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University Family Care
The Drug Formulary The drug formulary is a list of medications covered by University Family Care. It is intended for use by the plan, providers, and pharmacies. The formulary applies only to outpatient prescription medications. It does not apply to inpatient medications obtained from or administered by a physician. Brand name medications are listed on the formulary in all CAPS. Generic medications are listed on the formulary in lower case italics. Reference brand names listed next to generic medications in (parentheses) are examples only, and do not denote coverage. The University Family Care drug formulary and tier assignments are subject to change. Changes may not be reflected in the printed or on-line drug formulary. Prior Authorization Prior authorizations are required when designated as [PA]. Medications not listed in the drug formulary are not covered unless prior authorization has been obtained from University Physicians Health Plans. Please fax prior authorization requests to (866) 349-0338. Prior authorization forms are available on the web at The drug formulary has certain medications listed as step therapy [ST]. If a medication is listed as ST, members are required to try a formulary medication before requesting the step therapy medication. If these steps are not followed, the provider must request a prior authorization before the member is allowed to receive the prescribed medication. Prior authorization forms are available on the web Certain medications have quantity limitations to encourage appropriate utilization. Quantity limits are based on clinically approved prescribing guidelines to ensure safe and proper use of medications. Drugs that have established quantity limits are identified by the symbol [QL]. University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Covered by ALTCS Plans Only
Please note: University Family Care (or Maricopa Health Plan) is not an ALTCS
Plan

Risperdal M-Tab (ODT) Zyprexa Zydis (ODT) Injectable Steroids methylprednisolone Contact Information Prior Authorization Fax (866) 349-0338 UPHP Pharmacy Help Desk (800) 582-8686 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Analgesics

Analgesics, Miscellaneous
acetaminophen with codeine solution, (Acetaminophen with QL: 180 in 30 days tablet: 300mg-15mg, 300mg-30mg, 300mg-60mg acetaminophen with codeine solution, (Tylenol-Codeine QL: 180 in 30 days (PA tablet: 300mg-15mg, 300mg-30mg, required for > 2 Rx/ 300mg-60mg month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) acetaminophen acetaminophen/phenyltolx tablet: 500mg- 30mg, 500mg-50mg, 650mg-50mg butalb/acetaminophen/caffeine capsule: 50- (Fioricet) 325-40; solution, tablet butalbit/acetamin/caff/codeine capsule: 50- (Fioricet with Codeine) QL: 180 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) (Fiorinal with Codeine QL: 180 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) PA, QL: 10 in 30 days PA, QL: 10 in 30 days (PA required for > 1 Rx/month; applies to all long-acting narcotics combined) University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
hydrocodone/acetaminophen solution QL: 600 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) hydrocodone/acetaminophen solution QL: 600 in 30 days hydrocodone/acetaminophen tablet: 2.5- 325mg hydrocodone/acetaminophen tablet: 5mg- QL: 180 in 30 days (PA 325mg, 7.5-325mg, 10mg-325mg required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) hydrocodone/ibuprofen tablet: 10mg- 200mg hydrocodone/ibuprofen tablet: 2.5-200mg, QL: 180 in 30 days (PA 5mg-200mg, 7.5-200mg, 10mg-200mg required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) hydrocodone/ibuprofen tablet: 2.5-200mg, QL: 180 in 30 days 5mg-200mg, 7.5-200mg, 10mg-200mg hydromorphone hcl liquid, tablet QL: 180 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) hydromorphone hcl liquid, tablet QL: 180 in 30 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
ibuprofen/oxycodone hcl (Ibuprofen/Oxycodone QL: 180 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) meperidine hcl solution, tablet QL: 180 in 30 days meperidine hcl solution, tablet (Meperidine HCl) QL: 180 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) methadone hcl oral conc, solution, tablet, QL: 180 in 30 days (PA tablet sol required for > 1 Rx/month; applies to all long-acting narcotics combined) methadone hcl oral conc, solution, tablet, QL: 180 in 30 days tablet sol morphine sulfate cap er pel, cpmp 24hr: QL: 90 in 30 days 30mg, 60mg; tablet er morphine sulfate cap er pel, cpmp 24hr: (Morphine Sulfate ER) QL: 90 in 30 days (PA 30mg, 60mg; tablet er required for > 1 Rx/month; applies to all long-acting narcotics combined) morphine sulfate solution, supp.rect (Morphine Sulfate) QL: 180 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) morphine sulfate solution, supp.rect (Morphine Sulfate) QL: 180 in 30 days MORPHINE SULFATE QL: 180 in 30 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
oxycodone hcl tab er 12h PA, QL: 90 in 30 days (PA required for > 1 Rx/month; applies to all long-acting narcotics combined) oxycodone hcl tab er 12h PA, QL: 90 in 30 days oxycodone hcl solution QL: 500 in 30 days oxycodone hcl capsule, oral conc, tablet QL: 180 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) oxycodone hcl capsule, oral conc, tablet QL: 180 in 30 days oxycodone hcl/acetaminophen solution, QL: 180 in 30 days (PA tablet: 2.5-325mg, 5mg-325mg, 7.5- required for > 2 Rx/ 325mg, 10mg-325mg month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) oxycodone hcl/acetaminophen solution, QL: 180 in 30 days tablet: 2.5-325mg, 5mg-325mg, 7.5- 325mg, 10mg-325mg oxycodone hcl/aspirin QL: 180 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) oxycodone hcl/oxycodon ter/asa QL: 180 in 30 days (PA Oxycodon Ter/Asa) required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) tramadol hcl tablet QL: 240 in 30 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
CAPITAL W-CODEINE QL: 600 in 30 days (PA required for > 2 Rx/month for a short-acting narcotic. QL of 180/month applies to all short-acting narcotics combined) PA, QL: 90 in 30 days Nonsteroidal Anti-Inflammatory Agents
aspirin/calcium carbonate/mag tablet: (Aspirin/Calcium 325mg, 500mg celecoxib choline sal/mag salicylate (Choline Sal/Mag COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN diclofenac potassium diclofenac sodium tab er 24h, tablet dr (Diclofenac Sodium) diflunisal fenoprofen calcium (Fenoprofen Calcium) flurbiprofen ibuprofen indomethacin ketoprofen ketorolac tromethamine tablet QL: 20 in 5 days meclofenamate sodium meloxicam nabumetone naproxen sodium capsule, tablet oxaprozin piroxicam salsalate University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Anesthetics

Local Anesthetics
lidocaine hcl jel (ml), jel/pf app: 2%; solution: 2%, 40mg/ml lidocaine oint. (g) lidocaine adh. patch Anti-Addiction/Substance Abuse Treatment Agents

Anti-Addiction/Substance Abuse Treatment Agents
bupropion hcl nicotine polacrilex Age must be >= 17 nicotine polacrilex Age must be >= 17 (PA required for patients under age 18. QL of 12 weeks/180 days of all smoking cessation products combined) NICOTINE POLACRILEX Age must be >= 17 (PA required for patients under age 18. QL of 12 weeks/180 days of all smoking cessation products combined) nicotine patch td24: 7mg/24hr, 11mg/24hr, (Nicoderm Cq) Age must be >= 17 (PA 14mg/24hr, 22mg/24hr required for patients under age 18. QL of 12 weeks/180 days of all smoking cessation products combined) nicotine patch td24: 7mg/24hr, 11mg/24hr, (Nicoderm Cq) Age must be >= 17 14mg/24hr, 22mg/24hr CHANTIX Age must be >= 17 (PA required for patients under age 18. QL of 12 weeks/180 days of all smoking cessation products combined) University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Age must be >= 17 (PA required for patients under age 18. QL of 12 weeks/180 days of all smoking cessation products combined) Antianxiety Agents

alprazolam tablet QL: 120 in 30 days (PA required for >1 Rx/month for all anxiolytic products combined. QL of 120/month for all anxiolytic products combined) alprazolam tablet QL: 120 in 30 days chlordiazepoxide hcl (Chlordiazepoxide QL: 120 in 30 days (PA required for >1 Rx/month for all anxiolytic products combined. QL of 120/month for all anxiolytic products combined) clonazepam QL: 120 in 30 days (PA required for >1 Rx/month for all anxiolytic products combined. QL of 120/month for all anxiolytic products combined) clorazepate dipotassium (Tranxene T-Tab) QL: 120 in 30 days (PA required for >1 Rx/month for all anxiolytic products combined. QL of 120/month for all anxiolytic products combined) diazepam kit (Diastat Acudial) QL: 2 in 365 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
diazepam oral conc, solution, tablet QL: 120 in 30 days (PA required for >1 Rx/month for all anxiolytic products combined. QL of 120/month for all anxiolytic products combined) estazolam QL: 30 in 30 days (PA required for >1 Rx/month for all hypnotic products combined. QL of 30/month for all hypnotic products combined, except Rozerem) flurazepam hcl (Flurazepam HCl) QL: 30 in 30 days (PA required for >1 Rx/month for all hypnotic products combined. QL of 30/month for all hypnotic products combined, except Rozerem) lorazepam tablet QL: 120 in 30 days (PA required for >1 Rx/month for all anxiolytic products combined. QL of 120/month for all anxiolytic products combined) lorazepam tablet QL: 120 in 30 days QL: 120 in 30 days (PA required for >1 Rx/month for all anxiolytic products combined. QL of 120/month for all anxiolytic products combined) University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
temazepam QL: 30 in 30 days (PA required for >1 Rx/month for all hypnotic products combined. QL of 30/month for all hypnotic products combined, except Rozerem) Antibacterials

neomycin sulfate (Neomycin Sulfate) tobramycin in 0.225% nacl Antibacterials, Miscellaneous
clindamycin hcl clindamycin palmitate hcl (Cleocin Palmitate) nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitrofurantoin vancomycin hcl capsule ZYVOX susp recon, tablet cefaclor capsule, susp recon cefadroxil cefpodoxime proxetil (Cefpodoxime Proxetil) cefprozil cefuroxime axetil CEFUROXIME AXETIL cephalexin SUPRAX tab chew, tablet QL: 1 in 30 days Macrolides
azithromycin packet, susp recon, tablet clarithromycin ery e-succ/sulfisoxazole erythromycin base (Erythromycin Base) erythromycin ethylsuccinate susp recon: 200mg/5ml; tablet erythromycin stearate University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Penicillins
amoxicillin capsule, susp recon, tab chew, tablet amoxicillin/potassium clav ampicillin trihydrate (Ampicillin Trihydrate) dicloxacillin sodium (Dicloxacillin Sodium) penicillin v potassium Quinolones
ciprofloxacin hcl ciprofloxacin ciprofloxacin/ciprofloxa hcl tbmp 24hr: levofloxacin solution, tablet ofloxacin sulfadiazine sulfamethoxazole/trimethoprim oral susp, tablet sulfasalazine QL: 240 in 30 days demeclocycline hcl (Demeclocycline HCl) doxycycline hyclate capsule, capsule dr, tablet, tablet dr doxycycline monohydrate capsule, susp recon, tablet minocycline hcl capsule, tab er 24h: 45mg, (Minocin) 135mg; tablet tetracycline hcl capsule (Tetracycline HCl) Anticancer Agents

Anticancer Agents
anastrozole exemestane flutamide hydroxyurea letrozole mercaptopurine methotrexate sodium tablet (Methotrexate Sodium) tamoxifen citrate (Tamoxifen Citrate) LUPRON DEPOT-PED University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Anticholinergic Agents

propantheline bromide Anticonvulsants

carbamazepine DILANTIN capsule DILANTIN tab chew divalproex sodium ethosuximide felbamate gabapentin lamotrigine tablet, tb chw dsp levetiracetam solution, tablet oxcarbazepine phenobarbital phenytoin sodium extended phenytoin primidone topiramate cap sprink, tablet valproic acid (as sodium salt) solution valproic acid zonisamide DEPAKOTE SPRINKLE GABITRIL tablet: 12mg, 16mg LAMICTAL tablet, tb chw dsp: 5mg, VIMPAT solution, tablet Antidementia Agents

Antidementia Agents
donepezil hcl tablet University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
galantamine hbr solution, tablet rivastigmine tartrate EXELON patch td24 Antidepressants

amitriptyline hcl (Amitriptyline HCl) bupropion hcl tablet er: 150mg Age must be >= 17 bupropion hcl tab er 24h, tablet, tablet er: 100mg, 150mg, 200mg citalopram hydrobromide desipramine hcl doxepin hcl duloxetine hcl QL: 30 in 30 days escitalopram oxalate fluoxetine hcl capsule, solution, tablet fluvoxamine maleate tablet (Fluvoxamine Maleate) imipramine hcl imipramine pamoate maprotiline hcl (Maprotiline HCl) mirtazapine tablet nortriptyline hcl paroxetine hcl oral susp, tablet protriptyline hcl (Protriptyline HCl) sertraline hcl trazodone hcl venlafaxine hcl cap er 24h, tablet Antidiabetic Agents

Antidiabetic Agents, Miscellaneous
metformin hcl nateglinide pioglitazone hcl pioglitazone hcl/metformin hcl repaglinide University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Insulins
NOVOLIN 70-30 vial HUMALOG MIX 50-50 vial HUMALOG MIX 50-50 insuln pen HUMALOG MIX 75-25 vial HUMALOG MIX 75-25 insuln pen HUMALOG insuln pen HUMULIN 70/30 KWIKPEN HUMULIN N KWIKPEN LEVEMIR FLEXTOUCH NOVOLIN 70-30 cartridge NOVOLIN N cartridge NOVOLIN R cartridge NOVOLOG MIX 70-30 FLEXPEN NOVOLOG MIX 70-30 glimepiride glipizide glipizide/metformin hcl (Glipizide/Metformin glyburide glyburide/metformin hcl Antifungals

Antifungals
clotrimazole cream (g), cream/appl, solution: 1%; tablet, troche clotrimazole/betamethasone dip University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
fluconazole susp recon, tablet: 50mg, 100mg, 200mg fluconazole tablet: 150mg QL: 10 in 30 days flucytosine griseofulvin, microsize Age must be <= 12 itraconazole ketoconazole LOTRIMIN AF cream (g) miconazole nitrate aero powd, cmb pf crm, (Miconazole Nitrate) cream (g), cream/appl, kit, oint. (g), spray, supp.vag: 100mg; tincture miconazole/skin cleanser no.17 (Miconazole/Skin (Nystatin/Triamcin) terbinafine hcl cream (g) terbinafine hcl tablet QL: 90 in 365 days tioconazole voriconazole susp recon, tablet Age must be <= 12 SPORANOX solution Antihistamines

brompheniramine maleate drops: 1mg/ml; (Brompheniramine cetirizine hcl solution, tab chew, tablet (Cetirizine HCl) cetirizine hcl/pseudoephedrine CHILDREN'S ZYRTEC ALLERGY CHILDREN'S ZYRTEC chlorpheniramine maleate capsule sa: 8mg; (Chlor-Trimeton) drops, syrup, tablet, tablet er, tablet sa: 8mg chlorpheniramine tannate (Myci Chlor-Tan) clemastine fumarate (Clemastine Fumarate) cyproheptadine hcl (Cyproheptadine HCl) dexchlorpheniramine maleate (Dexchlorpheniramine University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
diphenhydramine hcl capsule, elixir, liquid, (Benadryl) tab rapdis, tablet fexofenadine hcl (Allegra-D 24 Hour) loratadine (Claritin-D 24 Hour) QL: 30 in 30 days phenylephrine hcl/prometh hcl (Phenylephrine HCl/ QL: 480 in 30 days promethazine hcl (Promethazine HCl) pseudoephedrine/brompheniramin drops, liquid, tablet
Anti-infectives (Skin and Mucous Membrane)

Anti-infectives (Skin and Mucous Membrane)
clindamycin phosphate metronidazole (Metrogel-Vaginal) Antimigraine Agents

Antimigraine Agents
ergotamine tartrate/caffeine (Ergotamine Tartrate/ QL: 12 in 30 days naratriptan hcl QL: 9 in 30 days rizatriptan benzoate QL: 9 in 30 days sumatriptan succinate cartridge, syringe, QL: 2 in 30 days vial sumatriptan succinate tablet QL: 9 in 30 days sumatriptan QL: 6 in 30 days Antimycobacterials

ethambutol hcl isoniazid pyrazinamide rifampin capsule Antinausea Agents

Antinausea Agents
granisetron hcl solution, tablet (Granisetron HCl) meclizine hcl University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
ondansetron hcl tablet: 4mg, 8mg QL: 30 in 30 days ondansetron hcl solution QL: 50 in 30 days ondansetron QL: 30 in 30 days prochlorperazine maleate (Prochlorperazine promethazine hcl supp.rect, tablet, vial: (Promethazine HCl) 25mg/ml ANZEMET tablet EMEND cap ds pk, capsule QL: 6 in 30 days Antiparasite Agents

Antiparasite Agents
atovaquone/proguanil hcl chloroquine phosphate hydroxychloroquine sulfate ivermectin mebendazole mefloquine hcl (Mefloquine HCl) metronidazole quinine sulfate Antiparkinsonian Agents

Antiparkinsonian Agents
amantadine hcl (Amantadine HCl) benztropine mesylate tablet (Benztropine Mesylate) bromocriptine mesylate (Sinemet 25-100) entacapone pramipexole di-hcl tablet ropinirole hcl tablet selegiline hcl trihexyphenidyl hcl (Trihexyphenidyl HCl) Antipsychotic Agents

Antipsychotic Agents
risperidone solution University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Antivirals (Systemic)

abacavir sulfate didanosine lamivudine nevirapine stavudine zidovudine APTIVUS solution VIRAMUNE XR tab er 24h: 100mg University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Antivirals, Miscellaneous
foscarnet sodium rimantadine hcl (Rimantadine HCl) QL: 40 in 30 days TAMIFLU capsule: 45mg, 75mg QL: 10 in 5 days TAMIFLU susp recon: 6mg/ml QL: 120 in 5 days TAMIFLU capsule: 30mg QL: 20 in 5 days TAMIFLU susp recon: 12mg/ml QL: 50 in 5 days Hcv Antivirals
Interferons
PEGASYS PROCLICK PEGINTRON REDIPEN Nucleosides and Nucleotides
acyclovir adefovir dipivoxil entecavir famciclovir ganciclovir sodium ganciclovir ribavirin capsule, tab ds pk: 200-400(7), 400-400mg, 600-400mg; tablet valacyclovir hcl valganciclovir hcl BARACLUDE solution cidofovir VALCYTE soln recon Blood Products/Modifiers/Volume Expanders

enoxaparin sodium (Less than or equal to a 10 day supply) heparin sod,porcine-0.9 % nacl (Heparin Sod,Porcine- University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
heparin sodium,porcine heparin sodium,porcine/pf syringe: 1unit/ (Monoject Prefill ml, 10unit/ml, 100/ml(1), 200/2ml, 5000/ 0.5ml; vial warfarin sodium XARELTO tab ds pk, tablet: 15mg, 20mg XARELTO tablet: 10mg QL: 35 in 365 days Blood Formation Modifiers
Hematologic Agents, Miscellaneous
aminocaproic acid solution, tablet anagrelide hcl Platelet-Aggregation Inhibitors
cilostazol clopidogrel bisulfate dipyridamole Caloric Agents

Caloric Agents
Cardiovascular Agents

Alpha-Adrenergic Agents
clonidine hcl clonidine (Catapres-Tts 3) doxazosin mesylate guanfacine hcl methyldopa prazosin hcl Angiotensin II Receptor Antagonists
irbesartan losartan potassium University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
valsartan Angiotensin-Converting Enzyme Inhibitors
benazepril hcl captopril (tablet and powder) Hydrochlorothiazide) enalapril maleate fosinopril sodium (Fosinopril Sodium) Hydrochlorothiazide) lisinopril moexipril hcl perindopril erbumine quinapril hcl trandolapril Antiarrhythmic Agents
amiodarone hcl tablet disopyramide phosphate flecainide acetate mexiletine hcl (Mexiletine HCl) procainamide hcl capsule, tablet sa (Procainamide HCl) propafenone hcl tablet quinidine gluconate tablet er (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) Beta-Adrenergic Blocking Agents
bisoprolol fumarate University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
bisoprolol fumarate/hctz carvedilol labetalol hcl tablet metoprolol succinate metoprolol tartrate tablet propranolol hcl cap sa 24h, solution, tablet (Propranolol HCl) sotalol hcl Calcium-Channel Blocking Agents
diltiazem hcl cap er 24h, cap er deg, QL: 30 in 30 days capsule er, tab er 24h: 180mg, 240mg, 300mg, 360mg, 420mg diltiazem hcl tab er 24h: 180mg, 240mg, 300mg, 360mg, 420mg; tablet diltiazem hcl cap er 12h QL: 60 in 30 days verapamil hcl tablet verapamil hcl cap24h pct, cap24h pel, QL: 30 in 30 days tablet er Cardiovascular Agents, Miscellaneous
digoxin tablet epinephrine auto injct: 0.3mg/0.3 epinephrine auto injct: 0.15/0.15; syringe QL: 2 in 365 days hydralazine hcl tablet (Hydralazine HCl) QL: 2 in 365 days QL: 2 in 365 days QL: 2 in 365 days amlodipine besylate QL: 30 in 30 days amlodipine besylate/benazepril felodipine isradipine nicardipine hcl capsule (Nicardipine HCl) nifedipine tab er 24, tablet er QL: 30 in 30 days nifedipine capsule nimodipine nisoldipine Diuretics
bumetanide tablet University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
chlorothiazide (Chlorothiazide) chlorthalidone (Chlorthalidone) furosemide solution, tablet indapamide metolazone torsemide tablet atorvastatin calcium QL: 30 in 30 days cholestyramine (with sugar) (Questran Light) colestipol hcl fenofibrate nanocrystallized tablet: 48mg fenofibrate gemfibrozil lovastatin QL: 30 in 30 days niacin (inositol niacinate) capsule: (No Flush Niacin) 400(500mg); tablet niacin pravastatin sodium QL: 30 in 30 days simvastatin QL: 30 in 30 days Renin-Angiotensin-Aldosterone System Inhibitors
spironolactone (tablet and powder) eplerenone tablet: 25mg isosorbide dinitrate (Isordil Titradose) isosorbide mononitrate minoxidil nitroglycerin capsule er, patch td24, spray Central Nervous System Agents

Central Nervous System Agents
dextroamphetamine sulfate capsule er, (Dextroamphetamine QL: 60 in 30 days tablet: 5mg, 10mg dextroamphetamine/amphetamine cap er QL: 30 in 30 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
QL: 60 in 30 days methylphenidate hcl cpbp 30-70: 10mg, QL: 30 in 30 days 50mg, 60mg; tab er 24, tablet er methylphenidate hcl solution QL: 300 in 30 days methylphenidate hcl cpbp 30-70: 20mg, QL: 60 in 30 days 40mg; cpbp 50-50, tab chew, tablet RITALIN LA cpbp 50-50: 10mg PA, QL: 30 in 30 days PA, QL: 60 in 30 days Contraceptives

desogestrel-ethinyl estradiol DUREX AVANTI BARE ethynodiol d-ethinyl estradiol (Ethynodiol D-Ethinyl FC CONDOM, FEMALE FC2 FEMALE CONDOM KIMONO MICROTHIN AQUA LUBE KIMONO MICROTHIN each: n/a KIMONO MICROTHIN each: n/a levonorgestrel (Plan B One-Step) levonorgestrel-ethin estradiol tablet: 0.1- 0.02, 0.15-0.03, 6-5-10 nonoxynol 9 noreth-ethinyl estradiol/iron norethindrone ac-eth estradiol norethindrone (Ortho Micronor) (Loestrin 24 Fe) 30(21), 1mg-20(21), 1mg-20(24), 5-7-9-7 norethindrone-ethinyl estrad tablet: 0.4- 0.035, 0.5-0.035, 1mg-35mcg, 7-9-5, 7daysx3, 10-11 norethindrone-mestranol University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
norgestimate-ethinyl estradiol (Ortho Tri-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl ORTHO ALL-FLEX each ORTHO ALL-FLEX kit TRUSTEX LATEX CONDOM TRUSTEX-RIA each: n/a TRUSTEX-RIA each: n/a WIDE SEAL DIAPHRAGM Cough And Cold Products

Cough And Cold Products
benzonatate brompheniram/phenylephrine/dm liquid: 4- (Ala-Hist Dm) QL: 480 in 30 days 7.5-15/5 brompheniram/phenylephrine/dm liquid: 4- (Dimetapp) 10-20/5; solution bromphenrm/pseudoeph/dihydrocd Pseudoeph/Dihydrocd) QL: 60 in 30 days dextromethorphan polistirex dm/phenyleph/chlorpheniramine drops: 3- Age must be >= 5, QL: 2-1mg/ml, 3-3.5-1/ml; liquid: 15-10-4/5; syrup: 15-10-2/5, 15-12.5-4 dm/phenyleph/chlorpheniramine drops: 3- 2-1mg/ml, 3-3.5-1/ml; liquid: 10-5-2mg/5, 15-5-2mg/5; syrup: 15-10-2/5; tablet d-methorphan hb/p-epd hcl/bpm elixir: 5- (D-Methorphan Hb/P- 15-1mg/5; liquid: 15-30-3/5, 20-30-1/5, 30- Epd HCl/Bpm) 50-3mg d-methorphan hb/p-epd hcl/bpm elixir: 5- (D-Methorphan Hb/P- QL: 480 in 30 days 15-1mg/5; liquid: 15-30-3/5, 20-20-4/5, 30- Epd HCl/Bpm) 50-3mg; syrup, tablet d-methorphan hb/p-ephed hcl/cp liquid, (Child Triaminic-D Mt- syrup, tablet d-methorphan hb/p-ephed hcl/cp drops (D-Methorphan Hb/P- QL: 480 in 30 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
d-methorphan hb/prometh hcl (D-Methorphan Hb/ QL: 480 in 30 days guaifenesin (Robitussin Mucus- guaifenesin/codeine phosphate capsule (Guaifenesin/Codeine QL: 360 in 30 days guaifenesin/codeine phosphate liquid: 200- (M-Clear Wc) 8mg/5 guaifenesin/codeine phosphate liquid: 100- (M-Clear Wc) QL: 480 in 30 days 10mg/5, 100-6.3/5, 200-10mg/5, 200-8mg/5, 225-7.5/5, 300-10mg/5 guaifenesin/dextromethorphan various dosage and/or strengths are available Dextromethorphan) guaifenesin/dextromethorphan various QL: 480 in 30 days dosage and/or strengths are available guaifenesin/dm/pseudoephedrine capsule, QL: 120 in 30 days tablet: 400-15-45, 400-20-40, 400-20-60 Pseudoephedrine) guaifenesin/dm/pseudoephedrine liquid: (Tusnel Pediatric) 175-15-30; tablet: 200-10-30 guaifenesin/dm/pseudoephedrine liquid: (Tusnel Pediatric) QL: 480 in 30 days 50-5-15/5, 67-10, 150-15-30; oral susp, solution, syrup guaifenesin/d-methorphan hb/pe guaifenesin/ephedrine hcl (Guaifenesin/Ephedrine guaifenesin/phenylephrine hcl Phenylephrine HCl) guaifenesin/pseudoephedrne hcl hydrocodone bit/homatrop me-br (Hydrocodone Bit/ QL: 480 in 30 days promethazine hcl/codeine (Promethazine HCl/ QL: 480 in 30 days QL: 480 in 30 days Phenyleph/Codeine) pseudoephedrine hcl liquid: 15mg/5ml (Pseudoephedrine HCl) QL: 180 in 30 days pseudoephedrine hcl liquid: 30mg/5ml (Pseudoephedrine HCl) QL: 720 in 30 days pseudoephedrine hcl drops (Pseudoephedrine HCl) QL: 90 in 30 days pseudoephedrine hcl tab er 24h, tablet: (Sudafed 12 Hour) 30mg; tablet er pseudoephedrine hcl tablet: 60mg (Sudafed 12 Hour) QL: 120 in 30 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
pseudoephedrine hcl tablet: 30mg (Sudafed 12 Hour) QL: 240 in 30 days QL: 240 in 30 days TUSNEL PEDIATRIC liquid: 50-5-15/5 QL: 480 in 30 days QL: 480 in 30 days PANATUSS DXP PEDIATRIC QL: 480 in 30 days Dental And Oral Agents

Dental And Oral Agents
chlorhexidine gluconate sodium fluoride solution triamcinolone acetonide Dermatological Agents

Dermatological Agents, Other
alcohol antiseptic pads (Alcohol Antiseptic aluminum chloride benzoyl peroxide and skin cleansr5 (Benzoyl Peroxide and benzoyl peroxide microspheres (Benzoyl Peroxide benzoyl peroxide bar, cleanser, cream (g), (Benzoyl Peroxide) foam, gel (gram), kit: 8%-5%; lotion, med. pad, towelette benzoyl peroxide/aloe vera (Benzoyl Peroxide/ BP WASH cleanser: 2.5% DESQUAM-X cleanser: 5% diphenhydramine hcl diphenhydramine hcl/zinc acet isotretinoin lidocaine salicylic acid salicylic acid/ceramide cmb #1 selenium sulfide (Selenium Sulfide) sulfacetamide sod/sulfur/urea University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
sulfacetamide sodium/sulfur cleanser, cream (g): 9.8%-4.8%, 10%-2%; foam, lotion, med. pad, suspension urea cream (g): 10%, 20%; lotion: 10%, 25% DENAVIR Dermatological Antibacterials
bacitracin zinc (Bacitracin Zinc) bacitracin bacitracin/polymyxin b sulfate (Bacitracin/Polymyxin clindamycin phosphate gel (gram), lotion, med. swab, solution erythromycin base/ethanol gel (gram), solution erythromycin/benzoyl peroxide gentamicin sulfate (Gentamicin Sulfate) metronidazole mupirocin calcium mupirocin neomy sulf/bacitrac zn/poly neomy sulf/polymyx b sulf/pram (Neosporin + Pain neomycn/baci zn/pmyx bs/pramox (Neomycn/Baci Zn/ selenium sulfide (Selenium Sulfide) selenium sulfide/menthol (Selenium Sulfide/ silver sulfadiazine Dermatological Anti-Inflammatory Agents
alclometasone dipropionate betamethasone dipropionate betamethasone valerate cream (g), lotion, oint. (g) betamethasone/propylene glyc clobetasol propionate cream (g), foam, gel (Temovate) (gram), lotion, oint. (g), shampoo, solution desonide diflorasone diacetate (Diflorasone Diacetate) University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
fluocinolone acetonide fluocinolone/shower cap (Derma-Smoothe-Fs) fluocinonide fluticasone propionate hydrocortisone acetate hydrocortisone acetate/aloe v hydrocortisone valerate hydrocortisone cream (g), cream(gm), cream/appl, enema, gel (gram), lotion: 0.5%, 1%; oint. (g), solution, spray hydrocortisone/pramoxine mometasone furoate triamcinolone acetonide CORDRAN med. tape PRAMOSONE oint. (g): 2.5%-1% Dermatological Retinoids
tretinoin Age must be <= 26 tretinoin/emollient base (Tretinoin/Emollient Age must be <= 26 Scabicides and Pediculicides
permethrin pip butox/pyrethrins/permeth (Pip Butox/Pyrethrins/ piperonyl butoxide/pyrethrins (Piperonyl Butoxide/ ACE AEROSOL CLOUD ENHANCER QL: 2 in 365 days AEROCHAMBER MINI QL: 2 in 365 days QL: 2 in 365 days AEROCHAMBER PLUS FLOW-VU QL: 2 in 365 days AEROCHAMBER PLUS Z STAT QL: 2 in 365 days AEROCHAMBER WITH FLOWSIGNAL QL: 2 in 365 days AEROCHAMBER Z-STAT PLUS QL: 2 in 365 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
QL: 2 in 365 days QL: 2 in 365 days QL: 2 in 365 days COMPACT SPACE CHAMBER PLUS QL: 2 in 365 days QL: 2 in 365 days ECLIPSE LUER-LOK SYRINGE QL: 2 in 365 days FREESTYLE CONTROL SOLUTION each: n/a FREESTYLE CONTROL SOLUTION each: n/a FREESTYLE FREEDOM LITE FREESTYLE FREEDOM FREESTYLE INSULINX TEST STRIPS FREESTYLE INSULINX each FREESTYLE INSULINX strip FREESTYLE LANCETS FREESTYLE LITE METER FREESTYLE LITE STRIPS FREESTYLE LITE TEST STRIPS FREESTYLE TEST STRIPS FREESTYLE UNISTIK 2 QL: 2 in 365 days QL: 2 in 365 days QL: 2 in 365 days QL: 2 in 365 days QL: 2 in 365 days needles, insulin disp., safety (Needles, Insulin Disp., needles, insulin disposable (Needles, Insulin QL: 2 in 365 days QL: 2 in 365 days QL: 2 in 365 days QL: 2 in 365 days PRECISION GLUCOSE CONTROL PRECISION XTRA each PRECISION XTRA strip: n/a University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
PRECISION XTRA strip: n/a PRECISION combo. pkg QL: 2 in 365 days QL: 2 in 365 days QL: 2 in 365 days SPACE CHAMBER PLUS QL: 2 in 365 days syring w-ndl,disp,insul,0.3 ml Ndl,Disp,Insul,0.3 Ml) syring w-ndl,disp,insul,0.5 ml Ndl,Disp,Insul,0.5 Ml) syringe and needle,insulin,1 ml Needle,Insulin,1 Ml) QL: 2 in 365 days QL: 2 in 365 days Enzyme Replacement/Modifiers

Enzyme Replacement/Modifiers
QL: 500 in 30 days QL: 500 in 30 days QL: 500 in 30 days QL: 500 in 30 days QL: 500 in 30 days QL: 500 in 30 days QL: 500 in 30 days ZENPEP capsule dr: 3k-10k-16k, 10-34- QL: 500 in 30 days 55k, 15-51-82k, 20-68-109k, 25-85-136k,
40k-136k
Eye, Ear, Nose, Throat Agents

Eye, Ear, Nose, Throat Agents, Miscellaneous
atropine sulfate (Isopto Atropine) azelastine hcl carteolol hcl cromolyn sodium (Cromolyn Sodium) cyclopentolate hcl homatropine hbr (Isopto Homatropine) ipratropium bromide ketotifen fumarate University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
naphazoline hcl/glycerin (Clear Eyes Redness naphazoline hcl/hypromellose (Advanced Eye Relief naphazoline hcl/peg 300 (Naphazoline HCl/Peg naphazoline hcl/pheniramine polyvinyl alcohol (Polyvinyl Alcohol) polyvinyl alcohol/povidone (Polyvinyl Alcohol/ Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid acetic acid/hydrocortisone bacitracin bacitracin/polymyxin b sulfate (Bacitracin/Polymyxin carbamide peroxide carbamide peroxide/sea water (Carbamide Peroxide/ ciprofloxacin hcl erythromycin base oint. (g): 5mg/g (Erythromycin Base) gentamicin sulfate neo/polymyx b sulf/dexameth neomy sulf/bacitra/polymyxin b oint. (g): (Triple Antibiotic) 3.5mg-400 neomy sulf/bacitrac zn/poly/hc (Neomy Sulf/Bacitrac neomycin/polymyxin b sulf/hc neomycin/polymyxn b/gramicidin ofloxacin polymyxin b sulf/trimethoprim sulfacetamide sodium sulfacetamide/prednisolone sp Prednisolone Sp) tobramycin trifluridine University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
BLEPHAMIDE S.O.P. TOBRADEX oint. (g) Eye, Ear, Nose, Throat Anti-Inflammatory Agents
dexamethasone sod phosphate diclofenac sodium (Diclofenac Sodium) flunisolide fluorometholone flurbiprofen sodium fluticasone propionate ketorolac tromethamine prednisolone acetate prednisolone sod phosphate triamcinolone acetonide Gastrointestinal Agents

simethicone (Infants' Mylicon) SIMETHICONE liquid: n/a Antiulcer Agents And Acid Suppressants
famotidine oral susp, tablet lansoprazole omeprazole magnesium omeprazole pantoprazole sodium tablet dr ranitidine hcl capsule, syrup, tablet sucralfate tablet FIRST-LANSOPRAZOLE Age must be <= 12 FIRST-OMEPRAZOLE Gastrointestinal Agents, Other
calcium carbonate cromolyn sodium dicyclomine hcl University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
diphenoxylate hcl/atropine hyoscyamine sulfate QL: 120 in 30 days lactulose loperamide hcl (Loperamide HCl) magnesium oxide MAGNESIUM OXIDE tablet: 250mg metoclopramide hcl solution, tablet glycopyrrolate tablet Laxatives
bisacodyl docusate calcium docusate sodium (Docusate Sodium) magnesium citrate (Magnesium Citrate) magnesium hydroxide (Phillips' Milk Of peg 3350/na sulf,bicarb,cl/kcl polyethylene glycol 3350 (Polyethylene Glycol POLYETHYLENE GLYCOL 3350 psyllium husk psyllium husk/ca carbonate (Fiber Plus Calcium) psyllium husk/laxative no.1 psyllium seed (with dextrose) psyllium seed (with sugar) psyllium seed senna/fennel sennosides sennosides/docusate sodium (Sennosides/Docusate sodium chloride/nahco3/kcl/peg soln recon: (Nulytely with Flavor Phosphate Binders
calcium acetate University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
sodium polystyrene sulfonate (Sodium Polystyrene Genitourinary Agents

Antispasmodics, Urinary
oxybutynin chloride (Oxybutynin Chloride) (ER and IR forms) tolterodine tartrate trospium chloride tablet Genitourinary Agents, Miscellaneous
phenazopyridine hcl tamsulosin hcl terazosin hcl Hormonal Agents, Stimulant/Replacement/Modifying

Androgens
fluoxymesterone (Fluoxymesterone) testosterone cypionate (Depo-Testosterone) testosterone enanthate testosterone gel (gram), gel md pmp ANDROGEL gel md pmp: 20.25/1.25; gel packet: 1.25g-1.62, 2.5g-1.62%, 50mg(1%) DELATESTRYL Estrogens and Antiestrogens
estradiol/norethindrone acet tablet: 0.5- 0.1mg, 1mg-0.5mg norethindrone ac-eth estradiol estradiol estradiol/norethindrone acet tablet: 0.5- 0.1mg, 1mg-0.5mg estropipate raloxifene hcl ESTRACE cream/appl University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
PREMARIN cream/appl dexamethasone fludrocortisone acetate (Fludrocortisone hydrocortisone prednisolone sod phosphate solution prednisolone prednisone Pituitary
desmopressin acetate solution, spray/pump, (DDAVP) tablet INCRELEX NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX NUTROPIN AQ NUSPIN SEROSTIM vial: 5mg, 6mg Progestins
medroxyprogesterone acetate syringe, vial (Depo-Provera) medroxyprogesterone acet (Medroxyprogesterone medroxyprogesterone acetate tablet norethindrone acetate DEPO-SUBQ PROVERA 104 Thyroid and Antithyroid Agents
levothyroxine sodium tablet liothyronine sodium tablet methimazole propylthiouracil (Propylthiouracil) TIROSINT capsule: 50mcg University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Immunological Agents

Immunological Agents
azathioprine cyclosporine capsule, solution cyclosporine, modified leflunomide mycophenolate mofetil mycophenolate sodium sirolimus tacrolimus RAPAMUNE solution Vaccines
AFLURIA 2013-2014 syringe AFLURIA 2013-2014 vial AFLURIA 2014-2015 syringe AFLURIA 2014-2015 vial FLUARIX 2013-2014 FLUARIX 2014-2015 FLUARIX QUAD 2013-2014 FLUARIX QUAD 2014-2015 FLUBLOK 2012-2013 FLUBLOK 2013-2014 FLUBLOK 2014-2015 FLUCELVAX 2014-2015 FLUCELVAX syringe: 45mcg/.5ml FLUCELVAX syringe: 45mcg/.5ml FLULAVAL 2013-2014 FLULAVAL 2014-2015 syringe FLULAVAL 2014-2015 vial FLULAVAL QUAD 2013-2014 FLULAVAL QUAD 2014-2015 FLUMIST QUAD 2014-2015 FLUVIRIN 2012-2013 FLUVIRIN 2013-2014 FLUVIRIN 2014-2015 syringe FLUVIRIN 2014-2015 vial FLUZONE 2013-2014 vial: 45mcg/.5ml University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
FLUZONE 2013-2014 vial: 45mcg/.5ml FLUZONE 2014-2015 syringe FLUZONE 2014-2015 vial FLUZONE HIGH-DOSE 2014-2015 Age must be >= 65, PA FLUZONE INTRADERM QUAD 2014-15 FLUZONE INTRADERMAL 2014-2015 FLUZONE PEDI 2013-2014 FLUZONE QUAD PEDI 2014-2015 PHYSICIANS EZ USE FLU 2012-13 Age must be >= 21, PA Age must be >= 21, PA SINGLE USE EZ FLU 2013-2014 syringekit: 45mcg/.5ml SINGLE USE EZ FLU 2013-2014 syringekit: 60mcg/.5ml
Inflammatory Bowel Disease Agents

Inflammatory Bowel Disease Agents
balsalazide disodium QL: 270 in 30 days budesonide QL: 240 in 30 days QL: 240 in 30 days QL: 240 in 30 days QL: 30 in 30 days QL: 240 in 30 days QL: 120 in 30 days QL: 240 in 30 days QL: 240 in 30 days Metabolic Bone Disease Agents

Metabolic Bone Disease Agents
alendronate sodium tablet calcitriol capsule Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents
allopurinol buspirone hcl QL: 120 in 30 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
buspirone hcl QL: 120 in 30 days (PA required for >1 Rx/month for all anxiolytic products combined. QL of 120/month for all anxiolytic products combined) chloral hydrate (Chloral Hydrate) QL: 30 in 30 days (PA required for >1 Rx/month for all hypnotic products combined. QL of 30/month for all hypnotic products combined, except Rozerem) finasteride hydroxyzine hcl syrup, tablet, vial: 25mg/ (Hydroxyzine HCl) ml hydroxyzine pamoate methylergonovine maleate tablet (Methylergonovine POLYETHYLENE GLYCOL 3350 probenecid AVONEX ADMINISTRATION PACK GLUCAGON EMERGENCY KIT QL: 2 in 365 days University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Ophthalmic Agents

Antiglaucoma Agents
acetazolamide betaxolol hcl brimonidine tartrate dorzolamide hcl dorzolamide hcl/timolol maleat latanoprost QL: 2.5 per fill levobunolol hcl methazolamide metipranolol pilocarpine hcl (Isopto Carpine) timolol maleate Replacement Preparations

Replacement Preparations
calcium carbonate calcium carbonate/vitamin d2 tablet: (Calcium Carbonate/ 500mg-200 calcium carbonate/vitamin d3 (Caltrate 600 + D) calcium citrate/vitamin d3 (Citracal-Vitamin D) calcium gluconate tablet (Calcium Gluconate) calcium lactate (Calcium Lactate) CALTRATE 600 + D magnesium oxide/mag aa chelate (Magnesium Oxide/ magnesium oxide/pyridoxine hcl (Magnesium Oxide/ pot chloride/pot bicarb/cit ac (Pot Chloride/Pot potassium bicarbonate/cit ac potassium chloride capsule er, liquid, (Potassium Chloride) packet, tab er prt, tablet er, tablet sa potassium citrate University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
potassium citrate/citric acid packet: 3300- (Potassium Citrate/ 1002; solution sod/pot/k cit/sod cit/cit acid solution: 500- (Sod/Pot/K Cit/Sod Cit/ zinc sulfate capsule, tablet Respiratory Tract Agents

Anti-Inflammatories, Inhaled Corticosteroids
budesonide Age must be <= 5 PULMICORT FLEXHALER PULMICORT ampul-neb: 1mg/2ml Age must be <= 5 montelukast sodium zafirlukast albuterol sulfate solution, syrup, vial-neb ipratropium bromide (Ipratropium Bromide) ipratropium/albuterol sulfate theophylline anhydrous COMBIVENT RESPIMAT SPIRIVA RESPIMAT TUDORZA PRESSAIR Respiratory Tract Agents, Other
cromolyn sodium (Cromolyn Sodium) sodium chloride for inhalation University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Skeletal Muscle Relaxants

Skeletal Muscle Relaxants
COMFORT PAC-CYCLOBENZAPRINE COMFORT PAC-TIZANIDINE cyclobenzaprine hcl tablet: 5mg, 10mg dantrolene sodium capsule methocarbamol tablet tizanidine hcl Sleep Disorder Agents

Sleep Disorder Agents
QL: 30 in 30 days (PA required for >1 Rx/month for all hypnotic products combined. QL of 30/month for all hypnotic products combined, except Rozerem) zolpidem tartrate tablet: 10mg QL: 30 in 30 days (PA required for >1 Rx/month for all hypnotic products combined. QL of 30/month for all hypnotic products combined, except Rozerem) zolpidem tartrate tablet: 5mg QL: 60 in 30 days (PA required for >1 Rx/month for all hypnotic products combined. QL of 30/month for all hypnotic products combined, except Rozerem) University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
Vasodilating Agents

Vasodilating Agents
epoprostenol sodium (glycine) REVATIO susp recon, tablet TYVASO ampul-neb: 1.74mg/2.9 TYVASO ampul-neb: 1.74mg/2.9 TYVASO ampul-neb: 1.74mg/2.9 Vitamins and Minerals

Vitamins and Minerals
b complex and c no.10/folic acid (B Complex and C No.10/Folic Acid) b complex and c no.20/folic acid capsule: 1mg cholecalciferol (vitamin d3) capsule, drops, (Vitamin D) liquid, tab chew: 400unit; tablet: 400unit, 1000unit, 2000unit, 5000unit ergocalciferol (vitamin d2) ferrous gluconate ferrous sulfate (Ferrous Sulfate) ferrous sulfate, dried (Ferrous Sulfate, Dried) folic acid tablet folic acid/vitamin b comp w-c iron polysaccharide complex capsule: 50mg, 150mg, 200mg LOZI-FLUR multivitamin multivitamin/ferrous gluconate (Multivitamin/Ferrous multivitamins with iron tab chew: n/a (Multivitamins with University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 Drug Name
Drug Tier
multivit-min/folic acid/vit k (Multivit-Min/Folic ped multivit #46/iron sulfate (Ped Multivit #46/Iron pedi multivits a,c, and d3 no.21 (Pedi Multivits A,C, pedi mv no.79/ferrous fumarate Ferrous Fumarate) pedi mvi no.12/sodium fluoride (Multivitamins with pediatric multivit comb no.20 (Pediatric Multivit pnv with ca,no.72/iron/fa (Pnv with Ca,No.72/ pnv119/iron fumarate/fa/dss (Pnv119/Iron Fumarate/ pyridoxine hcl capsule, tablet, tablet er (Pyridoxine HCl) sodium fluoride (Sodium Fluoride) thiamine hcl tablet VITAMIN D3 drops, liquid, spray susp University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 abacavir sulfate . 19 allopurinol. 39 alprazolam . 9 aluminum chloride . 28 ADMINISTRATION PACK amantadine hcl . 18 acarbose . 14 aminocaproic acid . 21 azathioprine . 38 ACE AEROSOL CLOUD amiodarone hcl . 22 azelastine hcl . 32 azithromycin . 11 acetaminophen . 3 amitriptyline hcl . 14 acetaminophen with codeine . 3 amlodipine besylate . 23 b complex and c no.10/folic acetaminophen/phenyltolx . 3 acid . 44 acetazolamide . 41 b complex and c no.20/folic acetic acid . 33 amoxicillin. 12 acid . 44 acetic acid/hydrocortisone . 33 amoxicillin/potassium clav. 12 bacitracin . 29, 33 ampicillin trihydrate . 12 bacitracin zinc . 29 acyclovir . 20 anagrelide hcl . 21 bacitracin/polymyxin b sulfate anastrozole . 12 adefovir dipivoxil . 20 baclofen . 43 ADVAIR DISKUS. 42 balsalazide disodium . 39 antipyrine/benzocaine . 33 AEROCHAMBER MINI . 30 AEROCHAMBER MV . 30 benazepril hcl . 22 AEROCHAMBER PLUS APIDRA SOLOSTAR . 15 AEROCHAMBER PLUS Z BENICAR HCT . 22 AEROCHAMBER WITH benzonatate . 26 AEROCHAMBER Z-STAT benzoyl peroxide . 28 benzoyl peroxide and skin AEROTRACH PLUS . 31 aspirin . 7 cleansr5 . 28 AFLURIA 2013-2014 . 38 benzoyl peroxide microspheres AFLURIA 2014-2015 . 38 atenolol . 22 benzoyl peroxide/aloe vera . 28 atenolol/chlorthalidone . 22 benztropine mesylate . 18 atorvastatin calcium. 24 betamethasone dipropionate . 29 albuterol sulfate . 42 atovaquone/proguanil hcl . 18 betamethasone valerate . 29 alclometasone dipropionate . 29 alcohol antiseptic pads . 28 atropine sulfate . 32 alendronate sodium . 39 ATROVENT HFA . 42 betaxolol hcl . 41 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 carbamide peroxide . 33 citalopram hydrobromide . 14 bisacodyl . 35 carbamide peroxide/sea water clarithromycin . 11 bisoprolol fumarate . 22 clemastine fumarate . 16 bisoprolol fumarate/hctz . 23 carbidopa/levodopa . 18 CLIMARA PRO . 36 carteolol hcl . 32 clindamycin hcl . 11 BLEPHAMIDE S.O.P. 34 carvedilol . 23 clindamycin palmitate hcl . 11 cefaclor . 11 clindamycin phosphate. 17, 29 BREATHERITE . 31 cefadroxil . 11 clobetasol propionate. 29 cefdinir . 11 clonazepam . 9 cefpodoxime proxetil . 11 clonidine . 21 brimonidine tartrate . 41 cefprozil. 11 clonidine hcl . 21 bromocriptine mesylate . 18 cefuroxime axetil . 11 clopidogrel bisulfate . 21 CEFUROXIME AXETIL . 11 clorazepate dipotassium. 9 celecoxib . 7 clotrimazole. 15 brompheniramine maleate . 16 cephalexin . 11 dihydrocd . 26 budesonide . 39, 42 cetirizine hcl . 16 codeine/butalbital/asa/caffein . 3 bumetanide . 23 colestipol hcl . 24 bupropion hcl . 8, 14 buspirone hcl . 39, 40 butalb/acetaminophen/caffeine 3 CHILDREN'S ZYRTEC . 16 COMBIVENT RESPIMAT . 42 butalbit/acetamin/caff/codeine 3 CHILDREN'S ZYRTEC butalbital/aspirin/caffeine . 3 CYCLOBENZAPRINE . 43 chloral hydrate . 40 COMFORT PAC-IBUPROFEN chlordiazepoxide hcl . 9 calcitonin,salmon,synthetic . 39 chlorhexidine gluconate . 28 calcitriol . 39 chloroquine phosphate . 18 calcium acetate . 35 chlorothiazide . 24 COMFORT PAC-NAPROXEN calcium carbonate . 34, 41 chlorpheniramine maleate . 16 calcium carbonate/vitamin d241 chlorpheniramine tannate . 16 calcium carbonate/vitamin d341 chlorthalidone . 24 calcium citrate/vitamin d3 . 41 cholecalciferol (vitamin d3) . 44 calcium gluconate . 41 cholestyramine (with sugar) . 24 CHAMBER PLUS . 31 calcium lactate . 41 cholestyramine/aspartame . 24 CALTRATE 600 + D . 41 choline sal/mag salicylate . 7 cidofovir . 20 CAPEX SHAMPOO . 29 cilostazol . 21 CAPITAL W-CODEINE . 7 captopril . 22 ciprofloxacin . 12 ciprofloxacin hcl . 12, 33 carbamazepine . 13 ciprofloxacin/ciprofloxa hcl . 12 cromolyn sodium . 32, 34, 42 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 cyclobenzaprine hcl . 43 digoxin. 23 cyclopentolate hcl . 32 enalapril maleate . 22 cyclosporine . 38 cyclosporine, modified . 38 DILANTIN-125 . 13 cyproheptadine hcl . 16 diltiazem hcl . 23 danazol . 36 diphenhydramine hcl . 17, 28 enoxaparin sodium . 20 dantrolene sodium . 43 diphenhydramine hcl/zinc acet entacapone . 18 dapsone . 17 entecavir . 20 diphenoxylate hcl/atropine . 35 epinephrine . 23 DELATESTRYL . 36 dipyridamole . 21 EPIPEN 2-PAK . 23 disopyramide phosphate . 22 EPIPEN JR 2-PAK . 23 divalproex sodium . 13 demeclocycline hcl . 12 eplerenone . 24 chlorpheniramine . 26 d-methorphan hb/p-epd hcl/bpm epoprostenol sodium (glycine) DEPAKOTE ER . 13 DEPAKOTE SPRINKLE . 13 d-methorphan hb/p-ephed hcl/ DEPO-SUBQ PROVERA 104 d-methorphan hb/prometh hcl27 ergocalciferol (vitamin d2) . 44 desipramine hcl . 14 ergotamine tartrate/caffeine . 17 desmopressin acetate . 37 dexbromphenir . 28 ery e-succ/sulfisoxazole . 11 desog-e.estradiol/e.estradiol . 25 docusate calcium . 35 erythromycin base . 11, 33 desogestrel-ethinyl estradiol . 25 docusate sodium . 35 erythromycin base/ethanol . 29 desonide . 29 erythromycin ethylsuccinate . 11 donepezil hcl . 13 erythromycin stearate . 11 dexamethasone . 37 dorzolamide hcl . 41 dexamethasone sod phosphate dorzolamide hcl/timolol maleat escitalopram oxalate . 14 dexchlorpheniramine maleate16 doxazosin mesylate. 21 estazolam. 10 dextroamphetamine sulfate . 24 doxepin hcl . 14 doxycycline hyclate . 12 estradiol . 36 amphetamine . 24, 25 doxycycline monohydrate . 12 estradiol/norethindrone acet . 36 dextromethorphan polistirex . 26 dextrose . 21 duloxetine hcl . 14 estropipate. 36 diazepam . 9, 10 DUREX AVANTI BARE . 25 ethambutol hcl . 17 diclofenac potassium . 7 ethosuximide . 13 diclofenac sodium . 7, 34 ECLIPSE LUER-LOK ethynodiol d-ethinyl estradiol 25 dicloxacillin sodium . 12 etodolac . 7 dicyclomine hcl . 34 didanosine . 19 diflorasone diacetate . 29 diflunisal . 7 exemestane . 12 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 FLULAVAL 2014-2015 . 38 FLULAVAL QUAD 2013-2014 FREESTYLE CONTROL famciclovir . 20 famotidine . 34 FLULAVAL QUAD 2014-2015 FREESTYLE FREEDOM . 31 FREESTYLE FREEDOM LITE FC CONDOM, FEMALE . 25 FLUMIST QUAD 2014-201538 FC2 FEMALE CONDOM . 25 flunisolide . 34 FREESTYLE INSULINX . 31 felbamate . 13 fluocinolone acetonide . 30 FREESTYLE INSULINX felodipine. 23 fluocinolone/shower cap . 30 TEST STRIPS . 31 fluocinonide. 30 FREESTYLE LANCETS . 31 fluorometholone . 34 FREESTYLE LITE METER 31 fenofibrate . 24 fluoxetine hcl . 14 FREESTYLE LITE STRIPS 31 fenofibrate nanocrystallized. 24 FLUOXETINE HCL . 14 FREESTYLE LITE TEST fenofibrate,micronized . 24 fluoxymesterone . 36 fenoprofen calcium. 7 flurazepam hcl . 10 FREESTYLE TEST STRIPS 31 fentanyl . 3 flurbiprofen . 7 FREESTYLE UNISTIK 2 . 31 ferrous gluconate . 44 flurbiprofen sodium . 34 FULVICIN U/F . 16 ferrous sulfate . 44 flutamide . 12 furosemide . 24 ferrous sulfate, dried . 44 fluticasone propionate . 30, 34 fexofenadine hcl . 17 FLUVIRIN 2012-2013. 38 gabapentin. 13 FLUVIRIN 2013-2014. 38 FLUVIRIN 2014-2015. 38 galantamine hbr . 14 finasteride . 40 fluvoxamine maleate . 14 ganciclovir . 20 FIRST-LANSOPRAZOLE . 34 FLUZONE 2013-2014 . 38, 39 ganciclovir sodium . 20 FIRST-OMEPRAZOLE . 34 FLUZONE 2014-2015 . 39 gemfibrozil . 24 flecainide acetate . 22 FLUZONE HIGH-DOSE 2014- gentamicin sulfate . 29, 33 FLOVENT DISKUS . 42 FLOVENT HFA . 42 FLUZONE INTRADERM FLUARIX 2013-2014 . 38 QUAD 2014-15 . 39 glimepiride . 15 FLUARIX 2014-2015 . 38 FLUZONE INTRADERMAL glipizide . 15 FLUARIX QUAD 2013-2014 glipizide/metformin hcl . 15 FLUZONE PEDI 2013-2014 39 GLUCAGON EMERGENCY FLUARIX QUAD 2014-2015 FLUZONE QUAD PEDI 2014- glyburide . 15 FLUBLOK 2012-2013 . 38 folic acid. 44 glyburide,micronized . 15 FLUBLOK 2013-2014 . 38 glyburide/metformin hcl . 15 FLUBLOK 2014-2015 . 38 folic acid/vitamin b comp w-c 44 glycopyrrolate . 35 granisetron hcl . 17 FLUCELVAX 2014-2015 . 38 fluconazole . 16 foscarnet sodium . 20 griseofulvin, microsize . 16 flucytosine . 16 fosinopril sodium . 22 guaifenesin . 27 fludrocortisone acetate . 37 FLULAVAL 2013-2014 . 38 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 hydroxyzine pamoate . 40 hyoscyamine sulfate . 35 KLOR-CON 10 . 41 ibuprofen . 7 pseudoephedrine . 27 ibuprofen/oxycodone hcl . 5 KLOR-CON-EF . 41 imipramine hcl . 14 KONSYL EASY MIX . 35 imipramine pamoate . 14 labetalol hcl . 23 guaifenesin/ephedrine hcl . 27 lactulose . 35 indapamide . 24 indomethacin . 7 lamivudine . 19 lamivudine/zidovudine . 19 lamotrigine . 13 guanfacine hcl . 21 INSPIRACHAMBER . 31 LANCING DEVICE . 31 guar gum . 35 lansoprazole . 34 heparin sod,porcine-0.9 % nacl LANTUS SOLOSTAR . 15 heparin sodium,porcine . 21 latanoprost . 41 heparin sodium,porcine/pf . 21 ipratropium bromide . 32, 42 leflunomide . 38 homatropine hbr. 32 ipratropium/albuterol sulfate 42 irbesartan . 21 letrozole. 12 HUMALOG MIX 50-50 . 15 HUMALOG MIX 75-25 . 15 LEVEMIR FLEXTOUCH . 15 iron polysaccharide complex 44 levetiracetam . 13 HUMULIN 70/30 KWIKPEN levobunolol hcl . 41 isoniazid . 17 levofloxacin . 12 HUMULIN 70-30 . 15 isosorbide dinitrate . 24 levonorgestrel . 25 isosorbide mononitrate . 24 levonorgestrel-ethin estradiol 25 HUMULIN N KWIKPEN . 15 isotretinoin . 28 levothyroxine sodium . 37 isradipine . 23 hydralazine hcl . 23 itraconazole. 16 hydrochlorothiazide . 24 ivermectin . 18 lidocaine . 8, 28 hydrocodone bit/homatrop me- lidocaine hcl . 8 lidocaine/prilocaine . 8 hydrocodone/acetaminophen . 4 hydrocodone/ibuprofen . 4 ketoconazole . 16 hydrocortisone . 30, 37 ketoprofen . 7 liothyronine sodium . 37 hydrocortisone acetate . 30 ketorolac tromethamine . 7, 34 lipase/protease/amylase . 32 hydrocortisone acetate/aloe v 30 ketotifen fumarate . 32 lisinopril . 22 hydrocortisone valerate . 30 hydrocortisone/pramoxine . 30 KIMONO MAXX . 25 hydromorphone hcl . 4 KIMONO MICROTHIN . 25 hydroxychloroquine sulfate . 18 KIMONO MICROTHIN hydroxyurea . 12 loperamide hcl . 35 hydroxyzine hcl . 40 KIMONO TEXTURED . 25 loratadine . 17 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 loratadine/pseudoephedrine . 17 metoclopramide hcl . 35 naphazoline hcl/pheniramine 33 lorazepam . 10 metolazone . 24 naproxen . 7 losartan potassium . 21 metoprolol succinate . 23 naproxen sodium . 7 losartan/hydrochlorothiazide 22 metoprolol tartrate . 23 naratriptan hcl . 17 LOTRIMIN AF . 16 metronidazole . 17, 18, 29 lovastatin . 24 mexiletine hcl . 22 nateglinide. 14 miconazole nitrate . 16 needles, insulin disp., safety . 31 miconazole/skin cleanser no.17 needles, insulin disposable. 31 LUPRON DEPOT . 12 neo/polymyx b sulf/dexameth 33 LUPRON DEPOT-PED . 12 MICROCHAMBER . 31 neomy sulf/bacitra/polymyxin b MICROSPACER . 31 magnesium citrate . 35 neomy sulf/bacitrac zn/poly . 29 magnesium hydroxide . 35 minocycline hcl . 12 neomy sulf/bacitrac zn/poly/hc magnesium oxide . 35 minoxidil . 24 MAGNESIUM OXIDE . 35 mirtazapine . 14 neomy sulf/polymyx b sulf/pram magnesium oxide/mag aa moexipril hcl . 22 chelate . 41 neomycin sulfate. 11 magnesium oxide/pyridoxine hcl neomycin/polymyxin b sulf/hc 33 mometasone furoate . 30 maprotiline hcl . 14 MONAGHAN Z STAT . 31 gramicidin . 33 mebendazole . 18 montelukast sodium . 42 neomycn/baci zn/pmyx bs/ meclizine hcl. 17 morphine sulfate. 5 pramox . 29 meclofenamate sodium . 7 MORPHINE SULFATE . 5 NESSI SPACER . 31 medroxyprogesterone acet . 37 medroxyprogesterone acetate 37 mefloquine hcl . 18 nevirapine . 19 meloxicam . 7 niacin. 24 multivitamin . 44 niacin (inositol niacinate) . 24 nicardipine hcl . 23 meperidine hcl . 5 nicotine . 8 mercaptopurine . 12 multivitamins with iron . 44 nicotine polacrilex . 8 multivit-min/folic acid/vit k . 45 NICOTINE POLACRILEX . 8 metformin hcl . 14 mupirocin . 29 methadone hcl . 5 mupirocin calcium . 29 nifedipine. 23 methazolamide . 41 mycophenolate mofetil . 38 nimodipine. 23 methimazole . 37 mycophenolate sodium . 38 nisoldipine . 23 methocarbamol . 43 nabumetone . 7 methotrexate sodium . 12 nadolol . 23 nitrofurantoin . 11 methyldopa . 21 nitrofurantoin macrocrystal . 11 methylergonovine maleate . 40 naphazoline hcl/glycerin . 33 methylphenidate hcl . 25 methylprednisolone . 37 nitroglycerin . 24 metipranolol . 41 naphazoline hcl/peg 300 . 33 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 nonoxynol 9 . 25 phenytoin . 13 NORDITROPIN FLEXPRO . 37 phenytoin sodium extended . 13 NORDITROPIN NORDIFLEX ORTHO ALL-FLEX . 26 PHYSICIANS EZ USE FLU oxaprozin. 7 noreth-ethinyl estradiol/iron . 25 oxazepam. 10 pilocarpine hcl . 41 norethindrone . 25 oxcarbazepine . 13 pindolol . 23 norethindrone acetate . 37 oxybutynin chloride . 36 pioglitazone hcl . 14 norethindrone ac-eth estradiol oxycodone hcl. 6 pioglitazone hcl/metformin hcl oxycodone hcl/acetaminophen 6 oxycodone hcl/aspirin . 6 pip butox/pyrethrins/permeth 30 oxycodone hcl/oxycodon ter/asa piperonyl butoxide/pyrethrins 30 norethindrone-ethinyl estrad 25 piroxicam . 7 norethindrone-mestranol . 25 PNEUMOVAX 23 . 39 PANATUSS DXP PEDIATRIC pnv with ca,no.72/iron/fa . 45 pnv119/iron fumarate/fa/dss . 45 norgestrel-ethinyl estradiol . 26 POCKET CHAMBER . 31 pantoprazole sodium . 34 polyethylene glycol 3350. 35 nortriptyline hcl . 14 paroxetine hcl. 14 POLYETHYLENE GLYCOL ped multivit #46/iron sulfate . 45 NOVOLIN 70-30 . 15 pedi multivits a,c, and d3 no.21 polymyxin b sulf/trimethoprim pedi mv no.79/ferrous fumarate POLY-TUSSIN DM . 27 polyvinyl alcohol . 33 NOVOLOG FLEXPEN . 15 pedi mvi no.12/sodium fluoride polyvinyl alcohol/povidone . 33 NOVOLOG MIX 70-30 . 15 pot chloride/pot bicarb/cit ac 41 NOVOLOG MIX 70-30 pediatric multivit comb no.20 45 potassium bicarbonate/cit ac 41 peg 3350/na sulf,bicarb,cl/kcl 35 potassium chloride . 41 PEG 3350-GRX . 35 potassium citrate . 41 potassium citrate/citric acid . 42 PEGASYS PROCLICK . 20 NUTROPIN AQ NUSPIN . 37 pramipexole di-hcl . 18 PEGINTRON REDIPEN . 20 nystatin . 16 penicillin v potassium . 12 pravastatin sodium . 24 prazosin hcl . 21 nystatin/triamcin . 16 PERFOROMIST . 42 ofloxacin . 12, 33 perindopril erbumine . 22 PRECISION GLUCOSE omeprazole . 34 permethrin . 30 omeprazole magnesium . 34 PRECISION XTRA . 31, 32 ondansetron. 18 phenazopyridine hcl . 36 ondansetron hcl . 18 phenobarbital . 13 prednisolone . 37 phenylephrine hcl/prometh hcl prednisolone acetate . 34 prednisolone sod phosphate . 34, OPTICHAMBER . 31 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 prednisone . 37 pyridoxine hcl. 45 selegiline hcl . 18 quinapril hcl . 22 selenium sulfide . 28, 29 selenium sulfide/menthol . 29 quinidine gluconate . 22 senna/fennel . 35 quinidine sulfate . 22 sennosides . 35 PRILOSEC OTC . 34 quinine sulfate . 18 sennosides/docusate sodium . 35 raloxifene hcl . 36 SEREVENT DISKUS . 42 primidone . 13 ramipril . 22 sertraline hcl . 14 probenecid. 40 ranitidine hcl . 34 silver sulfadiazine . 29 procainamide hcl . 22 simethicone . 34 SIMETHICONE . 34 prochlorperazine maleate . 18 simvastatin . 24 REBIF REBIDOSE . 40 SINGLE USE EZ FLU 2013- PROCTOFOAM-HC . 30 progesterone,micronized . 37 sirolimus . 38 PROLASTIN C . 43 sod/pot/k cit/sod cit/cit acid . 42 sodium chloride for inhalation promethazine hcl . 17, 18 repaglinide . 14 promethazine hcl/codeine . 27 codeine . 27 sodium fluoride . 28, 45 propafenone hcl . 22 sodium polystyrene sulfonate 36 propantheline bromide . 13 sotalol hcl . 23 propranolol hcl . 23 ribavirin . 20 SPACE CHAMBER PLUS . 32 propylthiouracil . 37 rifampin . 17 spinosad . 30 protriptyline hcl . 14 rimantadine hcl . 20 pseudoephedrine hcl . 27, 28 SPIRIVA RESPIMAT . 42 risperidone . 18 brompheniramin . 17 psyllium husk . 35 spironolactone. 24 psyllium husk/ca carbonate. 35 rivastigmine tartrate . 14 psyllium husk/laxative no.1 . 35 rizatriptan benzoate . 17 stavudine . 19 psyllium seed . 35 ropinirole hcl . 18 psyllium seed (with dextrose) 35 psyllium seed (with sugar) . 35 salicylic acid . 28 salicylic acid/ceramide cmb #1 PULMICORT FLEXHALER 42 sucralfate. 34 salsalate . 7 pyrazinamide . 17 sulfacetamide sod/sulfur/urea 28 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015 sulfacetamide sodium . 33 tizanidine hcl . 43 valproic acid . 13 sulfacetamide sodium/sulfur . 29 valproic acid (as sodium salt) 13 tobramycin . 33 valsartan . 22 tobramycin in 0.225% nacl . 11 sulfadiazine . 12 tobramycin/dexamethasone . 33 tolterodine tartrate . 36 vancomycin hcl. 11 topiramate . 13 sulfasalazine . 12 torsemide . 24 venlafaxine hcl . 14 sulindac . 7 sumatriptan . 17 tramadol hcl . 6 verapamil hcl . 23 sumatriptan succinate . 17 trandolapril . 22 trazodone hcl . 14 tretinoin . 30 tretinoin/emollient base . 30 triamcinolone acetonide. 28, 30, syring w-ndl,disp,insul,0.3 ml 32 VIRAMUNE XR . 19 syring w-ndl,disp,insul,0.5 ml 32 syringe and needle,insulin,1 ml trifluridine . 33 tacrolimus . 38 trihexyphenidyl hcl . 18 voriconazole . 16 tamoxifen citrate . 12 trospium chloride . 36 tamsulosin hcl . 36 warfarin sodium . 21 temazepam. 11 TRUSTEX CONDOM . 26 terazosin hcl . 36 TRUSTEX LATEX CONDOM WIDE SEAL DIAPHRAGM 26 terbinafine hcl . 16 TRUSTEX-RIA . 26 zafirlukast . 42 testosterone . 36 zaleplon . 43 testosterone cypionate . 36 TUDORZA PRESSAIR . 42 testosterone enanthate . 36 TUSNEL PEDIATRIC . 28 tetracycline hcl . 12 zidovudine . 19 theophylline anhydrous . 42 zinc sulfate . 42 thiamine hcl . 45 urea . 29 zolpidem tartrate . 43 ursodiol . 35 zonisamide. 13 timolol maleate. 41 tioconazole . 16 valacyclovir hcl . 20 valganciclovir hcl. 20 University Family Care Effective: April 01, 2015 Formulary ID: 81166.000, Version: 2Q2015

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