AGENTS - OPIATE ANTAGONISTS
naloxone T1
naltrexone T1
REVERSAL AGENTS - HEPARIN ANTAGONISTS
protamine T1
ANTI-INFECTIVE AGENTS
AMEBICIDES
paromomycin T1
AMINOGLYCOSIDE ANTIBIOTIC
amikacin T1
gentamicin T1
gentamicin (bulk) T1
gentamicin in nacl (iso-osm) T1
gentamicin sulfate (ped) (pf) T1
gentamicin sulfate (pf) T1
neomycin T1
streptomycin T1
tobramycin in 0.9 % nacl T1
tobramycin sulfate T1
AMINOPENICILLIN ANTIBIOTIC
amoxicillin T1
ampicillin T1
ampicillin sodium T1
AMINOPENICILLIN ANTIBIOTIC - BETA-LACTAMASE INHIBITOR COMBINATIONS
amoxicillin-pot clavulanate T1
ampicillin-sulbactam T1
ANTHELMINTIC AGENTS OTHER
ivermectin T1
ANTIBACTERIAL FOLATE ANTAGONIST - OTHER COMBINATIONS
sulfamethoxazole-trimethoprim T1
Friday Health plans of Colorado
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Page 7 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
ANTIBACTERIAL FOLATE ANTAGONIST OTHERS
trimethoprim T1
ANTIFUNGAL - ALLYLAMINES
terbinafine hcl T1
ANTIFUNGAL - AMPHOTERIC POLYENE MACROLIDES
amphotericin b T1
nystatin T1
ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)
caspofungin T1
ANTIFUNGAL - IMIDAZOLES
ketoconazole T1
ANTIFUNGAL - TRIAZOLES
fluconazole T1
fluconazole in dextrose(iso-o) T1
fluconazole in nacl (iso-osm) T1
voriconazole T1
ANTIFUNGAL OTHER
flucytosine T1
griseofulvin microsize T1
ANTILEPROTIC - SULFONE AGENTS
dapsone T1
ANTIMALARIAL COMBINATIONS
atovaquone-proguanil T1
ANTIMALARIALS
chloroquine phosphate T1
hydroxychloroquine T1
mefloquine T1
primaquine T1
quinine sulfate T1
ANTIPROTOZOAL-ANTIBACTERIAL 1ST GENERATION 2-METHYL-5-NITROIMIDAZOLE
metronidazole T1
metronidazole (bulk) T1
metronidazole in nacl (iso-os) T1
ANTIPROTOZOAL-ANTIBACTERIAL 2ND GENERATION 2-METHYL-5-NITROIMIDAZOLE
tinidazole T1
ANTIRETROVIRAL - NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIB (NNRTI)
nevirapine T1
ANTIRETROVIRAL - NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir T1
didanosine T1
Friday Health plans of Colorado
is serviced by
Page 8 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
lamivudine T1
stavudine T1
zidovudine T1
ANTITUBERCULAR - D-ALANINE ANALOGS
cycloserine T1
ANTITUBERCULAR - ISONICOTINIC ACID DERIVATIVES
isoniazid T1
ANTITUBERCULAR - NIACINAMIDE DERIVATIVES
pyrazinamide T1
ANTITUBERCULAR - RIFAMYCIN AND DERIVATIVES
rifabutin T1
rifampin T1
ANTITUBERCULAR AGENTS OTHER
ethambutol T1
CARBAPENEM ANTIBIOTICS (THIENAMYCINS)
doripenem T1
meropenem T1
meropenem-0.9% sodium chloride T1
CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION
cefadroxil T1
cefazolin T1
cefazolin in dextrose (iso-os) T1
cefazolin in sterile water T1
cephalexin T1
CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION
cefaclor T1
cefotetan T1
cefotetan in dextrose, iso-osm T1
cefoxitin T1
cefoxitin in dextrose, iso-osm T1
cefprozil T1
cefuroxime axetil T1
cefuroxime sodium T1
CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION
cefdinir T1
cefditoren pivoxil T1
cefotaxime T1
cefpodoxime T1
ceftazidime T1
ceftazidime in d5w T1
Friday Health plans of Colorado
is serviced by
Page 9 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
ceftriaxone T1
ceftriaxone in dextrose,iso-os T1
TAZICEF T1
CEPHALOSPORIN ANTIBIOTICS - 4TH GENERATION
cefepime T1
cefepime in dextrose 5 % T1
cefepime in dextrose,iso-osm T1
CHLORAMPHENICOL ANTIBIOTICS AND DERIVATIVES - SINGLE AGENTS
chloramphenicol sod succinate T1
CMV ANTIVIRAL AGENT - NUCLEOSIDE ANALOGS
valganciclovir T1 PA
CMV ANTIVIRAL AGENT - NUCLEOTIDE ANALOGS
cidofovir T1
FLUOROQUINOLONE ANTIBIOTICS
ciprofloxacin T1
ciprofloxacin hcl T1
ciprofloxacin in 5 % dextrose T1
ciprofloxacin lactate T1
levofloxacin T1
levofloxacin in d5w T1
moxifloxacin T1
ofloxacin T1
CIPRO T1
GLYCOPEPTIDE ANTIBIOTICS
vancomycin T1
vancomycin in 0.9% sodium cl T1
vancomycin in dextrose 5 % T1
HEPATITIS B TREATMENT- NUCLEOSIDE ANALOGS (ANTIVIRAL)
entecavir T1
HEPATITIS B TREATMENT- NUCLEOTIDE ANALOGS (ANTIVIRAL)
adefovir T1
HERPES ANTIVIRAL AGENT - PURINE ANALOGS
acyclovir T1
acyclovir sodium T1
valacyclovir T1
HERPES ANTIVIRAL AGENT - THYMIDINE ANALOGS
famciclovir T1
INFLUENZA ANTIVIRAL AGENTS - NEURAMINIDASE INHIBITORS
oseltamivir T1
INFLUENZA-A ANTIVIRAL AGENTS
Friday Health plans of Colorado
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Page 10 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
rimantadine T1
LINCOSAMIDE ANTIBIOTICS
clindamycin hcl T1
clindamycin in 5 % dextrose T1
clindamycin palmitate hcl T1
clindamycin phosphate T1
MACROLIDES
azithromycin T1
clarithromycin T1
erythromycin T1
erythromycin ethylsuccinate T1
ERY-TAB T1
MONOBACTAM ANTIBIOTICS
aztreonam T1
OXAZOLIDINONE ANTIBIOTICS
linezolid T1
PENICILLIN ANTIBIOTIC - NATURAL
penicillin g pot in dextrose T1
penicillin g potassium T1
penicillin g procaine T1
penicillin g sodium T1
penicillin v potassium T1
PENICILLIN ANTIBIOTIC - PENICILLINASE-RESISTANT
dicloxacillin T1
nafcillin T1
nafcillin in dextrose iso-osm T1
oxacillin T1
oxacillin in dextrose(iso-osm) T1
PENICILLIN ANTIBIOTIC, EXTENDED-SPECTRUM AND BETA-LACTAMASE INHIB COMB
piperacillin-tazobactam T1
POLYMYXINS AND DERIVATIVES - SINGLE AGENTS
bacitracin T1
polymyxin b sulfate T1
PROTEASE INHIBITORS (PEPTIDIC) ANTIRETROVIRAL
fosamprenavir T1
RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS
rifabutin T1
rifampin T1
SULFONAMIDE ANTIBIOTIC
sulfadiazine T1
Friday Health plans of Colorado
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Page 11 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
TETRACYCLINE ANTIBIOTICS
demeclocycline T1
doxycycline hyclate T1
doxycycline monohydrate T1
minocycline T1
ANTINEOPLASTICS
ANTINEOPLASTIC - ALKYLATING AGENT - NITROGEN MUSTARDS
cyclophosphamide T1
melphalan T1
ANTINEOPLASTIC - ANTIANDROGENS
bicalutamide T1
flutamide T1
ANTINEOPLASTIC - ANTIMETABOLITE - FOLIC ACID ANALOGS
methotrexate sodium T1
methotrexate sodium (pf) T1
ANTINEOPLASTIC - ANTIMETABOLITE - PURINE ANALOGS
mercaptopurine T1
ANTINEOPLASTIC - ANTIMETABOLITE - PYRIMIDINE ANALOGS
capecitabine T1
cytarabine T1
cytarabine (pf) T1
gemcitabine T1
ANTINEOPLASTIC - ANTIMETABOLITE - UREA DERIVATIVES
hydroxyurea T1
ANTINEOPLASTIC - AROMATASE INHIBITORS
anastrozole T1
letrozole T1
ANTINEOPLASTIC - PROGESTINS
megestrol T1
ANTINEOPLASTIC - RETINOIDS
tretinoin (chemotherapy) T1
ANTINEOPLASTIC - SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)
tamoxifen T1
ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS
irinotecan T1
ANTINEOPLASTIC - VINCA ALKALOIDS AND ANALOGS
vinorelbine T1
CARDIAC PROTECTIVE AGENTS USED IN CONJUNCTION WITH CHEMOTHERAPY
dexrazoxane hcl T1
METHOTREXATE RESCUE AGENTS
Friday Health plans of Colorado
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Page 12 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
leucovorin calcium T1
METHOTREXATE RESCUE AGENTS - FOLIC ACID ANTAGONIST TYPE
leucovorin calcium T1
levoleucovorin T1
URINARY TRACT PROTECTIVE AGENTS USED IN CONJUNCTION WITH CHEMOTHERAPY
mesna T1
ANTISEPTICS AND DISINFECTANTS
ANTISEPTIC - ALCOHOLS
alcohol swabs T1
ANTISEPTIC - OTHERS
formaldehyde T1
ANTISEPTIC - PHENOL DERIVATIVES
phenol T1
BIOLOGICALS
IMMUNE SERUMS - BOTULINUM ANTITOXINS
botulism antitoxin heptavalent T1
LIVE VACCINES
bcg vaccine, live (pf) T1
TOXOID VACCINE COMBINATIONS
tetanus,diphtheria tox ped(pf) T1
tetanus-diphtheria toxoids-td T1
VACCINE BACTERIAL - OTHER
bcg vaccine, live (pf) T1
CARDIOVASCULAR THERAPY AGENTS
ACE INHIBITOR AND CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine-benazepril T1
trandolapril-verapamil T1
ACE INHIBITOR AND DIURETIC COMBINATIONS
benazepril-hydrochlorothiazide T1
captopril-hydrochlorothiazide T1
enalapril-hydrochlorothiazide T1
fosinopril-hydrochlorothiazide T1
lisinopril-hydrochlorothiazide T1
moexipril-hydrochlorothiazide T1
quinapril-hydrochlorothiazide T1
ACE INHIBITORS
benazepril T1
captopril T1
enalapril maleate T1
enalaprilat T1
Friday Health plans of Colorado
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Page 13 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
fosinopril T1
lisinopril T1
moexipril T1
perindopril erbumine T1
quinapril T1
ramipril T1
trandolapril T1
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone T1
spironolactone T1
ALPHA-BETA BLOCKERS
carvedilol T1
labetalol T1
ANGIOTENSIN II RECEPTOR BLOCKER (ARB)-CALCIUM CHANNEL BLOCKER COMB.
amlodipine-olmesartan T1
amlodipine-valsartan T1
telmisartan-amlodipine T1
ANGIOTENSIN II RECEPTOR BLOCKER (ARB)-CALCIUM CHANNEL BLOCKER-DIURETIC
amlodipine-valsartan-hcthiazid T1
olmesartan-amlodipin-hcthiazid T1
ANGIOTENSIN II RECEPTOR BLOCKER (ARB)-DIURETIC COMBINATIONS
candesartan-hydrochlorothiazid T1
irbesartan-hydrochlorothiazide T1
losartan-hydrochlorothiazide T1
olmesartan-hydrochlorothiazide T1
telmisartan-hydrochlorothiazid T1
valsartan-hydrochlorothiazide T1
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS)
candesartan T1
eprosartan T1
irbesartan T1
losartan T1
olmesartan T1
telmisartan T1
valsartan T1
ANTIANGINAL - CORONARY VASODILATORS (NITRATES)
isosorbide dinitrate T1
isosorbide mononitrate T1
nitroglycerin T1
nitroglycerin in 5 % dextrose T1
Friday Health plans of Colorado
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Page 14 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
ANTIARRHYTHMIC - CLASS IA
disopyramide phosphate T1
procainamide T1
quinidine gluconate T1
quinidine sulfate T1
ANTIARRHYTHMIC - CLASS IB
lidocaine (pf) T1
lidocaine in 5 % dextrose (pf) T1
mexiletine T1
phenytoin sodium T1
ANTIARRHYTHMIC - CLASS IC
flecainide T1
propafenone T1
ANTIARRHYTHMIC - CLASS II
esmolol T1
sotalol T1
SOTALOL AF T1
ANTIARRHYTHMIC - CLASS III
amiodarone T1
amiodarone in dextrose 5 % T1
ibutilide fumarate T1
ANTIARRHYTHMIC - CLASS IV
diltiazem hcl T1
verapamil T1
ANTIARRHYTHMIC OTHERS
adenosine T1
ANTIHYPERLIPIDEMIC - BILE ACID SEQUESTRANTS
cholestyramine (with sugar) T1
colestipol T1
CHOLESTYRAMINE LIGHT T1
PREVALITE T1
ANTIHYPERLIPIDEMIC - FIBRIC ACID DERIVATIVES
fenofibrate T1
fenofibrate micronized T1
fenofibrate nanocrystallized T1
fenofibric acid T1
fenofibric acid (choline) T1
gemfibrozil T1
ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS (STATINS)
atorvastatin T1
Friday Health plans of Colorado
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Page 15 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
fluvastatin T1 ST
lovastatin T1
pravastatin T1
rosuvastatin T1
simvastatin T1
ANTIHYPERLIPIDEMIC - NICOTINIC ACID DERIVATIVES
niacin T1
ANTIHYPERLIPIDEMIC - SELECTIVE CHOLESTEROL ABSORPTION INHIBITOR
ezetimibe T1 ST
ANTIHYPERLIPIDEMIC AGENTS - DIETARY SOURCE
TRIKLO T1
ANTIHYPERLIPIDEMIC AGENTS - DIETARY SOURCE COMBINATIONS
vitamin e T1
ANTIHYPERLIPIDEMIC HMG COA REDUCT INHIB AND CALCIUM CHANNEL BLOCKER
amlodipine-atorvastatin T1
ANTIHYPERLIPIDEMIC-HMG COA REDUCT INHIB AND CHOLESTEROL ABSORP INHIBIT
ezetimibe-simvastatin T1
BETA BLOCKERS CARDIAC SELECTIVE
atenolol T1
betaxolol T1
bisoprolol fumarate T1
esmolol T1
metoprolol succinate T1
metoprolol tartrate T1
BETA BLOCKERS CARDIAC SELECTIVE, INTRINSIC SYMPATHOMIMETIC ACTIVITY
acebutolol T1
BETA BLOCKERS NON-CARDIAC SELECT., INTRINSIC SYMPATHOMIMETIC ACTIVITY
pindolol T1
BETA BLOCKERS NON-CARDIAC SELECTIVE
nadolol T1
propranolol T1
sotalol T1
timolol maleate T1
SOTALOL AF T1
CALCIUM CHANNEL BLOCKERS - BENZOTHIAZEPINES
diltiazem hcl T1
diltiazem hcl in 0.9% nacl T1
CARTIA XT T1
TAZTIA XT T1
CALCIUM CHANNEL BLOCKERS - DIHYDROPYRIDINES
Friday Health plans of Colorado
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Page 16 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
amlodipine T1
felodipine T1
nicardipine T1
nifedipine T1
CALCIUM CHANNEL BLOCKERS - DIHYDROPYRIDINES - CEREBROVASCULAR SPECIFIC
nimodipine T1
CALCIUM CHANNEL BLOCKERS - PHENYLAKYLAMINES
verapamil T1
CARDIAC INOTROPES - PHOSPHODIESTERASE INHIBITORS
milrinone T1
milrinone in 5 % dextrose T1
CARDIAC SELECTIVE BETA BLOCKER-THIAZIDE DIURETIC AND RELATED COMB.
atenolol-chlorthalidone T1
bisoprolol-hydrochlorothiazide T1
metoprolol ta-hydrochlorothiaz T1
CARDIOVASCULAR SYMPATHOMIMETIC - ANAPHYLAXIS THERAPY SINGLE AGENTS
epinephrine T1
ADYPHREN T1
CARDIOVASCULAR SYMPATHOMIMETICS
dobutamine T1
dobutamine in d5w T1
dopamine T1
dopamine in 5 % dextrose T1
ephedrine sulfate T1
ephedrine sulfate-0.9%nacl(pf) T1
epinephrine T1
midodrine T1
norepinephrine bitartrate T1
phenylephrine hcl T1
phenylephrine hcl in 0.9% nacl T1
CENTRAL ALPHA-2 AGONISTS-THIAZIDE DIURETIC AND RELATED COMB.
methyldopa-hydrochlorothiazide T1
CENTRAL ALPHA-2 RECEPTOR AGONISTS
clonidine T1
clonidine hcl T1
guanfacine T1
methyldopa T1
methyldopate T1
DIGITALIS GLYCOSIDES
digoxin T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
DIRECT ACTING VASODILATORS
hydralazine T1
DIURETIC - ALDOSTERONE RECEPTOR ANTAGONIST, NON-SELECTIVE
spironolactone T1
DIURETIC - ALDOSTERONE RECEPTOR ANTAGONIST, SELECTIVE
eplerenone T1
DIURETIC - CARBONIC ANHYDRASE INHIBITORS
acetazolamide T1
acetazolamide sodium T1
methazolamide T1
DIURETIC - INORGANIC SALT
ammonium chloride T1
DIURETIC - LOOP
bumetanide T1
ethacrynate sodium T1
furosemide T1
torsemide T1
DIURETIC - OSMOTIC
mannitol 10 % T1
mannitol 20 % T1
mannitol 25 % T1
mannitol 5 % T1
DIURETIC - POTASSIUM SPARING
amiloride T1
DIURETIC - POTASSIUM SPARING-THIAZIDE AND RELATED COMBINATIONS
amiloride-hydrochlorothiazide T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid T1
DIURETIC - THIAZIDES AND RELATED
chlorothiazide T1
chlorthalidone T1
hydrochlorothiazide T1
indapamide T1
methyclothiazide T1
metolazone T1
GANGLIONIC BLOCKING, NON-DEPOLARIZING
VECAMYL T1
MUSCARINIC RECEPTOR ANTAGONISTS (ANTICHOLINERGIC)
atropine T1
atropine (bulk) T1
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Drug Name Formulary Tier Restrictions
NON-CARDIAC SELECTIVE BETA BLOCKER-THIAZIDE DIURETIC AND RELATED COMB.
nadolol-bendroflumethiazide T1
propranolol-hydrochlorothiazid T1
PATENT DUCTUS ARTERIOSUS (PDA) TREATMENT AGENTS , NSAID-TYPE
indomethacin sodium T1
PATENT DUCTUS ARTERIOSUS (PDA) TREATMENT AGENTS, PROSTAGLANDIN-TYPE
alprostadil T1
PERIPHERAL ALPHA-1 RECEPTOR BLOCKERS
doxazosin T1
prazosin T1
terazosin T1
PERIPHERAL VASODILATORS, SINGLE AGENTS
isoxsuprine T1
papaverine T1
PULMONARY ANTIHYPERTENSIVE AGENTS - PROSTACYCLIN-TYPE
epoprostenol (glycine) T1 PA
CENTRAL NERVOUS SYSTEM AGENTS
ANTIANXIETY AGENT - ANTIHISTAMINE TYPE
hydroxyzine hcl T1
hydroxyzine pamoate T1
ANTIANXIETY AGENT - BENZODIAZEPINES
alprazolam T1
chlordiazepoxide hcl T1
clonazepam T1
clorazepate dipotassium T1
diazepam T1
lorazepam T1
oxazepam T1
ALPRAZOLAM INTENSOL T1
DIAZEPAM INTENSOL T1
ANTIANXIETY AGENT - DICARBAMATE TYPE
meprobamate T1
ANTIANXIETY AGENT - NON-BENZODIAZEPINE
buspirone T1
ANTICONVULSANT - BARBITURATES AND DERIVATIVES
phenobarbital T1
phenobarbital sodium T1
primidone T1
ANTICONVULSANT - BENZODIAZEPINES
clonazepam T1
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Drug Name Formulary Tier Restrictions
diazepam T1
ANTICONVULSANT - CARBAMATES
felbamate T1
ANTICONVULSANT - CARBOXYLIC ACID DERIVATIVES
divalproex T1
valproic acid T1
valproic acid (as sodium salt) T1
ANTICONVULSANT - GABA ANALOGS
gabapentin T1
ANTICONVULSANT - HYDANTOINS
fosphenytoin T1
phenytoin T1
phenytoin sodium T1
phenytoin sodium extended T1
ANTICONVULSANT - IMINOSTILBENE DERIVATIVES
carbamazepine T1
oxcarbazepine T1
ANTICONVULSANT - MONOSACCHARIDE DERIVATIVES
topiramate T1
ANTICONVULSANT - PHENYLTRIAZINE DERIVATIVES
lamotrigine T1
ANTICONVULSANT - PYRROLIDINE DERIVATIVES
levetiracetam T1
ANTICONVULSANT - SUCCINIMIDES
ethosuximide T1
ANTICONVULSANT - SULFONAMIDE DERIVATIVES
zonisamide T1
ANTIDEPRESSANT - ALPHA-2 RECEPTOR ANTAGONISTS (NASSA)
mirtazapine T1
ANTIDEPRESSANT - MAO INHIBITOR NONSELECTIVE AND IRREVERSIBLE-TYPES A,B
phenelzine T1
ANTIDEPRESSANT - SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
citalopram T1
escitalopram oxalate T1
fluoxetine T1
fluvoxamine T1
paroxetine hcl T1
sertraline T1
ANTIDEPRESSANT - SEROTONIN-2 ANTAGONIST-REUPTAKE INHIBITORS (SARIS)
nefazodone T1
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trazodone T1
ANTIDEPRESSANT - SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
desvenlafaxine T1
desvenlafaxine fumarate T1
desvenlafaxine succinate T1
duloxetine T1
venlafaxine T1
ANTIDEPRESSANT - TRICYCLIC AND ANTIPSYCHOTIC, PHENOTHIAZINE COMB
perphenazine-amitriptyline T1
ANTIDEPRESSANT - TRICYCLIC-BENZODIAZEPINE COMBINATIONS
amitriptyline-chlordiazepoxide T1
ANTIDEPRESSANT-NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIS)
bupropion hcl T1
ANTIDEPRESSANT-TRICYCLICS AND RELATED (NON-SELECT REUPTAKE INHIBITORS)
amitriptyline T1
amoxapine T1
clomipramine T1 PA
desipramine T1
doxepin T1
imipramine hcl T1
imipramine pamoate T1
maprotiline T1
nortriptyline T1
protriptyline T1
ANTIPARKINSON - DOPAMINERGIC-PERIPH COMT-DOPA-DECARBOXYLASE INHIB COMB
carbidopa-levodopa-entacapone T1
ANTIPARKINSON - DOPAMINERG-PERIPHERAL DOPA-DECARBOXYLASE INHIBIT COMB
carbidopa-levodopa T1
ANTIPARKINSON ADJUVANT - PERIPHERAL COMT INHIBITORS
entacapone T1
ANTIPARKINSON THERAPY - ANTICHOLINERGIC AGENTS
benztropine T1
trihexyphenidyl T1
ANTIPARKINSON THERAPY - MONOAMINE OXIDASE INHIBITOR(MAO-B)
rasagiline T1
selegiline hcl T1
ANTIPARKINSON THERAPY - NON-ERGOT DOPAMINE AGONIST AGENTS
amantadine hcl T1
pramipexole T1
ropinirole T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
ANTIPSYCHOTIC - ATYPICAL DOPAMINE-SEROTONIN ANTAG- BENZISOTHIAZOLONES
ziprasidone hcl T1
ANTIPSYCHOTIC - ATYPICAL DOPAMINE-SEROTONIN ANTAG- BENZISOXAZOLE DERIV
paliperidone T1
risperidone T1
ANTIPSYCHOTIC - ATYPICAL DOPAMINE-SEROTONIN ANTAG-DIBENZODIAZEPINE DER
clozapine T1
ANTIPSYCHOTIC - BUTYROPHENONE DERIVATIVES
haloperidol T1
haloperidol decanoate T1
haloperidol lactate T1
ANTIPSYCHOTIC - DIBENZOXAZEPINE DERIVATIVES
loxapine succinate T1
ANTIPSYCHOTIC - PHENOTHIAZINES, ALIPHATIC
chlorpromazine T1
ANTIPSYCHOTIC - PHENOTHIAZINES, PIPERAZINE
fluphenazine hcl T1
perphenazine T1
prochlorperazine maleate T1
trifluoperazine T1
ANTIPSYCHOTIC - PHENOTHIAZINES, PIPERIDINE
thioridazine T1
ANTIPSYCHOTIC - THIOXANTHENES
thiothixene T1
ANTIPSYCHOTIC -ATYPICAL DOPAMINE-SEROTONIN ANTAG-DIBENZOTHIAZEPINE DER
quetiapine T1
ANTIPSYCHOTIC -ATYPICAL DOPAMINE-SEROTONIN ANTAG-THIENOBENZODIAZEPINES
olanzapine T1
ANTIPSYCHOTIC-ATYPICAL,D2 RECEPTOR PARTIAL AGONIST-5HT SEROTONIN MIXED
aripiprazole T1
ATTENTION DEFICIT-HYPERACTIVITY (ADHD) THERAPY, STIMULANT-TYPE
dexmethylphenidate T1
dextroamphetamine T1
dextroamphetamine-amphetamine T1
methylphenidate hcl T1
ATTENTION DEFICIT-HYPERACTIVITY DISORDER (ADHD) THERAPY, NRI-TYPE
atomoxetine T1
BENZODIAZEPINES
amitriptyline-chlordiazepoxide T1
chlordiazepoxide-clidinium T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
diazepam T1
lorazepam T1
DIAZEPAM INTENSOL T1
BIPOLAR THERAPY AGENTS - ANTICONVULSANT TYPE
carbamazepine T1
divalproex T1
lamotrigine T1
valproic acid T1
valproic acid (as sodium salt) T1
BIPOLAR THERAPY AGENTS - ATYPICAL ANTIPSYCHOTICS
aripiprazole T1
olanzapine T1
quetiapine T1
risperidone T1
ziprasidone hcl T1
BIPOLAR THERAPY AGENTS - LITHIUM
lithium carbonate T1
CNS STIMULANT - AMPHETAMINE COMBINATIONS
dextroamphetamine-amphetamine T1
CNS STIMULANT - AMPHETAMINES
dextroamphetamine T1
DEXEDRINE SPANSULE T1
CNS STIMULANT - ANALEPTICS
caffeine citrate T1
caffeine-sodium benzoate T1
doxapram T1
FIBROMYALGIA AGENTS - SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)
duloxetine T1
MIGRAINE THERAPY - ANALGESIC-VASOCONSTRICTORS
isomethepten-caf-acetaminophen T1
MIGRAINE THERAPY - ANALGESIC-VASOCONSTRICTOR-SEDATIVE COMBINATIONS
isometh-dichloral-acetaminophn T1
MIGRAINE THERAPY - CARBOXYLIC ACID DERIVATIVES
divalproex T1
MIGRAINE THERAPY - ERGOT ALKALOIDS AND DERIVATIVES
dihydroergotamine T1
MIGRAINE THERAPY - ERGOT COMBINATIONS
MIGERGOT T1
MIGRAINE THERAPY - SELECTIVE SEROTONIN AGONISTS 5-HT(1)
eletriptan hbr T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
naratriptan T1
rizatriptan T1
sumatriptan succinate T1
zolmitriptan T1
NARCOLEPSY THERAPY AGENTS - STIMULANT-TYPE, PIPERADINE DERIVATIVE
methylphenidate hcl T1
NARCOLEPSY THERAPY AGENTS- STIMULANT-TYPE,SYMPATHOMIMETIC,AMPHETAMINES
dextroamphetamine T1
SEDATIVE-HYPNOTIC - BARBITURATES
phenobarbital T1
phenobarbital sodium T1
SEDATIVE-HYPNOTIC - BENZODIAZEPINES
estazolam T1
flurazepam T1
lorazepam T1
midazolam T1
quazepam T1
temazepam T1
triazolam T1
SEDATIVE-HYPNOTIC - GABA-RECEPTOR MODULATORS
eszopiclone T1
zaleplon T1
zolpidem T1
SEDATIVE-HYPNOTIC - SELECTIVE ALPHA2-ADRENORECEPTOR AGONISTS
dexmedetomidine T1
CHEMICAL DEPENDENCY, AGENTS TO TREAT
AGENTS FOR NARCOTIC WITHDRAWAL
buprenorphine hcl T1 ST
ALCOHOL ABSTINENCE THERAPY - GLUTAMATE AND GABA SYSTEM TYPE
acamprosate T1
ALCOHOL DETERRENTS
disulfiram T1
SMOKING DETERRENTS - NE AND DOPAMINE REUPTAKE INHIBITOR (NDRI)-TYPE
bupropion hcl T1
SMOKING DETERRENTS - NICOTINE-TYPE
nicotine (polacrilex) T1
CHEMICALS-PHARMACEUTICAL ADJUVANTS
BULK CHEMICALS
belladonna tincture (bulk) T1
CHEMICALS - ACIDS
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
glycolic acid (bulk) T1
CHEMICALS - BASES
sodium hydroxide (bulk) T1
CHEMICALS - SOLVENTS
ethyl alcohol (bulk) T1
sodium succinate T1
PHARMACEUTICAL ADJUVANT - ANTICORROSIVE AGENTS
butylated hydroxytoluene T1
sodium bisulfite T1
PHARMACEUTICAL ADJUVANT - FLAVORING AGENTS
banana creme flavor (bulk) T1
ethyl acetate T1
PHARMACEUTICAL ADJUVANT - INHALATION VEHICLES
sodium chloride T1
PHARMACEUTICAL ADJUVANT - ORAL VEHICLES
sorbitol T1
PHARMACEUTICAL ADJUVANT - SUSPENDING AGENTS
oleic acid T1
PHARMACEUTICAL ADJUVANT - TABLETING
cellulose (bulk) T1
lactose (bulk) T1
magnesium stearate T1
COGNITIVE DISORDER THERAPY
ALZHEIMER'S DISEASE THERAPY - CHOLINESTERASE INHIBITORS
donepezil T1
galantamine T1
rivastigmine tartrate T1
ALZHEIMER'S DISEASE THERAPY - NMDA RECEPTOR ANTAGONISTS
memantine T1
COGNITIVE DISORDER THERAPY - CEREBRAL VASODILATORS
ergoloid T1
CONTRACEPTIVES
CONTRACEPTIVE INJECTABLE - PROGESTIN
medroxyprogesterone T1
CONTRACEPTIVE ORAL - BIPHASIC
DAYSEE T1
KARIVA (28) T1
VIORELE (28) T1
CONTRACEPTIVE ORAL - MONOPHASIC
desogestrel-ethinyl estradiol T1
Friday Health plans of Colorado
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
drospirenone-e.estradiol-lm.fa T1
drospirenone-ethinyl estradiol T1
ethynodiol diac-eth estradiol T1
levonorgestrel-ethinyl estrad T1
mibelas 24 fe T1
noreth-ethinyl estradiol-iron T1
norethindrone-e.estradiol-iron T1
norgestimate-ethinyl estradiol T1
AMETHYST T1
APRI T1
AVIANE T1
BRIELLYN T1
CYCLAFEM 1/35 (28) T1
ELINEST T1
EMOQUETTE T1
GIANVI (28) T1
GILDAGIA T1
ISIBLOOM T1
JOLESSA T1
JUNEL 1.5/30 (21) T1
JUNEL 1/20 (21) T1
JUNEL FE 1.5/30 (28) T1
JUNEL FE 1/20 (28) T1
KELNOR 1/35 (28) T1
LILLOW T1
LORYNA (28) T1
MELODETTA 24 FE T1
MICROGESTIN FE 1.5/30 (28) T1
MICROGESTIN FE 1/20 (28) T1
MONONESSA (28) T1
NORTREL 0.5/35 (28) T1
NORTREL 1/35 (21) T1
NORTREL 1/35 (28) T1
OCELLA T1
ORSYTHIA T1
PHILITH T1
PIRMELLA T1
QUASENSE T1
RAJANI T1
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Drug Name Formulary Tier Restrictions
SPRINTEC (28) T1
SRONYX T1
ZARAH T1
ZOVIA 1/35E (28) T1
ZOVIA 1/50E (28) T1
CONTRACEPTIVE ORAL - PROGESTIN
CAMILA T1
HEATHER T1
NORLYDA T1
CONTRACEPTIVE ORAL - QUADRAPHASIC
FAYOSIM T1
RIVELSA T1
CONTRACEPTIVE ORAL - TRIPHASIC
norgestimate-ethinyl estradiol T1
ALYACEN 7/7/7 (28) T1
ARANELLE (28) T1
CAZIANT (28) T1
CYCLAFEM 7/7/7 (28) T1
DASETTA 7/7/7 (28) T1
LEVONEST (28) T1
MYZILRA T1
NECON 7/7/7 (28) T1
NORTREL 7/7/7 (28) T1
TILIA FE T1
TRI FEMYNOR T1
TRINESSA (28) T1
TRI-PREVIFEM (28) T1
TRI-SPRINTEC (28) T1
CONTRACEPTIVE TRANSDERMAL COMBINATIONS
XULANE T1
CONTRACEPTIVE TRANSDERMAL COMBINATIONS - ESTROGEN AND PROGESTIN COMB.
XULANE T1
EMERGENCY CONTRACEPTIVES
MY WAY T1
NEXT CHOICE ONE DOSE T1
EMERGENCY CONTRACEPTIVES - PROGESTIN TYPE
MY WAY T1
NEXT CHOICE ONE DOSE T1
DERMATOLOGICAL
ACNE THERAPY SYSTEMIC - TETRACYCLINES
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Drug Name Formulary Tier Restrictions
minocycline T1
ACNE THERAPY TOPICAL - ANTI-INFECTIVE
clindamycin phosphate T1
erythromycin with ethanol T1
metronidazole T1
ACNE THERAPY TOPICAL - ANTI-INFECTIVE-KERATOLYTIC COMBINATIONS
erythromycin-benzoyl peroxide T1
sulfacetamide sodium-sulfur T1
sulfacetamide sod-sulfur-urea T1
sulfacetamide-sulfur-cleansr23 T1
sulfact na-sul-avobnz-otn-ocsa T1
ACNE THERAPY TOPICAL - KERATOLYTIC
benzoyl peroxide T1
potassium hydroxide T1
BP WASH ACNE TREATMENT T1
ACNE THERAPY TOPICAL - RETINOID COMBINATIONS OTHER
adapalene-benzoyl peroxide T1
ACNE THERAPY TOPICAL - RETINOIDS AND DERIVATIVES
adapalene T1
DERMATOLOGICAL - ANTIBACTERIAL AMINOGLYCOSIDES
gentamicin T1
DERMATOLOGICAL - ANTIBACTERIAL OTHER
mupirocin T1
mupirocin calcium T1
silver nitrate T1
NORMLGEL AG T1
DERMATOLOGICAL - ANTIBACTERIAL SULFONAMIDES
sulfacetamide sodium-sulfur T1
DERMATOLOGICAL - ANTIFUNGAL AMPHOTERIC POLYENE MACROLIDES
nystatin T1
DERMATOLOGICAL - ANTIFUNGAL COMBINATIONS OTHER
EXODERM T1
DERMATOLOGICAL - ANTIFUNGAL HYDROXYPYRIDINONE
ciclopirox T1
ciclopirox-ure-camph-menth-euc T1
DERMATOLOGICAL - ANTIFUNGAL IMIDAZOLE AND RELATED AGENTS
clotrimazole T1
ketoconazole T1
oxiconazole T1
DERMATOLOGICAL - ANTIFUNGAL-GLUCOCORTICOID COMBINATIONS
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Proprietary and Confidential
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clotrimazole-betamethasone T1
iodoquinol-hc T1
nystatin-triamcinolone T1
DERMATOLOGICAL - ANTIFUNGALS OTHER
triacetin T1
DERMATOLOGICAL - ANTINEOPLASTIC ANTIMETABOLITES
fluorouracil T1
DERMATOLOGICAL - ANTIPSORIATIC AGENTS SYSTEMIC, VITAMIN A DERIVATIVES
acitretin T1
DERMATOLOGICAL - ANTIPSORIATIC AGENTS TOPICAL
calcipotriene T1
calcitriol T1
tazarotene T1
DERMATOLOGICAL - ANTISEBORRHEIC
selenium sulfide T1
sulfacetamide sodium T1
DERMATOLOGICAL - BURN PRODUCTS ANTI-INFECTIVE
silver sulfadiazine T1
DERMATOLOGICAL - DEPIGMENTING AGENTS
hydroquinone T1
hydroquinone microspheres T1
DERMATOLOGICAL - EMOLLIENT COMBINATIONS OTHER
HPR PLUS-MB HYDROGEL T1
MB HYDROGEL T1
MB HYDROGEL (CYCLOMETHICONE) T1
DERMATOLOGICAL - EMOLLIENT MIXTURES
AVO CREAM T1
EMULSION SB T1
HPR T1
HPR PLUS T1
PRUCLAIR T1
PRUMYX T1
PRUTECT T1
SONAFINE T1
DERMATOLOGICAL - EMOLLIENTS
ammonium lactate T1
urea T1
DERMATOLOGICAL - GLUCOCORTICOID
alclometasone T1
amcinonide T1
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betamethasone dipropionate T1
betamethasone valerate T1
betamethasone, augmented T1
desonide T1
diflorasone T1
fluocinolone T1
fluocinolone and shower cap T1
fluocinonide T1
fluticasone T1
halobetasol propionate T1
hydrocortisone T1
hydrocortisone butyrate T1
hydrocortisone valerate T1
hydrocortisone-pramoxine T1
mometasone T1
prednicarbate T1
triamcinolone acetonide T1
FLUOCINONIDE-E T1
PROCTO-PAK T1
PROCTOZONE-HC T1
SCALACORT T1
TRIDERM T1
DERMATOLOGICAL - GLUCOCORTICOID-EMOLLIENT COMBINATIONS
hydrocortisone-min oil-wht pet T1
DERMATOLOGICAL - GLUCOCORTICOID-LOCAL ANESTHETIC COMBINATIONS
hydrocortisone-pramoxine T1
lidocaine hcl-hydrocortison ac T1
DERMATOLOGICAL - IMMUNOMODULATOR - IMIDAZOQUINOLINAMINES
imiquimod T1
DERMATOLOGICAL - KERATOLYTIC-ANTIMITOTIC COMBINATIONS
silver nitrate applicators T1
DERMATOLOGICAL - KERATOLYTIC-ANTIMITOTIC SINGLE AGENTS
podofilox T1
salicylic acid T1
salicylic acid er-ceramides T1
trichloroacetic acid T1
urea T1
BP-50% UREA T1
UMECTA T1
DERMATOLOGICAL - KERATOPLASTIC TAR PRODUCTS
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coal tar T1
DERMATOLOGICAL - LOCAL ANESTHETIC COMBINATIONS
lidocaine-prilocaine T1
DERMATOLOGICAL - LOCAL ANESTHETIC GAS SINGLE AGENTS
ethyl chloride T1
DERMATOLOGICAL - PROTECTANT COMBINATIONS
HYGEL T1
PR CREAM T1
DERMATOLOGICAL - ROSACEA THERAPY, TOPICAL
metronidazole T1
sulfacetamide sod-sulfur-urea T1
sulfact na-sul-avobnz-otn-ocsa T1
DERMATOLOGICAL - TOPICAL LOCAL ANESTHETIC AMIDES
lidocaine hcl T1
lidocaine-tetracaine T1
DERMATOLOGICAL - TOPICAL LOCAL ANESTHETIC ESTERS
cocaine T1
DERMATOLOGICAL IRRITANTS-COUNTER-IRRITANT SINGLE AGENTS
methyl salicylate T1
SCABICIDE AND PEDICULICIDE SINGLE AGENTS
lindane T1
permethrin T1
spinosad T1
DIAGNOSTIC AGENTS
CONTRAST MEDIA - BARIUM
LIQUID E-Z PAQUE T1
CONTRAST MEDIA - IODINATED IONIC
MD-GASTROVIEW T1
DIAGNOSTIC DRUGS - CARDIOVASCULAR
dipyridamole T1
DIAGNOSTIC DRUGS - IN VIVO OTHER
isosulfan blue T1
DIAGNOSTIC DRUGS - PITUITARY FUNCTION
cosyntropin T1
DIAGNOSTIC RADIOPHARMACEUTICALS - BONE OR SKELETAL IMAGING
kit prep of tc-99m-sod pyroph T1
kit prep tc-99m-medronate sod T1
DIAGNOSTIC RADIOPHARMACEUTICALS - HEPATOBILIARY IMAGING
kit prep of tc-99m-mebrofenin T1
DIAGNOSTIC RADIOPHARMACEUTICALS - MISC.
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kit for tc 99m-sod thiosulfate T1
DIAGNOSTIC RADIOPHARMACEUTICALS - MYOCARDIAL PERFUSION IMAGING
kit for tc 99m-sestamibi no.1 T1
kit prep of tc-99m-sod pyroph T1
thallous chloride tl-201 T1
DIAGNOSTIC RADIOPHARMACEUTICALS - RADIOLABELING AUTOLOGOUS LEUKOCYTES
indium in-111 oxyquinoline T1
EATING DISORDER THERAPY
ANOREXIANTS
diethylpropion T1
phendimetrazine tartrate T1
APPETITE STIMULANTS - PROGESTIN HORMONE TYPE
megestrol T1
ELECTROLYTE BALANCE-NUTRITIONAL PRODUCTS
B-COMPLEX VITAMIN COMBINATIONS
FOLBEE PLUS T1
MYNEPHROCAPS T1
RENAL CAPS T1
RENO CAPS T1
TRIPHROCAPS T1
VIRT-VITE PLUS T1
B-COMPLEX VITAMINS AND COMBINATIONS
RENA-VITE RX T1
VOL-CARE RX T1
DEXTROSE AND LACTATED RINGER'S SOLUTIONS
dextrose 5 %-lactated ringers T1
DEXTROSE AND SODIUM CHLORIDE SOLUTIONS
d10 %-0.45 % sodium chloride T1
d2.5 %-0.45 % sodium chloride T1
d5 % and 0.9 % sodium chloride T1
d5 %-0.45 % sodium chloride T1
dextrose 10 % and 0.2 % nacl T1
dextrose 5%-0.2 % sod chloride T1
dextrose 5%-0.3 % sod.chloride T1
DEXTROSE SOLUTIONS
dextrose 10 % in water (d10w) T1
dextrose 20 % in water (d20w) T1
dextrose 25 % in water (d25w) T1
dextrose 30 % in water (d30w) T1
dextrose 40 % in water (d40w) T1
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Proprietary and Confidential
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dextrose 5 % in water (d5w) T1
dextrose 50 % in water (d50w) T1
dextrose 70 % in water (d70w) T1
DEXTROSE SOLUTIONS, CONCENTRATED
dextrose 20 % in water (d20w) T1
dextrose 25 % in water (d25w) T1
dextrose 30 % in water (d30w) T1
dextrose 40 % in water (d40w) T1
dextrose 50 % in water (d50w) T1
dextrose 70 % in water (d70w) T1
DIETARY PRODUCT - DIETARY SUPPLEMENTS
VP-ZEL T1
DILUENTS - SODIUM CHLORIDE
sodium chloride 0.9 % T1
DILUENTS - STERILE WATER FOR INJECTION
water for inject, bacteriostat T1
water for injection, sterile T1
ELECTROLYTE DEPLETERS - ION EXCHANGE RESIN
sodium polystyrene sulfonate T1
KIONEX (WITH SORBITOL) T1
SPS (WITH SORBITOL) T1
IRRIGATION SOLUTIONS
lactated ringers T1
ringer's T1
water for irrigation, sterile T1
MINERALS AND ELECTROLYTES - BICARBONATE PRODUCING OR CONTAINING AGENTS
sodium acetate T1
sodium bicarbonate T1
sodium lactate T1
MINERALS AND ELECTROLYTES - CALCIUM REPLACEMENT
calcium acetate T1
calcium chloride T1
calcium gluconate T1
calcium gluconate in 0.9% nacl T1
calcium gluconate in d5w T1
MINERALS AND ELECTROLYTES - CALCIUM REPLACEMENT COMBINATIONS
CALCIUM-FOLIC ACID-VITAMIN D T1
TL G-FOL OS T1
MINERALS AND ELECTROLYTES - ELECTROLYTES AND DEXTROSE
dextrose 5 % in ringer's T1
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Drug Name Formulary Tier Restrictions
electrolyte-48 in d5w T1
MINERALS AND ELECTROLYTES - IODINE
LUGOLS T1
STRONG IODINE T1
MINERALS AND ELECTROLYTES - IRON
sodium ferric gluconat-sucrose T1
MINERALS AND ELECTROLYTES - IRON COMBINATIONS
CENTRATEX T1
CORVITA 150 T1
FEROCON T1
FERRAPLUS 90 T1
FERREX 150 FORTE T1
FERREX 150 FORTE PLUS T1
FERREX 28 T1
FERROCITE PLUS T1
FOLIVANE-F T1
FOLIVANE-PLUS T1
HEMATINIC PLUS VIT/MINERALS T1
HEMATINIC/FOLIC ACID T1
HEMATOGEN FA T1
HEMATOGEN FORTE T1
HEMETAB T1
IFEREX 150 FORTE T1
MULTIGEN T1
MULTIGEN FOLIC T1
MULTIGEN PLUS T1
POLY-IRON 150 FORTE T1
TARON FORTE T1
TL ICON T1
TL-HEM 150 T1
TRIGELS-F FORTE T1
MINERALS AND ELECTROLYTES - MAGNESIUM
magnesium chloride T1
magnesium sulfate T1
magnesium sulfate in d5w T1
magnesium sulfate in lr T1
magnesium sulfate in water T1
MINERALS AND ELECTROLYTES - MANGANESE
manganese chloride T1
MINERALS AND ELECTROLYTES - PHOSPHATE
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
potassium phosphate m-/d-basic T1
sodium phosphate T1
sodium phosphate in 0.9 % nacl T1
MINERALS AND ELECTROLYTES - POTASSIUM COMBINATIONS
potassium bicarb and chloride T1
MINERALS AND ELECTROLYTES - POTASSIUM FOR INJECTION
potassium acetate T1
potassium chlorid-d5-0.45%nacl T1
potassium chloride T1
potassium chloride in 0.9%nacl T1
potassium chloride in 5 % dex T1
potassium chloride in lr-d5 T1
potassium chloride-0.45 % nacl T1
potassium chloride-d5-0.2%nacl T1
potassium chloride-d5-0.3%nacl T1
potassium chloride-d5-0.9%nacl T1
MINERALS AND ELECTROLYTES - POTASSIUM, ORAL
potassium bicarb-citric acid T1
potassium chloride T1
MINERALS AND ELECTROLYTES - TRACE MINERAL COMBINATIONS
MULTITRACE-4 T1
MULTITRACE-4 CONCENTRATE T1
MULTITRACE-4 NEONATAL T1
MULTITRACE-5 T1
MULTITRACE-5 CONCENTRATE T1
MINERALS AND ELECTROLYTES - TRACE MINERALS
chromium chloride T1
selenium T1
COPPER CHLORIDE T1
MINERALS AND ELECTROLYTES - ZINC
zinc chloride T1
zinc sulfate T1
MULTIVITAMIN AND MINERAL COMBINATIONS
ADVANCED AM-PM T1
V-C FORTE T1
VIC-FORTE T1
MULTIVITAMINS
L-METHYL-MC T1
METAFOLBIC T1
PUREVIT DUALFE PLUS T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
SE-TAN PLUS T1
VIT 3 T1
PARENTERAL NUTRITION - AMINO ACID SOLUTIONS
cysteine (l-cysteine) T1
CLINISOL SF 15 % T1
PEDIATRIC VITAMINS
MVW COMPLETE FORMUL PEDIATRIC T1
PEDIATRIC VITAMINS WITH FLUORIDE COMBINATIONS
MULTIVITAMIN WITH FLUORIDE T1
MULTI-VITAMIN WITH FLUORIDE T1
MULTIVITAMINS WITH FLUORIDE T1
TRIPLE VITAMIN WITH FLUORIDE T1
TRI-VITAMIN WITH FLUORIDE T1
VITAMINS A,C,D AND FLUORIDE T1
PRENATAL VITAMINS AND MINERALS
C-NATE DHA T1
COMPLETE NATAL DHA T1
COMPLETENATE T1
ELITE OB WITH DHA T1
ELITE-OB 400 T1
EXTRA-VIRT PLUS DHA T1
FOLIVANE-OB T1
HEMENATAL OB T1
HEMENATAL OB + DHA T1
LEVOMEFOLATE DHA T1
MYNATAL T1
MYNATAL ADVANCE T1
MYNATAL PLUS T1
MYNATAL-Z T1
MYNATE 90 PLUS T1
OBSTETRIX DHA T1
PNV OB+DHA T1
PNV-DHA T1
PNV-DHA + DOCUSATE T1
PNV-OMEGA T1
PNV-SELECT T1
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PR NATAL 430 EC T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
PRENA1 TRUE T1
PRENAISSANCE T1
PRENAISSANCE PLUS T1
PRENATAL 19 (WITH DOCUSATE) T1
PRENATAL LOW IRON T1
PRENATAL PLUS T1
PRENATAL PLUS (CALCIUM CARB) T1
PRENATAL-U T1
RELNATE DHA T1
SE-NATAL 19 T1
SE-NATAL 19 (WITH DOCUSATE) T1
TARON-C DHA T1
TARON-PREX PRENATAL-DHA T1
TL-SELECT T1
TRIADVANCE T1
TRINATAL GT T1
TRINATAL RX 1 T1
TRIVEEN-DUO DHA T1
TRIVEEN-ONE T1
TRIVEEN-PRX RNF T1
TRUST NATAL DHA T1
ULTIMATECARE ONE T1
ULTIMATECARE ONE NF T1
VEMAVITE-PRX-2 T1
VENA-BAL DHA T1
VINACAL T1
VINATE GT T1
VINATE II T1
VINATE M T1
VINATE ONE T1
VINATE PN CARE T1
VINATE ULTRA T1
VIRT-PN T1
VIRT-PN DHA T1
VIRT-PN PLUS T1
VIRT-SELECT T1
VOL-NATE T1
VOL-TAB RX T1
VP-CH PLUS T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
VP-CH-PNV T1
VP-HEME ONE T1
VP-PNV-DHA T1
ZATEAN-CH T1
ZATEAN-PN DHA T1
ZATEAN-PN PLUS T1
PRENATAL VITAMINS WITHOUT IRON
VP-GGR-B6 T1
ZINGIBER T1
RINGER'S AND LACTATED RINGER'S SOLUTIONS
lactated ringers T1
ringer's T1
SODIUM CHLORIDE FLUSHES
sodium chloride 0.9 % T1
SODIUM CHLORIDE SOLUTIONS, CONCENTRATED
sodium chloride T1
sodium chloride 3 % T1
sodium chloride 5 % T1
SODIUM CHLORIDE, PARENTERAL
sodium chloride T1
sodium chloride 0.45 % T1
sodium chloride 0.9 % T1
sodium chloride 3 % T1
sodium chloride 5 % T1
STERILE WATER FOR INJECTION
water for injection, sterile T1
VITAMINS - B PREPARATION COMBINATIONS
folic acid-vit b6-vit b12 T1
FABB T1
FOLBIC RF T1
LMTHF-PYRIDOXINE-CYANOCOBALAMN T1
TL GARD RX T1
VITAMINS - B-1, THIAMINE AND DERIVATIVES
thiamine hcl (vitamin b1) T1
VITAMINS - B-12, CYANOCOBALAMIN AND DERIVATIVES
cyanocobalamin (vitamin b-12) T1
hydroxocobalamin T1
PHYSICIANS EZ USE B-12 T1
VITAMINS - B-3, NIACIN AND DERIVATIVES
niacin T1
Friday Health plans of Colorado
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
niacinamide (bulk) T1
VITAMINS - B-6, PYRIDOXINE AND DERIVATIVES
pyridoxine (vitamin b6) T1
VITAMINS - C, ASCORBIC ACID AND DERIVATIVES
ascorbic acid (vitamin c) T1
VITAMINS - D DERIVATIVES
calcitriol T1
ergocalciferol (vitamin d2) T1
VITAMINS - E
vitamin e T1
wheat germ oil T1
VITAMINS - FOLIC ACID AND DERIVATIVES
folic acid T1
levomefolate calcium T1
VITAMINS - FOLIC ACID COMBINATIONS
folic acid-vit b6-vit b12 T1
FABB T1
TL GARD RX T1
VITAMINS - K, PHYTONADIONE AND DERIVATIVES
phytonadione (vit k1) (bulk) T1
phytonadione (vitamin k1) T1
VITAMIN K T1
VITAMIN K1 T1
ENDOCRINE
AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS)
glucagon hcl T1
ANDROGEN - SINGLE AGENTS
methyltestosterone T1
testosterone T1
testosterone (bulk) T1
testosterone cypionate T1
testosterone enanthate T1
ANTIDIURETIC AND VASOPRESSOR HORMONES
desmopressin T1 PA
vasopressin T1
ANTIHYPERGLYCEMIC - ALPHA-GLUCOSIDASE INHIBITORS
acarbose T1
ANTIHYPERGLYCEMIC - DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
alogliptin T1
ANTIHYPERGLYCEMIC - MEGLITINIDE ANALOG AND BIGUANIDE COMBINATIONS
Friday Health plans of Colorado
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
repaglinide-metformin T1
ANTIHYPERGLYCEMIC - MEGLITINIDE ANALOGS
nateglinide T1
repaglinide T1
ANTIHYPERGLYCEMIC - SULFONYLUREA AND BIGUANIDE COMBINATIONS
glipizide-metformin T1
glyburide-metformin T1
ANTIHYPERGLYCEMIC - SULFONYLUREA DERIVATIVES
chlorpropamide T1
glimepiride T1
glipizide T1
glyburide T1
glyburide micronized T1
tolazamide T1
tolbutamide T1
ANTIHYPERGLYCEMIC - THIAZOLIDINEDIONE AND SULFONYLUREA COMBINATIONS
pioglitazone-glimepiride T1
ANTIHYPERGLYCEMIC-DIPEPTIDYL PEPTIDASE-4 INHIBIT AND THIAZOLIDINEDIONE
alogliptin-pioglitazone T1
ANTIHYPERGLYCEMIC-DIPEPTIDYL PEPTIDASE-4(DPP-4)INHIBITOR AND BIGUANIDE
alogliptin-metformin T1
ANTITHYROID AGENTS, THIONAMIDES - IMIDAZOLE DERIVATIVES
methimazole T1
ANTITHYROID AGENTS, THIONAMIDES - THIOURACIL DERIVATIVES
propylthiouracil T1
BONE RESORPTION INHIBITORS - BISPHOSPHONATES
alendronate T1
etidronate disodium T1
ibandronate T1
risedronate T1
CALCITONINS
calcitonin (salmon) T1
ESTROGEN-ANDROGEN
estrogens-methyltestosterone T1
ESTROGEN-PROGESTIN
estradiol-norethindrone acet T1
norethindrone ac-eth estradiol T1
AMABELZ T1
JINTELI T1
ESTROGENS
Friday Health plans of Colorado
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Page 40 of 54
Proprietary and Confidential
Drug Name Formulary Tier Restrictions
estradiol T1
estradiol valerate T1
estropipate T1
FERTILITY ENHANCER - OVULATION STIMULANT - SYNTHETIC (NON-FSH)
clomiphene citrate T1
GLUCOCORTICOID SALT COMBINATIONS
betamethasone acet,sod phos T1
GLUCOCORTICOIDS
cortisone T1
dexamethasone T1
dexamethasone in 0.9 % sod chl T1
dexamethasone sodium phos (pf) T1
dexamethasone sodium phosphate T1
hydrocortisone T1
methylprednisolone T1
methylprednisolone acetate T1
methylprednisolone sodium succ T1
prednisolone T1
prednisolone sodium phosphate T1
prednisone T1
DEXAMETHASONE INTENSOL T1
MILLIPRED DP T1
PREDNISONE INTENSOL T1
GONADOTROPIN INHIBITOR PITUITARY SUPPRESSANTS
danazol T1
INSULIN RESPONSE ENHANCERS - BIGUANIDES
metformin T1
INSULIN RESPONSE ENHANCERS - THIAZOLIDINEDIONES (PPAR-GAMMA AGONISTS)
pioglitazone T1
MENOPAUSAL SYMPTOMS SUPPRESSANT-SSRI ANTIDEPRESSANT TYPE
paroxetine mesylate T1
MINERALOCORTICOIDS
fludrocortisone T1
OXYTOCIC - ERGOT ALKALOIDS
methylergonovine T1
OXYTOCIC - OXYTOCIN AND ANALOGS
oxytocin T1
oxytocin in dextrose 5 % in lr T1
PROGESTINS
medroxyprogesterone T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
norethindrone acetate T1
progesterone T1
progesterone micronized T1
PROLACTIN INHIBITOR - ERGOT DERIVATIVE DOPAMINE RECEPTOR AGONISTS
cabergoline T1
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)
raloxifene T1
THYROID HORMONES - SYNTHETIC T3 (TRIIODOTHYRONINE)
liothyronine T1
THYROID HORMONES - SYNTHETIC T4 (THYROXINE)
levothyroxine T1
GASTROINTESTINAL THERAPY AGENTS
ANTACID - ALUMINUM
aluminum hydroxide gel T1
ANTIDIARRHEAL - ANTIPERISTALTIC AGENTS
opium tincture T1
paregoric T1
ANTIDIARRHEAL ANTIPERISTALTIC-ANTICHOLINERGIC COMBINATIONS
diphenoxylate-atropine T1
ANTIEMETIC - ANTICHOLINERGICS
scopolamine base T1
ANTIEMETIC - ANTIHISTAMINES
dimenhydrinate T1
meclizine T1
ANTIEMETIC - PHENOTHIAZINES
prochlorperazine T1
prochlorperazine maleate T1
promethazine T1
ANTIEMETIC - SELECTIVE SEROTONIN 5-HT3 ANTAGONISTS
granisetron (pf) T1
granisetron hcl T1
ondansetron T1
ondansetron hcl T1
ondansetron hcl (pf) T1
ondansetron in 0.9 % sod chlor T1
ANTIEMETIC - SUBSTANCE P-NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS
aprepitant T1
COLONIC ACIDIFIER (AMMONIA INHIBITOR)
lactulose T1
GALLSTONE SOLUBILIZING (LITHOLYSIS) AGENTS
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Drug Name Formulary Tier Restrictions
ursodiol T1
GASTRIC ACID SECRETION REDUCERS - HISTAMINE H2-RECEPTOR ANTAGONISTS
cimetidine T1
cimetidine hcl T1
famotidine T1
famotidine (pf) T1
famotidine (pf)-nacl (iso-os) T1
nizatidine T1
ranitidine hcl T1
GASTRIC ACID SECRETION REDUCING AGENTS - PROTON PUMP INHIBITORS (PPIS)
pantoprazole T1
rabeprazole T1
GASTRIC MUCOSA - CYTOPROTECTIVE PROSTAGLANDIN ANALOGS
misoprostol T1
GASTROINTESTINAL PROKINETIC AGENTS - D2 ANTAGONIST/5-HT4 AGONISTS
metoclopramide hcl T1
GI ANTISPASMODIC - BELLADONNA ALKALOIDS
atropine T1
atropine (bulk) T1
belladonna tincture (bulk) T1
hyoscyamine sulfate T1
scopolamine hbr T1
GI ANTISPASMODIC - QUATERNARY AMMONIUM COMPOUNDS
glycopyrrolate T1
propantheline T1
GI ANTISPASMODIC - SYNTHETIC TERTIARY AMINES
dicyclomine T1
GI ANTISPASMODIC AND BENZODIAZEPINE COMBINATIONS
chlordiazepoxide-clidinium T1
GI ANTISPASMODIC COMBINATIONS OTHER
belladonna alkaloids-opium T1
chlordiazepoxide-clidinium T1
BELLADONNA-OPIUM T1
INFLAMMATORY BOWEL AGENT - AMINOSALICYLATES AND RELATED AGENTS
balsalazide T1
mesalamine T1
sulfasalazine T1
INFLAMMATORY BOWEL AGENT - GLUCOCORTICOIDS
hydrocortisone T1
IRRITABLE BOWEL SYNDROME (IBS) AGENTS
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
alosetron T1 PA
LAXATIVE - SALINE AND OSMOTIC
lactulose T1
polyethylene glycol 3350 T1
sorbitol T1
LAXATIVE - SALINE/OSMOTIC MIXTURES
peg 3350-electrolytes T1
peg-electrolyte soln T1
PEPTIC ULCER - GASTRIC LUMEN ADHERENT CYTOPROTECTIVES
sucralfate T1
GENITOURINARY THERAPY
G.U. IRRIGANTS
acetic acid T1
glycine urologic solution T1
sorbitol T1
sorbitol-mannitol T1
G.U. IRRIGANTS - ANTI-INFECTIVE
neomycin-polymyxin b gu T1
PHOSPHATE BINDERS
calcium acetate T1
sevelamer carbonate T1
PROSTATIC HYPERTROPHY AGENT - ALPHA-1-ADRENOCEPTOR ANTAGONISTS
alfuzosin T1
tamsulosin T1
PROSTATIC HYPERTROPHY AGENT - TYPE II 5-ALPHA REDUCTASE INHIBITORS
finasteride T1
URINARY ACIDIFIER - OTHERS
ammonium chloride T1
URINARY ALKALINIZER - CITRATES
potassium citrate T1
sodium citrate-citric acid T1
CYTRA-3 T1
SHOHL'S MODIFIED T1
TRICITRATES T1
URINARY ANALGESICS
phenazopyridine T1
URINARY ANTIBACTERIAL - METHENAMINE AND SALTS
methenamine hippurate T1
methenamine mandelate T1
URINARY ANTIBACTERIAL - NITROFURAN DERIVATIVES
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MACRODANTIN T1
URINARY ANTIBACTERIAL - QUINOLONES
ciprofloxacin (mixture) T1
URINARY ANTI-INFECTIVE METHENAMINE-ANTISPAS-ANALG COMBINATIONS
HYOPHEN T1
PHOSPHASAL T1
UR N-C T1
URIN DS T1
URO-MP T1
USTELL T1
URINARY ANTI-INFECTIVE METHENAMINE-ANTISPASMODIC COMBINATIONS
URYL T1
URINARY ANTISPASMODIC - SMOOTH MUSCLE RELAXANTS
flavoxate T1
oxybutynin chloride T1
tolterodine T1
trospium T1
URINARY RETENTION THERAPY - PARASYMPATHOMIMETIC AGENTS
bethanechol chloride T1
GOUT AND HYPERURICEMIA THERAPY
GOUT ACUTE THERAPY - ANTIMITOTICS
colchicine T1
GOUT AND HYPERURICEMIA - ANTIMITOTIC-URICOSURIC COMBINATIONS
probenecid-colchicine T1
HYPERURICEMIA THERAPY - URICOSURICS
probenecid T1
HYPERURICEMIA THERAPY - XANTHINE OXIDASE INHIBITORS
allopurinol T1
HEMATOLOGICAL AGENTS
ANTICOAGULANTS - CITRATE-BASED
anticoag citrate phos dextrose T1
ANTICOAGULANTS - COUMARIN
warfarin T1
HEMOSTATIC SYSTEMIC - ANTIFIBRINOLYTIC AGENTS
aminocaproic acid T1
tranexamic acid T1
HEMOSTATIC TOPICAL AGENTS
AVITENE FLOUR T1
SYRINGE AVITENE T1
ULTRAFOAM T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
HEPARIN FLUSH FORMULATIONS
heparin (porcine) in 0.9% nacl T1
heparin (porcine) in nacl (pf) T1
heparin flush(porcine)-0.9nacl T1
heparin lock flush (porcine) T1
heparin, porcine (pf) T1
HEP FLUSH-10 (PF) T1
HEPARINS
heparin (porcine) T1
heparin (porcine) (bulk) T1
heparin (porcine) in 0.9% nacl T1
heparin (porcine) in 5 % dex T1
heparin (porcine) in nacl (pf) T1
heparin flush(porcine)-0.9nacl T1
heparin lock flush (porcine) T1
heparin(porcine) in 0.45% nacl T1
heparin, porcine (pf) T1
HEP FLUSH-10 (PF) T1
HUMAN ALBUMIN
albumin, human 25 % T1
albumin, human 5 % T1
INDIRECT FACTOR XA INHIBITORS
fondaparinux T1
LOW MOLECULAR WEIGHT HEPARINS
enoxaparin T1
FRAGMIN T1
PLASMA EXPANDERS
hetastarch 6 % in 0.9 % nacl T1
PLATELET AGGREGATION INHIBITOR COMBINATIONS
aspirin-dipyridamole T1
PLATELET AGGREGATION INHIBITORS - PHOSPHODIESTERASE III INHIBITORS
cilostazol T1
PLATELET AGGREGATION INHIBITORS - QUINAZOLINE AGENTS
anagrelide T1
PLATELET AGGREGATION INHIBITORS - THIENOPYRIDINE AGENTS
clopidogrel T1
prasugrel T1
ticlopidine T1
PLATELET AGGREGATION INHIB-PDESTERASE AND ADENOSINE DEAMINASE INHIBITR
dipyridamole T1
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Proprietary and Confidential
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THROMBIN INHIBITOR - SELECTIVE DIRECT AND REVERSIBLE
argatroban T1
argatroban in 0.9 % sod chlor T1
argatroban in nacl (iso-os) T1
THROMBIN INHIBITOR - SELECTIVE DIRECT AND REVERSIBLE - HIRUDIN TYPE
bivalirudin T1
IMMUNOSUPPRESSIVE AGENTS
IMMUNOSUPPRESSIVE - CALCINEURIN INHIBITORS
cyclosporine T1
cyclosporine (bulk) T1
cyclosporine modified T1
tacrolimus T1
IMMUNOSUPPRESSIVE - INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS
mycophenolate mofetil T1
IMMUNOSUPPRESSIVE - PURINE ANALOGS
azathioprine T1
LOCOMOTOR SYSTEM
ANTIMYASTHENIC AGENT - REVERSIBLE CHOLINESTERASE INHIBITORS
neostigmine methylsulfate T1
pyridostigmine bromide T1
ANTIMYASTHENIC AGENTS OTHER
guanidine T1
NEUROMUSCULAR BLOCKER - DEPOLARIZING AGENTS
succinylcholine chloride T1
NEUROMUSCULAR BLOCKER - NONDEPOLARIZING AGENTS
atracurium T1
cisatracurium T1
pancuronium T1
rocuronium T1
vecuronium bromide T1
SKELETAL MUSCLE RELAXANT - ANALGESIC SALICYLATE COMBINATIONS
carisoprodol-aspirin T1
SKELETAL MUSCLE RELAXANT - CENTRAL MUSCLE RELAXANTS
baclofen T1
chlorzoxazone T1
cyclobenzaprine T1
metaxalone T1
methocarbamol T1
orphenadrine citrate T1
tizanidine T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
SKELETAL MUSCLE RELAXANT - DIRECT MUSCLE RELAXANTS
dantrolene T1
REVONTO T1
SKELETAL MUSCLE RELAXANT - NARCOTIC ANALGESIC COMBINATIONS
carisoprodol-asa-codeine T1
SKELETAL MUSCLE RELAXANT, SALICYLATE, AND NARCOTIC ANALGESIC COMB.
carisoprodol-asa-codeine T1
MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (DME)
MEDICAL SUPPLIES AND DME - GLUCOSE MONITORING TEST SUPPLIES
blood glucose contrl hi,normal T1
lancets T1
lancing device T1
lancing device with lancets T1
MEDICAL SUPPLIES AND DME - INSULIN NEEDLES-SYRINGES AND ADMIN SUPPLIES
insulin syr/ndl u100 half mark T1
insulin syringe needleless T1
insulin syringe-needle u-100 T1
insulin syringes (disposable) T1
pen needle, diabetic T1
MEDICAL SUPPLIES AND DME - NEEDLES AND SYRINGES
huber safety needles (disp.) T1
needle (disp) 16 g T1
needle (disp) 18 g T1
needle (disp) 19 g T1
needle (disp) 23 gauge T1
needles, huber disposable T1
safety needles T1
syringe (disposable) T1
syringe (reusable) T1
syringe with needle T1
syringe with needle, safety T1
tuberculin-allergy syringes T1
MEDICAL SUPPLY, FDB SUPERSET
MEDICAL SUPPLY, FDB SUPERSET
blood glucose contrl hi,normal T1
huber safety needles (disp.) T1
insulin syr/ndl u100 half mark T1
insulin syringe needleless T1
insulin syringe-needle u-100 T1
insulin syringes (disposable) T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
lancets T1
lancing device T1
lancing device with lancets T1
needle (disp) 16 g T1
needle (disp) 18 g T1
needle (disp) 19 g T1
needle (disp) 23 gauge T1
needles, huber disposable T1
pen needle, diabetic T1
safety needles T1
syringe (disposable) T1
syringe (reusable) T1
syringe with needle T1
syringe with needle, safety T1
tuberculin-allergy syringes T1
METABOLIC MODIFIERS
HYPERPARATHYROID TREATMENT AGENTS - VITAMIN D ANALOG-TYPE
doxercalciferol T1
paricalcitol T1
METABOLIC MODIFIER - CARNITINE REPLENISHER AGENTS
levocarnitine T1
levocarnitine (with sugar) T1
METABOLIC MODIFIER - UREA CYCLE DISORDER AGENTS-CONJUGATING AGENTS
sodium benzoate-sod phenylacet T1
sodium phenylbutyrate T1
MOUTH-THROAT-DENTAL - PREPARATIONS
DENTAL PRODUCT - FLUORIDE PREPARATIONS
fluoride (sodium) T1
FLURA-DROPS T1
DENTAL PRODUCT - LOCAL ANESTHETICS
bupivacaine-epinephrine bitart T1
lidocaine-epinephrine bit T1
mepivacaine (pf) T1
MOUTH AND THROAT - ANTIFUNGALS
clotrimazole T1
nystatin T1
MOUTH AND THROAT - ANTISEPTICS
chlorhexidine gluconate T1
MOUTH AND THROAT - GLUCOCORTICOIDS
triamcinolone acetonide T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
MOUTH AND THROAT - LOCAL ANESTHETIC AMIDES
lidocaine hcl T1
MOUTH AND THROAT - SALIVA STIMULANTS
pilocarpine hcl T1
PERIODONTAL PRODUCT - TETRACYCLINE-TYPE, COLLAGENASE INHIBITORS
doxycycline hyclate T1
OPHTHALMIC AGENTS
MIOTICS - DIRECT ACTING
pilocarpine hcl T1
OPHTHALMIC - ANTIBACTERIAL-GLUCOCORTICOID COMBINATIONS
neomycin-bacitracin-poly-hc T1
neomycin-polymyxin b-dexameth T1
neomycin-polymyxin-hc T1
sulfacetamide-prednisolone T1
tobramycin-dexamethasone T1
OPHTHALMIC - ANTICHOLINERGICS
atropine T1
cyclopentolate T1
homatropine hbr T1
tropicamide T1
OPHTHALMIC - ANTIHISTAMINES
azelastine T1
epinastine T1
olopatadine T1
OPHTHALMIC - ANTI-INFLAMMATORY, GLUCOCORTICOIDS
dexamethasone sodium phosphate T1
fluorometholone T1
prednisolone acetate T1
prednisolone sodium phosphate T1
OPHTHALMIC - ANTI-INFLAMMATORY, NSAIDS
bromfenac T1
diclofenac sodium T1
flurbiprofen sodium T1
ketorolac T1
OPHTHALMIC - BETA BLOCKERS-CARBONIC ANHYDRASE INHIBITOR COMBINATIONS
dorzolamide-timolol T1
OPHTHALMIC - CARBONIC ANHYDRASE INHIBITORS
dorzolamide T1
OPHTHALMIC - DECONGESTANTS
phenylephrine hcl T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
OPHTHALMIC - DIAGNOSTIC AGENTS
fluorescein (bulk) T1
fluorescein-proparacaine T1
FLUORESCITE T1
FUL-GLO T1
OPHTHALMIC - INTRAOCULAR PRESSURE REDUCING AGENTS, BETA-BLOCKERS
betaxolol T1
carteolol T1
levobunolol T1
metipranolol T1
timolol maleate T1
OPHTHALMIC - LOCAL ANESTHETIC ESTERS
proparacaine T1
tetracaine hcl T1
tetracaine hcl (pf) T1
OPHTHALMIC - MAST CELL STABILIZERS
cromolyn T1
OPHTHALMIC - SURGICAL AIDS OTHER
OCUCOAT T1
OPHTHALMIC ANTIBACTERIAL MIXTURES
bacitracin-polymyxin b T1
neomycin-bacitracin-polymyxin T1
neomycin-polymyxin-gramicidin T1
polymyxin b sulf-trimethoprim T1
OPHTHALMIC ANTIBIOTIC - AMINOGLYCOSIDES
gentamicin T1
tobramycin T1
OPHTHALMIC ANTIBIOTIC - DEHYDROPEPTIDASE INHIBITORS
bacitracin T1
OPHTHALMIC ANTIBIOTIC - FLUOROQUINOLONES
ciprofloxacin hcl T1
levofloxacin T1
moxifloxacin T1
ofloxacin T1
OPHTHALMIC ANTIBIOTIC - MACROLIDES
erythromycin T1
OPHTHALMIC ANTIBIOTIC - SULFONAMIDES
sulfacetamide sodium T1
OPHTHALMIC ANTIVIRALS
trifluridine T1
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Proprietary and Confidential
Drug Name Formulary Tier Restrictions
OPHTHALMIC-INTRAOCULAR PRESS. REDUCING, SEL. ALPHA ADRENERGIC AGONISTS
apraclonidine T1
brimonidine T1
OPHTHALMIC-INTRAOCULAR PRESSURE REDUCING AGENTS, PROSTAGLANDIN ANALOGS
bimatoprost T1
latanoprost T1
ORGAN PRESERVATION SOLUTIONS
CARDIOPLEGIC SOLUTIONS
cardioplegic soln T1
OTIC
OTIC - ANTI-INFECTIVE-GLUCOCORTICOID COMBINATIONS
neomycin-polymyxin-hc T1
OTIC - ANTI-INFECTIVES OTHER
acetic acid T1
OTIC - FLUOROQUINOLONES
ciprofloxacin hcl T1
ofloxacin T1
OTIC - GLUCOCORTICOIDS
fluocinolone acetonide oil T1
hydrocortisone-acetic acid T1
RESPIRATORY THERAPY AGENTS
1ST GENERATION ANTIHISTAMINE-DECONGESTANT COMBINATIONS
CENTERGY T1
PROMETHAZINE VC T1
ANTIHISTAMINE - 1ST GENERATION - ETHANOLAMINES
carbinoxamine maleate T1
clemastine T1
diphenhydramine hcl T1
ANTIHISTAMINE - 1ST GENERATION - ETHYLENEDIAMINES
tripelennamine (bulk) T1
ANTIHISTAMINE - 1ST GENERATION - PHENOTHIAZINES
promethazine T1
ANTIHISTAMINE - 1ST GENERATION - PIPERIDINES
cyproheptadine T1
ANTIHISTAMINES - 1ST GENERATION
carbinoxamine maleate T1
clemastine T1
cyproheptadine T1
diphenhydramine hcl T1
promethazine T1
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ANTIHISTAMINES - 2ND GENERATION
desloratadine T1
levocetirizine T1
ANTIHISTAMINES - 2ND GENERATION - PIPERAZINES
levocetirizine T1
ANTIHISTAMINES - 2ND GENERATION - PIPERIDINES
desloratadine T1
ANTITUSSIVES - NONNARCOTIC
benzonatate T1
ASTHMA THERAPY - ALPHA/BETA ADRENERGIC AGENTS
epinephrine T1
ASTHMA THERAPY - LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast T1
zafirlukast T1
ASTHMA THERAPY - XANTHINES
aminophylline T1
aminophylline (bulk) T1
theophylline T1
theophylline in dextrose 5 % T1
ASTHMA/COPD THERAPY - BETA 2-ADRENERGIC AGENTS, INHALED, SHORT ACTING
albuterol sulfate T1
levalbuterol hcl T1
levalbuterol tartrate T1
ASTHMA/COPD THERAPY - BETA ADRENERGIC AGENTS
metaproterenol T1
terbutaline T1
ASTHMA/COPD THERAPY - BETA ADRENERGIC-ANTICHOLINERGIC COMBINATIONS
ipratropium-albuterol T1
ASTHMA/COPD THERAPY - BETA ADRENERGIC-GLUCOCORTICOID COMBINATIONS
fluticasone-salmeterol T1
MUCOLYTICS
acetylcysteine T1
acetylcysteine (bulk) T1
NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE COMBINATIONS
hydrocodone-chlorpheniramine T1
promethazine-codeine T1
NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS
hydrocodone-homatropine T1
NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATIONS
codeine-guaifenesin T1
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M-CLEAR WC T1
RELCOF C T1
NASAL ANTICHOLINERGICS
ipratropium bromide T1
NASAL ANTIHISTAMINES
azelastine T1
NON-NARC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT COMBINATIONS
CENTERGY DM T1
NON-NARCOTIC ANTITUSSIVE-ANTIHISTAMINE COMBINATIONS
promethazine-dm T1
PLEURAL SCLEROSING AGENTS
sterile talc T1
VAGINAL PRODUCTS
VAGINAL ANTIBACTERIAL - LINCOSAMIDES
clindamycin phosphate T1
VAGINAL ANTIFUNGAL - IMIDAZOLES
GYNAZOLE-1 T1
MICONAZOLE-3 T1
VAGINAL ANTIFUNGAL - TRIAZOLES
terconazole T1
VAGINAL ANTIPROTOZOAL-ANTIBACTERIAL - NITROIMIDAZOLE DERIVATIVES
metronidazole T1
VAGINAL ANTISEPTIC MIXTURES
RELAGARD T1
VAGINAL ESTROGENS
estradiol T1
54
Index
INDEX \e " " \c "3" \h "A" \z "1033"