4D Pharmacy Managed Formulary Updates

Transcription

4D Pharmacy Managed Formulary Updates
4D Pharmacy Managed Formulary Updates
January, 2008
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2008
ELESTRIN
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2008
ELESTRIN
estradiol
ADD UM: GENDER
Female
01/01/2014
nicotine gum
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2014
nicorelief
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2014
quit 2
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2014
nicotine gum
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2014
nicorelief
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2014
quit 4
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2014
nicotine patch
nicotine
ADD TO FORMULARY
Preventative
01/01/2014
nicotine patch
nicotine
ADD TO FORMULARY
Preventative
01/01/2014
nicotine patch
nicotine
ADD TO FORMULARY
Preventative
01/01/2014
nicotine patch
nicotine
ADD TO FORMULARY
Preventative
01/01/2014
nts
nicotine
ADD TO FORMULARY
Preventative
01/01/2014
nicotine patch
nicotine
ADD TO FORMULARY
Preventative
01/01/2014
nicotine patch
nicotine
ADD TO FORMULARY
Preventative
01/01/2014
bupropion hcl sr
bupropion hcl
ADD TO FORMULARY
Preventative
01/01/2014
bupropion hcl sr
bupropion hcl
ADD UM: AGE
60 to 30 yrs old
01/01/2014
ZYBAN
bupropion hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
ZYBAN
bupropion hcl
ADD UM: AGE
60 to 30 yrs old
01/01/2014
buproban
bupropion hcl
ADD TO FORMULARY
Preventative
01/01/2014
buproban
bupropion hcl
ADD UM: AGE
60 to 30 yrs old
01/01/2014
8-MOP
methoxsalen
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 1
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ABILIFY,ABILIFY aripiprazole
MAINTENA,ABILI
FY DISCMELT
ADD TO FORMULARY
Preferred Brands
01/01/2014
ACTIMMUNE
ADD TO FORMULARY
Preferred Brands
01/01/2014
ACTONEL,ATEL risedronate sodium
VIA
ADD TO FORMULARY
Preferred Brands
01/01/2014
pioglitazonepioglitazone hcl/metformin
metformin,actopl hcl
us met,actoplus
met xr
ADD TO FORMULARY
Preferred Brands
01/01/2014
ADVAIR
fluticasone
DISKUS,ADVAIR propionate/salmeterol
HFA
xinafoate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ADVATE,ADVAT
E L,ADVATE
M,ADVATE
H,ADVATE
SH,ADVATE
UH,XYNTHA,XY
NTHA
SOLOFUSE
antihemophilic factor (fviii)
recomb,full length (albfree),antihemophilic factor
(factor viii) recomb,b-domain
deleted
ADD TO FORMULARY
Preferred Brands
01/01/2014
AGGRENOX
aspirin/dipyridamole
ADD TO FORMULARY
Preferred Brands
01/01/2014
AGRYLIN
anagrelide hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
AKNE-MYCIN
erythromycin base
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALDURAZYME
laronidase
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALINIA
nitazoxanide
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALINIA
nitazoxanide
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALKERAN
melphalan hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALKERAN
melphalan
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALOCRIL
nedocromil sodium
ADD TO FORMULARY
Preventative
interferon gamma1b,recomb.
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 2
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ALOMIDE
lodoxamide tromethamine
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPHAGAN P
brimonidine tartrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPHAGAN P
brimonidine tartrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
onsolis,fentanyl fentanyl citrate
citrate,abstral,laz
anda,actiq,fentor
a
CHANGE TIER
Non-Formulary
01/01/2014
benzaclin,duac,cli clindamycin
ndamycinphosphate/benzoyl peroxide
benzoyl
peroxide,acanya,
clindamycin
phos-benzoyl
perox
CHANGE TIER
Non-Formulary
01/01/2014
ACCOLATE
zafirlukast
ADD TO FORMULARY
Non-Formulary
01/01/2014
ACCOLATE
zafirlukast
ADD TO FORMULARY
Non-Formulary
01/01/2014
ADVANCED DNA lidocaine hcl/glycerin
MEDICATED
COLLECT
01/01/2014
DYSPORT
abobotulinumtoxina
01/01/2014
FORTESTA
testosterone
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
GELNIQUE
oxybutynin chloride
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
GELNIQUE
oxybutynin
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
GELX
povidone/taurine/zinc
gluconate/peg-40 castor oil
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
GILTUSS TR
guaifenesin/dextromethorph
an hbr/phenylephrine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
HEPSERA
adefovir dipivoxil
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
HYLATOPICPLU emollient combination no.53
S
CHANGE TIER
Preferred Brands
Non-Formulary
CHANGE TIER
Preferred Brands
ADD TO FORMULARY
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 3
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
HYLATOPICPLU emollient combination no.53
S
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
HYPERTENSA
caffeine/choline bitartrate/aa
comb11/herbal complex no.
130
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ISTALOL
timolol maleate
CHANGE TIER
01/01/2014
JETREA
ocriplasmin/pf
CHANGE TIER
01/01/2014
KAPVAY
clonidine hcl
CHANGE TIER
Non-Formulary
01/01/2014
KAPVAY
clonidine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
KLARON
sulfacetamide sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
KOATE-DVI
antihemophilic factor,
human
CHANGE TIER
01/01/2014
KOATE-DVI
antihemophilic factor,
human
ADD TO FORMULARY
01/01/2014
KOATE-DVI
antihemophilic factor,
human
CHANGE TIER
01/01/2014
KOATE-DVI
antihemophilic factor,
human
ADD TO FORMULARY
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 4
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
ADD TO FORMULARY
Non-Formulary
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
ADD TO FORMULARY
Non-Formulary
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
ADD TO FORMULARY
Non-Formulary
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
ADD TO FORMULARY
Non-Formulary
01/01/2014
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
ADD TO FORMULARY
Non-Formulary
01/01/2014
LIDODERM
lidocaine
CHANGE TIER
Non-Formulary
01/01/2014
ANDRODERM
testosterone
ADD TO FORMULARY
Non-Formulary
01/01/2014
ANDRODERM
testosterone
ADD TO FORMULARY
Non-Formulary
01/01/2014
LIPOFEN
fenofibrate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LIPOFEN
fenofibrate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LITHOBID
lithium carbonate
01/01/2014
LIVALO
01/01/2014
ADD TO FORMULARY
Non-Formulary
pitavastatin calcium
CHANGE TIER
Non-Formulary
LIVALO
pitavastatin calcium
CHANGE TIER
Non-Formulary
01/01/2014
LUPANETA
PACK
leuprolide
acetate/norethindrone
acetate
CHANGE TIER
01/01/2014
LYSTEDA
tranexamic acid
CHANGE TIER
01/01/2014
MACUGEN
pegaptanib sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
MAKENA
hydroxyprogesterone
caproate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
MENOSTAR
estradiol
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
MENTAX
butenafine hcl
01/01/2014
METHYLIN
methylphenidate hcl
Preferred Brands
Non-Formulary
ADD TO FORMULARY
CHANGE TIER
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 5
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Non-Formulary
01/01/2014
METHYLIN
methylphenidate hcl
CHANGE TIER
01/01/2014
METHYLIN
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
METHYLIN
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
MONONINE
factor ix
ADD TO FORMULARY
Non-Formulary
01/01/2014
mononessa
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
mononessa
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
MORGIDOX
doxycycline hyclate/skin
cleanser comb no.19
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
MORGIDOX
doxycycline hyclate/skin
cleanser comb no.19
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NATA
KOMPLETE
prenatal vitamin #50/iron
fumarate,bisglycinate/folic
acid
ADD TO FORMULARY
Non-Formulary
01/01/2014
NATA
KOMPLETE
prenatal vitamin #50/iron
fumarate,bisglycinate/folic
acid
ADD UM: GENDER
Female
01/01/2014
NEEVODHA
prenatal no.64/iron fum/lmefolate ca/algal oil/soy
lecithin
CHANGE TIER
01/01/2014
NEEVO DHA
prenatal vitamin comb
no.79/iron
fumarat/fa/lmefolate ca/dha
ADD TO FORMULARY
Non-Formulary
01/01/2014
NEUPRO
rotigotine
ADD TO FORMULARY
Non-Formulary
01/01/2014
NEUPRO
rotigotine
ADD TO FORMULARY
Non-Formulary
01/01/2014
NEUPRO
rotigotine
ADD TO FORMULARY
Non-Formulary
01/01/2014
NEUPRO
rotigotine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NEUPRO
rotigotine
CHANGE TIER
Preferred Brands
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 6
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
NEUPRO
rotigotine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NICAZEL FORTE niacinamide/azelaic
ac/quercet/turmer/fa/b6/zinc
ox/copper
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NICAZEL
niacinamide/azelaic
acid/zinc oxide/vit
b6/copper/fa
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NIRAVAM
alprazolam
ADD TO FORMULARY
Non-Formulary
01/01/2014
NIRAVAM
alprazolam
ADD TO FORMULARY
Non-Formulary
01/01/2014
NIRAVAM
alprazolam
ADD TO FORMULARY
Non-Formulary
01/01/2014
NIRAVAM
alprazolam
ADD TO FORMULARY
Non-Formulary
01/01/2014
normlgel ag
silver carbonate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NUEDEXTA
dextromethorphan
hbr/quinidine sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NUOX
benzoyl peroxide/sulfur
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NUVAIL
poly-ureaurethane
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NUVARING
etonogestrel/ethinyl estradiol
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NUVARING
etonogestrel/ethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
nuzole
miconazole nitrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
onetouch ultra
test strips
blood sugar diagnostic
CHANGE TIER
Non-Formulary
01/01/2014
onetouch verio
blood sugar diagnostic
CHANGE TIER
Non-Formulary
01/01/2014
ORAFATE
sucralfate malate,
polymerized
CHANGE TIER
01/01/2014
OXYTROL
oxybutynin
CHANGE TIER
Non-Formulary
01/01/2014
OXYTROL FOR
WOMEN
oxybutynin
ADD TO FORMULARY
Generics
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 7
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
PEDIATEX TD
triprolidine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Not Covered
01/01/2014
PENLAC
ciclopirox
ADD TO FORMULARY
Non-Formulary
01/01/2014
precision xtra
blood sugar diagnostic
CHANGE TIER
01/01/2014
precision xtra
blood ketone test,strips
ADD TO FORMULARY
01/01/2014
precision q-i-d
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
precision pcx
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
precision pcx
plus
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
precision point of blood sugar diagnostic
care
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
PROVENTIL
HFA
CHANGE TIER
01/01/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
CHANGE TIER
01/01/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
ADD TO FORMULARY
01/01/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
CHANGE TIER
01/01/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
ADD TO FORMULARY
01/01/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
CHANGE TIER
01/01/2014
REMESENSE
potassium oxalate
01/01/2014
REMICADE
infliximab
01/01/2014
RILUTEK
riluzole
ADD TO FORMULARY
Non-Formulary
01/01/2014
SALAGEN
pilocarpine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
SALAGEN
pilocarpine hcl
ADD TO FORMULARY
Non-Formulary
albuterol sulfate
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
ADD TO FORMULARY
CHANGE TIER
Non-Formulary
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 8
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Non-Formulary
01/01/2014
SANCTURA
trospium chloride
CHANGE TIER
01/01/2014
SANCTURA XR
trospium chloride
ADD TO FORMULARY
01/01/2014
SAPHRIS
asenapine maleate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
SAPHRIS
asenapine maleate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
SAPHRIS
asenapine maleate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
SAPHRIS
asenapine maleate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
se bpo
benzoyl peroxide
microspheres
ADD TO FORMULARY
Non-Formulary
01/01/2014
se bpo
benzoyl peroxide
microspheres
ADD TO FORMULARY
Non-Formulary
01/01/2014
SEMPREX-D
pseudoephedrine
hcl/acrivastine
ADD TO FORMULARY
Non-Formulary
01/01/2014
SENTRA AM
aa comb.no9/acetylcarnitine
hcl/dextrose/cocoa/hrb
cb127
ADD TO FORMULARY
Non-Formulary
01/01/2014
SENTRA PM
aa comb.no9/acetylcarnitine
hcl/dextrose/cocoa/hrb
cb128
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
sodium
sulfacetamidesulfur
sulfacetamide
sodium/sulfur/urea
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
SOLARAZE
diclofenac sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
stagesic
hydrocodone
bitartrate/acetaminophen
ADD TO FORMULARY
Non-Formulary
01/01/2014
symbyax,olanzap olanzapine/fluoxetine hcl
ine-fluoxetine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
TESTOPEL
testosterone
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
TEV-TROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
THALITONE
chlorthalidone
Non-Formulary
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 9
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
THERAMINE
choline bitartrate/aa
comb10/g-aminobuty
acid/hrb cb129
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
TINDAMAX
tinidazole
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
TINDAMAX
tinidazole
ADD TO FORMULARY
Non-Formulary
01/01/2014
TRELSTAR
triptorelin pamoate
ADD TO FORMULARY
Non-Formulary
01/01/2014
TRELSTAR
triptorelin pamoate
ADD TO FORMULARY
Non-Formulary
01/01/2014
TRELSTAR
triptorelin pamoate
ADD TO FORMULARY
Non-Formulary
01/01/2014
TRELSTAR
triptorelin pamoate
ADD TO FORMULARY
Non-Formulary
01/01/2014
TRELSTAR
triptorelin pamoate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
TRELSTAR
triptorelin pamoate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
TRETIN-X
tretinoin
CHANGE TIER
01/01/2014
TRETIN-X
tretinoin
CHANGE TIER
01/01/2014
TRICODE AR
chlorpheniramine
maleate/pseudoephedrine
hcl/codeine
ADD TO FORMULARY
Non-Formulary
01/01/2014
TRICODE GF
pseudoephedrine
hcl/codeine
phosphate/guaifenesin
ADD TO FORMULARY
Preferred Brands
01/01/2014
truetrack test
strip
blood sugar diagnostic
CHANGE TIER
Non-Formulary
01/01/2014
truetest test strips blood sugar diagnostic
CHANGE TIER
Non-Formulary
01/01/2014
TUSSIONEX
hydrocodone
polistirex/chlorpheniramine
polistirex
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
VANOS
fluocinonide
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
VELTIN
clindamycin
phosphate/tretinoin
Non-Formulary
Preferred Brands
ADD TO FORMULARY
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 10
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Non-Formulary
01/01/2014
VIRAMUNE XR
nevirapine
CHANGE TIER
01/01/2014
VIRAMUNE XR
nevirapine
ADD TO FORMULARY
01/01/2014
VOSPIRE ER
albuterol sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
VOSPIRE ER
albuterol sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
VPRIV
velaglucerase alfa
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XOPENEX
levalbuterol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XOPENEX
levalbuterol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XOPENEX
levalbuterol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XOPENEX
levalbuterol hcl
CONCENTRATE
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XOPENEX HFA
levalbuterol tartrate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ZUTRIPRO
hydrocodone
bitart/chlorpheniramine
maleate/pseudoephedrine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
aspirin
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
aspirin
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
aspirin
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
aspirin ec
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
aspirin ec
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
aspirin ec
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
aspir-trin
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
aspir-trin
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
aspir-trin
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
ecpirin
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
ecpirin
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ecpirin
aspirin
ADD UM: AGE
45 to 79 yrs old
Not Covered
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 11
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
lite coat aspirin
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
lite coat aspirin
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
lite coat aspirin
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
low dose aspirin
ec
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
low dose aspirin
ec
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
low dose aspirin
ec
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
aspir-low
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
aspir-low
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
aspir-low
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
aspirin ec
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
aspirin ec
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
aspirin ec
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
aspir 81
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
aspir 81
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
aspir 81
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
aspirin ec
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
aspirin ec
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
aspirin ec
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
aspirin ec,lo-dose aspirin
aspirin ec
ADD TO FORMULARY
Preventative
01/01/2014
aspirin ec,lo-dose aspirin
aspirin ec
ADD UM: QUANTITY
30 / 30 days
01/01/2014
aspirin ec,lo-dose aspirin
aspirin ec
ADD UM: AGE
45 to 79 yrs old
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 12
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
adult low dose
aspirin ec
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
adult low dose
aspirin ec
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
adult low dose
aspirin ec
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
miniprin
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
miniprin
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
miniprin
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
folic acid
folic acid
ADD TO FORMULARY
Preventative
01/01/2014
folic acid
folic acid
ADD UM: QUANTITY
30 / 30 days
01/01/2014
folic acid
folic acid
ADD UM: AGE
12 to 60 yrs old
01/01/2014
folic acid
folic acid
ADD UM: GENDER
Female
01/01/2014
folic acid
folic acid
ADD TO FORMULARY
Preventative
01/01/2014
folic acid
folic acid
ADD UM: QUANTITY
30 / 30 days
01/01/2014
folic acid
folic acid
ADD UM: AGE
12 to 60 yrs old
01/01/2014
folic acid
folic acid
ADD UM: GENDER
Female
01/01/2014
ferrous
ferrous sulfate
sulfate,children's
ferrous sulfate
ADD TO FORMULARY
Preventative
01/01/2014
ferrous
ferrous sulfate
sulfate,children's
ferrous sulfate
ADD UM: QUANTITY
50 / 30 days
01/01/2014
ferrous
ferrous sulfate
sulfate,children's
ferrous sulfate
ADD UM: AGE
0.6 to 1 yrs old
01/01/2014
fer-iron
ferrous sulfate
ADD TO FORMULARY
Preventative
01/01/2014
fer-iron
ferrous sulfate
ADD UM: QUANTITY
50 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 13
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
fer-iron
ferrous sulfate
ADD UM: AGE
0.6 to 1 yrs old
01/01/2014
children's iron
ferrous sulfate
ADD TO FORMULARY
Preventative
01/01/2014
children's iron
ferrous sulfate
ADD UM: QUANTITY
50 / 30 days
01/01/2014
children's iron
ferrous sulfate
ADD UM: AGE
0.6 to 1 yrs old
01/01/2014
sodium fluoride
sodium fluoride
ADD TO FORMULARY
Preventative
01/01/2014
sodium fluoride
sodium fluoride
ADD UM: QUANTITY
50 / 30 days
01/01/2014
sodium fluoride
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
sodium fluoride
sodium fluoride
ADD TO FORMULARY
Preventative
01/01/2014
sodium fluoride
sodium fluoride
ADD UM: QUANTITY
30 / 30 days
01/01/2014
sodium fluoride
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
fluoride,sodium
fluoride
sodium fluoride
ADD TO FORMULARY
Preventative
01/01/2014
fluoride,sodium
fluoride
sodium fluoride
ADD UM: QUANTITY
30 / 30 days
01/01/2014
fluoride,sodium
fluoride
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
ludent fluoride
sodium fluoride
ADD TO FORMULARY
Preventative
01/01/2014
ludent fluoride
sodium fluoride
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ludent fluoride
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
fluoride
sodium fluoride
ADD TO FORMULARY
Preventative
01/01/2014
fluoride
sodium fluoride
ADD UM: QUANTITY
30 / 30 days
01/01/2014
fluoride
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
ludent fluoride
sodium fluoride
ADD TO FORMULARY
Preventative
01/01/2014
ludent fluoride
sodium fluoride
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ludent fluoride
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
fluoritab
sodium fluoride
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 14
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
fluoritab
sodium fluoride
ADD UM: QUANTITY
30 / 30 days
01/01/2014
fluoritab
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
sodium
fluoride,fluoride
sodium fluoride
ADD TO FORMULARY
Preventative
01/01/2014
sodium
fluoride,fluoride
sodium fluoride
ADD UM: QUANTITY
30 / 30 days
01/01/2014
sodium
fluoride,fluoride
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
ludent fluoride
sodium fluoride
ADD TO FORMULARY
Preventative
01/01/2014
ludent fluoride
sodium fluoride
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ludent fluoride
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
revatio,viagra,sild sildenafil citrate
enafil,sildenafil
citrate
ADD UM: QUANTITY
6 / 30 days
01/01/2014
CIALIS,ADCIRC
A
ADD UM: QUANTITY
6 / 30 days
01/01/2014
LEVITRA,STAXY vardenafil hcl
N
ADD UM: QUANTITY
6 / 30 days
01/01/2014
prostin vr
alprostadil
pediatric,caverjec
t,muse,alprostadil
,edex,prostaglan
din e1
ADD UM: QUANTITY
6 / 30 days
01/01/2014
CAVERJECT
alprostadil
CHANGE TIER
Non-Formulary
01/01/2014
CAVERJECT
alprostadil
ADD UM: GENDER
Male
01/01/2014
prostin vr
alprostadil
pediatric,caverjec
t,muse,alprostadil
,edex,prostaglan
din e1
ADD UM: GENDER
Male
tadalafil
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 15
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Non-Formulary
01/01/2014
CAVERJECT
alprostadil
CHANGE TIER
01/01/2014
alprostadil
alprostadil
ADD TO FORMULARY
Not Covered
01/01/2014
prostaglandin e1 alprostadil
ADD TO FORMULARY
Not Covered
01/01/2014
PROSTIN VR
PEDIATRIC
alprostadil
ADD TO FORMULARY
Not Covered
01/01/2014
STENDRA
avanafil
ADD UM: GENDER
Female
01/01/2014
minitran
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
minitran
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
minitran
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
NITRO-BID
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
minitran
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
STENDRA
avanafil
ADD UM: QUANTITY
6 / 30 days
01/01/2014
STENDRA
avanafil
ADD UM: GENDER
Male
01/01/2014
STENDRA
avanafil
ADD UM: QUANTITY
6 / 30 days
01/01/2014
STENDRA
avanafil
ADD UM: QUANTITY
6 / 30 days
01/01/2014
STENDRA
avanafil
ADD UM: GENDER
Male
01/01/2014
isoxsuprine hcl
isoxsuprine hcl
ADD TO FORMULARY
Generics
01/01/2014
isosorbide
isosorbide dinitrate
dinitrate,isochron,
isoditrate,dilatrate
-sr,isordil
titradose,isordil
ADD TO FORMULARY
Generics
01/01/2014
ISORDIL
TITRADOSE
ADD TO FORMULARY
Non-Formulary
01/01/2014
caduet,amlodipin amlodipine
e-atorvastatin
besylate/atorvastatin
calcium
CHANGE TIER
Non-Formulary
isosorbide dinitrate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 16
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Generics
01/01/2014
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Generics
01/01/2014
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Generics
01/01/2014
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Generics
01/01/2014
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Generics
01/01/2014
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Generics
01/01/2014
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Generics
01/01/2014
caduet,amlodipin amlodipine
e-atorvastatin
besylate/atorvastatin
calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
01/01/2014
PLAN B ONESTEP
levonorgestrel
ADD TO FORMULARY
Non-Formulary
ADD UM: QUANTITY
Generics
12 / 365 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 17
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
provera,depomedroxyprogesterone
provera,depoacetate
subq provera
104,medroxyprog
esterone acetate
ADD UM: QUANTITY
1 / 75 days
01/01/2014
provera,depomedroxyprogesterone
provera,depoacetate
subq provera
104,medroxyprog
esterone acetate
ADD UM: GENDER
Female
01/01/2014
DEPOPROVERA
01/01/2014
medroxyprogeste medroxyprogesterone
rone acetate
acetate
01/01/2014
DEPOPROVERA
01/01/2014
medroxyprogeste medroxyprogesterone
rone acetate
acetate
ADD TO FORMULARY
Preventative
01/01/2014
clopidogrel
clopidogrel bisulfate
ADD TO FORMULARY
Generics
01/01/2014
clopidogrel
clopidogrel bisulfate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
clopidogrel
clopidogrel bisulfate
ADD TO FORMULARY
Generics
01/01/2014
surestep pro
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
freestyle test
strips
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
optium
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
accu-chek active blood sugar diagnostic
01/01/2014
evencare
medroxyprogesterone
acetate
medroxyprogesterone
acetate
blood sugar diagnostic
CHANGE TIER
Preferred Brands
ADD TO FORMULARY
CHANGE TIER
Preventative
Preferred Brands
ADD TO FORMULARY
CHANGE TIER
Non-Formulary
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 18
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
blood glucose
blood sugar diagnostic
test,glucose test
strip,premium
blood glucose
test,blood
glucose test strip
01/01/2014
accu-chek
comfort curve
01/01/2014
Type of Change
Previous Value
New Value
CHANGE TIER
Non-Formulary
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
ultima
blood sugar diagnostic
CHANGE TIER
Non-Formulary
01/01/2014
easygluco test
strips
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ez smart
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
control ast test
strip,control
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
accu-chek aviva
blood sugar diagnostic
ADD TO FORMULARY
01/01/2014
ez smart plus
blood sugar diagnostic
CHANGE TIER
01/01/2014
contour
blood sugar diagnostic
ADD TO FORMULARY
Preferred Brands
01/01/2014
smartest test
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
01/01/2014
rightest gs300
test strips
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
01/01/2014
nova max
glucose test
strips
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
freestyle lite
strips,freestyle
lite test strips
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
advocate test
strip
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
01/01/2014
assure pro
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 19
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
easygluco test
blood sugar diagnostic
strips,easy gluco
g2
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
g-4
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
clever choice
voice+ tst strip
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
surechek test
strips
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
01/01/2014
microdot
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
01/01/2014
easy check test
strip
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 20
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
01/01/2014
Brand Name
Generic Name
contour,contour blood sugar diagnostic
next,bgstar,assure
pro,assure
platinum,assure
4,glucocard
expression,relion
prime test
strips,micro,relion
confirmmicro,glucocard
01 sensor
plus,glucocard
vital,glucocard
vital
sensor,evencare
g2,evencare,eve
ncare
g3,easygluco test
strips,easy gluco
g2,control
g3,control ast test
strip,control,g4,maxima,infinity
test strips,acura
test
strips,easygluco
plus,prodigy no
coding,easy
touch test
strip,eclipse,envis
ion,evolution test
strips,element
test
strips,smartdiabet
es xpres,element
plus,glucolab,sm
artest
test,glucocom
Type of Change
Previous Value
CHANGE TIER
New Value
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 21
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
glucose,rightest
gs300 test
strips,rightest
gs100 test
strips,rightest
gs550 test
strips,ge100
blood glucose
test strip,nova
max glucose test
strips,keynote,wa
vesense
jazz,wavesense
presto,agamatrix
amp,blood
glucose
test,liberty test
strips,ultratrak,ult
ratrak
ultimate,solus v2
test
strips,caresens
n,smart caresens
n,reveal test
strip,glucose test
strip,truetest test
strips,truetrack
test
strip,premium
blood glucose
test,foracare
gd20,fora
v10,choicedm
g20,fora g20,fora
test strip,fora
g71a,foracare
gd40,premium
v10,fora
v12,refuah
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 22
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
plus,surechek
test strips,sure
edge test
strips,vocal
point,truetrack
smart
system,easymax,
easymax
15,myglucohealth
,accu-chek
comfort
curve,accu-chek
active,microdot,m
icrodot xtra,ez
smart,ez smart
plus,onetouch
ultra test
strips,onetouch
verio,surestep
pro,precision pcx
plus,precision
point of
care,optium
ez,precision q-id,precision
pcx,optium,precis
ion xtra,neutek
2tek test
strips,telcare,sure
-test easyplus
mini,accu-chek
aviva,accutrend
glucose,accuchek aviva
plus,accu-chek
smartview,ultima,
on call plus test
strip,on call vivid
test strip,gmate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 23
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
test strips,gluco
navii,choicedm
clarus test
strips,quintet,quin
tet ac,easy
step,easy
plus,easy
trak,easy
talk,easy plus
ii,easy check test
strip,fifty50 test
strip,embrace,vict
ory,advocate test
strip,advocate
redicode,advocate
redi-code+,clever
choice test
strips,clever
choice voice+ tst
strip,clever
choice
pro,pharmacist
choice,clever
choice micro test
strip,clever
choice talk,fora
d10,fora
d15c,fora
d15z,fora
v20,fora v22,fora
g30a,fora
d15g,fora
d20,fora g90,fora
v30a,freestyle
test
strips,freestyle
lite
strips,freestyle
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 24
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lite test
strips,freestyle
insulinx test
strips,freestyle
insulinx,test
n'go,optumrx,ele
ment
compact,blood
glucose test
strip,diatrue
plus,td gold test
strip,rightest
gs260 test
strips,rightest
gs250s test
strips,smart
sense test
strips,genstrip,uni
strip1,embrace
evo,embrace
pro,on call
express test
strip,healthpro
test strips
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 25
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
01/01/2014
Brand Name
Generic Name
contour,contour blood sugar diagnostic
next,bgstar,assure
pro,assure
platinum,assure
4,glucocard
expression,relion
prime test
strips,micro,relion
confirmmicro,glucocard
01 sensor
plus,glucocard
vital,glucocard
vital
sensor,evencare
g2,evencare,eve
ncare
g3,easygluco test
strips,easy gluco
g2,control
g3,control ast test
strip,control,g4,maxima,infinity
test strips,acura
test
strips,easygluco
plus,prodigy no
coding,easy
touch test
strip,eclipse,envis
ion,evolution test
strips,element
test
strips,smartdiabet
es xpres,element
plus,glucolab,sm
artest
test,glucocom
Type of Change
Previous Value
ADD UM: QUANTITY
New Value
100 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 26
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
glucose,rightest
gs300 test
strips,rightest
gs100 test
strips,rightest
gs550 test
strips,ge100
blood glucose
test strip,nova
max glucose test
strips,keynote,wa
vesense
jazz,wavesense
presto,agamatrix
amp,blood
glucose
test,liberty test
strips,ultratrak,ult
ratrak
ultimate,solus v2
test
strips,caresens
n,smart caresens
n,reveal test
strip,glucose test
strip,truetest test
strips,truetrack
test
strip,premium
blood glucose
test,foracare
gd20,fora
v10,choicedm
g20,fora g20,fora
test strip,fora
g71a,foracare
gd40,premium
v10,fora
v12,refuah
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 27
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
plus,surechek
test strips,sure
edge test
strips,vocal
point,truetrack
smart
system,easymax,
easymax
15,myglucohealth
,accu-chek
comfort
curve,accu-chek
active,microdot,m
icrodot xtra,ez
smart,ez smart
plus,onetouch
ultra test
strips,onetouch
verio,surestep
pro,precision pcx
plus,precision
point of
care,optium
ez,precision q-id,precision
pcx,optium,precis
ion xtra,neutek
2tek test
strips,telcare,sure
-test easyplus
mini,accu-chek
aviva,accutrend
glucose,accuchek aviva
plus,accu-chek
smartview,ultima,
on call plus test
strip,on call vivid
test strip,gmate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 28
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
test strips,gluco
navii,choicedm
clarus test
strips,quintet,quin
tet ac,easy
step,easy
plus,easy
trak,easy
talk,easy plus
ii,easy check test
strip,fifty50 test
strip,embrace,vict
ory,advocate test
strip,advocate
redicode,advocate
redi-code+,clever
choice test
strips,clever
choice voice+ tst
strip,clever
choice
pro,pharmacist
choice,clever
choice micro test
strip,clever
choice talk,fora
d10,fora
d15c,fora
d15z,fora
v20,fora v22,fora
g30a,fora
d15g,fora
d20,fora g90,fora
v30a,freestyle
test
strips,freestyle
lite
strips,freestyle
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 29
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lite test
strips,freestyle
insulinx test
strips,freestyle
insulinx,test
n'go,optumrx,ele
ment
compact,blood
glucose test
strip,diatrue
plus,td gold test
strip,rightest
gs260 test
strips,rightest
gs250s test
strips,smart
sense test
strips,genstrip,uni
strip1,embrace
evo,embrace
pro,on call
express test
strip,healthpro
test strips
01/01/2014
contour
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
contour next
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
breeze 2
blood sugar diagnostic, disctype
ADD TO FORMULARY
Preferred Brands
01/01/2014
breeze 2
blood sugar diagnostic, disctype
ADD UM: QUANTITY
100 / 30 days
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD TO FORMULARY
Generics
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD UM: QUANTITY
18 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 30
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD TO FORMULARY
Generics
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD UM: QUANTITY
18 / 30 days
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD TO FORMULARY
Generics
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD TO FORMULARY
Generics
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD UM: QUANTITY
18 / 30 days
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD TO FORMULARY
Generics
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD TO FORMULARY
Generics
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD TO FORMULARY
Generics
01/01/2014
sumatriptan
succinate
sumatriptan succinate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
sumatriptan
sumatriptan
ADD TO FORMULARY
Generics
01/01/2014
sumatriptan
sumatriptan
ADD UM: QUANTITY
6 / 30 days
01/01/2014
sumatriptan
sumatriptan
ADD TO FORMULARY
Generics
01/01/2014
sumatriptan
sumatriptan
ADD UM: QUANTITY
6 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 31
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
kariva
desogestrel-ethinyl
estradiol/ethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
kariva
desogestrel-ethinyl
estradiol/ethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
kariva,mircette,az desogestrel-ethinyl
urette,viorele,pim estradiol/ethinyl estradiol
trea
CHANGE TIER
Preventative
01/01/2014
kariva,mircette,az desogestrel-ethinyl
urette,viorele,pim estradiol/ethinyl estradiol
trea
ADD UM: GENDER
Female
01/01/2014
MIRCETTE
01/01/2014
desogen,apri,em desogestrel-ethinyl estradiol
oquette,orthocept,reclipsen,en
skyce,desogestre
l-ethinyl estradiol
CHANGE TIER
Preventative
01/01/2014
desogen,apri,em desogestrel-ethinyl estradiol
oquette,orthocept,reclipsen,en
skyce,desogestre
l-ethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
DESOGEN
desogestrel-ethinyl estradiol
CHANGE TIER
01/01/2014
ORTHO-CEPT
desogestrel-ethinyl estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
cyclessa,velivet,c desogestrel-ethinyl estradiol
aziant
CHANGE TIER
Preventative
01/01/2014
cyclessa,velivet,c desogestrel-ethinyl estradiol
aziant
ADD UM: GENDER
Female
desogestrel-ethinyl
estradiol/ethinyl estradiol
CHANGE TIER
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 32
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ocella,syeda,yas ethinyl
min
estradiol/drospirenone
28,zarah,drospire
none-ethinyl
estradiol
CHANGE TIER
Non-Formulary
01/01/2014
ocella,syeda,yas ethinyl
min
estradiol/drospirenone
28,zarah,drospire
none-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
NATAZIA
estradiol valerate/dienogest
CHANGE TIER
01/01/2014
NATAZIA
estradiol valerate/dienogest
ADD UM: GENDER
Female
01/01/2014
BEYAZ
drospirenone/ethinyl
estradiol/levomefolate
calcium
ADD UM: GENDER
Female
01/01/2014
YAZ
ethinyl
estradiol/drospirenone
CHANGE TIER
01/01/2014
YAZ
ethinyl
estradiol/drospirenone
ADD UM: GENDER
01/01/2014
ocella
ethinyl
estradiol/drospirenone
ADD TO FORMULARY
01/01/2014
gianvi
ethinyl
estradiol/drospirenone
ADD TO FORMULARY
Generics
01/01/2014
gianvi
ethinyl
estradiol/drospirenone
ADD UM: GENDER
Female
01/01/2014
loryna
ethinyl
estradiol/drospirenone
ADD TO FORMULARY
Preventative
01/01/2014
loryna
ethinyl
estradiol/drospirenone
ADD UM: GENDER
Female
01/01/2014
kelnor 1-35,zovia ethynodiol diacetate-ethinyl
1-35e
estradiol
ADD TO FORMULARY
Preventative
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
Female
Non-Formulary
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 33
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
kelnor 1-35,zovia ethynodiol diacetate-ethinyl
1-35e
estradiol
01/01/2014
zovia 1-50e
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
ethynodiol diacetate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
zovia 1-50e
ethynodiol diacetate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
SAFYRAL
drospirenone/ethinyl
estradiol/levomefolate
calcium
CHANGE TIER
01/01/2014
SAFYRAL
drospirenone/ethinyl
estradiol/levomefolate
calcium
ADD UM: GENDER
Female
01/01/2014
vestura
ethinyl
estradiol/drospirenone
ADD TO FORMULARY
Preventative
01/01/2014
vestura
ethinyl
estradiol/drospirenone
ADD UM: GENDER
Female
01/01/2014
SEASONIQUE
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
CHANGE TIER
01/01/2014
SEASONIQUE
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
levonorg-eth
levonorgestrel/ethinyl
estrad eth estrad estradiol and ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
levonorg-eth
levonorgestrel/ethinyl
estrad eth estrad estradiol and ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
LOSEASONIQU levonorgestrel/ethinyl
E
estradiol and ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 34
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
LOSEASONIQU levonorgestrel/ethinyl
E
estradiol and ethinyl
estradiol
01/01/2014
amethia
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD TO FORMULARY
Preventative
amethia
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
camrese
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
camrese
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
daysee
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
daysee
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
QUARTETTE
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
QUARTETTE
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
lessina,aviane,or levonorgestrel-ethinyl
sythia,falmina,lut estradiol
era,sronyx,levono
rgestrel-eth
estradiol,aubra
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 35
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
lessina,aviane,or levonorgestrel-ethinyl
sythia,falmina,lut estradiol
era,sronyx,levono
rgestrel-eth
estradiol,aubra
ADD UM: GENDER
Female
01/01/2014
camrese
levonorgestrel/ethinyl
lo,loseasonique,a estradiol and ethinyl
methia
estradiol
lo,levonorg-eth
estrad eth estrad
ADD TO FORMULARY
Preventative
01/01/2014
camrese
levonorgestrel/ethinyl
lo,loseasonique,a estradiol and ethinyl
methia
estradiol
lo,levonorg-eth
estrad eth estrad
ADD UM: GENDER
Female
01/01/2014
NORDETTE-28
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
NORDETTE-28
levonorgestrel-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
levora-28
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
levora-28
levonorgestrel-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
portia
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
portia
levonorgestrel-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
enpresse
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
enpresse
levonorgestrel-ethinyl
estradiol
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 36
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
jolessa,introvale, levonorgestrel-ethinyl
quasense,levonor estradiol
gestrel-eth
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
jolessa,introvale, levonorgestrel-ethinyl
quasense,levonor estradiol
gestrel-eth
estradiol
ADD UM: GENDER
Female
01/01/2014
levonorgestrellevonorgestrel-ethinyl
eth
estradiol
estradiol,portia,alt
avera,chateal,nor
dette-28,levora28,kurvelo,marlis
sa
ADD TO FORMULARY
Preventative
01/01/2014
levonorgestrellevonorgestrel-ethinyl
eth
estradiol
estradiol,portia,alt
avera,chateal,nor
dette-28,levora28,kurvelo,marlis
sa
ADD UM: GENDER
Female
01/01/2014
next
levonorgestrel
choice,levonorge
strel
ADD TO FORMULARY
Preventative
01/01/2014
next
levonorgestrel
choice,levonorge
strel
ADD UM: GENDER
Female
01/01/2014
SKYLA
levonorgestrel
CHANGE TIER
01/01/2014
SKYLA
levonorgestrel
ADD UM: GENDER
Female
01/01/2014
ORTHO EVRA
norelgestromin/ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ORTHO EVRA
norelgestromin/ethinyl
estradiol
ADD UM: GENDER
Female
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 37
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
xulane
norelgestromin/ethinyl
estradiol
ADD TO FORMULARY
Generics
01/01/2014
xulane
norelgestromin/ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
PLAN B ONESTEP
levonorgestrel
ADD TO FORMULARY
Non-Formulary
01/01/2014
next choice one
dose
levonorgestrel
ADD TO FORMULARY
Generics
01/01/2014
next choice one
dose
levonorgestrel
ADD UM: GENDER
Female
01/01/2014
junel fe,gildess
fe,loestrin
fe,microgestin
fe,larin fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
01/01/2014
junel fe,gildess
fe,loestrin
fe,microgestin
fe,larin fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
estrostep fe,trilegest fe,tilia fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
01/01/2014
estrostep fe,trilegest fe,tilia fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
loestrin 24
fe,lomedia 24 fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
Preventative
01/01/2014
loestrin 24
fe,lomedia 24 fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
gianvi
ethinyl
estradiol/drospirenone
CHANGE TIER
Generics
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 38
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
trivora-28
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
trivora-28
levonorgestrel-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
amethyst
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
amethyst
levonorgestrel-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
levonest
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
levonest
levonorgestrel-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
levonorgestrel
levonorgestrel
ADD TO FORMULARY
Preventative
01/01/2014
levonorgestrel
levonorgestrel
ADD UM: GENDER
Female
01/01/2014
LOESTRIN FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Non-Formulary
01/01/2014
LOESTRIN FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
microgestin fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
01/01/2014
microgestin fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
junel fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 39
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
junel fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
LO LOESTRIN
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
01/01/2014
LO LOESTRIN
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
01/01/2014
MINASTRIN 24
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
01/01/2014
MINASTRIN 24
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
LO MINASTRIN
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Non-Formulary
01/01/2014
LO MINASTRIN
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
LOESTRIN
norethindrone acetateethinyl estradiol
CHANGE TIER
01/01/2014
LOESTRIN
norethindrone acetateethinyl estradiol
ADD UM: GENDER
01/01/2014
LOESTRIN
norethindrone acetateethinyl estradiol
CHANGE TIER
01/01/2014
LOESTRIN
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
microgestin
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
Preferred Brands
Non-Formulary
Female
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
Female
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 40
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
microgestin
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
microgestin
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
microgestin
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
gildess
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
gildess
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
larin
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
larin
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
FEMCON FE
norethindrone-ethinyl
estradiol/ferrous fumarate
CHANGE TIER
01/01/2014
FEMCON FE
norethindrone-ethinyl
estradiol/ferrous fumarate
ADD UM: GENDER
01/01/2014
zeosa
norethindrone-ethinyl
estradiol/ferrous fumarate
CHANGE TIER
01/01/2014
zeosa
norethindrone-ethinyl
estradiol/ferrous fumarate
ADD UM: GENDER
01/01/2014
GENERESS FE
norethindrone-ethinyl
estradiol/ferrous fumarate
CHANGE TIER
01/01/2014
GENERESS FE
norethindrone-ethinyl
estradiol/ferrous fumarate
ADD UM: GENDER
01/01/2014
wymzya fe
norethindrone-ethinyl
estradiol/ferrous fumarate
CHANGE TIER
01/01/2014
wymzya fe
norethindrone-ethinyl
estradiol/ferrous fumarate
ADD UM: GENDER
Preferred Brands
Non-Formulary
Female
Preferred Brands
Preventative
Female
Preferred Brands
Non-Formulary
Female
Preferred Brands
Non-Formulary
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 41
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ORTHO-NOVUM norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ORTHO-NOVUM norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
PLAN B ONESTEP
levonorgestrel
ADD UM: GENDER
Female
01/01/2014
gildess fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
01/01/2014
gildess fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
junel
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
junel
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
junel
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
junel
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
gildess
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
gildess
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
zenchent fe
norethindrone-ethinyl
estradiol/ferrous fumarate
CHANGE TIER
Preventative
01/01/2014
zenchent fe
norethindrone-ethinyl
estradiol/ferrous fumarate
ADD UM: GENDER
Female
01/01/2014
MODICON
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 42
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
MODICON
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
NORINYL 1+35
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
NORINYL 1+35
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
BREVICON
norethindrone-ethinyl
estradiol
CHANGE TIER
01/01/2014
BREVICON
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
TRI-NORINYL
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
TRI-NORINYL
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
necon
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
necon
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
nortrel
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
nortrel
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
necon
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
necon
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
myzilra
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
myzilra
levonorgestrel-ethinyl
estradiol
ADD UM: GENDER
Female
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 43
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
LOESTRIN FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
Preventative
Non-Formulary
01/01/2014
ESTROSTEP FE norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
Preventative
Non-Formulary
01/01/2014
larin fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
01/01/2014
larin fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/01/2014
ORTHO-NOVUM norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ORTHO-NOVUM norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
OVCON-35
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
nortrel
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
nortrel
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
necon
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
necon
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
necon
norethindrone-ethinyl
estradiol
CHANGE TIER
01/01/2014
necon
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Preferred Brands
Preventative
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 44
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
nortrel
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
nortrel
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
aranelle
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
aranelle
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
balziva
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
balziva
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
leena
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
leena
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
zenchent
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
zenchent
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
briellyn
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
briellyn
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
alyacen
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
alyacen
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
alyacen
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 45
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
alyacen
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
philith
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
philith
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
wera
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
wera
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
my way,plan b
levonorgestrel
one-step,next
choice one
dose,levonorgest
rel
CHANGE UM: GENDER
Female
01/01/2014
my way,plan b
levonorgestrel
one-step,next
choice one
dose,levonorgest
rel
CHANGE UM: QUANTITY
23 / 365 days
01/01/2014
my way
levonorgestrel
ADD TO FORMULARY
Generics
01/01/2014
nortrel
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
nortrel
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
cyclafem
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
cyclafem
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
cyclafem
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 46
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
cyclafem
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
dasetta
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
dasetta
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
dasetta
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
dasetta
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
gildagia
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
gildagia
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
pirmella
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
pirmella
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
NORINYL 1+50
norethindrone-mestranol
CHANGE TIER
01/01/2014
NORINYL 1+50
norethindrone-mestranol
ADD UM: GENDER
01/01/2014
necon
norethindrone-mestranol
CHANGE TIER
01/01/2014
necon
norethindrone-mestranol
ADD UM: GENDER
Female
01/01/2014
NOR-Q-D
norethindrone
ADD TO FORMULARY
Non-Formulary
01/01/2014
NOR-Q-D
norethindrone
ADD UM: GENDER
Female
01/01/2014
necon
norethindrone-mestranol
01/01/2014
ORTHO
MICRONOR
norethindrone
ADD TO FORMULARY
Preventative
01/01/2014
ORTHO
MICRONOR
norethindrone
ADD UM: GENDER
Female
CHANGE TIER
Preferred Brands
Non-Formulary
Female
Preferred Brands
Preferred Brands
Preventative
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 47
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
camila
norethindrone
ADD TO FORMULARY
Preventative
01/01/2014
camila
norethindrone
ADD UM: GENDER
Female
01/01/2014
pirmella
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
pirmella
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
vyfemla
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
vyfemla
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
nora-be
norethindrone
ADD TO FORMULARY
Preventative
01/01/2014
nora-be
norethindrone
ADD UM: GENDER
Female
01/01/2014
jolivette
norethindrone
ADD TO FORMULARY
Preventative
01/01/2014
jolivette
norethindrone
ADD UM: GENDER
Female
01/01/2014
heather
norethindrone
ADD TO FORMULARY
Preventative
01/01/2014
heather
norethindrone
ADD UM: GENDER
Female
01/01/2014
ORTHO TRICYCLEN
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ORTHO TRICYCLEN
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
ELLA
ulipristal acetate
CHANGE TIER
Non-Formulary
01/01/2014
ELLA
ulipristal acetate
ADD UM: GENDER
Female
01/01/2014
ampicillin
trihydrate
ampicillin trihydrate
ADD TO FORMULARY
Generics
01/01/2014
ampicillin
trihydrate
ampicillin trihydrate
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 48
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
AVIDOXY DK
doxycycline
monohydrate/salicylic
acid/octinoxate/zinc oxide
ADD TO FORMULARY
Non-Formulary
01/01/2014
amantadine
amantadine hcl
ADD TO FORMULARY
Generics
01/01/2014
amoxicillin
amoxicillin
ADD TO FORMULARY
Generics
01/01/2014
amoxicillin
amoxicillin
ADD TO FORMULARY
Generics
01/01/2014
ALODOX
doxycycline hyclate/eyelid
cleanser no2/eyelid cleanser
no3
ADD TO FORMULARY
Non-Formulary
01/01/2014
albuterol sulfate
albuterol sulfate
ADD TO FORMULARY
Generics
01/01/2014
aminocaproic
acid
aminocaproic acid
ADD TO FORMULARY
Generics
01/01/2014
aminocaproic
acid
aminocaproic acid
ADD TO FORMULARY
Generics
01/01/2014
aminocaproic
acid
aminocaproic acid
ADD TO FORMULARY
Generics
01/01/2014
anagrelide hcl
anagrelide hcl
ADD TO FORMULARY
Generics
01/01/2014
advanced am/pm omega-3 fatty acids/calcium
carb/vitamin d3/fa/mv cmb
13
ADD TO FORMULARY
Generics
01/01/2014
acetaminophencodeine
acetaminophen with codeine
phosphate
ADD TO FORMULARY
Generics
01/01/2014
alprostadil
alprostadil
ADD TO FORMULARY
Generics
01/01/2014
aspirin ec
aspirin
ADD TO FORMULARY
Generics
01/01/2014
acetaminophcaffdihydrocodein
acetaminophen/caffeine/dihy
drocodeine bitartrate
ADD TO FORMULARY
Generics
01/01/2014
AVITENE
microfibrillar collagen
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 49
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
acetaminophen with codeine
phosphate
ADD TO FORMULARY
Generics
01/01/2014
acetaminophencodeine
01/01/2014
dextroamphetami dextroamphetamine sulfne-amphetamine saccharate/amphetamine
sulf-aspartate
ADD TO FORMULARY
Generics
01/01/2014
alprazolam
intensol
alprazolam
ADD TO FORMULARY
Generics
01/01/2014
alagesic lq
butalbital/acetaminophen/caf
feine
ADD TO FORMULARY
Generics
01/01/2014
amoxapine
amoxapine
ADD TO FORMULARY
Generics
01/01/2014
amoxapine
amoxapine
ADD TO FORMULARY
Generics
01/01/2014
amoxapine
amoxapine
ADD TO FORMULARY
Generics
01/01/2014
amoxapine
amoxapine
ADD TO FORMULARY
Generics
01/01/2014
acetic acidaluminum
acetic acid/aluminum
acetate
ADD TO FORMULARY
Generics
01/01/2014
acetazolamide
acetazolamide
ADD TO FORMULARY
Generics
01/01/2014
antipyrinebenzocaine
antipyrine/benzocaine
ADD TO FORMULARY
Generics
01/01/2014
atropine sulfate
atropine sulfate
ADD TO FORMULARY
Generics
01/01/2014
androxy
fluoxymesterone
ADD TO FORMULARY
Generics
01/01/2014
ANDROGEL
testosterone
ADD TO FORMULARY
Preferred Brands
01/01/2014
ANDROGEL
testosterone
ADD UM: GENDER
Male
01/01/2014
ANDROGEL
testosterone
ADD TO FORMULARY
Preferred Brands
01/01/2014
ANDROGEL
testosterone
ADD UM: GENDER
Male
01/01/2014
ANDROGEL
testosterone
ADD TO FORMULARY
Preferred Brands
01/01/2014
ANDROGEL
testosterone
ADD UM: GENDER
Male
01/01/2014
AXIRON
testosterone
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 50
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
AXIRON
testosterone
CHANGE UM: GENDER
Male
01/01/2014
ANDROGEL
testosterone
ADD TO FORMULARY
Preferred Brands
01/01/2014
ANDROGEL
testosterone
ADD UM: GENDER
Male
01/01/2014
ANDROGEL
testosterone
ADD TO FORMULARY
Non-Formulary
01/01/2014
ANDROGEL
testosterone
ADD UM: GENDER
Male
01/01/2014
ANDROGEL
testosterone
ADD TO FORMULARY
Non-Formulary
01/01/2014
ANDROGEL
testosterone
ADD UM: GENDER
Male
01/01/2014
ALORA
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ALORA
estradiol
CHANGE UM: GENDER
Female
01/01/2014
ALORA
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ALORA
estradiol
CHANGE UM: GENDER
Female
01/01/2014
ALORA
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ALORA
estradiol
CHANGE UM: GENDER
Male
01/01/2014
ALORA
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ALORA
estradiol
CHANGE UM: GENDER
Male
01/01/2014
alendronate
sodium
alendronate sodium
ADD TO FORMULARY
Generics
01/01/2014
AVONEX
interferon beta-1a/albumin
human
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVONEX
interferon beta-1a/albumin
human
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AVONEX
interferon beta-1a
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVONEX
interferon beta-1a
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AVONEX PEN
interferon beta-1a
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVONEX PEN
interferon beta-1a
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AVC
sulfanilamide
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 51
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
AVC
sulfanilamide
01/01/2014
amcinonide
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
amcinonide
ADD TO FORMULARY
Generics
amcinonide
amcinonide
ADD TO FORMULARY
Generics
01/01/2014
apexicon e
diflorasone
diacetate/emollient base
ADD TO FORMULARY
Generics
01/01/2014
BEBULIN VH
IMMUNO
factor ix complex,
prothrombin complex conc.
(pcc) comb. 6
ADD TO FORMULARY
Preferred Brands
01/01/2014
BEBULIN
factor ix complex,
prothrombin cplx conc(pcc)
no.6, 3-factor
ADD TO FORMULARY
Preferred Brands
01/01/2014
BENEFIX
factor ix human recombinant
ADD TO FORMULARY
Preferred Brands
01/01/2014
belladonnaopium
opium/belladonna alkaloids
ADD TO FORMULARY
Generics
01/01/2014
belladonnaopium
opium/belladonna alkaloids
ADD TO FORMULARY
Generics
01/01/2014
butalbacetaminophcaff-codein
butalbital/acetaminophen/caf
feine/codeine phosphate
ADD TO FORMULARY
Generics
01/01/2014
butalbital-aspirin- butalbital/aspirin/caffeine
caffeine
ADD TO FORMULARY
Generics
01/01/2014
bacitracin
bacitracin
ADD TO FORMULARY
Generics
01/01/2014
BUCALSEP
benzocaine/zinc
chloride/pine
tar/cetylpyridinium chloride
ADD TO FORMULARY
Preferred Brands
01/01/2014
BUCALSEP
benzocaine/zinc
chloride/pine
tar/cetylpyridinium chloride
ADD TO FORMULARY
Preferred Brands
01/01/2014
bensal hp
benzoic acid/salicylic acid
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 52
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
betamethasone
dipropionate
betamethasone dipropionate
ADD TO FORMULARY
Generics
01/01/2014
bpo
benzoyl peroxide
ADD TO FORMULARY
Generics
01/01/2014
bpo
benzoyl peroxide
ADD TO FORMULARY
Generics
01/01/2014
bpo
benzoyl peroxide
ADD TO FORMULARY
Generics
01/01/2014
bpo
benzoyl peroxide
ADD TO FORMULARY
Generics
01/01/2014
bpo
benzoyl peroxide
ADD TO FORMULARY
Generics
01/01/2014
bensal hp
salicylic acid
ADD TO FORMULARY
Generics
01/01/2014
bp 10-1
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Generics
01/01/2014
b-plex plus
multivits,therap w-fe,hematin
ADD TO FORMULARY
Generics
01/01/2014
b-plex
folic acid/vitamin b comp
and c
ADD TO FORMULARY
Generics
01/01/2014
vit 3
omega-3/dha/epa/b12/folic
acid/pyridoxine
hcl/phytosterols
ADD TO FORMULARY
Generics
01/01/2014
cefaclor
cefaclor
ADD TO FORMULARY
Generics
01/01/2014
cefaclor er
cefaclor
ADD TO FORMULARY
Generics
01/01/2014
cefaclor
cefaclor
ADD TO FORMULARY
Generics
01/01/2014
cefaclor
cefaclor
ADD TO FORMULARY
Generics
01/01/2014
cefditoren pivoxil cefditoren pivoxil
ADD TO FORMULARY
Generics
01/01/2014
cefditoren pivoxil cefditoren pivoxil
ADD TO FORMULARY
Generics
01/01/2014
cephalexin
cephalexin
ADD TO FORMULARY
Generics
01/01/2014
cephalexin
cephalexin
ADD TO FORMULARY
Generics
01/01/2014
ciprofloxacin hcl
ciprofloxacin hcl
ADD TO FORMULARY
Generics
01/01/2014
cycloserine
cycloserine
ADD TO FORMULARY
Generics
01/01/2014
cyproheptadine
hcl
cyproheptadine hcl
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 53
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
captoprilcaptopril/hydrochlorothiazide
hydrochlorothiazi
de
ADD TO FORMULARY
Generics
01/01/2014
captoprilcaptopril/hydrochlorothiazide
hydrochlorothiazi
de
ADD TO FORMULARY
Generics
01/01/2014
captoprilcaptopril/hydrochlorothiazide
hydrochlorothiazi
de
ADD TO FORMULARY
Generics
01/01/2014
captoprilcaptopril/hydrochlorothiazide
hydrochlorothiazi
de
ADD TO FORMULARY
Generics
01/01/2014
choline mag
trisalicylate
ADD TO FORMULARY
Generics
01/01/2014
chlordiazepoxide- amitriptyline
amitriptyline
hcl/chlordiazepoxide
ADD TO FORMULARY
Generics
01/01/2014
chlordiazepoxide- amitriptyline
amitriptyline
hcl/chlordiazepoxide
ADD TO FORMULARY
Generics
01/01/2014
cytra-k
potassium citrate/citric acid
ADD TO FORMULARY
Generics
01/01/2014
chlorothiazide
chlorothiazide
ADD TO FORMULARY
Generics
01/01/2014
chlorthalidone
chlorthalidone
ADD TO FORMULARY
Generics
01/01/2014
cascara sagrada aromatic cascara fluid
extract
ADD TO FORMULARY
Generics
01/01/2014
chlorpropamide
chlorpropamide
ADD TO FORMULARY
Generics
01/01/2014
chlorpropamide
chlorpropamide
ADD TO FORMULARY
Generics
01/01/2014
COMBIPATCH
estradiol/norethindrone
acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
COMBIPATCH
estradiol/norethindrone
acetate
ADD UM: GENDER
Female
choline
salicylate/magnesium
salicylate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 54
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
COMBIPATCH
estradiol/norethindrone
acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
COMBIPATCH
estradiol/norethindrone
acetate
ADD UM: GENDER
Female
01/01/2014
CLINPRO 5000
sodium fluoride
ADD TO FORMULARY
Preferred Brands
01/01/2014
cyclophosphamid cyclophosphamide
e
ADD TO FORMULARY
Generics
01/01/2014
cyclophosphamid cyclophosphamide
e
ADD TO FORMULARY
Generics
01/01/2014
cyclosporine
modified
ADD TO FORMULARY
Generics
01/01/2014
cromolyn sodium cromolyn sodium
ADD TO FORMULARY
Generics
01/01/2014
clemastine
fumarate
clemastine fumarate
ADD TO FORMULARY
Generics
01/01/2014
codeine sulfate
codeine sulfate
ADD TO FORMULARY
Generics
01/01/2014
codeine sulfate
codeine sulfate
ADD TO FORMULARY
Generics
01/01/2014
codeine sulfate
codeine sulfate
ADD TO FORMULARY
Generics
01/01/2014
codeine sulfate
codeine sulfate
ADD TO FORMULARY
Generics
01/01/2014
clindamycin
phosphate
clindamycin phosphate
ADD TO FORMULARY
Generics
01/01/2014
clindamycin
phosphate
clindamycin phosphate
ADD UM: GENDER
Female
01/01/2014
clotrimazole
clotrimazole
ADD TO FORMULARY
Generics
01/01/2014
cyclophene
cyclobenzaprine hcl
ADD TO FORMULARY
Generics
01/01/2014
complete-rf
prenatal
prenatal vitamin
no.17/iron,carbonyl/folic
acid/docusate sod
ADD TO FORMULARY
Generics
cyclosporine, modified
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 55
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
complete-rf
prenatal
prenatal vitamin
no.17/iron,carbonyl/folic
acid/docusate sod
01/01/2014
cavan-alpha kit
01/01/2014
cavan-alpha kit
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
prenatal vit no.67/sodium
feredetate-iron ps/folic
acid/omg3
ADD TO FORMULARY
Generics
prenatal vit no.67/sodium
feredetate-iron ps/folic
acid/omg3
ADD UM: GENDER
Female
cavan-ec sod dha prenatal vitamins comb
no.48/iron na
feredetate/fa/omega-3
ADD TO FORMULARY
Generics
01/01/2014
cavan-ec sod dha prenatal vitamins comb
no.48/iron na
feredetate/fa/omega-3
ADD UM: GENDER
Female
01/01/2014
completenate
prenatal vitamins combo
no.14/ferrous fumarate/folic
acid
ADD TO FORMULARY
Generics
01/01/2014
completenate
prenatal vitamins combo
no.14/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
dapsone
dapsone
ADD TO FORMULARY
Generics
01/01/2014
dapsone
dapsone
ADD TO FORMULARY
Generics
01/01/2014
dexchlorphenira
mine maleate
dexchlorpheniramine
maleate
ADD TO FORMULARY
Generics
01/01/2014
doxytex
doxylamine succinate
ADD TO FORMULARY
Generics
01/01/2014
dicyclomine hcl
dicyclomine hcl
CHANGE TIER
Generics
01/01/2014
diphenoxylateatropine
diphenoxylate hcl/atropine
sulfate
ADD TO FORMULARY
Generics
01/01/2014
digoxin
digoxin
ADD TO FORMULARY
Generics
01/01/2014
diazepam
diazepam
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 56
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
diazepam
diazepam
ADD TO FORMULARY
Generics
01/01/2014
diazepam
diazepam
ADD TO FORMULARY
Generics
01/01/2014
desvenlafaxine
fumarate er
desvenlafaxine fumarate
ADD TO FORMULARY
Generics
01/01/2014
desvenlafaxine
fumarate er
desvenlafaxine fumarate
ADD TO FORMULARY
Generics
01/01/2014
desvenlafaxine er desvenlafaxine
ADD TO FORMULARY
Non-Formulary
01/01/2014
desvenlafaxine er desvenlafaxine
ADD TO FORMULARY
Non-Formulary
01/01/2014
doxepin hcl
doxepin hcl
ADD TO FORMULARY
Generics
01/01/2014
doxepin hcl
doxepin hcl
ADD TO FORMULARY
Generics
01/01/2014
dexamethasone
dexamethasone
ADD TO FORMULARY
Generics
01/01/2014
dexamethasone
dexamethasone
ADD TO FORMULARY
Generics
01/01/2014
dexamethasone
dexamethasone
ADD TO FORMULARY
Generics
01/01/2014
dexamethasone
intensol
dexamethasone
ADD TO FORMULARY
Generics
01/01/2014
denta 5000 plus
sodium fluoride
ADD TO FORMULARY
Generics
01/01/2014
dentagel
sodium fluoride
ADD TO FORMULARY
Generics
01/01/2014
DYSPORT
abobotulinumtoxina
ADD TO FORMULARY
Non-Formulary
01/01/2014
DYSPORT
abobotulinumtoxina
ADD UM: AUTHORIZATION
PA applies
01/01/2014
difil-g 400
guaifenesin/dyphylline
ADD TO FORMULARY
Generics
01/01/2014
desoximetasone desoximetasone
ADD TO FORMULARY
Generics
01/01/2014
desoximetasone desoximetasone
ADD TO FORMULARY
Generics
01/01/2014
diflorasone
diacetate
diflorasone diacetate
ADD TO FORMULARY
Generics
01/01/2014
diflorasone
diacetate
diflorasone diacetate
ADD TO FORMULARY
Preventative
01/01/2014
erythromycin
erythromycin base
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 57
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
erythromycin
erythromycin base
ADD TO FORMULARY
Generics
01/01/2014
erythromycin
erythromycin base
ADD TO FORMULARY
Generics
01/01/2014
erythromycinsulfisoxazole
erythromycin
ethylsuccinate/sulfisoxazole
acetyl
ADD TO FORMULARY
Generics
01/01/2014
erythromycin
ethylsuccinate
erythromycin ethylsuccinate
ADD TO FORMULARY
Generics
01/01/2014
etoposide
etoposide
ADD TO FORMULARY
Generics
01/01/2014
EXELON
rivastigmine
ADD TO FORMULARY
Non-Formulary
01/01/2014
EXELON
rivastigmine
ADD TO FORMULARY
Non-Formulary
01/01/2014
ergoloid
mesylates
ergoloid mesylates
ADD TO FORMULARY
Generics
01/01/2014
EMSAM
selegiline
ADD TO FORMULARY
Preferred Brands
01/01/2014
EMSAM
selegiline
ADD TO FORMULARY
Preferred Brands
01/01/2014
EMSAM
selegiline
ADD TO FORMULARY
Preferred Brands
01/01/2014
ESTRING
estradiol
ADD TO FORMULARY
Preferred Brands
01/01/2014
ESTRING
estradiol
ADD UM: GENDER
Female
01/01/2014
ESTRACE
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ESTRACE
estradiol
ADD UM: GENDER
Female
01/01/2014
estradiol
estradiol
ADD TO FORMULARY
Generics
01/01/2014
estradiol
estradiol
ADD UM: GENDER
Female
01/01/2014
estradiol
estradiol
ADD TO FORMULARY
Generics
01/01/2014
estradiol
estradiol
ADD UM: GENDER
Female
01/01/2014
estradiol
estradiol
ADD TO FORMULARY
Generics
01/01/2014
estradiol
estradiol
ADD UM: GENDER
Female
01/01/2014
estradiol
estradiol
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 58
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
estradiol
estradiol
ADD UM: GENDER
Female
01/01/2014
estradiol
estradiol
ADD TO FORMULARY
Generics
01/01/2014
estradiol
estradiol
ADD UM: GENDER
Female
01/01/2014
estropipate
estropipate
ADD TO FORMULARY
Generics
01/01/2014
estropipate
estropipate
ADD UM: GENDER
Female
01/01/2014
estropipate
estropipate
ADD TO FORMULARY
Generics
01/01/2014
estropipate
estropipate
ADD UM: GENDER
Female
01/01/2014
ENDOMETRIN
progesterone,micronized
ADD TO FORMULARY
Preferred Brands
01/01/2014
ENDOMETRIN
progesterone,micronized
ADD UM: GENDER
Female
01/01/2014
etidronate
disodium
etidronate disodium
ADD TO FORMULARY
Generics
01/01/2014
etidronate
disodium
etidronate disodium
ADD TO FORMULARY
Generics
01/01/2014
exoderm
sodium thiosulfate/salicylic
acid
ADD TO FORMULARY
Generics
01/01/2014
elite ob dha
prenatal vitamin no.7-ferrous
fumarate-folic acid-dha
ADD TO FORMULARY
Generics
01/01/2014
elite ob dha
prenatal vitamin no.7-ferrous
fumarate-folic acid-dha
ADD UM: GENDER
Female
01/01/2014
ferrex 150 forte
plus
iron
asp,gly,ps/ascorb.calcium/b
12/folic/calcium/succ.acid
ADD TO FORMULARY
Generics
01/01/2014
ferrex 28
iron asp.gly,fum/vit c/folic
acid/m-vit no.11/calcium
threon
ADD TO FORMULARY
Generics
01/01/2014
ferraplus 90
iron,carbonyl/folic
acid/vitamin b12/vitamin
c/docusate na
ADD TO FORMULARY
Generics
01/01/2014
furosemide
furosemide
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 59
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
FLECTOR
diclofenac epolamine
ADD TO FORMULARY
Preferred Brands
01/01/2014
fenoprofen
calcium
fenoprofen calcium
ADD TO FORMULARY
Generics
01/01/2014
fluoxetine hcl
fluoxetine hcl
ADD TO FORMULARY
Generics
01/01/2014
fluoxetine hcl
fluoxetine hcl
ADD UM: QUANTITY
4 / 30 days
01/01/2014
fluphenazine
decanoate
fluphenazine decanoate
ADD TO FORMULARY
Generics
01/01/2014
fluphenazine hcl
fluphenazine hcl
ADD TO FORMULARY
Generics
01/01/2014
fluphenazine hcl
fluphenazine hcl
ADD TO FORMULARY
Generics
01/01/2014
fluphenazine hcl
fluphenazine hcl
ADD TO FORMULARY
Generics
01/01/2014
femcap
cervical cap
ADD TO FORMULARY
Preferred Brands
01/01/2014
femcap
cervical cap
ADD TO FORMULARY
Preferred Brands
01/01/2014
femcap
cervical cap
ADD TO FORMULARY
Preferred Brands
01/01/2014
flunisolide
flunisolide
ADD TO FORMULARY
Generics
01/01/2014
fluoresceinproparacaine
proparacaine hcl/fluorescein
sodium
ADD TO FORMULARY
Generics
01/01/2014
FEMRING
estradiol acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FEMRING
estradiol acetate
ADD UM: GENDER
Female
01/01/2014
FEMRING
estradiol acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FEMRING
estradiol acetate
ADD UM: GENDER
Female
01/01/2014
FIRSTprogesterone
PROGESTERON
E VGS 50
ADD TO FORMULARY
Preferred Brands
01/01/2014
FIRSTprogesterone
PROGESTERON
E VGS 50
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 60
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
FIRSTprogesterone
PROGESTERON
E VGS 100
ADD TO FORMULARY
Preferred Brands
01/01/2014
FIRSTprogesterone
PROGESTERON
E VGS 100
ADD UM: GENDER
Female
01/01/2014
FIRSTprogesterone
PROGESTERON
E VGS 200
ADD TO FORMULARY
Preferred Brands
01/01/2014
FIRSTprogesterone
PROGESTERON
E VGS 200
ADD UM: GENDER
Female
01/01/2014
flanax
naproxen sodium
ADD TO FORMULARY
Generics
01/01/2014
fluoritab
sodium fluoride
ADD TO FORMULARY
Preventative
01/01/2014
fluoritab
sodium fluoride
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
FEM PH
acetic acid/oxyquinoline
sulfate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FEM PH
acetic acid/oxyquinoline
sulfate
ADD UM: GENDER
Female
01/01/2014
focalgin-b
prenatal vit/folic
acid/b6/calcium phosph
di,tribasic/ginger
ADD TO FORMULARY
Generics
01/01/2014
focalgin-b
prenatal vit/folic
acid/b6/calcium phosph
di,tribasic/ginger
ADD UM: GENDER
Female
01/01/2014
folbee plus cz
folic acid/vitamin b comp
and c/copper/zinc oxide
ADD TO FORMULARY
Generics
01/01/2014
folbee plus
folic acid/vitamin b comp
and c
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 61
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
gastrinex nf
hyoscyamine
sulfate/phenyltoloxamine
citrate
ADD TO FORMULARY
Generics
01/01/2014
nicotine lozenge
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2014
nicotine lozenge
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2014
guanidine hcl
guanidine hcl
ADD TO FORMULARY
Generics
01/01/2014
GELFOAM
gelatin sponge,absorbable
ADD TO FORMULARY
Preferred Brands
01/01/2014
gabapentin
gabapentin
ADD TO FORMULARY
Generics
01/01/2014
gabapentin
gabapentin
ADD TO FORMULARY
Generics
01/01/2014
GELCLAIR
potassium
sorbate/hydroxyethylcellulos
e/povidone/hyalur ac
ADD TO FORMULARY
Preferred Brands
01/01/2014
green glo
lissamine green
ADD TO FORMULARY
Generics
01/01/2014
glutaraldehyde
glutaraldehyde
ADD TO FORMULARY
Generics
01/01/2014
gelfilm
gelatin
ADD TO FORMULARY
Preferred Brands
01/01/2014
gentamicin
sulfate
gentamicin sulfate
ADD TO FORMULARY
Generics
01/01/2014
gentamicin
sulfate
gentamicin sulfate
ADD TO FORMULARY
Generics
01/01/2014
silver nitrate
applicator
silver nitrate/potassium
nitrate
ADD TO FORMULARY
Generics
01/01/2014
HUMATE-P
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Preferred Brands
01/01/2014
HUMATE-P
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 62
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
HUMATE-P
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Preferred Brands
01/01/2014
HEMOFIL M
antihemophilic factor,
human
ADD TO FORMULARY
Preferred Brands
01/01/2014
HEMOFIL M
antihemophilic factor,
human
ADD TO FORMULARY
Preferred Brands
01/01/2014
HEMOFIL M
antihemophilic factor,
human
ADD TO FORMULARY
Preferred Brands
01/01/2014
HEMOFIL M
antihemophilic factor,
human
ADD TO FORMULARY
Preferred Brands
01/01/2014
aspirin
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
aspirin
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
aspirin
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
halfprin
aspirin
ADD TO FORMULARY
Preventative
01/01/2014
halfprin
aspirin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
halfprin
aspirin
ADD UM: AGE
45 to 79 yrs old
01/01/2014
heparin sodium in heparin sodium,porcine in
0.45% nacl
0.45 % sodium chloride
ADD TO FORMULARY
Generics
01/01/2014
hydrocodoneacetaminophen
hydrocodone
bitartrate/acetaminophen
ADD TO FORMULARY
Generics
01/01/2014
hydrocodoneacetaminophen
hydrocodone
bitartrate/acetaminophen
ADD TO FORMULARY
Generics
01/01/2014
hydrocodoneacetaminophen
hydrocodone
bitartrate/acetaminophen
ADD TO FORMULARY
Generics
01/01/2014
hydrocodoneacetaminophen
hydrocodone
bitartrate/acetaminophen
ADD TO FORMULARY
Generics
01/01/2014
hydrocodoneacetaminophen
hydrocodone
bitartrate/acetaminophen
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 63
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
hydrocodoneacetaminophen
hydrocodone
bitartrate/acetaminophen
ADD TO FORMULARY
Generics
01/01/2014
hydrocodoneacetaminophen
hydrocodone
bitartrate/acetaminophen
ADD TO FORMULARY
Generics
01/01/2014
hydromorphone
hcl
hydromorphone hcl
ADD TO FORMULARY
Generics
01/01/2014
hydromorphone
hcl
hydromorphone hcl
ADD TO FORMULARY
Generics
01/01/2014
hydromorphone
hcl
hydromorphone hcl
ADD TO FORMULARY
Generics
01/01/2014
hydromorphone
hcl
hydromorphone hcl
ADD TO FORMULARY
Generics
01/01/2014
hydromorphone
hcl
hydromorphone hcl
ADD TO FORMULARY
Generics
01/01/2014
hydroxyzine
pamoate
hydroxyzine pamoate
ADD TO FORMULARY
Generics
01/01/2014
hollihesive skin
barrier
ostomy supply
ADD TO FORMULARY
Generics
01/01/2014
hydrofera blue
polyvinyl alcohol/gentian
violet/methylene blue
ADD TO FORMULARY
Preferred Brands
01/01/2014
hydrocodonehydrocodone
homatropine mbr bitartrate/homatropine
methylbromide
ADD TO FORMULARY
Generics
01/01/2014
halonate
halobetasol
propionate/ammonium
lactate
ADD TO FORMULARY
Generics
01/01/2014
halonate pac
halobetasol
propionate/ammonium
lactate
ADD TO FORMULARY
Generics
01/01/2014
hydrocortisone
acetate
hydrocortisone acetate/aloe
vera
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 64
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
hydrocortisone
valerate
hydrocortisone valerate
ADD TO FORMULARY
Generics
01/01/2014
hydrocortisone
hydrocortisone/mineral
oil/petrolatum,white
ADD TO FORMULARY
Generics
01/01/2014
hydrocortisonelidocaine
hydrocortisone
acetate/lidocaine hcl/aloe
vera
ADD TO FORMULARY
Generics
01/01/2014
hydroquinone
hydroquinone microspheres
ADD TO FORMULARY
Generics
01/01/2014
hematogen fa
ferrous fumarate/ascorbic
acid/cyanocobalamin/folic
acid
ADD TO FORMULARY
Generics
01/01/2014
LUPRON
DEPOT-PED
leuprolide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
LUPRON
DEPOT-PED
leuprolide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
LUPRON
DEPOT-PED
leuprolide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
LUPRON DEPOT leuprolide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
LUPRON
DEPOT-PED
leuprolide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
levorphanol
tartrate
levorphanol tartrate
ADD TO FORMULARY
Generics
01/01/2014
lithium
lithium citrate
ADD TO FORMULARY
Generics
01/01/2014
lorazepam
lorazepam
ADD TO FORMULARY
Generics
01/01/2014
lorazepam
lorazepam
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 65
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
01/01/2014
insulin
syringe,easytouch insulin
syringe,monoject
insulin
syringe,ulticare,in
tegra
syringe,eclipse
syringe,safetyglid
e syringe,ultilet
insulin
syringe,ultra
comfort,ultracomf
ort,orsini insulin
syringe,prodigy
insulin
syringe,easy
touch insulin
syringe,easy
touch,terumo
insulin
syringe,thinpro
insulin
syringe,vanishpoi
nt,trueplus insulin
syringe,lite
touch,topcare
ultra
comfort,glucopro,
sure-ject insulin
syringe,sure
comfort,maxicomfort,ultra-thin
ii,easy comfort
insulin
syringe,advocate
syringes,comfort
ez,freestyle
precision,easy
Generic Name
syringe with
needle,disposable,insulin 1
ml,syringe with needle,
insulin, safety, 1 ml
Type of Change
Previous Value
ADD TO FORMULARY
New Value
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 66
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
touch insulin
safety
01/01/2014
leucovorin
calcium
leucovorin calcium
ADD TO FORMULARY
Generics
01/01/2014
leucovorin
calcium
leucovorin calcium
ADD TO FORMULARY
Generics
01/01/2014
loratadine
loratadine
ADD TO FORMULARY
Generics
01/01/2014
loratadine
loratadine
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
loratadine-d
loratadine/pseudoephedrine
sulfate
ADD TO FORMULARY
Generics
01/01/2014
loratadine-d
loratadine/pseudoephedrine
sulfate
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
loratadine
d,loratadine-d
loratadine/pseudoephedrine
sulfate
ADD TO FORMULARY
Generics
01/01/2014
loratadine
d,loratadine-d
loratadine/pseudoephedrine
sulfate
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
loratadine,childre loratadine
n's
loratadine,loratad
ine hives
relief,loratadine
allergy
ADD TO FORMULARY
Generics
01/01/2014
loratadine,childre loratadine
n's
loratadine,loratad
ine hives
relief,loratadine
allergy
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
loratadine
loratadine
ADD TO FORMULARY
Generics
01/01/2014
loratadine
loratadine
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 67
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
loradamed
loratadine
ADD TO FORMULARY
Generics
01/01/2014
loradamed
loratadine
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
lusair
guaifenesin/phenylephrine
hcl
ADD TO FORMULARY
Generics
01/01/2014
lidocainehydrocortisone
hydrocortisone
acetate/lidocaine hcl/aloe
vera
ADD TO FORMULARY
Generics
01/01/2014
lidocainehydrocortisone
hydrocortisone
acetate/lidocaine hcl/aloe
vera
ADD TO FORMULARY
Generics
01/01/2014
lidocainehydrocortisone
lidocaine hcl/hydrocortisone
acetate
ADD TO FORMULARY
Generics
01/01/2014
lidocainehydrocortisone
lidocaine hcl/hydrocortisone
acetate
ADD TO FORMULARY
Generics
01/01/2014
lidocaine hcl
lidocaine hcl
ADD TO FORMULARY
Generics
01/01/2014
lidocaineprilocaine
lidocaine/prilocaine
ADD TO FORMULARY
Generics
01/01/2014
LUPRON DEPOT leuprolide acetate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LUPRON DEPOT leuprolide acetate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LUPRON
DEPOT-PED
leuprolide acetate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LUPRON DEPOT leuprolide acetate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LUPRON DEPOT leuprolide acetate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
levalbuterol hcl
levalbuterol hcl
CHANGE TIER
Preferred Brands
Generics
01/01/2014
levalbuterol hcl
levalbuterol hcl
CHANGE TIER
Preferred Brands
Generics
01/01/2014
LOVENOX
enoxaparin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOVENOX
enoxaparin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 68
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
LOVENOX
enoxaparin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOVENOX
enoxaparin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOVENOX
enoxaparin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOVENOX
enoxaparin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOVENOX
enoxaparin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOVENOX
enoxaparin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LIPITOR
atorvastatin calcium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LIPITOR
atorvastatin calcium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LIPITOR
atorvastatin calcium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
lofibra
fenofibrate,micronized
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
lofibra
fenofibrate,micronized
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LESCOL XL
fluvastatin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LESCOL
fluvastatin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOVAZA
omega-3 acid ethyl esters
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOTREL
amlodipine
besylate/benazepril hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOTREL
amlodipine
besylate/benazepril hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOTREL
amlodipine
besylate/benazepril hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOTREL
amlodipine
besylate/benazepril hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LOTREL
amlodipine
besylate/benazepril hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LEXAPRO
escitalopram oxalate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LEXAPRO
escitalopram oxalate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
LEXAPRO
escitalopram oxalate
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 69
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
LUVOX CR
fluvoxamine maleate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
lindane
lindane
CHANGE TIER
Preferred Brands
Generics
01/01/2014
lindane
lindane
CHANGE TIER
Preferred Brands
Generics
01/01/2014
lidocainehydrocortisone
lidocaine hcl/hydrocortisone
acetate
CHANGE TIER
Preferred Brands
Generics
01/01/2014
l-methylfolate
calcium
levomefolate calcium
CHANGE TIER
01/01/2014
l-methylfolate
levomefolate calcium
CHANGE TIER
Preferred Brands
Generics
01/01/2014
l-methyl-b6-b12
mecobalamin/levomefolate
calcium/pyridoxal phosphate
CHANGE TIER
Preferred Brands
Generics
01/01/2014
levomefolate dha prenatal vitamin comb
no.79/iron
fumarat/fa/lmefolate ca/dha
CHANGE TIER
Preferred Brands
Generics
01/01/2014
MINOCIN
minocycline hcl/skin
cleanser combination no.4
ADD TO FORMULARY
Non-Formulary
01/01/2014
MINOCIN
minocycline hcl/skin
cleanser combination no.4
ADD TO FORMULARY
Non-Formulary
01/01/2014
MYOBLOC
rimabotulinumtoxinb
ADD TO FORMULARY
Preferred Brands
01/01/2014
MYOBLOC
rimabotulinumtoxinb
ADD UM: AUTHORIZATION
PA applies
01/01/2014
MYOBLOC
rimabotulinumtoxinb
ADD TO FORMULARY
Preferred Brands
01/01/2014
MYOBLOC
rimabotulinumtoxinb
ADD UM: AUTHORIZATION
PA applies
01/01/2014
methyldopamethyldopa/hydrochlorothia
hydrochlorothiazi zide
de
ADD TO FORMULARY
Generics
01/01/2014
methyldopamethyldopa/hydrochlorothia
hydrochlorothiazi zide
de
ADD TO FORMULARY
Generics
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 70
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
multigen folic
iron asp gly/ascorb.cal/vit
b12/fa/ca-threonte/succinic
acid
ADD TO FORMULARY
Generics
01/01/2014
multigen
iron aspgly/ascorb.cal/vit
b12/calcium
thr/succ.acid/stomach
ADD TO FORMULARY
Generics
01/01/2014
multigen plus
iron
fum,ag/ascorb.calcium/b12/f
olic acid/calcium/succ.acid
ADD TO FORMULARY
Generics
01/01/2014
multi-vitamin w- pediatric multivitamin combo
fluorideno.45/fluoride/ferrous sulfate
iron,multi-vitaminfluor-iron
ADD TO FORMULARY
Generics
01/01/2014
multi-vitamin w- pediatric multivitamin combo
fluorideno.45/fluoride/ferrous sulfate
iron,multi-vitaminfluor-iron
ADD UM: AGE
0.6 to 2 yrs old
01/01/2014
mexiletine hcl
mexiletine hcl
ADD TO FORMULARY
Generics
01/01/2014
mexiletine hcl
mexiletine hcl
ADD TO FORMULARY
Generics
01/01/2014
mexiletine hcl
mexiletine hcl
ADD TO FORMULARY
Generics
01/01/2014
meclofenamate
sodium
meclofenamate sodium
ADD TO FORMULARY
Generics
01/01/2014
meclofenamate
sodium
meclofenamate sodium
ADD TO FORMULARY
Generics
01/01/2014
morphine sulfate morphine sulfate
ADD TO FORMULARY
Generics
01/01/2014
morphine sulfate morphine sulfate
ADD TO FORMULARY
Generics
01/01/2014
morphine sulfate morphine sulfate
ADD TO FORMULARY
Generics
01/01/2014
morphine sulfate morphine sulfate
ADD TO FORMULARY
Generics
01/01/2014
morphine sulfate morphine sulfate
ADD TO FORMULARY
Generics
01/01/2014
morphine sulfate morphine sulfate
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 71
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
methylphenidate methylphenidate hcl
er
ADD TO FORMULARY
Generics
01/01/2014
migergot
ergotamine tartrate/caffeine
ADD TO FORMULARY
Generics
01/01/2014
maprotiline hcl
maprotiline hcl
ADD TO FORMULARY
Generics
01/01/2014
maprotiline hcl
maprotiline hcl
ADD TO FORMULARY
Generics
01/01/2014
maprotiline hcl
maprotiline hcl
ADD TO FORMULARY
Generics
01/01/2014
medi-lance
lancets
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 72
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
01/01/2014
Brand Name
Generic Name
fingerstix,microlet lancets,lancing
,singledevice/lancets
let,lancets,careon
e,kinney brand
lancets,thin
lancets,ultra thin
lancets,incontrol
ultra thin
lancets,unilet
lancets,alternate
site lancets,super
thin
lancets,advanced
travel
lancets,comfort
lancets,aurora
super thin
lancets,incontrol
super thin
lancets,healthy
accents unilet
lancet,ulticare,lan
cets thin,lancets
ultra thin,fine 30
universal
lancets,medlance
plus,glucosource,
bd ultra-fine,bd
ultra-fine ii,bd
microtainer
lancets,techlite
lancets,assure
haemolance
plus,assure
lance,ultilet
safety,ultilet
classic,ultilet
lancets,ultilet
basic,safety
Type of Change
Previous Value
ADD TO FORMULARY
New Value
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 73
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lancets,pressure
activated
lancets,unilet
lancet,unilet gp
lancet,unilet
comfortouch,unile
t excelite,unilet
excelite ii,unistik
3,unistik
czt,unistik 3
extra,prodigy
twist top
lancet,prodigy
lancets,actilance,droplet
lancets,easy
touch,1st choice
lancets,1st tier
unilet
comfortouch,fifty5
0 safety seal
lancets,smartdiab
etes
vantage,smartest
lancet,glucocom
lancets,glucocom
,rightest gl300
lancets,nova
sureflex,nova
safety
lancets,sterilance
tl,ultralance,solus
v2 lancets,solus
v2,invacare
lancets,monolet
lancets,monolet
thin lancets,color
lancets,e-zject
lancets,micro thin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 74
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lancets,trueplus
lancets,medilance,lite
touch,universal
1,smart sense
lancets,topcare
universal1 thin
lancet,e-z ject
lancets,ultra thin
plus,smart
sense,ultra thin
plus
lancets,renew
advanced microlancets,bullseye
mini safety
lancets,safetylet,safety seal
lancets,easy twist
& cap
lancets,reliamed,r
eliamed safety
seal
lancets,myglucoh
ealth
lancets,coaguche
k,accu-chek safet-pro plus,accuchek,soft
touch,accu-chek
safe-t-pro,accuchek softclix,ez
smart
lancets,onetouch
finepoint
lancets,onetouch
suresoft,onetouc
h delica,onetouch
lancets,medisens
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 75
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
e thin
lancets,telcare,su
re-lance,suretouch,softclix,acc
u-chek fastclix,on
call plus
lancet,on call
lancet,sure
comfort
lancets,ultra-thin
ii,inject ease
lancets,easy
comfort,easy
touch
lancets,ultratlc
lancets,advocate
lancet,advocate
lancets,clever
chek
lancets,foracare
lancets,freestyle
lancets,freestyle
unistik
2,gmate,on-thego,relion
thin,comfort
ez,embrace
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 76
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
01/01/2014
Brand Name
Generic Name
fingerstix,microlet lancets,lancing
,singledevice/lancets
let,lancets,careon
e,kinney brand
lancets,thin
lancets,ultra thin
lancets,incontrol
ultra thin
lancets,unilet
lancets,alternate
site lancets,super
thin
lancets,advanced
travel
lancets,comfort
lancets,aurora
super thin
lancets,incontrol
super thin
lancets,healthy
accents unilet
lancet,ulticare,lan
cets thin,lancets
ultra thin,fine 30
universal
lancets,medlance
plus,glucosource,
bd ultra-fine,bd
ultra-fine ii,bd
microtainer
lancets,techlite
lancets,assure
haemolance
plus,assure
lance,ultilet
safety,ultilet
classic,ultilet
lancets,ultilet
basic,safety
Type of Change
Previous Value
ADD UM: CUSTOM
New Value
History of Blood
Glucose Strips
REQUIRED
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 77
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lancets,pressure
activated
lancets,unilet
lancet,unilet gp
lancet,unilet
comfortouch,unile
t excelite,unilet
excelite ii,unistik
3,unistik
czt,unistik 3
extra,prodigy
twist top
lancet,prodigy
lancets,actilance,droplet
lancets,easy
touch,1st choice
lancets,1st tier
unilet
comfortouch,fifty5
0 safety seal
lancets,smartdiab
etes
vantage,smartest
lancet,glucocom
lancets,glucocom
,rightest gl300
lancets,nova
sureflex,nova
safety
lancets,sterilance
tl,ultralance,solus
v2 lancets,solus
v2,invacare
lancets,monolet
lancets,monolet
thin lancets,color
lancets,e-zject
lancets,micro thin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 78
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lancets,trueplus
lancets,medilance,lite
touch,universal
1,smart sense
lancets,topcare
universal1 thin
lancet,e-z ject
lancets,ultra thin
plus,smart
sense,ultra thin
plus
lancets,renew
advanced microlancets,bullseye
mini safety
lancets,safetylet,safety seal
lancets,easy twist
& cap
lancets,reliamed,r
eliamed safety
seal
lancets,myglucoh
ealth
lancets,coaguche
k,accu-chek safet-pro plus,accuchek,soft
touch,accu-chek
safe-t-pro,accuchek softclix,ez
smart
lancets,onetouch
finepoint
lancets,onetouch
suresoft,onetouc
h delica,onetouch
lancets,medisens
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 79
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
e thin
lancets,telcare,su
re-lance,suretouch,softclix,acc
u-chek fastclix,on
call plus
lancet,on call
lancet,sure
comfort
lancets,ultra-thin
ii,inject ease
lancets,easy
comfort,easy
touch
lancets,ultratlc
lancets,advocate
lancet,advocate
lancets,clever
chek
lancets,foracare
lancets,freestyle
lancets,freestyle
unistik
2,gmate,on-thego,relion
thin,comfort
ez,embrace
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 80
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
01/01/2014
novofine
32,novofine,novot
wist,unifine
pentips,pen
needle,incontrol
pen needle,pen
needles,unifine
pentips
plus,healthy
accents unifine
pentip,ulticare
pen
needle,insupen,in
sulin pen
needle,bd ultrafine pen
needle,ultilet pen
needle,clickfine,r
elion pen
needles,ultracomf
ort,prodigy pen
needle,easy
touch pen
needle,1st tier
unifine
pentips,1st tier
unifine pentips
plus,lite
touch,needles,top
care
clickfine,sure-fine
pen needles,sure
comfort,ultra-thin
ii,mini ultra-thin
ii,advocate pen
needles,comfort
ez,easy comfort
pen needles
Generic Name
pen needle,
diabetic,needles, insulin
disposable,syringe with
needle,disposable,insulin 1
ml
Type of Change
Previous Value
ADD TO FORMULARY
New Value
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 81
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
syringe with needle, insulin,
safety, 0.3 ml
ADD TO FORMULARY
Generics
01/01/2014
magellan insulin
safety
syrng,magellan
insulin syringe
01/01/2014
methyclothiazide methyclothiazide
ADD TO FORMULARY
Generics
01/01/2014
MINIVELLE
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
MINIVELLE
estradiol
ADD UM: GENDER
Female
01/01/2014
MINIVELLE
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
MINIVELLE
estradiol
ADD UM: GENDER
Female
01/01/2014
MINIVELLE
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
MINIVELLE
estradiol
ADD UM: GENDER
Female
01/01/2014
MINIVELLE
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
MINIVELLE
estradiol
ADD UM: GENDER
Female
01/01/2014
multi-vitamin wfluoride
pediatric multivitamin
combination no.2/sodium
fluoride
ADD TO FORMULARY
Generics
01/01/2014
multi-vitamin wfluoride
pediatric multivitamin
combination no.2/sodium
fluoride
ADD UM: AGE
0.6 to 1 yrs old
01/01/2014
multi-vitamin wfluoride
pediatric multivitamin
combination no.2/sodium
fluoride
ADD TO FORMULARY
Generics
01/01/2014
multi-vitamin wfluoride
pediatric multivitamin
combination no.2/sodium
fluoride
ADD UM: AGE
0.6 to 1 yrs old
01/01/2014
multivitamin with pediatric multivitamins no.17
fluoride,multivita with sodium
mins with fluoride fluoride,pediatric
multivitamins no.16 with
sodium fluoride
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 82
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
multivitamin with pediatric multivitamins no.17
fluoride,multivita with sodium
mins with fluoride fluoride,pediatric
multivitamins no.16 with
sodium fluoride
ADD TO FORMULARY
Generics
01/01/2014
multivitamins with pediatric multivitamins no.16
fluoride
with sodium fluoride
ADD TO FORMULARY
Generics
01/01/2014
metaproterenol
sulfate
metaproterenol sulfate
ADD TO FORMULARY
Generics
01/01/2014
metaproterenol
sulfate
metaproterenol sulfate
ADD TO FORMULARY
Generics
01/01/2014
metaproterenol
sulfate
metaproterenol sulfate
ADD TO FORMULARY
Generics
01/01/2014
metronidazole
metronidazole
ADD TO FORMULARY
Generics
01/01/2014
metronidazole
metronidazole
ADD UM: GENDER
Female
01/01/2014
METROGELVAGINAL
metronidazole
ADD TO FORMULARY
Non-Formulary
01/01/2014
METROGELVAGINAL
metronidazole
ADD UM: GENDER
Female
01/01/2014
miconazole 3
miconazole nitrate
ADD TO FORMULARY
Generics
01/01/2014
miconazole 3
miconazole nitrate
ADD UM: GENDER
Female
01/01/2014
melpaque hp
hydroquinone/ferric oxide
ADD UM: CUSTOM
Agents for
Cosmetic Use
are Not Covered
01/01/2014
methenamine
mandelate
methenamine mandelate
ADD TO FORMULARY
Generics
01/01/2014
nystatin
nystatin
ADD TO FORMULARY
Generics
01/01/2014
nystatin
nystatin
ADD TO FORMULARY
Generics
01/01/2014
nystatin
nystatin
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 83
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
non-drowsy
allergy
loratadine
ADD TO FORMULARY
Generics
01/01/2014
non-drowsy
allergy
loratadine
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
niacor
niacin
ADD TO FORMULARY
Generics
01/01/2014
nisoldipine
nisoldipine
ADD TO FORMULARY
Generics
01/01/2014
nisoldipine
nisoldipine
ADD TO FORMULARY
Generics
01/01/2014
nisoldipine
nisoldipine
ADD TO FORMULARY
Generics
01/01/2014
nisoldipine
nisoldipine
ADD TO FORMULARY
Generics
01/01/2014
nitroglycerin
patch
nitroglycerin
ADD TO FORMULARY
Generics
01/01/2014
nitroglycerin
patch
nitroglycerin
ADD TO FORMULARY
Generics
01/01/2014
nitroglycerin
nitroglycerin
ADD TO FORMULARY
Generics
01/01/2014
nitroglycerin
patch
nitroglycerin
ADD TO FORMULARY
Generics
01/01/2014
NITRO-DUR
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
NITRO-DUR
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
nitroglycerin
nitroglycerin
ADD TO FORMULARY
Generics
01/01/2014
NITRO-DUR
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
NITRO-DUR
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
NITROLINGUAL nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2014
nefazodone hcl
nefazodone hcl
ADD TO FORMULARY
Generics
01/01/2014
nefazodone hcl
nefazodone hcl
ADD TO FORMULARY
Generics
01/01/2014
nefazodone hcl
nefazodone hcl
ADD TO FORMULARY
Generics
01/01/2014
nefazodone hcl
nefazodone hcl
ADD TO FORMULARY
Generics
01/01/2014
nefazodone hcl
nefazodone hcl
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 84
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
nortriptyline hcl
nortriptyline hcl
ADD TO FORMULARY
Generics
01/01/2014
NUMOISYN
flaxseed
ADD TO FORMULARY
Non-Formulary
01/01/2014
neomycinpolymyxin-hc
neomycin sulfate/polymyxin
b sulfate/hydrocortisone
ADD TO FORMULARY
Generics
01/01/2014
naphazoline hcl
naphazoline hcl
ADD TO FORMULARY
Generics
01/01/2014
naphazoline hcl
naphazoline hcl
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
NOVOLIN R
insulin regular, human
ADD TO FORMULARY
Preferred Brands
01/01/2014
NOVOLIN 70-30 insulin nph human
isophane/insulin regular,
human
ADD TO FORMULARY
Preferred Brands
01/01/2014
NOVOLIN N
insulin nph human isophane
ADD TO FORMULARY
Preferred Brands
01/01/2014
sodium fluoride
sodium fluoride
ADD TO FORMULARY
Generics
01/01/2014
NAFRINSE
sodium fluoride
DAILY-NEUTRAL
ADD TO FORMULARY
Preferred Brands
01/01/2014
naproderm
naproxen
ADD TO FORMULARY
Preferred Brands
01/01/2014
napro
naproxen
ADD TO FORMULARY
Preferred Brands
01/01/2014
ofloxacin
ofloxacin
ADD TO FORMULARY
Generics
01/01/2014
ofloxacin
ofloxacin
ADD TO FORMULARY
Generics
01/01/2014
ofloxacin
ofloxacin
ADD TO FORMULARY
Generics
01/01/2014
orphenadrine
compound forte
orphenadrine
citrate/aspirin/caffeine
ADD TO FORMULARY
Generics
01/01/2014
orphenadrine
compound
orphenadrine
citrate/aspirin/caffeine
ADD TO FORMULARY
Generics
01/01/2014
ortho all-flex
diaphragms, arc-spring
ADD TO FORMULARY
Preferred Brands
01/01/2014
ortho all-flex
diaphragms, arc-spring
ADD UM: GENDER
Female
01/01/2014
ortho all-flex
diaphragms, arc-spring
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 85
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
ortho all-flex
diaphragms, arc-spring
01/01/2014
ortho all-flex
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
diaphragm fitting set,arcspring
ADD TO FORMULARY
Preventative
ortho all-flex
diaphragm fitting set,arcspring
ADD UM: GENDER
Female
01/01/2014
ORTHOVISC
hyaluronate sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
wound matrix
porcine submucosa,
fenestrated
ADD TO FORMULARY
Preferred Brands
01/01/2014
otozin
antipyrine/benzocaine/glycer
in/zinc acetate
ADD TO FORMULARY
Generics
01/01/2014
ORASEP
benzocaine/tannic
acid/menthol/cetylpyridinium
chloride
ADD TO FORMULARY
Preferred Brands
01/01/2014
oticin
chloroxylenol/pramoxine hcl
ADD TO FORMULARY
Generics
01/01/2014
ondansetron hcl
ondansetron hcl
ADD TO FORMULARY
Generics
01/01/2014
ondansetron hcl
ondansetron hcl/pf
ADD TO FORMULARY
Generics
01/01/2014
ogestrel
norgestrel-ethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
ogestrel
norgestrel-ethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
ORAVIG
miconazole
ADD TO FORMULARY
Preferred Brands
01/01/2014
oralone
triamcinolone acetonide
ADD TO FORMULARY
Generics
01/01/2014
primaquine
primaquine phosphate
ADD TO FORMULARY
Generics
01/01/2014
promethegan
promethazine hcl
ADD TO FORMULARY
Generics
01/01/2014
promethazine vc phenylephrine
hcl/promethazine hcl
ADD TO FORMULARY
Generics
01/01/2014
propantheline
bromide
ADD TO FORMULARY
Generics
01/01/2014
stop smoking aid nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2014
stop smoking aid nicotine polacrilex
ADD TO FORMULARY
Preventative
propantheline bromide
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 86
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
propranololpropranolol
hydrochlorothiazi hcl/hydrochlorothiazide
d
ADD TO FORMULARY
Generics
01/01/2014
propranololpropranolol
hydrochlorothiazi hcl/hydrochlorothiazide
d
ADD TO FORMULARY
Generics
01/01/2014
propranolol hcl
propranolol hcl
ADD TO FORMULARY
Generics
01/01/2014
primlev
oxycodone
hcl/acetaminophen
ADD TO FORMULARY
Generics
01/01/2014
pentazocineacetaminophen
pentazocine
hcl/acetaminophen
ADD TO FORMULARY
Generics
01/01/2014
phendimetrazine phendimetrazine tartrate
tartrate
ADD TO FORMULARY
Generics
01/01/2014
phendimetrazine phendimetrazine tartrate
tartrate
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
phenobarbital
phenobarbital
ADD TO FORMULARY
Generics
01/01/2014
phenobarbital
phenobarbital
ADD TO FORMULARY
Generics
01/01/2014
phenobarbital
phenobarbital
ADD TO FORMULARY
Generics
01/01/2014
phenobarbital
phenobarbital
ADD TO FORMULARY
Generics
01/01/2014
phenobarbital
phenobarbital
ADD TO FORMULARY
Generics
01/01/2014
phenytoin
phenytoin
ADD TO FORMULARY
Generics
01/01/2014
perphenazineamitriptyline
perphenazine/amitriptyline
hcl
ADD TO FORMULARY
Generics
01/01/2014
perphenazineamitriptyline
perphenazine/amitriptyline
hcl
ADD TO FORMULARY
Generics
01/01/2014
perphenazineamitriptyline
perphenazine/amitriptyline
hcl
ADD TO FORMULARY
Generics
01/01/2014
perphenazineamitriptyline
perphenazine/amitriptyline
hcl
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 87
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
perphenazineamitriptyline
perphenazine/amitriptyline
hcl
ADD TO FORMULARY
Generics
01/01/2014
prumyx
emollient combination no.35
ADD TO FORMULARY
Generics
01/01/2014
potassium
chloride
potassium
chloride/potassium
bicarbonate/citric acid
ADD TO FORMULARY
Generics
01/01/2014
PERIDEX
chlorhexidine gluconate
ADD TO FORMULARY
Non-Formulary
01/01/2014
periogard
chlorhexidine gluconate
ADD TO FORMULARY
Generics
01/01/2014
prednisolone
sodium
phosphate
prednisolone sod phosphate
ADD TO FORMULARY
Generics
01/01/2014
paregoric
paregoric
ADD TO FORMULARY
Generics
01/01/2014
prednisone
prednisone
ADD TO FORMULARY
Generics
01/01/2014
prednisone
prednisone
ADD TO FORMULARY
Generics
01/01/2014
prednisone
prednisone
ADD TO FORMULARY
Generics
01/01/2014
prednisone
intensol
prednisone
ADD TO FORMULARY
Generics
01/01/2014
prednisone
prednisone
ADD TO FORMULARY
Generics
01/01/2014
PREMARIN
estrogens, conjugated
ADD TO FORMULARY
Preferred Brands
01/01/2014
PREMARIN
estrogens, conjugated
ADD UM: GENDER
Female
01/01/2014
PREVIDENT
sodium fluoride/potassium
5000 SENSITIVE nitrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
PREVIDENT
5000 ENAMEL
PROTECT
sodium fluoride/potassium
nitrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
phos-flur
sodium fluoride
ADD TO FORMULARY
Generics
01/01/2014
PREVIDENT
sodium fluoride
ADD TO FORMULARY
Non-Formulary
01/01/2014
prevident
sodium fluoride
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 88
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
PREVIDENT
5000 PLUS
sodium fluoride
ADD TO FORMULARY
Non-Formulary
01/01/2014
PREVIDENT
5000
sodium fluoride
ADD TO FORMULARY
Non-Formulary
01/01/2014
PROSTIN E2
VAGINAL
SUPPOSITORY
dinoprostone
ADD TO FORMULARY
Preferred Brands
01/01/2014
PREPIDIL
dinoprostone
ADD TO FORMULARY
Non-Formulary
01/01/2014
promethazine vc- promethazine/phenylephrine
codeine
hcl/codeine
ADD TO FORMULARY
Generics
01/01/2014
phenazopyridine phenazopyridine
plus
hcl/hyoscyamine/butabarbita
l
ADD TO FORMULARY
Generics
01/01/2014
potassium
hydroxide
potassium hydroxide
ADD TO FORMULARY
Generics
01/01/2014
podocon-25
podophyllum resin
ADD TO FORMULARY
Generics
01/01/2014
promar
multivits w-iron,hematinic
ADD TO FORMULARY
Generics
01/01/2014
promar
multivits w-iron,hematinic
ADD UM: CUSTOM
Vitamin Benefit
Rider REQUIRED
01/01/2014
pr natal 430 ec
prenatal vit #55/iron bisgly
hcl,suc-prot/folic
acid/omega-3
ADD TO FORMULARY
Generics
01/01/2014
pr natal 430 ec
prenatal vit #55/iron bisgly
hcl,suc-prot/folic
acid/omega-3
ADD UM: GENDER
Female
01/01/2014
prenaissance dha prenatal vitamin no.105/iron
harmony
edta
&polysaccha/fa/om3/dha/ep
a
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 89
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
prenaissance dha prenatal vitamin no.105/iron
harmony
edta
&polysaccha/fa/om3/dha/ep
a
01/01/2014
quinidine sulfate
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
quinidine sulfate
ADD TO FORMULARY
Generics
ribasphere
ribavirin
ADD TO FORMULARY
Generics
01/01/2014
ribasphere
ribavirin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ribasphere
ribavirin
ADD TO FORMULARY
Generics
01/01/2014
ribasphere
ribavirin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
cetiri-d
cetirizine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Generics
01/01/2014
cetiri-d
cetirizine
hcl/pseudoephedrine hcl
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
cetirizine hcl
cetirizine hcl
ADD TO FORMULARY
Generics
01/01/2014
cetirizine hcl
cetirizine hcl
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
allergy
relief,allergy
cetirizine hcl,loratadine
ADD TO FORMULARY
Generics
01/01/2014
allergy
relief,allergy
cetirizine hcl,loratadine
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
children's allergy cetirizine hcl
relief
ADD TO FORMULARY
Generics
01/01/2014
children's allergy cetirizine hcl
relief
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
allergy relief-d
fexofenadine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Generics
01/01/2014
allergy relief-d
fexofenadine
hcl/pseudoephedrine hcl
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
allergy relief
fexofenadine hcl
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 90
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
allergy relief
fexofenadine hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
allergy relief
fexofenadine hcl
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
lorata-d
loratadine/pseudoephedrine
sulfate
ADD TO FORMULARY
Generics
01/01/2014
lorata-d
loratadine/pseudoephedrine
sulfate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
lorata-d
loratadine/pseudoephedrine
sulfate
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
allergycongestion
relief,allergycongestion
loratadine/pseudoephedrine
sulfate
ADD TO FORMULARY
Generics
01/01/2014
allergycongestion
relief,allergycongestion
loratadine/pseudoephedrine
sulfate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
allergycongestion
relief,allergycongestion
loratadine/pseudoephedrine
sulfate
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
reserpine
reserpine
ADD TO FORMULARY
Generics
01/01/2014
reserpine
reserpine
ADD TO FORMULARY
Generics
01/01/2014
REVATIO
sildenafil citrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
restore
silver sulfate/foam bandage
ADD TO FORMULARY
Non-Formulary
01/01/2014
restore
silver sulfate/foam bandage
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 91
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
01/01/2014
ultra
comfort,monoject
,insulin
syringe,ulticare,e
xel insulin
syringe,safetyglid
e insulin
syringe,ultilet
insulin
syringe,ultracomf
ort,orsini insulin
syringe,prodigy
insulin
syringe,easy
touch insulin
syringe,easy
touch,monoject
insulin
syringe,terumo
insulin
syringe,thinpro
insulin
syringe,vanishpoi
nt,trueplus insulin
syringe,lite
touch,topcare
ultra
comfort,glucopro,
sure-ject insulin
syringe,sure
comfort,maxicomfort,ultra-thin
ii,easy comfort
insulin
syringe,advocate
syringes,comfort
ez,freestyle
precision
syringe with
needle,insulin,0.5 ml,syringe
with needle,insulin
disposable,0.5 ml,syringeneedle,insulin,0.5
ml/container,empty
ADD TO FORMULARY
Previous Value
New Value
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 92
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
radiagel
emollient base
ADD TO FORMULARY
Preferred Brands
01/01/2014
restore contact
layer silver
silver sulfate/non-adherent
bandage
ADD TO FORMULARY
Non-Formulary
01/01/2014
restore calcium
alginate
silver/calcium alginate
ADD TO FORMULARY
Non-Formulary
01/01/2014
restore
silver/calcium alginate
ADD TO FORMULARY
Non-Formulary
01/01/2014
relagard
acetic acid/oxyquinoline
sulfate
ADD TO FORMULARY
Generics
01/01/2014
relagard
acetic acid/oxyquinoline
sulfate
ADD UM: GENDER
Female
01/01/2014
refissa
tretinoin/emollient base
ADD TO FORMULARY
Preferred Brands
01/01/2014
sulfadiazine
sulfadiazine
ADD TO FORMULARY
Generics
01/01/2014
sulfamethoxazole sulfamethoxazole/trimethopr
-trimethoprim
im
ADD TO FORMULARY
Generics
01/01/2014
SYNAGIS
palivizumab
ADD TO FORMULARY
Preferred Brands
01/01/2014
SYNAGIS
palivizumab
ADD TO FORMULARY
Preferred Brands
01/01/2014
se-tan dha
prenatal vit no.10/iron
fum,polysac comp/folic
acid/omega-3
ADD TO FORMULARY
Generics
01/01/2014
se-tan dha
prenatal vit no.10/iron
fum,polysac comp/folic
acid/omega-3
ADD UM: GENDER
Female
01/01/2014
sulfacetamide
sodium
sulfacetamide sodium
ADD TO FORMULARY
Generics
01/01/2014
SANCUSO
granisetron
ADD TO FORMULARY
Non-Formulary
01/01/2014
STRIANT
testosterone
ADD TO FORMULARY
Preferred Brands
01/01/2014
STRIANT
testosterone
ADD UM: GENDER
Male
01/01/2014
sski
potassium iodide
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 93
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
sodium
polystyrene
sulfonate
sodium polystyrene
sulfonate
ADD TO FORMULARY
Generics
01/01/2014
sf
sodium fluoride
ADD TO FORMULARY
Generics
01/01/2014
sf 5000 plus
sodium fluoride
ADD TO FORMULARY
Generics
01/01/2014
stannous fluoride stannous fluoride
ADD TO FORMULARY
Generics
01/01/2014
SIMPONI ARIA
golimumab
ADD TO FORMULARY
Non-Formulary
01/01/2014
SIMPONI ARIA
golimumab
ADD UM: AUTHORIZATION
PA applies
01/01/2014
sodium
sulfacetamidesulfur
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Generics
01/01/2014
sodium
sulfacetamidesulfur
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Generics
01/01/2014
sodium
sulfacetamidesulfur
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Generics
01/01/2014
sss 10-4
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Generics
01/01/2014
sodium
sulfacetamide
sulfacetamide sodium/urea
ADD TO FORMULARY
Generics
01/01/2014
salicylic acid
salicylic acid
ADD TO FORMULARY
Generics
01/01/2014
salicylic acid
salicylic acid
ADD TO FORMULARY
Generics
01/01/2014
salicylic acid
salicylic acid
ADD TO FORMULARY
Generics
01/01/2014
silver nitrate
silver nitrate
ADD TO FORMULARY
Generics
01/01/2014
terbutaline sulfate terbutaline sulfate
ADD TO FORMULARY
Generics
01/01/2014
timolol maleate
timolol maleate
ADD TO FORMULARY
Generics
01/01/2014
timolol maleate
timolol maleate
ADD TO FORMULARY
Generics
01/01/2014
timolol maleate
timolol maleate
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 94
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
taron forte
iron
bisgly,pscmplx/ascorbate
calc/b12/folic acid/calc-threo
ADD TO FORMULARY
Generics
01/01/2014
therapeutic
hematinic
multivits,therap iron,hematin
ADD TO FORMULARY
Generics
01/01/2014
therapeutic
hematinic
multivits,therap iron,hematin
ADD UM: CUSTOM
Vitamin Benefit
Rider May Be
Required
01/01/2014
triveen-ten
prenatal vitamins
no.18/iron,carbonyl/fa/ubide
carenone/dha
ADD TO FORMULARY
Generics
01/01/2014
triveen-ten
prenatal vitamins
no.18/iron,carbonyl/fa/ubide
carenone/dha
ADD UM: GENDER
Female
01/01/2014
triveen-one
prenatal vits with calcium
#62/ferrous fumarate/fa/dha
ADD TO FORMULARY
Generics
01/01/2014
triveen-one
prenatal vits with calcium
#62/ferrous fumarate/fa/dha
ADD UM: GENDER
Female
01/01/2014
theophylline
theophylline anhydrous
ADD TO FORMULARY
Generics
01/01/2014
triamterenetriamterene/hydrochlorothiaz
hydrochlorothiazi ide
d
ADD TO FORMULARY
Generics
01/01/2014
tencon
butalbital/acetaminophen
ADD TO FORMULARY
Generics
01/01/2014
trezix
acetaminophen/caffeine/dihy
drocodeine bitartrate
ADD TO FORMULARY
Generics
01/01/2014
tolmetin sodium
tolmetin sodium
ADD TO FORMULARY
Generics
01/01/2014
tolmetin sodium
tolmetin sodium
ADD TO FORMULARY
Generics
01/01/2014
tramadol hcl er
tramadol hcl
ADD TO FORMULARY
Generics
01/01/2014
triamcinolone
acetonide
triamcinolone acetonide
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 95
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
travoprost
travoprost (benzalkonium)
ADD TO FORMULARY
Generics
01/01/2014
treagan otic
acetic
acid/antipyrine/benzocaine/p
olicosanol no.1/al acetat
ADD TO FORMULARY
Generics
01/01/2014
tetracaine hcl
tetracaine hcl/pf
ADD TO FORMULARY
Generics
01/01/2014
TRANSDERMSCOP
scopolamine
ADD TO FORMULARY
Preferred Brands
01/01/2014
TIGAN
trimethobenzamide hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
taron-prex
prenatal
prenatal vit with calcium
no.39/iron fum/folic
acid/dss/dha
ADD TO FORMULARY
Generics
01/01/2014
taron-prex
prenatal
prenatal vit with calcium
no.39/iron fum/folic
acid/dss/dha
ADD UM: GENDER
Female
01/01/2014
tolazamide
tolazamide
ADD TO FORMULARY
Generics
01/01/2014
tolbutamide
tolbutamide
ADD TO FORMULARY
Generics
01/01/2014
TESTIM
testosterone
ADD TO FORMULARY
Non-Formulary
01/01/2014
TESTIM
testosterone
ADD UM: GENDER
Male
01/01/2014
THYROSAFE
potassium iodide
ADD TO FORMULARY
Preferred Brands
01/01/2014
thyroshield
potassium iodide
ADD TO FORMULARY
Generics
01/01/2014
tri-vit with
fluoride-iron
fluoride/iron/vitamins a,c,and
d
ADD TO FORMULARY
Generics
01/01/2014
TYSABRI
natalizumab
ADD TO FORMULARY
Preferred Brands
01/01/2014
TYSABRI
natalizumab
ADD UM: AUTHORIZATION
PA applies
01/01/2014
terconazole
terconazole
ADD TO FORMULARY
Generics
01/01/2014
terconazole
terconazole
ADD UM: GENDER
Female
01/01/2014
TERAZOL 3
terconazole
ADD TO FORMULARY
Non-Formulary
01/01/2014
TERAZOL 3
terconazole
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 96
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
terconazole
terconazole
ADD TO FORMULARY
Generics
01/01/2014
terconazole
terconazole
ADD UM: GENDER
Female
01/01/2014
terconazole
terconazole
ADD TO FORMULARY
Generics
01/01/2014
terconazole
terconazole
ADD UM: GENDER
Female
01/01/2014
TERAZOL 7
terconazole
ADD TO FORMULARY
Non-Formulary
01/01/2014
TERAZOL 7
terconazole
ADD UM: GENDER
Female
01/01/2014
tretinoin
tretinoin/emollient base
ADD TO FORMULARY
Generics
01/01/2014
tretinoin
tretinoin/emollient base
ADD UM: AGE
Age Limit
01/01/2014
trichloroacetic
acid
trichloroacetic acid
ADD TO FORMULARY
Generics
01/01/2014
trichloroacetic
acid
trichloroacetic acid
ADD TO FORMULARY
Generics
01/01/2014
ultra comfort
syringe with needle,insulin
0.3 ml (half unit mark)
ADD TO FORMULARY
Generics
01/01/2014
ultra comfort
syringe with needle,insulin
0.3 ml (half unit mark)
ADD TO FORMULARY
Generics
01/01/2014
ultra comfort
syringe with needle,insulin
0.3 ml (half unit mark)
ADD TO FORMULARY
Generics
01/01/2014
ulticare,ultracomf syringe with needle,
ort,careone
insulin,1 ml and sharps
container
ADD TO FORMULARY
Generics
01/01/2014
ULTRAFOAM
microfibrillar collagen
ADD TO FORMULARY
Generics
01/01/2014
ULTRAFOAM
microfibrillar collagen
ADD TO FORMULARY
Generics
01/01/2014
ULTRAFOAM
microfibrillar collagen
ADD TO FORMULARY
Generics
01/01/2014
ULTRAFOAM
microfibrillar collagen
ADD TO FORMULARY
Generics
01/01/2014
u-cort
hydrocortisone acetate/urea
ADD TO FORMULARY
Generics
01/01/2014
urea
urea/hyaluronate sodium
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 97
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ultimatecare one prenatal vit,calcium
nf
no.35/iron/folic
acid/docusate/omega-3
ADD TO FORMULARY
Generics
01/01/2014
ultimatecare one prenatal vit,calcium
nf
no.35/iron/folic
acid/docusate/omega-3
ADD UM: GENDER
Female
01/01/2014
venatal complete prenatal vitamin
dha
no.77/sodium feredetateiron poly/fa/omega3
ADD TO FORMULARY
Generics
01/01/2014
venatal complete prenatal vitamin
dha
no.77/sodium feredetateiron poly/fa/omega3
ADD UM: GENDER
Female
01/01/2014
vp-era ob plus
prenatal vit no.8/iron
polysach,heme
polypeptide/folic acid
ADD TO FORMULARY
Generics
01/01/2014
vp-era ob plus
prenatal vit no.8/iron
polysach,heme
polypeptide/folic acid
ADD UM: GENDER
Female
01/01/2014
vinate ii
prenatal vitamins with
calcium/iron bg/folic acid
ADD TO FORMULARY
Generics
01/01/2014
vinate ii
prenatal vitamins with
calcium/iron bg/folic acid
ADD UM: GENDER
Female
01/01/2014
vinate az
prenatal vitamins with
calcium/fe bisgly/folic acid
ADD TO FORMULARY
Generics
01/01/2014
vinate az
prenatal vitamins with
calcium/fe bisgly/folic acid
ADD UM: GENDER
Female
01/01/2014
verapamil hcl
verapamil hcl
ADD TO FORMULARY
Generics
01/01/2014
added strength
pain reliever
aspirin/acetaminophen/caffei
ne
ADD TO FORMULARY
Not Covered
01/01/2014
vp-ch plus
prenatal vitamins combo
no.59/iron,carb/folic
acid/dss/dha
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 98
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
vp-ch plus
prenatal vitamins combo
no.59/iron,carb/folic
acid/dss/dha
01/01/2014
VIVELLE-DOT
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
estradiol
ADD TO FORMULARY
Non-Formulary
VIVELLE-DOT
estradiol
ADD UM: GENDER
Female
01/01/2014
VIVELLE-DOT
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
VIVELLE-DOT
estradiol
ADD UM: GENDER
Female
01/01/2014
VIVELLE-DOT
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
VIVELLE-DOT
estradiol
ADD UM: GENDER
Female
01/01/2014
VIVELLE-DOT
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
VIVELLE-DOT
estradiol
ADD UM: GENDER
Female
01/01/2014
VIVELLE-DOT
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
VIVELLE-DOT
estradiol
ADD UM: GENDER
Female
01/01/2014
VAGIFEM
estradiol
ADD TO FORMULARY
Preferred Brands
01/01/2014
VAGIFEM
estradiol
ADD UM: GENDER
Female
01/01/2014
VANTAS
histrelin acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
VANDAZOLE
metronidazole
ADD TO FORMULARY
Preferred Brands
01/01/2014
VANDAZOLE
metronidazole
ADD UM: GENDER
Female
01/01/2014
vasolex
trypsin/balsam peru/castor
oil
ADD TO FORMULARY
Generics
01/01/2014
vecamyl
mecamylamine hcl
ADD TO FORMULARY
Generics
01/01/2014
vinate ic
prenatal vits cmb w-o ca
no.2
ADD TO FORMULARY
Generics
01/01/2014
vinate ic
prenatal vits cmb w-o ca
no.2
ADD UM: GENDER
Female
01/01/2014
vitaspire
prenatal vits with calcium
#44/iron,carbonyl/folic acid
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 99
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
vitaspire
prenatal vits with calcium
#44/iron,carbonyl/folic acid
ADD UM: GENDER
Female
01/01/2014
vinate pn care
prenatal vits with calcium
#7/fe asp gly/docusate/folic
acid
ADD TO FORMULARY
Generics
01/01/2014
vinate pn care
prenatal vits with calcium
#7/fe asp gly/docusate/folic
acid
ADD UM: GENDER
Female
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD TO FORMULARY
Preventative
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD UM: GENDER
Female
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD TO FORMULARY
Preventative
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD UM: GENDER
Female
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD TO FORMULARY
Preventative
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD UM: GENDER
Female
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD TO FORMULARY
Preventative
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD UM: GENDER
Female
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD TO FORMULARY
Preventative
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD UM: GENDER
Female
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 100
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD UM: GENDER
Female
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD TO FORMULARY
Preventative
01/01/2014
wide seal
diaphragm
diaphragms, wide seal
ADD UM: GENDER
Female
01/01/2014
wal-dram
dimenhydrinate
ADD TO FORMULARY
Generics
01/01/2014
xeroform
petrolatum
dressing
bismuth
tribromophenate/petrolatum,
white
ADD TO FORMULARY
Preferred Brands
01/01/2014
xeroform
bismuth
tribromophenate/petrolatum,
white
ADD TO FORMULARY
Preferred Brands
01/01/2014
xeroform
petrolatum
dressing
bismuth
tribromophenate/petrolatum,
white
ADD TO FORMULARY
Preferred Brands
01/01/2014
XYLOCAINE
lidocaine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
x-viate
urea
ADD TO FORMULARY
Generics
01/01/2014
yohimbine hcl
yohimbine hcl
ADD TO FORMULARY
Generics
01/01/2014
yohimbine hcl
yohimbine hcl
ADD UM: GENDER
Male
01/01/2014
zgesic
acetaminophen/phenyltoloxa
mine citrate
ADD TO FORMULARY
Generics
01/01/2014
zflex
acetaminophen/phenyltoloxa
mine citrate
ADD TO FORMULARY
Generics
01/01/2014
zatean-ch
prenatal vit with calcium
#69/iron,carbon/folic
acid/dss/dha
ADD TO FORMULARY
Generics
01/01/2014
zatean-ch
prenatal vit with calcium
#69/iron,carbon/folic
acid/dss/dha
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 101
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
accolate,zafirluka zafirlukast
st
ADD UM: QUANTITY
60 / 30 days
01/01/2014
accuretic,quinapri quinapril
lhcl/hydrochlorothiazide
hydrochlorothiazi
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
accupril,quinapril quinapril hcl
hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ACIPHEX
rabeprazole sodium
CHANGE TIER
Non-Formulary
01/01/2014
ACIPHEX
SPRINKLE
rabeprazole sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
ACIPHEX
SPRINKLE
rabeprazole sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
aciphex,aciphex rabeprazole sodium
sprinkle,rabepraz
ole sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ACTEMRA
ADD TO FORMULARY
Non-Formulary
01/01/2014
onsolis,fentanyl fentanyl citrate
citrate,abstral,laz
anda,actiq,fentor
a
ADD UM: QUANTITY
13 / 30 days
01/01/2014
ACTONEL
risedronate sodium
ADD UM: QUANTITY
1 / 30 days
01/01/2014
ACTONEL
risedronate sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ACTONEL
risedronate sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ACTONEL
risedronate sodium
ADD UM: QUANTITY
4 / 30 days
01/01/2014
pioglitazone
hcl,actos
pioglitazone hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
adalat
cc,nifedipine
er,afeditab cr
nifedipine
ADD UM: QUANTITY
90 / 30 days
tocilizumab
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 102
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
adalat cc,nifediac nifedipine
cc,nifedipine er
ADD UM: QUANTITY
90 / 30 days
01/01/2014
adalat
cc,nifedipine
er,afeditab cr
nifedipine
ADD UM: QUANTITY
90 / 30 days
01/01/2014
ADALAT CC
nifedipine
ADD TO FORMULARY
Non-Formulary
01/01/2014
ADALAT CC
nifedipine
ADD TO FORMULARY
Non-Formulary
01/01/2014
ADALAT CC
nifedipine
ADD TO FORMULARY
Non-Formulary
01/01/2014
ADVAIR DISKUS fluticasone
propionate/salmeterol
xinafoate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
ADVAIR DISKUS fluticasone
propionate/salmeterol
xinafoate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
ADVAIR DISKUS fluticasone
propionate/salmeterol
xinafoate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
ADVAIR HFA
fluticasone
propionate/salmeterol
xinafoate
ADD UM: QUANTITY
12 / 30 days
01/01/2014
ADVAIR HFA
fluticasone
propionate/salmeterol
xinafoate
ADD UM: QUANTITY
12 / 30 days
01/01/2014
ADVAIR HFA
fluticasone
propionate/salmeterol
xinafoate
ADD UM: QUANTITY
12 / 30 days
01/01/2014
ADVICOR
niacin/lovastatin
CHANGE TIER
01/01/2014
ADVICOR
niacin/lovastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
imiquimod,aldara imiquimod
ADD TO FORMULARY
Preferred Brands
01/01/2014
imiquimod,aldara imiquimod
ADD UM: QUANTITY
15 / 30 days
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 103
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ALINIA
nitazoxanide
ADD UM: QUANTITY
7 / 30 days
01/01/2014
allergy reliefd,allegra-d 12
hour
fexofenadine
hcl/pseudoephedrine hcl
ADD UM: QUANTITY
60 / 30 days
01/01/2014
allegra-d 24
fexofenadine
hour,wal-fex d 24 hcl/pseudoephedrine hcl
hour,allergy relief
d,fexofenadinepse er
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ALLEGRA
fexofenadine hcl
ODT,CHILDREN'
S ALLEGRA
ALLERGY
ADD UM: QUANTITY
60 / 30 days
01/01/2014
fexofenadine
hcl,wal-fex
allergy,allergy
relief,allerease,allegra
allergy,aller-fex
CHANGE UM: QUANTITY
30 / 30 days
01/01/2014
allerfexofenadine hcl
ease,fexofenadin
e hcl,wal-fex
allergy,allegra
allergy,allergy
relief
ADD UM: QUANTITY
60 / 30 days
01/01/2014
ALLEGRA-D 24
HOUR
fexofenadine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
ALLEGRA ODT
fexofenadine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
ALOCRIL
nedocromil sodium
ADD UM: QUANTITY
5 / 30 days
01/01/2014
ALOMIDE
lodoxamide tromethamine
ADD UM: QUANTITY
10 / 30 days
01/01/2014
VIVELLEestradiol
DOT,ALORA,MIN
IVELLE
ADD UM: QUANTITY
8 / 30 days
fexofenadine hcl
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 104
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
VIVELLEestradiol
DOT,ALORA,MIN
IVELLE
ADD UM: QUANTITY
8 / 30 days
01/01/2014
VIVELLEestradiol
DOT,ALORA,MIN
IVELLE
ADD UM: QUANTITY
8 / 30 days
01/01/2014
VIVELLEDOT,ALORA
estradiol
ADD UM: QUANTITY
8 / 30 days
01/01/2014
ALTOPREV
lovastatin
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALTOPREV
lovastatin
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALTOPREV
lovastatin
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
mevacor,lovastati lovastatin
n,altoprev
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ALVESCO
ciclesonide
ADD UM: QUANTITY
6.1 / 30 days
01/01/2014
ALVESCO
ciclesonide
ADD UM: QUANTITY
12.2 / 30 days
01/01/2014
ambien,zolpidem zolpidem tartrate
tartrate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ambien,ambien zolpidem tartrate
cr,edluar,zolpide
m
tartrate,zolpimist,
zolpidem tartrate
er,intermezzo
ADD UM: QUANTITY
30 / 30 days
01/01/2014
AMBIEN
zolpidem tartrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
AMBIEN
zolpidem tartrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
AMBIEN CR
zolpidem tartrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
AMBIEN CR
zolpidem tartrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
AMITIZA
lubiprostone
ADD UM: QUANTITY
60 / 30 days
01/01/2014
ANDRODERM
testosterone
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 105
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ANDRODERM
testosterone
ADD UM: GENDER
Male
01/01/2014
ANDRODERM
testosterone
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ANDRODERM
testosterone
ADD UM: GENDER
Male
01/01/2014
ANDROGEL
testosterone
ADD UM: QUANTITY
75 / 30 days
01/01/2014
ANDROGEL
testosterone
ADD UM: QUANTITY
75 / 30 days
01/01/2014
ANDROGEL
testosterone
ADD UM: QUANTITY
75 / 30 days
01/01/2014
ANDROGEL
testosterone
ADD UM: QUANTITY
75 / 30 days
01/01/2014
ANDROGEL
testosterone
ADD UM: QUANTITY
75 / 30 days
01/01/2014
ANDROGEL
testosterone
ADD UM: QUANTITY
75 / 30 days
01/01/2014
ANDROGEL
testosterone
CHANGE UM: QUANTITY
75 / 30 days
90 / 30 days
01/01/2014
ANDROGEL
testosterone
CHANGE UM: QUANTITY
75 / 30 days
60 / 30 days
01/01/2014
ANDROGEL
testosterone
CHANGE UM: QUANTITY
75 / 30 days
60 / 30 days
01/01/2014
ANZEMET
dolasetron mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ANZEMET
dolasetron mesylate
ADD UM: QUANTITY
12 / 30 days
01/01/2014
ANZEMET
dolasetron mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ANZEMET
dolasetron mesylate
ADD UM: QUANTITY
12 / 30 days
01/01/2014
ASMANEX
mometasone furoate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ASMANEX
mometasone furoate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
ASMANEX
mometasone furoate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ASMANEX
mometasone furoate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
ASMANEX
mometasone furoate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ASMANEX
mometasone furoate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
ASMANEX
mometasone furoate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ASMANEX
mometasone furoate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
ASMANEX
mometasone furoate
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 106
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ASMANEX
mometasone furoate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
ASMANEX
mometasone furoate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ASMANEX
mometasone furoate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
ASTELIN
azelastine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
ASTELIN
azelastine hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
azelastine hcl
azelastine hcl
ADD TO FORMULARY
Generics
01/01/2014
azelastine hcl
azelastine hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
atacand
candesartan
hct,candesartan- cilexetil/hydrochlorothiazide
hydrochlorothiazi
d
ADD UM: QUANTITY
30 / 30 days
01/01/2014
atacand,candesa candesartan cilexetil
rtan cilexetil
ADD UM: QUANTITY
30 / 30 days
01/01/2014
atacand
candesartan
hct,candesartan- cilexetil/hydrochlorothiazide
hydrochlorothiazi
d
CHANGE TIER
Non-Formulary
01/01/2014
atacand
candesartan
hct,candesartan- cilexetil/hydrochlorothiazide
hydrochlorothiazi
d
CHANGE TIER
Non-Formulary
01/01/2014
atacand
candesartan
hct,candesartan- cilexetil/hydrochlorothiazide
hydrochlorothiazi
d
CHANGE TIER
Non-Formulary
01/01/2014
atacand,candesa candesartan cilexetil
rtan cilexetil
CHANGE TIER
01/01/2014
atacand,candesa candesartan cilexetil
rtan cilexetil
CHANGE TIER
01/01/2014
atacand,candesa candesartan cilexetil
rtan cilexetil
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 107
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
01/01/2014
ATACAND
01/01/2014
Generic Name
candesartan cilexetil
Type of Change
Previous Value
New Value
CHANGE TIER
Non-Formulary
ipratropium
ipratropium bromide
bromide,atrovent
ADD TO FORMULARY
Preferred Brands
01/01/2014
ATROVENT HFA ipratropium bromide
ADD TO FORMULARY
Preferred Brands
01/01/2014
ipratropium
ipratropium bromide
bromide,atrovent
ADD TO FORMULARY
Preferred Brands
01/01/2014
avalide,irbesartan irbesartan/hydrochlorothiazi
de
hydrochlorothiazi
de
ADD TO FORMULARY
Non-Formulary
01/01/2014
avalide,irbesartan irbesartan/hydrochlorothiazi
de
hydrochlorothiazi
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
avalide,irbesartan irbesartan/hydrochlorothiazi
de
hydrochlorothiazi
de
REMOVE UM: AGE
01/01/2014
avalide,irbesartan irbesartan/hydrochlorothiazi
de
hydrochlorothiazi
de
ADD TO FORMULARY
Non-Formulary
01/01/2014
avalide,irbesartan irbesartan/hydrochlorothiazi
de
hydrochlorothiazi
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
avapro,irbesartan irbesartan
ADD TO FORMULARY
Non-Formulary
01/01/2014
avapro,irbesartan irbesartan
ADD UM: QUANTITY
30 / 30 days
01/01/2014
avapro,irbesartan irbesartan
REMOVE UM: AGE
01/01/2014
avapro,irbesartan irbesartan
ADD TO FORMULARY
Non-Formulary
01/01/2014
avapro,irbesartan irbesartan
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 108
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
avapro,irbesartan irbesartan
REMOVE UM: AGE
01/01/2014
avapro,irbesartan irbesartan
ADD TO FORMULARY
Non-Formulary
01/01/2014
avapro,irbesartan irbesartan
ADD UM: QUANTITY
30 / 30 days
01/01/2014
avapro,irbesartan irbesartan
REMOVE UM: AGE
01/01/2014
candesartancandesartan
hydrochlorothiazi cilexetil/hydrochlorothiazide
d
CHANGE TIER
Generics
01/01/2014
candesartancandesartan
hydrochlorothiazi cilexetil/hydrochlorothiazide
d
CHANGE TIER
Generics
01/01/2014
candesartancandesartan
hydrochlorothiazi cilexetil/hydrochlorothiazide
d
CHANGE TIER
Generics
01/01/2014
candesartan
cilexetil
candesartan cilexetil
CHANGE TIER
Preferred Brands
Generics
01/01/2014
candesartan
cilexetil
candesartan cilexetil
CHANGE TIER
Preferred Brands
Generics
01/01/2014
candesartan
cilexetil
candesartan cilexetil
CHANGE TIER
Preferred Brands
Generics
01/01/2014
candesartan
cilexetil
candesartan cilexetil
CHANGE TIER
Preferred Brands
Generics
01/01/2014
irbesartanirbesartan/hydrochlorothiazi
hydrochlorothiazi de
de
ADD TO FORMULARY
Generics
01/01/2014
irbesartanirbesartan/hydrochlorothiazi
hydrochlorothiazi de
de
ADD TO FORMULARY
Generics
01/01/2014
irbesartan
irbesartan
ADD TO FORMULARY
Generics
01/01/2014
irbesartan
irbesartan
ADD TO FORMULARY
Generics
01/01/2014
irbesartan
irbesartan
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 109
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
avinza,morphine morphine sulfate
sulfate er
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
avinza,morphine morphine sulfate
sulfate er
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
avinza,morphine morphine sulfate
sulfate er
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
avinza,morphine morphine sulfate
sulfate er
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
avinza,morphine morphine sulfate
sulfate er
ADD TO FORMULARY
Non-Formulary
01/01/2014
avinza,morphine morphine sulfate
sulfate er
ADD TO FORMULARY
Non-Formulary
01/01/2014
OPTIVAR
azelastine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
azelastine hcl
azelastine hcl
ADD TO FORMULARY
Generics
01/01/2014
optivar,azelastine azelastine hcl
hcl
ADD UM: QUANTITY
6 / 30 days
01/01/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
ADD TO FORMULARY
Preferred Brands
01/01/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
ADD TO FORMULARY
Preferred Brands
01/01/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
ADD UM: QUANTITY
30 / 30 days
01/01/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
ADD UM: QUANTITY
30 / 30 days
01/01/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 110
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
ADD UM: QUANTITY
30 / 30 days
01/01/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
ADD TO FORMULARY
Preferred Brands
01/01/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
ADD UM: QUANTITY
30 / 30 days
01/01/2014
BECONASE AQ beclomethasone
dipropionate
ADD UM: QUANTITY
25 / 30 days
01/01/2014
BENICAR HCT
olmesartan
medoxomil/hydrochlorothiazi
de
ADD TO FORMULARY
Preferred Brands
01/01/2014
BENICAR HCT
olmesartan
medoxomil/hydrochlorothiazi
de
ADD TO FORMULARY
Preferred Brands
01/01/2014
BENICAR HCT
olmesartan
medoxomil/hydrochlorothiazi
de
ADD TO FORMULARY
Preferred Brands
01/01/2014
BENICAR
olmesartan medoxomil
ADD TO FORMULARY
Preferred Brands
01/01/2014
BENICAR
olmesartan medoxomil
ADD TO FORMULARY
Preferred Brands
01/01/2014
BENICAR
olmesartan medoxomil
ADD TO FORMULARY
Preferred Brands
01/01/2014
BENICAR HCT
olmesartan
medoxomil/hydrochlorothiazi
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
BENICAR
olmesartan medoxomil
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 111
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
01/01/2014
ADVATE,ADVAT
E L,ADVATE
M,ADVATE
H,ADVATE
SH,ADVATE
UH,XYNTHA,XY
NTHA
SOLOFUSE
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (albfree),antihemophilic factor
(factor viii) recomb,b-domain
deleted
01/01/2014
ALOCRIL
nedocromil sodium
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
ADD UM: AUTHORIZATION
PA applies
CHANGE TIER
Previous Value
New Value
PA applies
Preventative
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 112
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ALPHANINE SD factor ix
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPHANINE SD factor ix
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ALPHANINE SD factor ix
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPHANINE SD factor ix
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ALPHANINE SD factor ix
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPHANINE SD factor ix
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ALVESCO
ciclesonide
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALVESCO
ciclesonide
ADD TO FORMULARY
Preferred Brands
01/01/2014
amnesteem,clara isotretinoin
vis,absorica,zena
tane,myorisan
ADD TO FORMULARY
Preferred Brands
01/01/2014
amnesteem,clara isotretinoin
vis,absorica,zena
tane,myorisan
ADD TO FORMULARY
Preferred Brands
01/01/2014
amnesteem,clara isotretinoin
vis,absorica,zena
tane,myorisan
ADD TO FORMULARY
Preferred Brands
01/01/2014
AMTURNIDE
aliskiren
hemifumarate/amlodipine/hy
drochlorothiazide
ADD TO FORMULARY
Preferred Brands
01/01/2014
ANADROL-50
oxymetholone
ADD TO FORMULARY
Preferred Brands
01/01/2014
APOKYN
apomorphine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
APOKYN
apomorphine hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
APTIVUS
tipranavir/vitamin e tpgs
ADD TO FORMULARY
Preferred Brands
01/01/2014
APTIVUS
tipranavir
ADD TO FORMULARY
Preferred Brands
01/01/2014
ARANESP
darbepoetin alfa in
polysorbate 80
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 113
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ARMOUR
THYROID
thyroid,pork
ADD TO FORMULARY
Preferred Brands
01/01/2014
ARMOUR
THYROID
thyroid,pork
ADD TO FORMULARY
Preferred Brands
01/01/2014
ARMOUR
THYROID
thyroid,pork
ADD TO FORMULARY
Preferred Brands
01/01/2014
ARMOUR
THYROID
thyroid,pork
ADD TO FORMULARY
Preferred Brands
01/01/2014
ARMOUR
THYROID
thyroid,pork
ADD TO FORMULARY
Preferred Brands
01/01/2014
ARMOUR
THYROID
thyroid,pork
ADD TO FORMULARY
Preferred Brands
01/01/2014
ARMOUR
THYROID
thyroid,pork
ADD TO FORMULARY
Preferred Brands
01/01/2014
ARMOUR
THYROID
thyroid,pork
ADD TO FORMULARY
Preferred Brands
01/01/2014
ASACOL
mesalamine
ADD TO FORMULARY
Preferred Brands
01/01/2014
ASACOL HD
mesalamine
ADD TO FORMULARY
Preferred Brands
01/01/2014
ATRALIN
tretinoin
ADD TO FORMULARY
Preferred Brands
01/01/2014
ATRIPLA
efavirenz/emtricitabine/tenof
ovir disoproxil fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
AUVI-Q
epinephrine
ADD TO FORMULARY
Preferred Brands
01/01/2014
AUVI-Q
epinephrine
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVANDAMET
rosiglitazone
maleate/metformin hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVANDARYL
rosiglitazone
maleate/glimepiride
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVANDIA
rosiglitazone maleate
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 114
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
moxeza,vigamox, moxifloxacin hcl
avelox,avelox
abc
pack,moxifloxacin
hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVODART
dutasteride
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVONEX PEN
interferon beta-1a
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVONEX PEN
interferon beta-1a
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AVONEX
interferon beta-1a
ADD TO FORMULARY
Preferred Brands
01/01/2014
AVONEX
interferon beta-1a
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AZASAN
azathioprine
ADD TO FORMULARY
Preferred Brands
01/01/2014
AZASAN
azathioprine
ADD TO FORMULARY
Preferred Brands
01/01/2014
AZELEX
azelaic acid
ADD TO FORMULARY
Preferred Brands
01/01/2014
AZOPT
brinzolamide
ADD TO FORMULARY
Preferred Brands
01/01/2014
BARACLUDE
entecavir
ADD TO FORMULARY
Preferred Brands
01/01/2014
BARACLUDE
entecavir
ADD TO FORMULARY
Preferred Brands
01/01/2014
BARACLUDE
entecavir
ADD TO FORMULARY
Preferred Brands
01/01/2014
pen needle
needles, insulin disposable,
safety
ADD TO FORMULARY
Preferred Brands
01/01/2014
autoshield pen
needle
pen needle, diabetic, safety
ADD TO FORMULARY
Preferred Brands
01/01/2014
autoshield pen
needle
pen needle, diabetic, safety
ADD TO FORMULARY
Preferred Brands
01/01/2014
autoshield duo
pen needle
pen needle, diabetic
disposable, safety
ADD TO FORMULARY
Preferred Brands
01/01/2014
BETHKIS
tobramycin
ADD TO FORMULARY
Preferred Brands
01/01/2014
BETIMOL
timolol
ADD TO FORMULARY
Preferred Brands
01/01/2014
BETIMOL
timolol
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 115
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
BETOPTIC S
betaxolol hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
BIDIL
isosorbide
dinitrate/hydralazine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
BLEPHAMIDE
sulfacetamide
sodium/prednisolone
acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
BLEPHAMIDE
S.O.P.
sulfacetamide
sodium/prednisolone
acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
BRAVELLE
urofollitropin
ADD UM: CUSTOM
Fertility Rider
REQUIRED
01/01/2014
breeze 2
blood-glucose meter, disctype
ADD UM: CUSTOM
Provide Free of
Charge
01/01/2014
BRILINTA
ticagrelor
ADD TO FORMULARY
Preferred Brands
01/01/2014
BUPHENYL
sodium phenylbutyrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
BYETTA
exenatide
ADD TO FORMULARY
Preferred Brands
01/01/2014
BYETTA
exenatide
ADD TO FORMULARY
Preferred Brands
01/01/2014
levocarnitine,carn levocarnitine (with sugar)
itor
ADD TO FORMULARY
Preferred Brands
01/01/2014
levocarnitine,llevocarnitine,levocarnitine
carnitine,gtartrate
levocarnitine,bioc
arnitine
sf,carnitor,carnito
r sf
ADD TO FORMULARY
Preferred Brands
01/01/2014
CELEBREX
celecoxib
ADD TO FORMULARY
Preferred Brands
01/01/2014
CELEBREX
celecoxib
ADD TO FORMULARY
Preferred Brands
01/01/2014
CELEBREX
celecoxib
ADD TO FORMULARY
Preferred Brands
01/01/2014
CELEBREX
celecoxib
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 116
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
CELONTIN
methsuximide
ADD TO FORMULARY
Preferred Brands
01/01/2014
CHANTIX
varenicline tartrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
CIALIS,ADCIRC
A
tadalafil
CHANGE TIER
Preferred Brands
01/01/2014
CIALIS
tadalafil
ADD UM: CUSTOM
PA required for
QL = 30
01/01/2014
CIALIS
tadalafil
ADD UM: AUTHORIZATION
PA applies
01/01/2014
CIALIS
tadalafil
ADD UM: CUSTOM
PA required for
QL = 30
01/01/2014
CIALIS
tadalafil
ADD UM: AUTHORIZATION
PA applies
01/01/2014
CIPRO
ciprofloxacin hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
CIPRODEX
ciprofloxacin
hcl/dexamethasone
ADD TO FORMULARY
Preferred Brands
01/01/2014
CIPRO HC
ciprofloxacin
hcl/hydrocortisone
ADD TO FORMULARY
Preferred Brands
01/01/2014
ciprofloxacin hcl
ciprofloxacin hcl
ADD TO FORMULARY
Generics
01/01/2014
ciprofloxacin hcl
ciprofloxacin hcl
ADD TO FORMULARY
Generics
01/01/2014
CLARIFOAM EF sulfacetamide sodium/sulfur
ADD TO FORMULARY
Preferred Brands
01/01/2014
CLOBEX
clobetasol propionate
ADD TO FORMULARY
Preferred Brands
01/01/2014
COARTEM
artemether/lumefantrine
ADD TO FORMULARY
Preferred Brands
01/01/2014
COLCRYS
colchicine
ADD TO FORMULARY
Preferred Brands
01/01/2014
COLY-MYCIN M colistin (as colistimethate
PARENTERAL
sodium)
ADD TO FORMULARY
Preferred Brands
01/01/2014
COMBIGAN
brimonidine tartrate/timolol
maleate
ADD TO FORMULARY
Preferred Brands
01/01/2014
COMBIVENT
ipratropium
bromide/albuterol sulfate
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 117
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
COMBIVENT
RESPIMAT
ipratropium
bromide/albuterol sulfate
ADD TO FORMULARY
Preferred Brands
01/01/2014
COMPLERA
emtricitabine/rilpivirine
hcl/tenofovir disoproxil
fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
CONCERTA
methylphenidate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
CONCERTA
methylphenidate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
CONCERTA
methylphenidate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
CONCERTA
methylphenidate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
contour next ez
blood-glucose meter
ADD UM: CUSTOM
Provided Free of
Charge
01/01/2014
COPAXONE
glatiramer acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
COPAXONE
glatiramer acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
COPAXONE
glatiramer acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
CORDRAN
flurandrenolide
ADD TO FORMULARY
Preferred Brands
01/01/2014
CORTIFOAM
hydrocortisone acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
creon,pancrelipas lipase/protease/amylase
e 5,000,tri-pase
8,tri-pase
16,zenpep,pancr
eaze,ultresa,viok
ace,pertzye
ADD TO FORMULARY
Non-Formulary
01/01/2014
CRESTOR
rosuvastatin calcium
ADD TO FORMULARY
Preferred Brands
01/01/2014
CRIXIVAN
indinavir sulfate
ADD TO FORMULARY
Preferred Brands
01/01/2014
CYSTADANE
betaine
ADD TO FORMULARY
Preferred Brands
01/01/2014
CYSTAGON
cysteamine bitartrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
CYSTAGON
cysteamine bitartrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
DARAPRIM
pyrimethamine
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 118
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
DETROL
tolterodine tartrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
DETROL LA
tolterodine tartrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
DETROL
tolterodine tartrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
DETROL LA
tolterodine tartrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
detrol,detrol
tolterodine tartrate
la,tolterodine
tartrate,tolterodin
e tartrate er
ADD TO FORMULARY
Preferred Brands
01/01/2014
DEXILANT
dexlansoprazole
ADD TO FORMULARY
Preferred Brands
01/01/2014
DIBENZYLINE
phenoxybenzamine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
DIPENTUM
olsalazine sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
DORAL
quazepam
ADD TO FORMULARY
Non-Formulary
01/01/2014
DULERA
mometasone
furoate/formoterol fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
DULERA
mometasone
furoate/formoterol fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
DYRENIUM
triamterene
ADD TO FORMULARY
Preferred Brands
01/01/2014
DYRENIUM
triamterene
ADD TO FORMULARY
Preferred Brands
01/01/2014
EDURANT
rilpivirine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
EFFIENT
prasugrel hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
ELDEPRYL
selegiline hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
ELIDEL
pimecrolimus
ADD TO FORMULARY
Preferred Brands
01/01/2014
ELMIRON
pentosan polysulfate sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
ELIQUIS
apixaban
ADD TO FORMULARY
Preferred Brands
01/01/2014
EMCYT
estramustine phosphate
sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
EMTRIVA
emtricitabine
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 119
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ENBREL
etanercept
ADD TO FORMULARY
Preferred Brands
01/01/2014
ENBREL
etanercept
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EPIPEN JR 2PAK
epinephrine
ADD TO FORMULARY
Preferred Brands
01/01/2014
EPIPEN 2-PAK
epinephrine
ADD TO FORMULARY
Preferred Brands
01/01/2014
EPIVIR HBV
lamivudine
ADD TO FORMULARY
Non-Formulary
01/01/2014
EPIVIR HBV
lamivudine
ADD TO FORMULARY
Preferred Brands
01/01/2014
EPIVIR
lamivudine
ADD TO FORMULARY
Preferred Brands
01/01/2014
EPIVIR
lamivudine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
EPIVIR
lamivudine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
EPIVIR HBV
lamivudine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EPOGEN
epoetin alfa
ADD TO FORMULARY
Preferred Brands
01/01/2014
EPOGEN
epoetin alfa
ADD TO FORMULARY
Preferred Brands
01/01/2014
EPOGEN,PROC epoetin alfa
RIT
ADD TO FORMULARY
Preferred Brands
01/01/2014
EPZICOM
abacavir sulfate/lamivudine
ADD TO FORMULARY
Preferred Brands
01/01/2014
ESTRACE
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ESTRACE
estradiol
ADD UM: GENDER
Female
01/01/2014
ESTRACE
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ESTRACE
estradiol
ADD UM: GENDER
Female
01/01/2014
ESTRACE
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ESTRACE
estradiol
ADD UM: GENDER
Female
01/01/2014
ESTRACE
estradiol
ADD TO FORMULARY
01/01/2014
ESTROGEL
estradiol
ADD UM: GENDER
Female
01/01/2014
EVISTA
raloxifene hcl
ADD TO FORMULARY
Preferred Brands
Non-Formulary
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 120
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
FABRAZYME
agalsidase beta
ADD TO FORMULARY
Preferred Brands
01/01/2014
FABRAZYME
agalsidase beta
ADD TO FORMULARY
Preferred Brands
01/01/2014
FASLODEX
fulvestrant
ADD TO FORMULARY
Preferred Brands
01/01/2014
FEIBA NF
anti-inhibitor coagulant
complex
ADD TO FORMULARY
Preferred Brands
01/01/2014
FEIBA NF
anti-inhibitor coagulant
complex
ADD TO FORMULARY
Preferred Brands
01/01/2014
FEIBA NF
anti-inhibitor coagulant
complex
ADD TO FORMULARY
Preferred Brands
01/01/2014
felbamate
felbamate
ADD TO FORMULARY
Generics
01/01/2014
felbamate
felbamate
ADD TO FORMULARY
Generics
01/01/2014
FELBATOL
felbamate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
FELBATOL
felbamate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
felbamate
felbamate
ADD TO FORMULARY
Non-Formulary
01/01/2014
FIRMAGON
degarelix acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FLOVENT HFA
fluticasone propionate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FLOVENT HFA
fluticasone propionate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FLOVENT HFA
fluticasone propionate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FLOVENT
DISKUS
fluticasone propionate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FLOVENT
DISKUS
fluticasone propionate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FLOVENT
DISKUS
fluticasone propionate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FML
fluorometholone
CHANGE TIER
Preferred Brands
01/01/2014
FML S.O.P.
fluorometholone
ADD TO FORMULARY
Preferred Brands
01/01/2014
FOCALIN XR
dexmethylphenidate hcl
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 121
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
FOCALIN XR
dexmethylphenidate hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
FOCALIN XR
dexmethylphenidate hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
focalin,focalin
dexmethylphenidate hcl
xr,dexmethylphen
idate
hcl,dexmethylphe
nidate hcl er
CHANGE TIER
Preferred Brands
01/01/2014
arixtra,fondaparin fondaparinux sodium
ux sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
FORADIL
formoterol fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FOSRENOL
lanthanum carbonate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FRAGMIN
dalteparin sodium,porcine
ADD TO FORMULARY
Preferred Brands
01/01/2014
FUZEON
enfuvirtide
ADD TO FORMULARY
Preferred Brands
01/01/2014
FUZEON
enfuvirtide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
FUZEON
enfuvirtide
ADD TO FORMULARY
Preferred Brands
01/01/2014
FUZEON
enfuvirtide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
GASTROCROM
cromolyn sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 122
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GENOTROPIN
somatropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
GLEEVEC
imatinib mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
GLEEVEC
imatinib mesylate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
GONAL-F
follitropin alfa, recomb
RFF,GONALF,GONAL-F RFF
REDI-JECT
ADD TO FORMULARY
Preferred Brands
01/01/2014
GONAL-F
follitropin alfa, recomb
RFF,GONALF,GONAL-F RFF
REDI-JECT
ADD UM: CUSTOM
Fertility Benefit
Rider REQUIRED
01/01/2014
GRIFULVIN V
griseofulvin, microsize
ADD TO FORMULARY
Preferred Brands
01/01/2014
GRIS-PEG
griseofulvin ultramicrosize
ADD TO FORMULARY
Preferred Brands
01/01/2014
GRIS-PEG
griseofulvin ultramicrosize
ADD TO FORMULARY
Preferred Brands
01/01/2014
griseofulvin
ultramicrosize
griseofulvin ultramicrosize
ADD TO FORMULARY
Preferred Brands
01/01/2014
HALFLYTELYBISACODYL
bisacodyl/sodium
chlor/sodium
bicarb/potassium chl/peg
3350
ADD TO FORMULARY
Preferred Brands
01/01/2014
HECTOROL
doxercalciferol
ADD TO FORMULARY
Preferred Brands
01/01/2014
HECTOROL
doxercalciferol
ADD TO FORMULARY
Preferred Brands
01/01/2014
HECTOROL
doxercalciferol
ADD TO FORMULARY
Preferred Brands
01/01/2014
HECTOROL
doxercalciferol
ADD TO FORMULARY
Preferred Brands
01/01/2014
HEXALEN
altretamine
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 123
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
HUMALOG MIX insulin lispro protamine and
75-25,HUMALOG insulin lispro
MIX 5050,HUMALOG
MIX 75-25
KWIKPEN,HUMA
LOG MIX 50-50
KWIKPEN
ADD TO FORMULARY
Preferred Brands
01/01/2014
HUMALOG,HUM insulin lispro
ALOG KWIKPEN
U-100
ADD TO FORMULARY
Preferred Brands
01/01/2014
HUMIRA,HUMIR adalimumab
A PEN,HUMIRA
PEN CROHNUC-HS
STARTER,HUMI
RA PEN
PSORIASISUVEITIS
ADD TO FORMULARY
Preferred Brands
01/01/2014
HUMIRA,HUMIR adalimumab
A PEN,HUMIRA
PEN CROHNUC-HS
STARTER,HUMI
RA PEN
PSORIASISUVEITIS
ADD UM: AUTHORIZATION
PA applies
01/01/2014
HUMULIN R U500
ADD TO FORMULARY
Preferred Brands
01/01/2014
HUMULIN 70insulin nph human
30,NOVOLIN 70- isophane/insulin regular,
30,HUMULIN
human
70/30 KWIKPEN
CHANGE TIER
Preferred Brands
insulin regular, human
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 124
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
CHANGE TIER
Preferred Brands
01/01/2014
HUMULIN
N,NOVOLIN
N,HUMULIN N
KWIKPEN
insulin nph human isophane
01/01/2014
IMURAN
azathioprine
ADD TO FORMULARY
Preferred Brands
01/01/2014
INCIVEK
telaprevir
ADD TO FORMULARY
Preferred Brands
01/01/2014
INCIVEK
telaprevir
ADD UM: AUTHORIZATION
PA applies
01/01/2014
INSPRA
eplerenone
ADD TO FORMULARY
Preferred Brands
01/01/2014
INSPRA
eplerenone
ADD TO FORMULARY
Preferred Brands
01/01/2014
INTELENCE
etravirine
ADD TO FORMULARY
Preferred Brands
01/01/2014
INTRON A
interferon alfa-2b,recomb.
ADD TO FORMULARY
Preferred Brands
01/01/2014
INTRON A
interferon alfa-2b,recomb.
ADD UM: AUTHORIZATION
PA applies
01/01/2014
INVIRASE
saquinavir mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ISENTRESS
raltegravir potassium
ADD TO FORMULARY
Preferred Brands
01/01/2014
ISOPTO
CARBACHOL
carbachol
ADD TO FORMULARY
Preferred Brands
01/01/2014
ISOPTO
CARBACHOL
carbachol
ADD TO FORMULARY
Preferred Brands
01/01/2014
ISOPTO
CARPINE
pilocarpine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
ISOPTO
CARPINE
pilocarpine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
ISOPTO
CARPINE
pilocarpine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
JALYN
dutasteride/tamsulosin hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
JANUMET
XR,JANUMET
sitagliptin
phosphate/metformin hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
JANUVIA
sitagliptin phosphate
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 125
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
KADIAN
morphine sulfate
ADD TO FORMULARY
Preferred Brands
01/01/2014
KADIAN
morphine sulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
KADIAN
morphine sulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
KADIAN
morphine sulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
KADIAN
morphine sulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
KADIAN
morphine sulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
KADIAN
morphine sulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
KADIAN
morphine sulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
KALETRA
lopinavir/ritonavir
ADD TO FORMULARY
Preferred Brands
01/01/2014
KOMBIGLYZE
XR
saxagliptin hcl/metformin hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
LANTUS
insulin glargine,human
SOLOSTAR,LAN recombinant analog
TUS
ADD TO FORMULARY
Preferred Brands
01/01/2014
LETAIRIS
ambrisentan
ADD TO FORMULARY
Preferred Brands
01/01/2014
LETAIRIS
ambrisentan
ADD UM: AUTHORIZATION
PA applies
01/01/2014
LEUKERAN
chlorambucil
ADD TO FORMULARY
Preferred Brands
01/01/2014
LEUKINE
sargramostim
ADD TO FORMULARY
Preferred Brands
01/01/2014
LEVEMIR,LEVE
MIR FLEXPEN
insulin detemir
ADD TO FORMULARY
Preferred Brands
01/01/2014
LEXIVA
fosamprenavir calcium
ADD TO FORMULARY
Preferred Brands
01/01/2014
LIDOVIR
acyclovir/lidocaine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
LIPITOR
atorvastatin calcium
CHANGE TIER
Non-Formulary
01/01/2014
LODOSYN
carbidopa
ADD TO FORMULARY
Non-Formulary
01/01/2014
ALREX,LOTEMA loteprednol etabonate
X
CHANGE TIER
Preferred Brands
01/01/2014
LOTRONEX
ADD TO FORMULARY
Preferred Brands
alosetron hcl
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 126
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
lyrica,pregabalin pregabalin
ADD TO FORMULARY
Preferred Brands
01/01/2014
MACROBID
nitrofurantoin
monohydrate/macrocrystals
ADD TO FORMULARY
Preferred Brands
01/01/2014
MALARONE
atovaquone/proguanil hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
MALARONE
atovaquone/proguanil hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
MARPLAN
isocarboxazid
ADD TO FORMULARY
Preferred Brands
01/01/2014
MATULANE
procarbazine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
MEPRON
atovaquone
ADD TO FORMULARY
Non-Formulary
01/01/2014
MESNEX
mesna
ADD TO FORMULARY
Non-Formulary
01/01/2014
MESNEX
mesna
ADD TO FORMULARY
Preferred Brands
01/01/2014
pyridostigmine
pyridostigmine bromide
bromide,mestino
n,regonol
ADD TO FORMULARY
Preferred Brands
01/01/2014
METHITEST
methyltestosterone
ADD TO FORMULARY
Preferred Brands
01/01/2014
MIGRANAL
dihydroergotamine mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
MONOCLATEP,HEMOFIL
M,KOATE-DVI
antihemophilic factor,
human
CHANGE TIER
Preferred Brands
01/01/2014
MUGARD
glycerin/carbomer
homopolymer type
a/potassium hydroxide
ADD TO FORMULARY
Preferred Brands
01/01/2014
MYAMBUTOL
ethambutol hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
MYFORTIC
mycophenolate sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
MYFORTIC
mycophenolate sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
MYLERAN
busulfan
ADD TO FORMULARY
Preferred Brands
01/01/2014
MYOZYME
alglucosidase alfa
ADD TO FORMULARY
Preferred Brands
01/01/2014
NAMENDA,NAM memantine hcl
ENDA XR
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 127
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
NATROBA
spinosad
01/01/2014
armour
thyroid,pork,thyroid
thyroid,thyroid,np
thyroid,naturethroid,westhroid,
wp thyroid
01/01/2014
NEULASTA
01/01/2014
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Preferred Brands
CHANGE TIER
Preferred Brands
pegfilgrastim
ADD TO FORMULARY
Preferred Brands
NEVANAC
nepafenac
ADD TO FORMULARY
Preferred Brands
01/01/2014
NEXAVAR
sorafenib tosylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
NIASPAN
niacin
ADD TO FORMULARY
Preferred Brands
01/01/2014
NIASPAN
niacin
ADD TO FORMULARY
Preferred Brands
01/01/2014
NIASPAN
niacin
ADD TO FORMULARY
Preferred Brands
01/01/2014
NILANDRON
nilutamide
ADD TO FORMULARY
Preferred Brands
01/01/2014
NITROLINGUAL nitroglycerin
ADD TO FORMULARY
01/01/2014
NITROSTAT
nitroglycerin
ADD TO FORMULARY
Preferred Brands
01/01/2014
NITROSTAT
nitroglycerin
ADD TO FORMULARY
Preferred Brands
01/01/2014
NITROSTAT
nitroglycerin
ADD TO FORMULARY
Preferred Brands
01/01/2014
NORITATE
metronidazole
ADD TO FORMULARY
Preferred Brands
01/01/2014
novofine
pen needle, diabetic
CHANGE TIER
Generics
Preferred Brands
01/01/2014
novofine 32
pen needle, diabetic
CHANGE TIER
Generics
Preferred Brands
01/01/2014
NOVOLOG MIX insulin aspart protamine
70-30,NOVOLOG human/insulin aspart
MIX 70-30
FLEXPEN
ADD TO FORMULARY
Preferred Brands
01/01/2014
NOVOLOG,NOV insulin aspart
OLOG FLEXPEN
ADD TO FORMULARY
Preferred Brands
01/01/2014
NOVOSEVEN
RT
ADD TO FORMULARY
Preferred Brands
coagulation factor viia
(recombinant)
Non-Formulary
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 128
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
novotwist
pen needle, diabetic
CHANGE TIER
Generics
Preferred Brands
01/01/2014
novotwist
pen needle, diabetic
CHANGE TIER
Generics
Preferred Brands
01/01/2014
HUMATROPE,G somatropin
ENOTROPIN,NO
RDITROPIN
NORDIFLEX,NO
RDITROPIN
FLEXPRO,OMNI
TROPE,SEROST
IM,SAIZEN,ZOR
BTIVE,NUTROPI
N,NUTROPIN
AQ,NUTROPIN
AQ
NUSPIN,TEVTROPIN
01/01/2014
NUVIGIL
01/01/2014
CHANGE TIER
Preferred Brands
armodafinil
ADD TO FORMULARY
Preferred Brands
ONGLYZA
saxagliptin hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
ORAP
pimozide
ADD TO FORMULARY
Preferred Brands
01/01/2014
ORFADIN
nitisinone
ADD TO FORMULARY
Preferred Brands
01/01/2014
ORTHO TRICYCLEN LO
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preferred Brands
01/01/2014
ORTHO TRICYCLEN LO
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
OSMOPREP
sodium phosphate,m-basic
m-hyd/sodium
phosphate,dibasic
ADD TO FORMULARY
Preferred Brands
01/01/2014
OXSORALENULTRA
methoxsalen, rapid
ADD TO FORMULARY
Preferred Brands
01/01/2014
oxsoralen,8methoxsalen
mop,methoxsalen
,uvadex
CHANGE TIER
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 129
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
CHANGE TIER
New Value
01/01/2014
oxycodone
oxycodone hcl
hcl,oxycodone
hydrochloride,roxi
codone,oxycontin
,oxecta
Preferred Brands
01/01/2014
PANCREAZE
lipase/protease/amylase
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
PANCREAZE
lipase/protease/amylase
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
PANCREAZE
lipase/protease/amylase
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
PANCREAZE
lipase/protease/amylase
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
pancrelipase
5,000
lipase/protease/amylase
ADD TO FORMULARY
Non-Formulary
Generics
01/01/2014
PARCOPA
carbidopa/levodopa
ADD TO FORMULARY
Preferred Brands
01/01/2014
PARCOPA
carbidopa/levodopa
ADD TO FORMULARY
Preferred Brands
01/01/2014
PARCOPA
carbidopa/levodopa
ADD TO FORMULARY
Preferred Brands
01/01/2014
PATADAY
olopatadine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
PEGASYS,PEGA peginterferon alfa-2a
SYS PROCLICK
ADD TO FORMULARY
Preferred Brands
01/01/2014
PEGASYS,PEGA peginterferon alfa-2a
SYS PROCLICK
ADD UM: AUTHORIZATION
PA applies
01/01/2014
PEGINTRON,SY peginterferon alfa-2b
LATRON,SYLAT
RON 4PACK,PEGINTR
ON REDIPEN
CHANGE TIER
Preferred Brands
01/01/2014
PEGINTRON,SY peginterferon alfa-2b
LATRON,SYLAT
RON 4PACK,PEGINTR
ON REDIPEN
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 130
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
CHANGE TIER
New Value
01/01/2014
asacol,delzicol,as mesalamine
acol hd,5aminosalicylic
acid,mesalamine,
pentasa,lialda,ca
nasa,apriso,sfrow
asa
Preferred Brands
01/01/2014
creon,pancrelipas lipase/protease/amylase
e 5,000,tri-pase
8,tri-pase
16,zenpep,pancr
eaze,ultresa,viok
ace,pertzye
ADD TO FORMULARY
01/01/2014
PHOSLO
calcium acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
PHOSPHOLINE
IODIDE
echothiophate iodide
ADD TO FORMULARY
Preferred Brands
01/01/2014
PILOPINE HS
pilocarpine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
PLAVIX
clopidogrel bisulfate
CHANGE TIER
Non-Formulary
01/01/2014
PLAVIX
clopidogrel bisulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
PLETAL
cilostazol
ADD TO FORMULARY
Preferred Brands
01/01/2014
PLETAL
cilostazol
ADD TO FORMULARY
Preferred Brands
01/01/2014
PRADAXA
dabigatran etexilate
mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
PRED-G
gentamicin
sulfate/prednisolone acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
PRED-G
gentamicin
sulfate/prednisolone acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
PREMARIN
estrogens, conjugated
CHANGE TIER
Preferred Brands
01/01/2014
PREMARIN
estrogens, conjugated
CHANGE UM: GENDER
Female
Non-Formulary
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 131
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
PREMPRO,PRE estrogens,
MPHASE
conjugated/medroxyprogest
erone acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
PREMPRO,PRE estrogens,
MPHASE
conjugated/medroxyprogest
erone acetate
ADD UM: GENDER
Female
01/01/2014
PREVPAC
lansoprazole/amoxicillin
trihydrate/clarithromycin
ADD TO FORMULARY
Preferred Brands
01/01/2014
PREVACID
lansoprazole
ADD TO FORMULARY
Non-Formulary
01/01/2014
PREVACID
lansoprazole
CHANGE TIER
01/01/2014
PREZISTA
darunavir ethanolate
ADD TO FORMULARY
Preferred Brands
01/01/2014
PRISTIQ ER
desvenlafaxine succinate
ADD TO FORMULARY
Preferred Brands
01/01/2014
PRISTIQ ER
desvenlafaxine succinate
ADD TO FORMULARY
Preferred Brands
01/01/2014
PROAIR HFA
albuterol sulfate
ADD TO FORMULARY
Preferred Brands
01/01/2014
BEBULIN VH
factor ix complex,
IMMUNO,BEBUL prothrombin complex conc.
IN,PROFILNINE (pcc) comb. 6,factor ix
complex, prothrombin cplx
conc(pcc) no.6, 3factor,factor ix complex,
prothrombin cplx conc(pcc)
no.4, 3-factor
CHANGE TIER
Preferred Brands
01/01/2014
progesterone
progesterone,micronized
ADD TO FORMULARY
Generics
01/01/2014
progesterone
progesterone,micronized
ADD TO FORMULARY
Generics
01/01/2014
PROMETRIUM
progesterone,micronized
ADD TO FORMULARY
Preferred Brands
01/01/2014
PROMETRIUM
progesterone,micronized
ADD TO FORMULARY
Preferred Brands
01/01/2014
PROMISEB
COMPLETE
emollient combination
no.43/skin cleanser
combination #27
ADD TO FORMULARY
Preferred Brands
01/01/2014
PROVIGIL
modafinil
ADD TO FORMULARY
Preferred Brands
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 132
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
PROVIGIL
modafinil
ADD TO FORMULARY
Preferred Brands
01/01/2014
PULMICORT
FLEXHALER
budesonide
ADD TO FORMULARY
Preferred Brands
01/01/2014
PULMICORT
FLEXHALER
budesonide
ADD TO FORMULARY
Preferred Brands
01/01/2014
PULMICORT
budesonide
ADD TO FORMULARY
Preferred Brands
01/01/2014
PULMICORT
budesonide
ADD TO FORMULARY
Non-Formulary
01/01/2014
PULMICORT
budesonide
ADD TO FORMULARY
Non-Formulary
01/01/2014
PULMOZYME
dornase alfa
ADD TO FORMULARY
Preferred Brands
01/01/2014
PULMOZYME
dornase alfa
ADD UM: AUTHORIZATION
PA applies
01/01/2014
PURINETHOL
mercaptopurine
ADD TO FORMULARY
Preferred Brands
01/01/2014
beconase
beclomethasone
aq,beclomethaso dipropionate
ne
dipropionate,qvar
,qnasl
CHANGE TIER
Preferred Brands
01/01/2014
REBIF,REBIF
interferon beta-1a/albumin
REBIDOSE,AVO human
NEX
CHANGE TIER
Preferred Brands
01/01/2014
REBIF,REBIF
interferon beta-1a/albumin
REBIDOSE,AVO human
NEX
CHANGE UM:
AUTHORIZATION
PA applies
01/01/2014
RELPAX
eletriptan hbr
ADD TO FORMULARY
Preferred Brands
01/01/2014
RELPAX
eletriptan hbr
ADD UM: QUANTITY
18 / 30 days
01/01/2014
RENAGEL
sevelamer hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
RENAGEL
sevelamer hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 133
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
REQUIP
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP XL
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP XL
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP XL
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP XL
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
REQUIP XL
ropinirole hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
RESCRIPTOR
delavirdine mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
RESCRIPTOR
delavirdine mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
RESTASIS
cyclosporine
ADD TO FORMULARY
Preferred Brands
01/01/2014
REVLIMID
lenalidomide
ADD TO FORMULARY
Preferred Brands
01/01/2014
REYATAZ
atazanavir sulfate
ADD TO FORMULARY
Preferred Brands
01/01/2014
RHEUMATREX
methotrexate sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
RIDAURA
auranofin
ADD TO FORMULARY
Preferred Brands
01/01/2014
RIMSO-50
dimethyl sulfoxide
ADD TO FORMULARY
Preferred Brands
01/01/2014
RISPERDAL
CONSTA
risperidone microspheres
ADD TO FORMULARY
Preferred Brands
01/01/2014
RISPERDAL
risperidone
ADD TO FORMULARY
Non-Formulary
01/01/2014
RISPERDAL
risperidone
ADD TO FORMULARY
Generics
01/01/2014
RISPERDAL
risperidone
ADD TO FORMULARY
Generics
01/01/2014
RISPERDAL
risperidone
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 134
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
RISPERDAL MTAB
risperidone
ADD TO FORMULARY
Non-Formulary
01/01/2014
RISPERDAL
risperidone
ADD TO FORMULARY
Non-Formulary
01/01/2014
RISPERDAL
risperidone
ADD TO FORMULARY
Non-Formulary
01/01/2014
RISPERDAL
risperidone
ADD TO FORMULARY
Non-Formulary
01/01/2014
RISPERDAL MTAB
risperidone
ADD TO FORMULARY
Non-Formulary
01/01/2014
RISPERDAL MTAB
risperidone
ADD TO FORMULARY
Non-Formulary
01/01/2014
RISPERDAL MTAB
risperidone
ADD TO FORMULARY
Non-Formulary
01/01/2014
RISPERDAL MTAB
risperidone
ADD TO FORMULARY
Non-Formulary
01/01/2014
ROWASA
mesalamine with cleansing
wipes
ADD TO FORMULARY
Preferred Brands
01/01/2014
SECONAL
SODIUM
secobarbital sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
SELZENTRY
maraviroc
ADD TO FORMULARY
Preferred Brands
01/01/2014
SENSIPAR
cinacalcet hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
SEREVENT
DISKUS
salmeterol xinafoate
ADD TO FORMULARY
Preferred Brands
01/01/2014
SEROQUEL
quetiapine fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
SEROQUEL
quetiapine fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
SEROQUEL
quetiapine fumarate
CHANGE TIER
Non-Formulary
01/01/2014
SEROQUEL
quetiapine fumarate
CHANGE TIER
Non-Formulary
01/01/2014
SEROQUEL XR
quetiapine fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
SEROQUEL XR
quetiapine fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
SEROQUEL XR
quetiapine fumarate
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 135
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
SEROQUEL XR
quetiapine fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
SEROQUEL XR
quetiapine fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
SIMPONI,SIMPO golimumab
NI ARIA
ADD TO FORMULARY
Preferred Brands
01/01/2014
SIMPONI,SIMPO golimumab
NI ARIA
CHANGE UM:
AUTHORIZATION
PA applies
01/01/2014
SINGULAIR
montelukast sodium
CHANGE TIER
Non-Formulary
01/01/2014
SINGULAIR
montelukast sodium
CHANGE TIER
Non-Formulary
01/01/2014
SINGULAIR
montelukast sodium
CHANGE TIER
Non-Formulary
01/01/2014
SINGULAIR
montelukast sodium
CHANGE TIER
01/01/2014
spectracef,cefdito cefditoren pivoxil
ren pivoxil
01/01/2014
SPIRIVA
01/01/2014
Preferred Brands
Non-Formulary
CHANGE TIER
Preferred Brands
tiotropium bromide
ADD TO FORMULARY
Preferred Brands
SPRYCEL
dasatinib
ADD TO FORMULARY
Preferred Brands
01/01/2014
stavudine
stavudine
ADD TO FORMULARY
Generics
01/01/2014
stavudine
stavudine
ADD TO FORMULARY
Generics
01/01/2014
stavudine
stavudine
ADD TO FORMULARY
Generics
01/01/2014
stavudine
stavudine
ADD TO FORMULARY
Generics
01/01/2014
stavudine
stavudine
ADD TO FORMULARY
Generics
01/01/2014
STALEVO 50
carbidopa/levodopa/entacap
one
ADD TO FORMULARY
Preferred Brands
01/01/2014
STALEVO 100
carbidopa/levodopa/entacap
one
ADD TO FORMULARY
Preferred Brands
01/01/2014
STALEVO 150
carbidopa/levodopa/entacap
one
ADD TO FORMULARY
Preferred Brands
01/01/2014
STALEVO 200
carbidopa/levodopa/entacap
one
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 136
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
STALEVO 75
carbidopa/levodopa/entacap
one
ADD TO FORMULARY
Preferred Brands
01/01/2014
STALEVO 125
carbidopa/levodopa/entacap
one
ADD TO FORMULARY
Preferred Brands
01/01/2014
STIMATE
desmopressin acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
SUBOXONE
buprenorphine hcl/naloxone
hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
SUBOXONE
buprenorphine hcl/naloxone
hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
SUBOXONE
buprenorphine hcl/naloxone
hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
SUBOXONE
buprenorphine hcl/naloxone
hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
SUCRAID
sacrosidase
ADD TO FORMULARY
Preferred Brands
01/01/2014
SUSTIVA
efavirenz
ADD TO FORMULARY
Preferred Brands
01/01/2014
SUTENT
sunitinib malate
ADD TO FORMULARY
Preferred Brands
01/01/2014
SYMBICORT
budesonide/formoterol
fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
SYNAGIS
palivizumab
ADD UM: AUTHORIZATION
PA applies
01/01/2014
TAMBOCOR
flecainide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
TAMBOCOR
flecainide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
TAMBOCOR
flecainide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
TAPAZOLE
methimazole
ADD TO FORMULARY
Non-Formulary
01/01/2014
TAPAZOLE
methimazole
ADD TO FORMULARY
Non-Formulary
01/01/2014
TARCEVA
erlotinib hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
TARGRETIN
bexarotene
CHANGE TIER
Preferred Brands
01/01/2014
TASIGNA
nilotinib hcl
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 137
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
TASIGNA
nilotinib hcl
01/01/2014
TASMAR
tolcapone
01/01/2014
tazorac,avage,fa tazarotene
bior,tazarotene
01/01/2014
TEKAMLO
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
ADD TO FORMULARY
Preferred Brands
CHANGE TIER
Preferred Brands
ADD TO FORMULARY
Preferred Brands
TEKTURNA HCT aliskiren
hemifumarate/hydrochlorothi
azide
ADD TO FORMULARY
Preferred Brands
01/01/2014
TEKTURNA
ADD TO FORMULARY
Preferred Brands
01/01/2014
temodar,temozol temozolomide
omide
ADD TO FORMULARY
Preferred Brands
01/01/2014
THALOMID
thalidomide
ADD TO FORMULARY
Preferred Brands
01/01/2014
TOBRADEX
tobramycin/dexamethasone
ADD TO FORMULARY
Preferred Brands
01/01/2014
TOBRADEX
tobramycin/dexamethasone
ADD TO FORMULARY
Non-Formulary
01/01/2014
TOBRADEX ST
tobramycin/dexamethasone
ADD TO FORMULARY
Preferred Brands
01/01/2014
TOVIAZ
fesoterodine fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
TRACLEER
bosentan
ADD TO FORMULARY
Preferred Brands
01/01/2014
TRACLEER
bosentan
ADD UM: AUTHORIZATION
PA applies
01/01/2014
TRAVATAN Z
travoprost
ADD TO FORMULARY
Preferred Brands
01/01/2014
TREXALL
methotrexate sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
TREXALL
methotrexate sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
TREXALL
methotrexate sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
TREXALL
methotrexate sodium
ADD TO FORMULARY
Preferred Brands
01/01/2014
TRIBENZOR
olmesartan
medoxomil/amlodipine
besylate/hydrochlorothiazide
ADD TO FORMULARY
Preferred Brands
aliskiren
hemifumarate/amlodipine
besylate
aliskiren hemifumarate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 138
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
TRIZIVIR
abacavir
sulfate/lamivudine/zidovudin
e
ADD TO FORMULARY
Non-Formulary
01/01/2014
TRUVADA
emtricitabine/tenofovir
disoproxil fumarate
ADD TO FORMULARY
Non-Formulary
01/01/2014
TYKERB
lapatinib ditosylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ULESFIA
benzyl alcohol
ADD TO FORMULARY
Preferred Brands
01/01/2014
ULORIC
febuxostat
ADD TO FORMULARY
Preferred Brands
01/01/2014
UROCIT-K
potassium citrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
UROCIT-K
potassium citrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
UROCIT-K
potassium citrate
ADD TO FORMULARY
Non-Formulary
01/01/2014
UROGESICBLUE
methenamine/sodium
phosphate,monobasic/meth
blue/hyosc sul
ADD TO FORMULARY
Preferred Brands
01/01/2014
VENTOLIN HFA
albuterol sulfate
ADD TO FORMULARY
Preferred Brands
01/01/2014
VEXOL
rimexolone
ADD TO FORMULARY
Preferred Brands
01/01/2014
VIAGRA
sildenafil citrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
VIAGRA
sildenafil citrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
VIAGRA
sildenafil citrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
VIRACEPT
nelfinavir mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
VIRAMUNE XR
nevirapine
CHANGE TIER
01/01/2014
VIRAMUNE
nevirapine
ADD TO FORMULARY
Non-Formulary
01/01/2014
VIRAMUNE
nevirapine
ADD TO FORMULARY
Non-Formulary
01/01/2014
VIRAZOLE
ribavirin
ADD TO FORMULARY
Preferred Brands
01/01/2014
VIRAZOLE
ribavirin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
VIREAD
tenofovir disoproxil fumarate
ADD TO FORMULARY
Preferred Brands
01/01/2014
VIVELLE-DOT
estradiol
ADD TO FORMULARY
Not Covered
Non-Formulary
Preferred Brands
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 139
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
VIVELLE-DOT
estradiol
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
VIVELLE-DOT
estradiol
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
VIVELLE-DOT
estradiol
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
VIVELLE-DOT
estradiol
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2014
vol-tab rx
prenatal vits with calcium
#76/iron,carbonyl/folic acid
ADD TO FORMULARY
Non-Formulary
01/01/2014
VOLTAREN
diclofenac sodium
CHANGE TIER
Preferred Brands
01/01/2014
VUSION
miconazole nitrate/zinc
oxide/petrolatum,white
ADD TO FORMULARY
Preferred Brands
01/01/2014
VYVANSE
lisdexamfetamine
dimesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
WELCHOL
colesevelam hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
WELCHOL
colesevelam hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
XALATAN
latanoprost
CHANGE TIER
01/01/2014
XARELTO
rivaroxaban
ADD TO FORMULARY
Preferred Brands
01/01/2014
XELODA
capecitabine
ADD TO FORMULARY
Preferred Brands
01/01/2014
XELODA
capecitabine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XELODA
capecitabine
ADD TO FORMULARY
Preferred Brands
01/01/2014
XELODA
capecitabine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XOLEGEL
ketoconazole
ADD TO FORMULARY
Preferred Brands
01/01/2014
zemplar,paricalcit paricalcitol
ol
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZERIT
stavudine
ADD TO FORMULARY
Non-Formulary
01/01/2014
ZERIT
stavudine
ADD TO FORMULARY
Non-Formulary
01/01/2014
ZERIT
stavudine
ADD TO FORMULARY
Non-Formulary
01/01/2014
ZERIT
stavudine
ADD TO FORMULARY
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 140
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ZERIT
stavudine
ADD TO FORMULARY
Non-Formulary
01/01/2014
ZETIA
ezetimibe
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZIAGEN
abacavir sulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
ZIAGEN
abacavir sulfate
ADD TO FORMULARY
Non-Formulary
01/01/2014
ZOLINZA
vorinostat
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZOLVIT
hydrocodone
bitartrate/acetaminophen
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZOVIRAX
acyclovir
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ZOVIRAX
acyclovir
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ZOVIRAX
acyclovir
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZOVIRAX
acyclovir
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZOVIRAX
acyclovir
ADD TO FORMULARY
Non-Formulary
01/01/2014
ZOVIRAX
acyclovir
CHANGE TIER
01/01/2014
ZYPREXA
olanzapine
CHANGE TIER
Preferred Brands
01/01/2014
ZYPREXA
olanzapine
CHANGE TIER
Preferred Brands
01/01/2014
ZYPREXA
olanzapine
CHANGE TIER
Preferred Brands
01/01/2014
ZYPREXA
olanzapine
CHANGE TIER
Preferred Brands
01/01/2014
ZYTAZE
zinc citrate/phytase
ADD TO FORMULARY
Preferred Brands
01/01/2014
BIAXIN
clarithromycin
ADD TO FORMULARY
Non-Formulary
01/01/2014
BIAXIN XL
clarithromycin
CHANGE TIER
01/01/2014
BIAXIN
clarithromycin
ADD TO FORMULARY
Non-Formulary
01/01/2014
BIAXIN
clarithromycin
ADD TO FORMULARY
Non-Formulary
01/01/2014
TEVETEN HCT
eprosartan
mesylate/hydrochlorothiazid
e
CHANGE TIER
Preferred Brands
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 141
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
teveten,eprosarta eprosartan mesylate
n mesylate
01/01/2014
ARICEPT
01/01/2014
Type of Change
Previous Value
New Value
CHANGE TIER
Non-Formulary
donepezil hcl
ADD TO FORMULARY
Non-Formulary
ALPROLIX
factor ix recombinant, fc
fusion protein
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPROLIX
factor ix recombinant, fc
fusion protein
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALPROLIX
factor ix recombinant, fc
fusion protein
ADD TO FORMULARY
Preferred Brands
01/01/2014
ADEMPAS
riociguat
01/01/2014
IMPLANON,NEX etonogestrel
PLANON
ADD UM: GENDER
Female
01/01/2014
MIRENA
levonorgestrel
ADD UM: GENDER
Female
01/01/2014
errin
norethindrone
ADD TO FORMULARY
Preventative
01/01/2014
errin
norethindrone
ADD UM: GENDER
Female
01/01/2014
jencycla
norethindrone
ADD TO FORMULARY
Preventative
01/01/2014
jencycla
norethindrone
ADD UM: GENDER
Female
01/01/2014
lyza
norethindrone
ADD TO FORMULARY
Preventative
01/01/2014
lyza
norethindrone
ADD UM: GENDER
Female
01/01/2014
estarylla
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
estarylla
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
norethindrone
norethindrone
ADD TO FORMULARY
Preventative
01/01/2014
norethindrone
norethindrone
ADD UM: GENDER
Female
01/01/2014
mono-linyah
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
REMOVE UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 142
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
mono-linyah
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
ORTHOCYCLEN
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2014
ORTHOCYCLEN
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
previfem
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
previfem
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
sprintec
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
sprintec
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
cryselle
norgestrel-ethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
cryselle
norgestrel-ethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
elinest
norgestrel-ethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
elinest
norgestrel-ethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
low-ogestrel
norgestrel-ethinyl estradiol
ADD TO FORMULARY
Preventative
01/01/2014
low-ogestrel
norgestrel-ethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
norgestimateethinyl estradiol
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
norgestimateethinyl estradiol
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
norgestimateethinyl estradiol
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
norgestimateethinyl estradiol
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 143
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
tri-estarylla
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
tri-estarylla
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
tri-linyah
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
tri-linyah
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
tri-previfem
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
tri-previfem
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
tri-sprintec
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
tri-sprintec
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
trinessa
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/01/2014
trinessa
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/01/2014
PRENATE
ESSENTIAL
pnv no.35/iron
fumarate/folate comb.
#6/dha
ADD UM: GENDER
Female
01/01/2014
PRENATE
ENHANCE
prenatal vitamin combo
no.68/iron fumarate/fa
combo no.6/dha
ADD UM: GENDER
Female
01/01/2014
PRENATE MINI
prenatal vitamins
#44/iron,carbonyl/folic
acid/dha
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 144
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
PRENATE ELITE prenatal vitamins combo
#36/ferrous fumarate/folate
combo #6,prenatal vitamins
no.79/ferrous aspart
glycinate/folate no.1
ADD UM: GENDER
Female
01/01/2014
PRENATE
RESTORE
prenatal vitamins combo
no.69/iron fumarate/fa comb
no.6/dha
ADD UM: GENDER
Female
01/01/2014
PRENATE DHA
prenatal vitamins no.38/iron
fumarate/folate comb
no.6/dha,prenatal vitamins
no.78/iron asparto
glycin/folate no.1/dha
ADD UM: GENDER
Female
01/01/2014
PRENATE
CHEWABLE
prenatal vitamins
no.112/methyltetrahydrofolat
e glucosami,fa
ADD UM: GENDER
Female
01/01/2014
PRENATE AM
prenatal vitamins
no.114/methyltetrahydfolate
gluc,fa/ginger
ADD UM: GENDER
Female
01/01/2014
PREQUE 10
prenatal vitamins
no.18/fe,carbonyl/fa/docusat
e/ubidecar/dha
ADD UM: GENDER
Female
01/01/2014
vitapearl,prena1
pearl
prenatal vit no.71/iron fumsodium feredetate/folic
acid/dha
ADD UM: GENDER
Female
01/01/2014
LATISSE
bimatoprost
ADD UM: CUSTOM
Lifestyle Drugs
are Excluded
01/01/2014
morphine sulfate morphine sulfate
er
ADD TO FORMULARY
Non-Formulary
Generics
01/01/2014
morphine sulfate morphine sulfate
er
ADD TO FORMULARY
Non-Formulary
Generics
01/01/2014
morphine sulfate morphine sulfate
er
ADD TO FORMULARY
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 145
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Not Covered
01/01/2014
BOTOX
COSMETIC
onabotulinumtoxina
CHANGE TIER
01/01/2014
BOTOX
COSMETIC
onabotulinumtoxina
ADD UM: CUSTOM
01/01/2014
NOVOLIN R
insulin regular, human
CHANGE TIER
01/01/2014
NOVOLIN R
insulin regular, human
ADD UM: CUSTOM
Non Covered
Manufacturer
01/01/2014
HUMULIN R
insulin regular, human
ADD UM: CUSTOM
Non Covered
Manufacturer
01/01/2014
NOVOLIN 70-30 insulin nph human
isophane/insulin regular,
human
ADD UM: CUSTOM
Non Covered
Manufacturer
01/01/2014
HUMULIN 70-30 insulin nph human
isophane/insulin regular,
human
CHANGE TIER
01/01/2014
HUMULIN 70-30 insulin nph human
isophane/insulin regular,
human
ADD UM: CUSTOM
01/01/2014
NOVOLIN N
insulin nph human isophane
CHANGE TIER
01/01/2014
NOVOLIN N
insulin nph human isophane
ADD UM: CUSTOM
01/01/2014
HUMULIN N
insulin nph human isophane
CHANGE TIER
01/01/2014
HUMULIN N
insulin nph human isophane
ADD UM: CUSTOM
Non Covered
Manufacturer
01/01/2014
tamoxifen citrate tamoxifen citrate
ADD TO FORMULARY
Generics
01/01/2014
tamoxifen citrate tamoxifen citrate
ADD TO FORMULARY
Generics
01/01/2014
raloxifene hcl
ADD TO FORMULARY
Generics
01/01/2014
lescol,fluvastatin fluvastatin sodium
sodium
ADD UM: QUANTITY
30 / 30 days
raloxifene hcl
Lifestyle Drugs
are Excluded
Preferred Brands
Preferred Brands
Not Covered
Not Covered
Non Covered
Manufacturer
Preferred Brands
Not Covered
Non Covered
Manufacturer
Preferred Brands
Not Covered
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 146
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
lescol,fluvastatin fluvastatin sodium
sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
prevacid
lansoprazole
24hr,lansoprazol
e,heartburn
treatment 24
hour,heartburn
relief 24
hour,prevacid
ADD UM: QUANTITY
30 / 30 days
01/01/2014
lansoprazole,prev lansoprazole
acid
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CARDENE SR
nicardipine hcl
ADD UM: QUANTITY
60 / 30 days
01/01/2014
CARDENE SR
nicardipine hcl
ADD UM: QUANTITY
60 / 30 days
01/01/2014
CARDENE SR
nicardipine hcl
ADD UM: QUANTITY
60 / 30 days
01/01/2014
procardia
xl,nifedical
xl,nifedipine er
nifedipine
ADD UM: QUANTITY
30 / 30 days
01/01/2014
procardia
xl,nifedical
xl,nifedipine er
nifedipine
ADD UM: QUANTITY
30 / 30 days
01/01/2014
procardia
xl,nifedipine er
nifedipine
ADD UM: QUANTITY
30 / 30 days
01/01/2014
adalat
cc,nifedipine
er,afeditab cr
nifedipine
CHANGE UM: QUANTITY
90 / 30 days
30 / 30 days
01/01/2014
adalat
cc,nifedipine
er,afeditab cr
nifedipine
CHANGE UM: QUANTITY
90 / 30 days
30 / 30 days
01/01/2014
adalat cc,nifediac nifedipine
cc,nifedipine er
CHANGE UM: QUANTITY
90 / 30 days
30 / 30 days
01/01/2014
diltiazem 12hr er diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 147
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
diltiazem 12hr er diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diltiazem 24hr
diltiazem hcl
er,cardizem
cd,diltiazem 24hr
cd,dilt-cd,cartia xt
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diltiazem 24hr
diltiazem hcl
er,cardizem
cd,diltiazem 24hr
cd,dilt-cd,cartia xt
ADD UM: QUANTITY
60 / 30 days
01/01/2014
diltiazem 24hr
diltiazem hcl
er,cardizem
cd,diltiazem 24hr
cd,dilt-cd,cartia xt
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diltiazem 24hr
diltiazem hcl
er,cardizem
cd,diltiazem 24hr
cd,dilt-cd,cartia xt
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diltiazem
er,tiazac,diltzac
er,taztia xt
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diltiazem
er,tiazac,diltzac
er,taztia xt
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diltiazem
er,tiazac,diltzac
er,taztia xt
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diltiazem
er,tiazac,diltzac
er,taztia xt
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diltiazem
er,tiazac,diltzac
er,taztia xt
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TESTOPEL
testosterone
ADD UM: GENDER
Male
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 148
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
amlodipine
amlodipine besylate
besylate,norvasc
ADD UM: QUANTITY
30 / 30 days
01/01/2014
amlodipine
amlodipine besylate
besylate,norvasc
ADD UM: QUANTITY
30 / 30 days
01/01/2014
amlodipine
amlodipine besylate
besylate,norvasc
ADD UM: QUANTITY
30 / 30 days
01/01/2014
prilosec,omepraz omeprazole
ole
ADD UM: QUANTITY
30 / 30 days
01/01/2014
sumatriptan
sumatriptan succinate
succinate,imitrex
CHANGE UM: QUANTITY
18 / 30 days
01/01/2014
sumatriptan
sumatriptan succinate
succinate,imitrex
CHANGE UM: QUANTITY
18 / 30 days
01/01/2014
sumatriptan
sumatriptan succinate
succinate,imitrex
CHANGE UM: QUANTITY
18 / 30 days
01/01/2014
BYSTOLIC
nebivolol hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cardizem
diltiazem hcl
cd,diltiazem 24hr
er,diltiazem 24hr
cd
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diovan
valsartan/hydrochlorothiazid
hct,valsartane
hydrochlorothiazi
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diovan
valsartan/hydrochlorothiazid
hct,valsartane
hydrochlorothiazi
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TESTRED,ANDR methyltestosterone
OID
ADD UM: GENDER
Male
01/01/2014
androxy
fluoxymesterone
ADD UM: GENDER
Male
01/01/2014
ANADROL-50
oxymetholone
ADD UM: GENDER
Male
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 149
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
estradiol,estrace estradiol
CHANGE UM: GENDER
Female
01/01/2014
estradiol,estrace estradiol
CHANGE UM: GENDER
Female
01/01/2014
estradiol,estrace estradiol
CHANGE UM: GENDER
Female
01/01/2014
MENEST
estrogens,esterified
ADD UM: GENDER
Female
01/01/2014
MENEST
estrogens,esterified
ADD UM: GENDER
Female
01/01/2014
MENEST
estrogens,esterified
ADD UM: GENDER
Female
01/01/2014
MENEST
estrogens,esterified
ADD UM: GENDER
Female
01/01/2014
ogen,estropipate estropipate
ADD UM: GENDER
Female
01/01/2014
vynatalfa,mynatalz,mynatal plus
prenatal vitamins with
calcium/ferrous
fumarate/folic acid
ADD UM: GENDER
Female
01/01/2014
MYNATAL
prenatal vitamins with
calcium/ferrous
fumarate/folic acid
ADD UM: GENDER
Female
01/01/2014
O-CAL FA
prenatal vitamins with
calcium/ferrous
fumarate/folic acid
ADD UM: GENDER
Female
01/01/2014
MAKENA
hydroxyprogesterone
caproate
ADD UM: GENDER
Female
01/01/2014
norethindrone
norethindrone acetate
acetate,aygestin
ADD UM: GENDER
Female
01/01/2014
oxytocin,pitocin
ADD UM: GENDER
Female
01/01/2014
micardis
telmisartan/hydrochlorothiazi
hct,telmisartan- de
hydrochlorothiazi
d
ADD UM: QUANTITY
30 / 30 days
01/01/2014
micardis
telmisartan/hydrochlorothiazi
hct,telmisartan- de
hydrochlorothiazi
d
ADD UM: QUANTITY
30 / 30 days
oxytocin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 150
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
alendronate
sodium
alendronate sodium
ADD UM: QUANTITY
4 / 30 days
01/01/2014
AXERT
almotriptan malate
ADD UM: QUANTITY
18 / 30 days
01/01/2014
CENESTIN
estrogens,conj.,synthetic a
ADD UM: GENDER
Female
01/01/2014
clarinex,deslorata desloratadine
dine
ADD UM: QUANTITY
30 / 30 days
01/01/2014
setonet,pr natal
430
prenatal vitamins comb
no.54/iron b-g hcl sucp/fa/omega-3
ADD UM: GENDER
Female
01/01/2014
NEXIUM
esomeprazole magnesium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
NEXIUM
esomeprazole magnesium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
FOLLISTIM AQ
follitropin beta,recomb
ADD UM: GENDER
Female
01/01/2014
FOLLISTIM AQ
follitropin beta,recomb
ADD UM: GENDER
Female
01/01/2014
prozac
fluoxetine hcl
weekly,fluoxetine
dr
ADD UM: QUANTITY
4 / 30 days
01/01/2014
geodon,ziprasido ziprasidone hcl
ne hcl
ADD UM: GENDER
Female
01/01/2014
NATALVIT
prenatal vitamins with
calcium/ferrous
fumarate/folic acid
ADD UM: GENDER
Female
01/01/2014
AXERT
almotriptan malate
ADD UM: QUANTITY
18 / 30 days
01/01/2014
DIOVAN
valsartan
ADD UM: QUANTITY
30 / 30 days
01/01/2014
DIOVAN
valsartan
ADD UM: QUANTITY
30 / 30 days
01/01/2014
DIOVAN
valsartan
ADD UM: QUANTITY
30 / 30 days
01/01/2014
gengraf,neoral,cy cyclosporine, modified
closporine
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 151
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
c-nate
dha,relnate
dha,viva dha
prenatal vitamins
no.11/ferrous fumarate/folic
acid/omega-3
01/01/2014
zomig
zmt,zolmitriptan
odt
01/01/2014
SANCUSO
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
zolmitriptan
ADD UM: QUANTITY
18 / 30 days
granisetron
ADD UM: QUANTITY
6 / 30 days
venlafaxine hcl er venlafaxine hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
venlafaxine hcl er venlafaxine hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
venlafaxine hcl er venlafaxine hcl
ADD UM: QUANTITY
60 / 30 days
01/01/2014
VENLAFAXINE
HCL ER
venlafaxine hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ultimatecare
one,folcaps
omega-3
prenatal vit with calcium
no.37/iron,aspg/folic
acid/omega-3
ADD UM: GENDER
Female
01/01/2014
obstetrix
dha,obtrex dha
prenatal vitamins
no.12/iron,carbonyl/fa/docus
ate/omega-3
ADD UM: GENDER
Female
01/01/2014
citranatal
prenatal vitamin no.38/iron
assure,natalvirt carb,gluc/folic
ca,prenaissance acid/docusat/dha
promise
ADD UM: GENDER
Female
01/01/2014
cozaar,losartan
potassium
losartan potassium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cozaar,losartan
potassium
losartan potassium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
hyzaar,losartan- losartan
hydrochlorothiazi potassium/hydrochlorothiazi
de
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cozaar,losartan
potassium
ADD UM: QUANTITY
30 / 30 days
losartan potassium
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 152
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
hyzaar,losartan- losartan
hydrochlorothiazi potassium/hydrochlorothiazi
de
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
xyzal,levocetirizin levocetirizine
e dihydrochloride dihydrochloride
ADD UM: QUANTITY
30 / 30 days
01/01/2014
pravachol,pravast pravastatin sodium
atin sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
FEMHRT
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
01/01/2014
REBIF
interferon beta-1a/albumin
human
ADD UM: QUANTITY
12 / 28 days
01/01/2014
REBIF
interferon beta-1a/albumin
human
ADD UM: QUANTITY
12 / 28 days
01/01/2014
zatean-pn,pnvselect,virt-pn
prenatal vit with calcium no.
40/iron fumarate/fa cmb
no.1
ADD UM: GENDER
Female
01/01/2014
avinza,morphine morphine sulfate
sulfate er
ADD UM: QUANTITY
120 / 30 days
01/01/2014
avinza,morphine morphine sulfate
sulfate er
ADD UM: QUANTITY
120 / 30 days
01/01/2014
OXYCONTIN
oxycodone hcl
ADD UM: QUANTITY
240 / 30 days
01/01/2014
OXYCONTIN
oxycodone hcl
ADD UM: QUANTITY
240 / 30 days
01/01/2014
OXYCONTIN
oxycodone hcl
ADD UM: QUANTITY
240 / 30 days
01/01/2014
OXYCONTIN
oxycodone hcl
ADD UM: QUANTITY
240 / 30 days
01/01/2014
DEXILANT
dexlansoprazole
ADD UM: QUANTITY
30 / 30 days
01/01/2014
DEXILANT
dexlansoprazole
ADD UM: QUANTITY
30 / 30 days
01/01/2014
budeprion
sr,wellbutrin
sr,bupropion hcl
sr
bupropion hcl
ADD UM: QUANTITY
60 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 153
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
01/01/2014
COPAXONE
01/01/2014
Generic Name
glatiramer acetate
Type of Change
Previous Value
New Value
ADD UM: QUANTITY
30 / 30 days
effexor
venlafaxine hcl
xr,venlafaxine hcl
er
ADD UM: QUANTITY
30 / 30 days
01/01/2014
effexor
venlafaxine hcl
xr,venlafaxine hcl
er
ADD UM: QUANTITY
30 / 30 days
01/01/2014
effexor
venlafaxine hcl
xr,venlafaxine hcl
er
ADD UM: QUANTITY
60 / 30 days
01/01/2014
avinza,morphine morphine sulfate
sulfate er
ADD UM: QUANTITY
180 / 30 days
01/01/2014
avinza,morphine morphine sulfate
sulfate er
ADD UM: QUANTITY
120 / 30 days
01/01/2014
avinza,morphine morphine sulfate
sulfate er
ADD UM: QUANTITY
120 / 30 days
01/01/2014
avinza,morphine morphine sulfate
sulfate er
ADD UM: QUANTITY
120 / 30 days
01/01/2014
diovan
valsartan/hydrochlorothiazid
hct,valsartane
hydrochlorothiazi
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
retin-a
micro,tretinoin
microsphere
tretinoin microspheres
ADD UM: AGE
Up to 25 yrs old
01/01/2014
AVONEX
interferon beta-1a/albumin
human
ADD UM: QUANTITY
4 / 28 days
01/01/2014
CENESTIN
estrogens,conj.,synthetic a
ADD UM: GENDER
Female
01/01/2014
SPIRIVA
tiotropium bromide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
DIOVAN
valsartan
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ZETIA
ezetimibe
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 154
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
AVODART
dutasteride
ADD UM: GENDER
Male
01/01/2014
BYSTOLIC
nebivolol hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
singulair,montelu montelukast sodium
kast sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
HUMIRA
adalimumab
ADD UM: QUANTITY
4 / 28 days
01/01/2014
ZOMIG
zolmitriptan
ADD UM: QUANTITY
18 / 30 days
01/01/2014
PREVACID
lansoprazole
ADD UM: QUANTITY
30 / 30 days
01/01/2014
PREVACID
lansoprazole
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CIALIS
tadalafil
ADD UM: GENDER
Male
01/01/2014
CIALIS
tadalafil
ADD UM: GENDER
Male
01/01/2014
CRESTOR
rosuvastatin calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CRESTOR
rosuvastatin calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CRESTOR
rosuvastatin calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CARDIZEM LA
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cardizem
la,matzim
la,diltiazem er
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cardizem
la,matzim
la,diltiazem er
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cardizem
la,matzim
la,diltiazem er
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cardizem
la,matzim
la,diltiazem er
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cardizem
la,matzim
la,diltiazem er
diltiazem hcl
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 155
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
fentanyl,duragesi fentanyl
c
ADD UM: QUANTITY
15 / 30 days
01/01/2014
fentanyl,duragesi fentanyl
c
ADD UM: QUANTITY
15 / 30 days
01/01/2014
fentanyl,duragesi fentanyl
c
ADD UM: QUANTITY
15 / 30 days
01/01/2014
fentanyl,duragesi fentanyl
c
ADD UM: QUANTITY
15 / 30 days
01/01/2014
RESTASIS
cyclosporine
ADD UM: QUANTITY
60 / 30 days
01/01/2014
LEVITRA
vardenafil hcl
ADD UM: GENDER
Male
01/01/2014
LEVITRA
vardenafil hcl
ADD UM: GENDER
Male
01/01/2014
LEVITRA
vardenafil hcl
ADD UM: GENDER
Male
01/01/2014
maxalt,rizatriptan rizatriptan benzoate
ADD UM: QUANTITY
18 / 30 days
01/01/2014
maxalt,rizatriptan rizatriptan benzoate
ADD UM: QUANTITY
18 / 30 days
01/01/2014
maxalt
mlt,rizatriptan
rizatriptan benzoate
ADD UM: QUANTITY
18 / 30 days
01/01/2014
maxalt
mlt,rizatriptan
rizatriptan benzoate
ADD UM: QUANTITY
18 / 30 days
01/01/2014
FEMRING
estradiol acetate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
FEMRING
estradiol acetate
ADD UM: QUANTITY
1 / 30 days
01/01/2014
clarinex,deslorata desloratadine
dine
ADD UM: QUANTITY
30 / 30 days
01/01/2014
OBTREX
prenatal vitamin w-o
calcium/iron,carbonyl/docus
ate/fa
ADD UM: GENDER
Female
01/01/2014
EPIPEN JR 2PAK
epinephrine
ADD UM: QUANTITY
2 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 156
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
auvi-q,epipen 2- epinephrine
pak,adrenaclick,e
pinephrine
ADD UM: QUANTITY
2 / 30 days
01/01/2014
STRIANT
testosterone
ADD UM: QUANTITY
60 / 30 days
01/01/2014
estradiol,climara
estradiol
ADD UM: QUANTITY
8 / 28 days
01/01/2014
estradiol,climara
estradiol
CHANGE UM: GENDER
Female
01/01/2014
estradiol,climara
estradiol
ADD UM: QUANTITY
8 / 28 days
01/01/2014
estradiol,climara
estradiol
CHANGE UM: GENDER
Female
01/01/2014
AVONEX
interferon beta-1a
ADD UM: QUANTITY
4 / 28 days
01/01/2014
CRESTOR
rosuvastatin calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
LEVITRA
vardenafil hcl
ADD UM: GENDER
Male
01/01/2014
CLIMARA PRO
estradiol/levonorgestrel
ADD UM: QUANTITY
4 / 28 days
01/01/2014
CLIMARA PRO
estradiol/levonorgestrel
ADD UM: GENDER
Female
01/01/2014
PEXEVA
paroxetine mesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
PEXEVA
paroxetine mesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
PEXEVA
paroxetine mesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
PEXEVA
paroxetine mesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
AVONEX
interferon beta-1a
ADD UM: QUANTITY
4 / 28 days
01/01/2014
elestat,epinastine epinastine hcl
hcl
ADD UM: QUANTITY
5 / 30 days
01/01/2014
strovite
one,choice-tabs
multivit with min#10/folic
acid//vit d3/a lipoic
acid/lutein
ADD UM: GENDER
Female
01/01/2014
folivaneob,concept ob
prenatal vitamin no.15/iron
fumarate,polysac comp/folic
acid
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 157
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
taron-c
prenatal vit no.16/iron
dha,concept dha fum,ps complex/folic
acid/omega-3
ADD UM: GENDER
Female
01/01/2014
O-CAL
PRENATAL
prenatal vitamin with ca
no.127/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
FACTIVE
gemifloxacin mesylate
ADD UM: QUANTITY
120 / 30 days
01/01/2014
alendronate
sodium
alendronate sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
alendronate
sodium
alendronate sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
alendronate
sodium
alendronate sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CENESTIN
estrogens,conj.,synthetic a
ADD UM: GENDER
Female
01/01/2014
ESTRASORB
estradiol
ADD UM: GENDER
Female
01/01/2014
ESTROGEL
estradiol
ADD UM: QUANTITY
50 / 30 days
01/01/2014
EXFORGE HCT
amlodipine
besylate/valsartan/hydrochlo
rothiazide
ADD UM: QUANTITY
60 / 30 days
01/01/2014
EXFORGE HCT
amlodipine
besylate/valsartan/hydrochlo
rothiazide
ADD UM: QUANTITY
60 / 30 days
01/01/2014
EXFORGE HCT
amlodipine
besylate/valsartan/hydrochlo
rothiazide
ADD UM: QUANTITY
60 / 30 days
01/01/2014
EXFORGE HCT
amlodipine
besylate/valsartan/hydrochlo
rothiazide
ADD UM: QUANTITY
60 / 30 days
01/01/2014
EXFORGE HCT
amlodipine
besylate/valsartan/hydrochlo
rothiazide
ADD UM: QUANTITY
60 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 158
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
retin-a,tretinoin
tretinoin
ADD UM: AGE
Up to 25 yrs old
01/01/2014
retina,avita,tretinoin
tretinoin
ADD UM: AGE
Up to 25 yrs old
01/01/2014
ATRALIN
tretinoin
ADD UM: AGE
Up to 25 yrs old
01/01/2014
retin-a
micro,tretinoin
microsphere
tretinoin microspheres
ADD UM: AGE
Up to 25 yrs old
01/01/2014
retin-a,tretinoin
tretinoin
ADD UM: AGE
Up to 25 yrs old
01/01/2014
retin-a,tretinoin
tretinoin
ADD UM: AGE
Up to 25 yrs old
01/01/2014
retina,avita,tretinoin
tretinoin
ADD UM: AGE
Up to 25 yrs old
01/01/2014
PROVENTIL
HFA,VENTOLIN
HFA,PROAIR
HFA
albuterol sulfate
ADD UM: QUANTITY
18 / 30 days
01/01/2014
VYTORIN
ezetimibe/simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
VYTORIN
ezetimibe/simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
VYTORIN
ezetimibe/simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
VYTORIN
ezetimibe/simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cymbalta,duloxeti duloxetine hcl
ne hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cymbalta,duloxeti duloxetine hcl
ne hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cymbalta,duloxeti duloxetine hcl
ne hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
zatean-pn
prenatal vits with calcium
dha,pnv-dha,virt- #47/iron fum/fa cmb #1/dha
pn dha
ADD UM: GENDER
Female
01/01/2014
ENBREL
ADD UM: QUANTITY
4 / 28 days
etanercept
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 159
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
elite-ob 400,pnv- pnv no17/iron,carb/iron
total
bisgly/fa/fish oil/dha/omega
3,6 #1
01/01/2014
TARCEVA
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
erlotinib hcl
ADD UM: QUANTITY
30 / 30 days
TARCEVA
erlotinib hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TARCEVA
erlotinib hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
micardis,telmisart telmisartan
an
ADD UM: QUANTITY
30 / 30 days
01/01/2014
micardis,telmisart telmisartan
an
ADD UM: QUANTITY
30 / 30 days
01/01/2014
micardis,telmisart telmisartan
an
ADD UM: QUANTITY
30 / 30 days
01/01/2014
clonidine,catapre clonidine
s-tts 1
ADD UM: QUANTITY
4 / 30 days
01/01/2014
clonidine,catapre clonidine
s-tts 2
ADD UM: QUANTITY
4 / 30 days
01/01/2014
clonidine,catapre clonidine
s-tts 3
ADD UM: QUANTITY
4 / 30 days
01/01/2014
CLINDESSE
ADD UM: GENDER
Female
01/01/2014
eszopiclone,lune eszopiclone
sta
ADD UM: QUANTITY
30 / 30 days
01/01/2014
lunesta,eszopiclo eszopiclone
ne
ADD UM: QUANTITY
30 / 30 days
01/01/2014
lunesta,eszopiclo eszopiclone
ne
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ZOMIG
ADD UM: QUANTITY
18 / 30 days
01/01/2014
OBSTETRIX EC prenatal vitamin w-o
calcium/iron,carbonyl/docus
ate/fa
ADD UM: GENDER
Female
clindamycin phosphate
zolmitriptan
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 160
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
REBIF
interferon beta-1a/albumin
human
ADD UM: QUANTITY
1 / 180 days
01/01/2014
XOPENEX HFA
levalbuterol tartrate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CLARINEX-D 24 desloratadine/pseudoephedr
HOUR
ine sulfate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
boniva,ibandrona ibandronate sodium
te sodium
ADD UM: QUANTITY
1 / 30 days
01/01/2014
BYETTA
exenatide
ADD UM: QUANTITY
3 / 30 days
01/01/2014
BYETTA
exenatide
ADD UM: QUANTITY
3 / 30 days
01/01/2014
ATROVENT HFA ipratropium bromide
ADD UM: QUANTITY
12.9 / 30 days
01/01/2014
fentanyl,duragesi fentanyl
c
ADD UM: QUANTITY
15 / 30 days
01/01/2014
imitrex,sumatripta sumatriptan succinate
n succinate
CHANGE UM: QUANTITY
2 / 30 days
01/01/2014
revatio,sildenafil
sildenafil citrate
CHANGE UM: QUANTITY
01/01/2014
elite-ob,ob
complete
iron,carbonyl/folic
acid/multivitamin wminerals,iron,carbonyl/folic
acid/multivitamin with
minerals
ADD UM: GENDER
Female
01/01/2014
MAXINATE
prenatal vitamin no.3/iron
fumarate,gluconate/folic acid
ADD UM: GENDER
Female
01/01/2014
clarinex,deslorata desloratadine
dine
ADD UM: QUANTITY
30 / 30 days
01/01/2014
hyzaar,losartan- losartan
hydrochlorothiazi potassium/hydrochlorothiazi
de
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
clomiphene
clomiphene citrate
citrate,serophene
ADD UM: GENDER
Female
6 / 30 days
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 161
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
TRETIN-X
tretinoin/emollient
combination no. 9/skin cln1
ADD UM: AGE
Up to 25 yrs old
01/01/2014
TRETIN-X
tretinoin/emollient
combination no. 9/skin cln1
ADD UM: AGE
Up to 25 yrs old
01/01/2014
TRETIN-X
tretinoin/emollient
combination no. 9/skin cln1
ADD UM: AGE
Up to 25 yrs old
01/01/2014
REVLIMID
lenalidomide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
REVLIMID
lenalidomide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SUTENT
sunitinib malate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SUTENT
sunitinib malate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SUTENT
sunitinib malate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
cerefolin nac,lmethylfolatemecobalaminnac,alznac,metafolbic
plus,l-methyl-mc
nac
acetylcysteine/mecobalamin
/levomefolate calcium
ADD UM: GENDER
Female
01/01/2014
kadian,morphine morphine sulfate
sulfate er
ADD UM: QUANTITY
120 / 30 days
01/01/2014
morphine sulfate morphine sulfate
er,kadian
ADD UM: QUANTITY
120 / 30 days
01/01/2014
morphine sulfate morphine sulfate
er,kadian
ADD UM: QUANTITY
120 / 30 days
01/01/2014
morphine sulfate morphine sulfate
er,kadian
ADD UM: QUANTITY
180 / 30 days
01/01/2014
zocor,simvastatin simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
zocor,simvastatin simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
zocor,simvastatin simvastatin
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 162
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
zocor,simvastatin simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
zocor,simvastatin simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CLARINEX-D 12 desloratadine/pseudoephedr
HOUR
ine sulfate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
zegerid
omeprazole/sodium
otc,omeprazole- bicarbonate
sodium
bicarbonate,zege
rid
ADD UM: QUANTITY
30 / 30 days
01/01/2014
omeprazoleomeprazole/sodium
sodium
bicarbonate
bicarbonate,zege
rid
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ZEGERID
omeprazole/sodium
bicarbonate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ZEGERID
omeprazole/sodium
bicarbonate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
imitrex,sumatripta sumatriptan succinate
n succinate
ADD UM: QUANTITY
2 / 30 days
01/01/2014
imitrex,sumatripta sumatriptan succinate
n succinate
ADD UM: QUANTITY
2 / 30 days
01/01/2014
ENJUVIA
estrogens,conj.,synthetic b
ADD UM: GENDER
Female
01/01/2014
ENJUVIA
estrogens,conj.,synthetic b
ADD UM: GENDER
Female
01/01/2014
ENJUVIA
estrogens,conj.,synthetic b
ADD UM: GENDER
Female
01/01/2014
ENJUVIA
estrogens,conj.,synthetic b
ADD UM: GENDER
Female
01/01/2014
se-tan
plus,tandem
plus,purevit
dualfe plus
iron fumarate-iron polysacch
cplex/folic acid/multivit no.18
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 163
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
diovan
valsartan/hydrochlorothiazid
hct,valsartane
hydrochlorothiazi
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
diovan
valsartan/hydrochlorothiazid
hct,valsartane
hydrochlorothiazi
de
ADD UM: QUANTITY
30 / 30 days
01/01/2014
triveenu,prenatal-u
prenatal vits without calc
no5/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
SPRYCEL
dasatinib
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SPRYCEL
dasatinib
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SPRYCEL
dasatinib
ADD UM: QUANTITY
30 / 30 days
01/01/2014
REVLIMID
lenalidomide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
REVLIMID
lenalidomide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
AVONEX PEN
interferon beta-1a
ADD UM: QUANTITY
4 / 28 days
01/01/2014
astepro,azelastin azelastine hcl
e hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
BEPREVE
ADD UM: QUANTITY
10 / 30 days
01/01/2014
twynsta,telmisart telmisartan/amlodipine
an-amlodipine
besylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
twynsta,telmisart telmisartan/amlodipine
an-amlodipine
besylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
twynsta,telmisart telmisartan/amlodipine
an-amlodipine
besylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
twynsta,telmisart telmisartan/amlodipine
an-amlodipine
besylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
buproban,zyban, bupropion hcl
bupropion hcl sr
ADD UM: QUANTITY
60 / 30 days
bepotastine besilate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 164
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
auviepinephrine
q,adrenaclick,epi
nephrine
ADD UM: QUANTITY
2 / 30 days
01/01/2014
SUMAVEL
DOSEPRO
ADD UM: QUANTITY
1 / 30 days
01/01/2014
citranatal 90
prenatal vit,calcium #64/iron
dha,natalvirt 90 carb,gluc/folic acid/dss/dha
dha,prenaissance
90 dha
ADD UM: GENDER
Female
01/01/2014
triveen-prx
rnf,prefol-dha
ADD UM: GENDER
Female
01/01/2014
prefera-ob
prenatal vitamin no.19/iron
one,vp-heme one polysac,iron heme/folic
acid/dha
ADD UM: GENDER
Female
01/01/2014
zatean-pn
plus,pnvomega,virt-pn
plus
prenatal vit with ca
no.68/iron fumarate/folic
acid #1/dha
ADD UM: GENDER
Female
01/01/2014
paire ob plus
dha,ultimate ob
dha
prenatal vitamin no.8/iron ps
complex,asp gl/folic
acid/dha
ADD UM: GENDER
Female
01/01/2014
ferralet
90,natalvirt flt,fe
90 plus
iron carbonyl,gluc/folic
acid/vit b12/vit c/docusate
sodium
ADD UM: GENDER
Female
01/01/2014
PNV-IRON
prenatal vit with calcium
no8-iron ps cmplx,fa,lmefolate ca
ADD UM: GENDER
Female
01/01/2014
pnv-dha plus,lprenatal vit with calcium
methylfolate pnv no42/iron fum/fa/l-mefolate
dha
ca/dha
ADD UM: GENDER
Female
01/01/2014
cleocin,clindamyc clindamycin phosphate
in phosphate
CHANGE UM: GENDER
Female
sumatriptan succinate
prenatal vit with calcium
no.66/iron fum/folic
acid/dss/dha
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 165
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
LIVALO
pitavastatin calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
LIVALO
pitavastatin calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
LIVALO
pitavastatin calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
prenexa,vemavite prenatal vit with calcium
-prx 2,pnv-dha + no.66/iron fum/folic
docusate,folcal
acid/dss/dha
dha
ADD UM: GENDER
Female
01/01/2014
NATELLE ONE
prenatal vits with calcium
#70/ferrous fumarate/fa/dha
ADD UM: GENDER
Female
01/01/2014
tricare prenatal
dha one,tl-care
dha
pnv no.20/iron
fumarate/fa/docusate na/fish
oil conc/dha/epa
ADD UM: GENDER
Female
01/01/2014
volplus,prenaplus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
prenatal vitamin
plus low
iron,prenatal
plus,preplus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
prenatal low iron prenatal vits with calcium
#74/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
TRETIN-X
tretinoin
ADD UM: AGE
Up to 25 yrs old
01/01/2014
DULERA
mometasone
furoate/formoterol fumarate
ADD UM: QUANTITY
13 / 30 days
01/01/2014
DULERA
mometasone
furoate/formoterol fumarate
ADD UM: QUANTITY
13 / 30 days
01/01/2014
vol-tab
rx,prenatabs
rx,natal-v rx
prenatal vits with calcium
#76/iron,carbonyl/folic acid
ADD UM: GENDER
Female
01/01/2014
SIMCOR
niacin/simvastatin
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 166
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
01/01/2014
SIMCOR
01/01/2014
Generic Name
niacin/simvastatin
Type of Change
Previous Value
New Value
ADD UM: QUANTITY
30 / 30 days
VIVELLEestradiol
DOT,ALORA,MIN
IVELLE
CHANGE UM: GENDER
Female
01/01/2014
VIVELLEDOT,ALORA
estradiol
CHANGE UM: GENDER
Female
01/01/2014
estradiol,climara
estradiol
ADD UM: QUANTITY
8 / 28 days
01/01/2014
estradiol,climara
estradiol
CHANGE UM: GENDER
Female
01/01/2014
estradiol,climara
estradiol
ADD UM: QUANTITY
8 / 28 days
01/01/2014
estradiol,climara
estradiol
CHANGE UM: GENDER
Female
01/01/2014
VIVELLEestradiol
DOT,MINIVELLE
ADD UM: QUANTITY
8 / 28 days
01/01/2014
estradiol,climara
estradiol
ADD UM: QUANTITY
8 / 28 days
01/01/2014
estradiol,climara
estradiol
CHANGE UM: GENDER
Female
01/01/2014
estradiol,climara
estradiol
ADD UM: QUANTITY
8 / 28 days
01/01/2014
estradiol,climara
estradiol
ADD UM: GENDER
Female
01/01/2014
vol-nate,trinate
prenatal vits with calcium
#73/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
venatalfa,prenatabs fa
prenatal vits with calcium
#78/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
TEKAMLO
aliskiren
hemifumarate/amlodipine
besylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TEKAMLO
aliskiren
hemifumarate/amlodipine
besylate
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 167
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
TEKAMLO
aliskiren
hemifumarate/amlodipine
besylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TEKAMLO
aliskiren
hemifumarate/amlodipine
besylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
GILENYA
fingolimod hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
prefera
ob,hemenatal
ob,vp-heme ob
prenatal vit no.21/iron
polysacch,heme
polypep/folic acid
ADD UM: GENDER
Female
01/01/2014
neevo
prenatal vitamin comb
dha,levomefolate no.79/iron
dha,vinate dha
fumarat/fa/lmefolate ca/dha
ADD UM: GENDER
Female
01/01/2014
PREPOPIK
sodium
picosulfate/magnesium
oxide/citric acid
ADD UM: GENDER
Female
01/01/2014
LAZANDA
fentanyl citrate
01/01/2014
prefera-ob plus
dha,hemenatal
ob + dha,vpheme ob + dha
prenatal vitamin combo
no.22/iron/folic acid/omega3/dha
01/01/2014
CHANGE UM: QUANTITY
13 / 30 days
1 / 30 days
ADD UM: GENDER
Female
vena-bal dha,bal- prenatal vit
care dha
no.81/sod.feredetate-iron
ps/folic acid/omega-3
ADD UM: GENDER
Female
01/01/2014
OB COMPLETE
prenatal vits with calcium
#84/iron,carbonyl/folic
acid/dha
ADD UM: GENDER
Female
01/01/2014
OB COMPLETE
PREMIER
prenatal vitamins comb
#83/iron,carbonyl/iron
asparto gly/fa
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 168
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
OB COMPLETE
ONE
pnv no.85/iron
carb,aspart.glycinate/folic
acid/dha/fish oil
ADD UM: GENDER
Female
01/01/2014
CORVITE FE
iron,carbonyl/ferrous asparto
glycinate/folic acid/mvmin27
ADD UM: GENDER
Female
01/01/2014
ZOLPIMIST
zolpidem tartrate
01/01/2014
SPRYCEL
dasatinib
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SPRYCEL
dasatinib
ADD UM: QUANTITY
30 / 30 days
01/01/2014
tlprenatal vit with calcium
select,prenaissan no.80/iron fum/folic
ce,virt-select
acid/dss/dha
ADD UM: GENDER
Female
01/01/2014
nestabs,v-natal
ADD UM: GENDER
Female
01/01/2014
nestabs dha,vprenatal vitamins comb
natal dha,tri-tabs no.87/iron bisgly/folic
dha
acid/dha
ADD UM: GENDER
Female
01/01/2014
prenaissance
prenatal vit with calcium
plus,macnatal cn #69/iron,carbon/folic
dha
acid/dss/dha
ADD UM: GENDER
Female
01/01/2014
EDARBI
azilsartan medoxomil
ADD UM: QUANTITY
30 / 30 days
01/01/2014
EDARBI
azilsartan medoxomil
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SPRIX
ketorolac tromethamine
ADD UM: QUANTITY
30 / 30 days
01/01/2014
vitafol-one,pnvfirst
prenatal vitamins no.26/iron
polysaccharides/fa/dha
ADD UM: GENDER
Female
01/01/2014
OB COMPLETE
400
prenatal no.29/iron
carb,asp.glycin/folic
acid/dha/fish oil
ADD UM: GENDER
Female
01/01/2014
NATAFORT
prenatal vitamin no.27/iron
carbonyl and fumarate/folic
acid
ADD UM: GENDER
Female
prenatal vitamin no.86/iron
bis-glycinate/folic acid
CHANGE UM: QUANTITY
30 / 30 days
6 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 169
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
OB COMPLETE
WITH DHA
prenatal vit no.30/iron
carbonyl,asp glyc/folic
acid/omega-3
01/01/2014
AVONEX PEN
interferon beta-1a
01/01/2014
PUREFE PLUS
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
ADD UM: QUANTITY
4 / 28 days
prenatal vitamins
no.4/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
PUREFE OB
PLUS
prenatal vits #4/iron
fumarate, polysacc
complex/folic acid
ADD UM: GENDER
Female
01/01/2014
select-ob +
dha,choice-ob +
dha
prenatal vitamins combo
no.33/iron ps cmplx/folic
acid/dha
ADD UM: GENDER
Female
01/01/2014
prenaissance
prenatal vit #94/sodium
harmony dha,virt- feredetate-iron ps/folic
bal dha plus,virt- acid/omega3
bal dha
ADD UM: GENDER
Female
01/01/2014
prenaissance
prenatal vit/folic
next,zingiber,vp- acid/b6/calcium phosph
ggr-b6
di,tribasic/ginger
ADD UM: GENDER
Female
01/01/2014
prenaissance
balance,vp-chpnv
prenatal vitamins combo
no.34/iron,carb/folic
acid/dss/dha
ADD UM: GENDER
Female
01/01/2014
EDARBYCLOR
azilsartan
medoxomil/chlorthalidone
ADD UM: QUANTITY
30 / 30 days
01/01/2014
EDARBYCLOR
azilsartan
medoxomil/chlorthalidone
ADD UM: QUANTITY
30 / 30 days
01/01/2014
PRENATA
prenatal vitamins combo
no.37/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
ZETONNA
ciclesonide
ADD UM: QUANTITY
6.1 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 170
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
vitamedmd plus
rx,prena1 plus
prenatal vitamins #39/iron
amino acid chelate/fa
combo#6/dha
ADD UM: GENDER
Female
01/01/2014
JANUMET XR
sitagliptin
phosphate/metformin hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
JANUMET XR
sitagliptin
phosphate/metformin hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
JANUMET XR
sitagliptin
phosphate/metformin hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
vitamedmd one
rx,prena1
prenatal vitamins combo
no.25/iron fumarate/fa
combo#6/dha
ADD UM: GENDER
Female
01/01/2014
retin-a micro
pump,tretinoin
microsphere
tretinoin microspheres
ADD UM: AGE
Up to 25 yrs old
01/01/2014
retin-a micro
pump,tretinoin
microsphere
tretinoin microspheres
ADD UM: AGE
Up to 25 yrs old
01/01/2014
vitamedmd
redichew
rx,prena1 chew
prenatal vitamins comb
no.42/folic acid comb no.6
ADD UM: GENDER
Female
01/01/2014
REVLIMID
lenalidomide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
BAL-CARE DHA prenatal vit 100/iron sod
ESSENTIAL
edta,ps complex/folic
acid/omega-3
ADD UM: GENDER
Female
01/01/2014
DYMISTA
azelastine hcl/fluticasone
propionate
ADD UM: QUANTITY
23 / 30 days
01/01/2014
citranatal bcalm,vinacal b
prenatal vitamin
no.48/iron,carbonyl,gluconat
e/folic acid/b6
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 171
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
TRICARE
prenatal vits with
calcium#103/ferrous
fumarate/folic acid
01/01/2014
COMBIVENT
RESPIMAT
ipratropium
bromide/albuterol sulfate
01/01/2014
ANGELIQ
drospirenone/estradiol
01/01/2014
prenaissance dha prenatal vitamin no.105/iron
harmony,duet
edta
dha balanced
&polysaccha/fa/om3/dha/ep
a
01/01/2014
QSYMIA
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
ADD UM: QUANTITY
4 / 30 days
CHANGE UM: GENDER
Female
CHANGE UM: GENDER
Female
ADD UM: QUANTITY
30 / 30 days
DUET
prenatal vitamin no.106/sod
DHA,DUET DHA ferede-iron
400
poly/fa/om3/dha/epa
ADD UM: GENDER
Female
01/01/2014
DUET DHA
prenatal vitamin no.106/sod
ferede-iron
poly/fa/om3/dha/epa
ADD UM: GENDER
Female
01/01/2014
DUET DHA EC
prenatal vitamin no.107/sod
ferede-iron
poly/fa/om3/dha/epa
ADD UM: GENDER
Female
01/01/2014
DUET DHA EC
prenatal vitamin no.107/sod
ferede-iron
poly/fa/om3/dha/epa
ADD UM: GENDER
Female
01/01/2014
FLUMIST
influenza virus vaccine tv
live 2012-2013 (2 yrs-49 yrs)
ADD UM: QUANTITY
1 / 270 days
01/01/2014
QSYMIA
phentermine hcl/topiramate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
QSYMIA
phentermine hcl/topiramate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
QSYMIA
phentermine hcl/topiramate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
MYRBETRIQ
mirabegron
ADD UM: GENDER
Male
phentermine hcl/topiramate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 172
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
VP-PNV-DHA
prenatal vitamins combo
no.52/ferrous
fumarate/fa/dha
01/01/2014
b-nexa,focalgin-b prenatal vit/folic
acid/b6/calcium phos di &
tribasic/ginger,prenatal
vit/folic acid/b6/calcium
phosph di,tribasic/ginger
01/01/2014
NEXIUM
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
CHANGE UM: GENDER
Female
esomeprazole magnesium
ADD UM: QUANTITY
30 / 30 days
NEXIUM
esomeprazole magnesium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
KADIAN
morphine sulfate
ADD UM: QUANTITY
120 / 30 days
01/01/2014
KADIAN
morphine sulfate
ADD UM: QUANTITY
120 / 30 days
01/01/2014
KADIAN
morphine sulfate
ADD UM: QUANTITY
120 / 30 days
01/01/2014
KADIAN
morphine sulfate
ADD UM: QUANTITY
120 / 30 days
01/01/2014
AUBAGIO
teriflunomide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
AUBAGIO
teriflunomide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
VINATE CARE
prenatal vits with
calcium#109/ferrous
fumarate/folic acid
ADD UM: GENDER
Female
01/01/2014
NATACHEW
prenatal vitamin no.55/iron
fumarate,bisglycinate/folic
acid
ADD UM: GENDER
Female
01/01/2014
OB COMPLETE
PETITE
prenatal no56/iron
carbonyl,asparto
glycinate/folic acid/dha
ADD UM: GENDER
Female
01/01/2014
ANZEMET
dolasetron mesylate
CHANGE UM: QUANTITY
01/01/2014
ANZEMET
dolasetron mesylate
ADD UM: AGE
01/01/2014
ANZEMET
dolasetron mesylate
CHANGE UM: QUANTITY
12 / 30 days
12 / 15 days
At least 30 yrs
old
12 / 30 days
12 / 15 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 173
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
ANZEMET
dolasetron mesylate
01/01/2014
DUET DHA
BALANCED
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AGE
At least 30 yrs
old
prenatal vitamin no.110/iron
edta
&polysaccha/fa/om3/dha/ep
a
ADD UM: GENDER
Female
prenatal plus
prenatal vits with calcium
#72/iron,carbonyl/folic acid
ADD UM: GENDER
Female
01/01/2014
citranatal
harmony,vp-ch
plus
prenatal vitamins combo
no.59/iron,carb/folic
acid/dss/dha
CHANGE UM: GENDER
Female
01/01/2014
VIRT-VITE PLUS folic acid/vitamin b complex
with vitamin c no.17
ADD UM: GENDER
Female
01/01/2014
pnv folic acid +
iron
prenatal vitamins combo
no.60/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
OSPHENA
ospemifene
ADD UM: GENDER
Female
01/01/2014
TECFIDERA
dimethyl fumarate
ADD UM: QUANTITY
1 / 180 days
01/01/2014
TECFIDERA
dimethyl fumarate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
TECFIDERA
dimethyl fumarate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
TRICARE
PRENATAL
COMPLEAT
prenatal vitamin no.103/iron
fum/fa/dha/epa/other
omega-3s
ADD UM: GENDER
Female
01/01/2014
desvenlafaxine er desvenlafaxine
ADD UM: QUANTITY
30 / 30 days
01/01/2014
desvenlafaxine er desvenlafaxine
ADD UM: QUANTITY
30 / 30 days
01/01/2014
PRESERA
emollient combination no.80
ADD UM: GENDER
Female
01/01/2014
cerefolin nac,lmethylfolatemecobalaminnac,metafolbic
plus rf
levomefolate
ca/acetylcysteine/mecobala
min/schiz. algal oil
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 174
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
FLUMIST
influenza virus vaccine qval
live 2013-2014 (2 yrs-49 yrs)
ADD UM: QUANTITY
1 / 270 days
01/01/2014
REVLIMID
lenalidomide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
NEEVODHA
prenatal no.64/iron fum/lmefolate ca/algal oil/soy
lecithin
ADD UM: GENDER
Female
01/01/2014
NESTABS ABC
prenatal vitamin comb
no.86/iron ps cmplx/folic
acid/dha/epa
ADD UM: GENDER
Female
01/01/2014
active ob,r-natal
ob
prenatal vitamins combo
no.66/iron,carbonyl/folic
acid/dha
CHANGE UM: GENDER
Female
01/01/2014
prenatal 19,pnv- prenatal vitamins comb
ferrous fumarate- no.115/iron fumarate/folic
docu-fa
acid/dss
ADD UM: GENDER
Female
01/01/2014
INFANATE
BALANCE
prenatal vitamins combo
no.34/iron,carb/folic
acid/dss/dha
ADD UM: GENDER
Female
01/01/2014
prenatal 19
prenatal vitamins comb
no.115/iron fumarate/folic
acid
ADD UM: GENDER
Female
01/01/2014
fioricet with
codeine,butalbacetaminophcaff-codein
butalbital/acetaminophen/caf
feine/codeine phosphate
ADD UM: QUANTITY
180 / 30 days
01/01/2014
DUET DHA
BALANCED
prenatal vitamin no.117/sod
ferede-iron
poly/fa/om3/dha/epa
ADD UM: GENDER
Female
01/01/2014
OXYTROL FOR
WOMEN
oxybutynin
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 175
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
ADD UM: AGE
Up to 25 yrs old
01/01/2014
CORVITE FE
iron,carbonyl/methyltetrahyd
rofolate gluc,fa/mv, min
no.40
01/01/2014
TRETIN-X
tretinoin
01/01/2014
se-natal
19,prenatal 19
prenatal vits with
calcium#118/ferrous
fumarate/folic acid
ADD UM: GENDER
Female
01/01/2014
se-natal
19,prenatal 19
prenatal vitamins comb
no.119/iron fumarate/folic
acid/dss
ADD UM: GENDER
Female
01/01/2014
khedezla,desvenl desvenlafaxine
afaxine er
ADD UM: QUANTITY
30 / 30 days
01/01/2014
khedezla,desvenl desvenlafaxine
afaxine er
ADD UM: QUANTITY
30 / 30 days
01/01/2014
PRENAISSANCE prenatal vit/folic
NEXT-B
acid/b6/calcium carb/ginger
ADD UM: GENDER
Female
01/01/2014
STENDRA
avanafil
01/01/2014
ANORO
ELLIPTA
umeclidinium
bromide/vilanterol trifenatate
01/01/2014
DUAVEE
estrogens,
conjugated/bazedoxifene
acetate
01/01/2014
COPAXONE
glatiramer acetate
01/01/2014
CITRANATAL
HARMONY
prenatal vitamin no.59/iron
carb,fum/folic
acid/docusate/dha
01/01/2014
VINATE DHA RF prenatal no.64/iron fum/lmefolate ca/algal oil/soy
lecithin
01/01/2014
desvenlafaxine
fumarate er
desvenlafaxine fumarate
CHANGE UM: GENDER
Female
Male
ADD UM: QUANTITY
60 / 30 days
ADD UM: GENDER
Female
ADD UM: QUANTITY
12 / 28 days
ADD UM: GENDER
Female
ADD UM: GENDER
Female
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 176
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
01/01/2014
desvenlafaxine
fumarate er
01/01/2014
Generic Name
desvenlafaxine fumarate
Type of Change
Previous Value
New Value
ADD UM: QUANTITY
30 / 30 days
CITRANATAL 90 prenatal vit no.72/iron
DHA
carbony,gluc/folic
acid/docusate/dha
ADD UM: GENDER
Female
01/01/2014
multi-vitamin wfluoride
pediatric multivitamin
combination no.2/sodium
fluoride
CHANGE UM: AGE
0.6 to 1 yrs old
1 to 2 yrs old
01/01/2014
multi-vitamin wfluoride
pediatric multivitamin
combination no.2/sodium
fluoride
CHANGE UM: AGE
0.6 to 1 yrs old
1 to 2 yrs old
01/01/2014
multivitamins w- pediatric multivitamin combo
fluorideno.45/fluoride/ferrous sulfate
iron,multi-vitamin
w-fluorideiron,multi-vitaminfluor-iron
CHANGE UM: AGE
1 to 2 yrs old
01/01/2014
VITAMEDMD
REDICHEW
RX,PRENA1
CHEW
prenatal vitamins
combination no.42/folic acid
ADD UM: GENDER
Female
01/01/2014
FORADIL
formoterol fumarate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
children's allegra fexofenadine hcl
allergy,fexofenadi
ne hcl
ADD UM: QUANTITY
60 / 30 days
01/01/2014
pantoprazole
sodium,protonix
pantoprazole sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ZYFLO
zileuton
ADD UM: QUANTITY
60 / 30 days
01/01/2014
zomig
zmt,zolmitriptan
odt
zolmitriptan
ADD UM: QUANTITY
18 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 177
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ipratropium
ipratropium bromide
bromide,atrovent
ADD UM: QUANTITY
50 / 30 days
01/01/2014
ipratropium
ipratropium bromide
bromide,atrovent
ADD UM: QUANTITY
50 / 30 days
01/01/2014
singulair,montelu montelukast sodium
kast sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
PROSTIN E2
VAGINAL
SUPPOSITORY
ADD UM: GENDER
Female
01/01/2014
lipitor,atorvastatin atorvastatin calcium
calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
lipitor,atorvastatin atorvastatin calcium
calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
lipitor,atorvastatin atorvastatin calcium
calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
lipitor,atorvastatin atorvastatin calcium
calcium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
zomig,zolmitripta zolmitriptan
n
ADD UM: QUANTITY
18 / 30 days
01/01/2014
zomig,zolmitripta zolmitriptan
n
ADD UM: QUANTITY
18 / 30 days
01/01/2014
terazol
terconazole
7,terconazole,zaz
ole
CHANGE UM: GENDER
Female
01/01/2014
terazol
terconazole
3,terconazole,zaz
ole
CHANGE UM: GENDER
Female
01/01/2014
tretinoin
tretinoin
ADD UM: AGE
Up to 25 yrs old
01/01/2014
pravastatin
sodium
pravastatin sodium
ADD UM: QUANTITY
30 / 30 days
dinoprostone
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 178
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
pravachol,pravast pravastatin sodium
atin sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
pravachol,pravast pravastatin sodium
atin sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
all day
cetirizine hcl,loratadine
allergy,cetirizine
hcl,walzyr,zyrtec,all day
allergy
relief,allergy
relief,allergy,allertec
ADD UM: QUANTITY
30 / 30 days
01/01/2014
trimesis
rx,folinatal plus
b,folbecal
ADD UM: GENDER
Female
01/01/2014
imitrex,sumatripta sumatriptan
n
CHANGE UM: QUANTITY
6 / 30 days
01/01/2014
imitrex,sumatripta sumatriptan succinate
n
succinate,alsuma
CHANGE UM: QUANTITY
1 / 30 days
01/01/2014
sumatriptan
sumatriptan succinate
succinate,imitrex
CHANGE UM: QUANTITY
1 / 30 days
01/01/2014
imitrex,sumatripta sumatriptan
n
CHANGE UM: QUANTITY
6 / 30 days
01/01/2014
prometrium,proge progesterone,micronized
sterone
ADD UM: GENDER
Female
01/01/2014
prometrium,proge progesterone,micronized
sterone
ADD UM: GENDER
Female
01/01/2014
accolate,zafirluka zafirlukast
st
CHANGE UM: QUANTITY
60 / 30 days
01/01/2014
ENBREL
ADD UM: QUANTITY
4 / 28 days
prenatal without iron/folic
acid/calcium
carb/pyridoxine/b12
etanercept
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 179
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
FLOVENT
DISKUS
fluticasone propionate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
FLOVENT
DISKUS
fluticasone propionate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
FLOVENT
DISKUS
fluticasone propionate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
FLOVENT HFA
fluticasone propionate
ADD UM: QUANTITY
12 / 30 days
01/01/2014
FLOVENT HFA
fluticasone propionate
ADD UM: QUANTITY
12 / 30 days
01/01/2014
FLOVENT HFA
fluticasone propionate
ADD UM: QUANTITY
24 / 30 days
01/01/2014
walloratadine
itin,alavert,loratad
ine,allergy
relief,claritin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
astelin,azelastine azelastine hcl
hcl
CHANGE UM: QUANTITY
30 / 30 days
01/01/2014
walloratadine
itin,loratadine,clar
itin,children's
claritin,allergy
relief,children's
loratadine,childre
n's allergy
relief,loratadine
hives
relief,loratadine
allergy
ADD UM: QUANTITY
300 / 30 days
01/01/2014
loratadine,allergy loratadine
relief,walitin,allergy,nondrowsy
allergy,claritin,lor
adamed,allerclea
r
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 180
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
NEPHRON FA
ferrous
fumarate/docusate/folic
acid/vitamin b comp and c
01/01/2014
PULMICORT
budesonide
01/01/2014
refissa,tretinoin
tretinoin/emollient base
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
ADD UM: QUANTITY
120 / 30 days
CHANGE UM: AGE
Up to 25 yrs old
allergyloratadine/pseudoephedrine
congestion
sulfate
relief,wal-itin d 12
hour,alavert,lorat
adine d,claritin-d
12 hour,allergycongestion,allerg
y reliefd,loratadined,allergy relief
d12,allerclear d12hr,allergy relief
d
CHANGE UM: QUANTITY
60 / 30 days
01/01/2014
allergyloratadine/pseudoephedrine
congestion
sulfate
relief,wal-itin
d,loratadined,lorata-dine
d,allergy reliefnasal
decongest,claritin
-d 24 hour,loratad,allergy relief d24,allergy relief
d,allergycongestion reliefd,allerclear d24hr
CHANGE UM: QUANTITY
30 / 30 days
01/01/2014
SEREVENT
DISKUS
ADD UM: QUANTITY
60 / 30 days
salmeterol xinafoate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 181
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
covaryx h.s.,eemt estrogens,esterified/methylt
h.s.,estrogen &
estosterone
methyltestosteron
e,estrogenmethyltestosteron
e
ADD UM: GENDER
Female
01/01/2014
covaryx,eemt,estr estrogens,esterified/methylt
ogenestosterone
methyltestosteron
e
ADD UM: GENDER
Female
01/01/2014
COMBIPATCH
estradiol/norethindrone
acetate
ADD UM: QUANTITY
4 / 28 days
01/01/2014
COMBIPATCH
estradiol/norethindrone
acetate
ADD UM: QUANTITY
4 / 28 days
01/01/2014
butalbital
codeine
compoundphosphate/butalbital/aspirin/
codeine,ascomp caffeine
with
codeine,fiorinal
with codeine #3
ADD UM: QUANTITY
180 / 30 days
01/01/2014
EXTAVIA,BETAS interferon beta-1b
ERON
ADD UM: QUANTITY
15 / 30 days
01/01/2014
butalb-caffacetaminophcodein,fioricet
with codeine
butalbital/acetaminophen/caf
feine/codeine phosphate
ADD UM: QUANTITY
180 / 30 days
01/01/2014
NASONEX
mometasone furoate
ADD UM: QUANTITY
17 / 30 days
01/01/2014
COMBIVENT
ipratropium
bromide/albuterol sulfate
ADD UM: QUANTITY
4 / 30 days
01/01/2014
EMADINE
emedastine difumarate
ADD UM: QUANTITY
5 / 30 days
01/01/2014
QVAR
beclomethasone
dipropionate
ADD UM: QUANTITY
8.7 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 182
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
01/01/2014
QVAR
01/01/2014
Generic Name
beclomethasone
dipropionate
Type of Change
Previous Value
New Value
ADD UM: QUANTITY
8.7 / 30 days
naratriptan
naratriptan hcl
hcl,amerge,naratr
iptan
ADD UM: QUANTITY
18 / 30 days
01/01/2014
naratriptan
naratriptan hcl
hcl,amerge,naratr
iptan
ADD UM: QUANTITY
18 / 30 days
01/01/2014
fosamax,alendro alendronate sodium
nate sodium
ADD UM: QUANTITY
4 / 30 days
01/01/2014
LESCOL XL
ADD UM: QUANTITY
30 / 30 days
01/01/2014
RENOVA,RENO tretinoin/emollient base
VA PUMP
ADD UM: AGE
Up to 25 yrs old
01/01/2014
rhinocort
budesonide
aqua,budesonide
ADD UM: QUANTITY
8.6 / 30 days
01/01/2014
PREFEST
ADD UM: GENDER
Female
01/01/2014
prilosec,omepraz omeprazole
ole
ADD UM: QUANTITY
30 / 30 days
01/01/2014
prilosec,omepraz omeprazole
ole
ADD UM: QUANTITY
30 / 30 days
01/01/2014
teveten,eprosarta eprosartan mesylate
n mesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CENESTIN
estrogens,conj.,synthetic a
ADD UM: GENDER
Female
01/01/2014
CENESTIN
estrogens,conj.,synthetic a
ADD UM: GENDER
Female
01/01/2014
singulair,montelu montelukast sodium
kast sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
singulair,montelu montelukast sodium
kast sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
BRAVELLE
ADD UM: GENDER
Female
fluvastatin sodium
estradiol/norgestimate
urofollitropin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 183
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
mimvey,activella, estradiol/norethindrone
estradiolacetate
norethindrone
acetat
ADD UM: GENDER
Female
01/01/2014
maternity,vinate- prenatal vitamins with
m
calcium/ferrous
fumarate/fa/selenium
ADD UM: GENDER
Female
01/01/2014
pantoprazole
sodium,protonix
pantoprazole sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
CRINONE
progesterone,micronized
ADD UM: GENDER
Female
01/01/2014
HUMIRA
adalimumab
PEN,HUMIRA
PEN CROHNUC-HS
STARTER,HUMI
RA PEN
PSORIASISUVEITIS
ADD UM: QUANTITY
4 / 28 days
01/01/2014
JANUVIA
sitagliptin phosphate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
JANUVIA
sitagliptin phosphate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
JANUVIA
sitagliptin phosphate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
OMNARIS
ciclesonide
ADD UM: QUANTITY
12.5 / 30 days
01/01/2014
morphine sulfate morphine sulfate
er,kadian
ADD UM: QUANTITY
120 / 30 days
01/01/2014
morphine sulfate morphine sulfate
er,kadian
ADD UM: QUANTITY
120 / 30 days
01/01/2014
morphine sulfate morphine sulfate
er,kadian
ADD UM: QUANTITY
120 / 30 days
01/01/2014
VITAFOL-OB
ADD UM: GENDER
Female
prenatal vitamins comb
10/ferrous fumarate/folic
acid
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 184
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
VITAFOL-PN
prenatal vit with calcium
cmb 11/ferrous
fumarate/folic acid
ADD UM: GENDER
Female
01/01/2014
vol-care
rx,nephro-vite
rx,rena-vite rx
vitamin b complx no.3/folic
acid/ascorbic acid/biotin
ADD UM: GENDER
Female
01/01/2014
ENBREL
etanercept
ADD UM: QUANTITY
4 / 28 days
01/01/2014
accu-chek
compact,accuchek compact
plus
blood sugar diagnostic,
drum-type
ADD UM: QUANTITY
100 / 30 days
01/01/2014
xyzal,levocetirizin levocetirizine
e dihydrochloride dihydrochloride
ADD UM: QUANTITY
300 / 30 days
01/01/2014
EXFORGE
amlodipine
besylate/valsartan
ADD UM: QUANTITY
60 / 30 days
01/01/2014
EXFORGE
amlodipine
besylate/valsartan
ADD UM: QUANTITY
60 / 30 days
01/01/2014
vitafolob+dha,pnv-ob
with dha
prenatal vitamins comb
10/ferrous fumarate/folic
acid/dha
ADD UM: GENDER
Female
01/01/2014
PULMICORT
FLEXHALER
budesonide
ADD UM: QUANTITY
1 / 30 days
01/01/2014
PULMICORT
FLEXHALER
budesonide
ADD UM: QUANTITY
1 / 30 days
01/01/2014
NEXIUM
esomeprazole magnesium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
NEXIUM
esomeprazole magnesium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
VYVANSE
lisdexamfetamine
dimesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
VYVANSE
lisdexamfetamine
dimesylate
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 185
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
VYVANSE
lisdexamfetamine
dimesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TEKTURNA
aliskiren hemifumarate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TEKTURNA
aliskiren hemifumarate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
KADIAN
morphine sulfate
ADD UM: QUANTITY
180 / 30 days
01/01/2014
JANUMET
sitagliptin
phosphate/metformin hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
JANUMET
sitagliptin
phosphate/metformin hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
activella,estradiol estradiol/norethindrone
-norethindrone
acetate
acetat
CHANGE UM: GENDER
Female
01/01/2014
EXTAVIA,BETAS interferon beta-1b
ERON
ADD UM: QUANTITY
15 / 30 days
01/01/2014
ENBREL
etanercept
ADD UM: QUANTITY
4 / 28 days
01/01/2014
VERAMYST
fluticasone furoate
ADD UM: QUANTITY
10 / 30 days
01/01/2014
FOSAMAX PLUS alendronate
D
sodium/cholecalciferol
(vitamin d3)
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SYMBICORT
budesonide/formoterol
fumarate
ADD UM: QUANTITY
10.2 / 30 days
01/01/2014
SYMBICORT
budesonide/formoterol
fumarate
ADD UM: QUANTITY
10.2 / 30 days
01/01/2014
EXFORGE
amlodipine
besylate/valsartan
ADD UM: QUANTITY
60 / 30 days
01/01/2014
EXFORGE
amlodipine
besylate/valsartan
ADD UM: QUANTITY
60 / 30 days
01/01/2014
doxycycline
doxycycline monohydrate
monohydrate,ado
xa
CHANGE UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 186
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
ZYFLO CR
zileuton
01/01/2014
ENJUVIA
estrogens,conj.,synthetic b
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: QUANTITY
60 / 30 days
ADD UM: GENDER
Female
triadvance,mynat prenatal vitamin
al
no.15/iron,carbonyl/folic
advance,prenatal acid/docusate sod
ad,inatal advance
ADD UM: GENDER
Female
01/01/2014
trinatal gt,vinate
gt
prenatal vitamin
no.16/iron,carbonyl/folic
acid/docusate sod
ADD UM: GENDER
Female
01/01/2014
trinatal
ultra,vinate
ultra,inatal ultra
prenatal vitamin
no.18/iron,carbonyl/folic
acid/docusate sod
ADD UM: GENDER
Female
01/01/2014
triveen-duo
dha,pr natal 400
prenatal vitamins comb
no.53/iron b-g hcl sucp/fa/omega-3
ADD UM: GENDER
Female
01/01/2014
CORVITE FREE multivitamin with min
no.6/folic
acid/lutein/lycop/ubidecar
ADD UM: GENDER
Female
01/01/2014
citranatal rx,tri
rx,vinacal
prenatal vit no.22/iron
cbn,gluc/folic acid/docusate
sodium,prenatal vitamins
no.22/iron cbn & gluc/folic
acid/dss,prenatal vit
no.81/iron carbonyl,gluc/folic
acid/docusate
ADD UM: GENDER
Female
01/01/2014
BYSTOLIC
nebivolol hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
BYSTOLIC
nebivolol hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
OXYCONTIN
oxycodone hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
OXYCONTIN
oxycodone hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
OXYCONTIN
oxycodone hcl
ADD UM: QUANTITY
30 / 30 days
01/01/2014
clopidogrel,plavix clopidogrel bisulfate
CHANGE UM: QUANTITY
1 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 187
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
TEKTURNA HCT aliskiren
hemifumarate/hydrochlorothi
azide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TEKTURNA HCT aliskiren
hemifumarate/hydrochlorothi
azide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TEKTURNA HCT aliskiren
hemifumarate/hydrochlorothi
azide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
TEKTURNA HCT aliskiren
hemifumarate/hydrochlorothi
azide
ADD UM: QUANTITY
30 / 30 days
01/01/2014
VYVANSE
lisdexamfetamine
dimesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
VYVANSE
lisdexamfetamine
dimesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
VYVANSE
lisdexamfetamine
dimesylate
ADD UM: QUANTITY
30 / 30 days
01/01/2014
NEXIUM
esomeprazole magnesium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SIMCOR
niacin/simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SIMCOR
niacin/simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
SIMCOR
niacin/simvastatin
ADD UM: QUANTITY
30 / 30 days
01/01/2014
PROTONIX
pantoprazole sodium
ADD UM: QUANTITY
30 / 30 days
01/01/2014
HUMIRA
adalimumab
ADD UM: QUANTITY
4 / 28 days
01/01/2014
trinatal rx 1,vinate prenatal vitamin 27 with
one
calcium/ferrous
fumarate/folic acid
ADD UM: GENDER
Female
01/01/2014
SPRYCEL
ADD UM: QUANTITY
30 / 30 days
dasatinib
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 188
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
citranatal dha,pnv prenatal vit no.22/iron
ob+dha,prenaiss cbn,glucon/folic
ance dha
acid/docusate/dha,prenatal
vit no.76/iron
carbony,gluc/folic
acid/docusate/dha
01/01/2014
INFERGEN
01/01/2014
copegus,rebetol,r ribavirin
ibavirin,virazole,ri
batab,ribasphere,
ribasphere
ribapak,moderiba
01/01/2014
TAMIFLU
oseltamivir phosphate
01/01/2014
8-MOP
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
ADD UM: AUTHORIZATION
PA applies
CHANGE UM:
AUTHORIZATION
PA applies
ADD UM: AUTHORIZATION
PA applies
methoxsalen
ADD UM: CUSTOM
Specialty Drug
8-MOP
methoxsalen
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ACTEMRA
tocilizumab
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ACTEMRA
tocilizumab
CHANGE UM:
AUTHORIZATION
PA applies
01/01/2014
ACTIMMUNE
interferon gamma1b,recomb.
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ACTIMMUNE
interferon gamma1b,recomb.
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ADCETRIS
brentuximab vedotin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ADCIRCA
tadalafil
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ADCIRCA
tadalafil
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ADEMPAS
riociguat
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ADEMPAS
riociguat
ADD UM: AUTHORIZATION
PA applies
interferon alfacon-1
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 189
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ADVATE,ADVAT
E L,ADVATE
M,ADVATE
H,ADVATE
SH,ADVATE
UH,XYNTHA,XY
NTHA
SOLOFUSE
antihemophilic factor (fviii)
recomb,full length (albfree),antihemophilic factor
(factor viii) recomb,b-domain
deleted
ADD UM: CUSTOM
Specialty Drug
01/01/2014
AFINITOR
everolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
AFINITOR
everolimus
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AFINITOR
everolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
AFINITOR
everolimus
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AFINITOR
everolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
AFINITOR
everolimus
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AFINITOR
DISPERZ
everolimus
ADD TO FORMULARY
Non-Formulary
01/01/2014
AFINITOR
DISPERZ
everolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
AFINITOR
DISPERZ
everolimus
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AFINITOR
DISPERZ
everolimus
ADD TO FORMULARY
Non-Formulary
01/01/2014
AFINITOR
DISPERZ
everolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
AFINITOR
DISPERZ
everolimus
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AFINITOR
DISPERZ
everolimus
ADD TO FORMULARY
Non-Formulary
01/01/2014
AFINITOR
DISPERZ
everolimus
ADD UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 190
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
AFINITOR
DISPERZ
everolimus
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AFINITOR
everolimus
ADD TO FORMULARY
Preferred Brands
01/01/2014
AFINITOR
everolimus
ADD TO FORMULARY
Preferred Brands
01/01/2014
AFINITOR
everolimus
ADD TO FORMULARY
Preferred Brands
01/01/2014
AFINITOR
everolimus
ADD TO FORMULARY
Preferred Brands
01/01/2014
AFINITOR
everolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ALDURAZYME
laronidase
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ALDURAZYME
laronidase
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ALFERON N
interferon alfa-n3
ADD TO FORMULARY
Preferred Brands
01/01/2014
ALFERON N
interferon alfa-n3
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ALFERON N
interferon alfa-n3
ADD UM: AUTHORIZATION
PA applies
01/01/2014
HUMATEantihemophilic factor,
P,WILATE,ALPH human/von willebrand
ANATE
factor,human
ADD UM: CUSTOM
Specialty Drug
01/01/2014
MONONINE,ALP factor ix
HANINE SD
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ALPROLIX
factor ix recombinant, fc
fusion protein
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ARANESP
darbepoetin alfa in
polysorbate 80
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ARCALYST
rilonacept
ADD TO FORMULARY
Preferred Brands
01/01/2014
ARCALYST
rilonacept
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ARCALYST
rilonacept
ADD UM: AUTHORIZATION
PA applies
01/01/2014
AROMASIN
exemestane
ADD TO FORMULARY
Non-Formulary
01/01/2014
AROMASIN
exemestane
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ARZERRA
ofatumumab
ADD UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 191
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ASTAGRAF XL
tacrolimus
ADD TO FORMULARY
Non-Formulary
01/01/2014
ASTAGRAF XL
tacrolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ASTAGRAF XL
tacrolimus
ADD TO FORMULARY
Non-Formulary
01/01/2014
ASTAGRAF XL
tacrolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ASTAGRAF XL
tacrolimus
ADD TO FORMULARY
Non-Formulary
01/01/2014
ASTAGRAF XL
tacrolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
AUBAGIO
teriflunomide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
AUBAGIO
teriflunomide
ADD UM: STEP
ST applies
01/01/2014
REBIF,REBIF
interferon beta-1a/albumin
REBIDOSE,AVO human
NEX
ADD UM: CUSTOM
Specialty Drug
01/01/2014
AVONEX,AVON interferon beta-1a
EX PEN
ADD UM: CUSTOM
Specialty Drug
01/01/2014
BARACLUDE
entecavir
ADD UM: CUSTOM
Specialty Drug
01/01/2014
BARACLUDE
entecavir
ADD UM: AUTHORIZATION
PA applies
01/01/2014
BARACLUDE
entecavir
ADD UM: CUSTOM
Specialty Drug
01/01/2014
BARACLUDE
entecavir
ADD UM: CUSTOM
Specialty Drug
01/01/2014
BEBULIN VH
factor ix complex,
IMMUNO,BEBUL prothrombin complex conc.
IN,PROFILNINE (pcc) comb. 6,factor ix
complex, prothrombin cplx
conc(pcc) no.6, 3factor,factor ix complex,
prothrombin cplx conc(pcc)
no.4, 3-factor
ADD UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 192
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
BEBULIN VH
factor ix complex,
IMMUNO,BEBUL prothrombin complex conc.
IN,PROFILNINE (pcc) comb. 6,factor ix
complex, prothrombin cplx
conc(pcc) no.6, 3factor,factor ix complex,
prothrombin cplx conc(pcc)
no.4, 3-factor
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
bleomycin sulfate bleomycin sulfate
ADD TO FORMULARY
Generics
01/01/2014
bleomycin sulfate bleomycin sulfate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
bleomycin sulfate bleomycin sulfate
ADD TO FORMULARY
Generics
01/01/2014
bleomycin sulfate bleomycin sulfate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
BOSULIF
bosutinib
ADD TO FORMULARY
Non-Formulary
01/01/2014
BOSULIF
bosutinib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
BOSULIF
bosutinib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
BOSULIF
bosutinib
ADD TO FORMULARY
Non-Formulary
01/01/2014
BOSULIF
bosutinib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
BOSULIF
bosutinib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
BOTOX
COSMETIC
onabotulinumtoxina
ADD TO FORMULARY
Not Covered
01/01/2014
BOTOX
COSMETIC
onabotulinumtoxina
ADD UM: CUSTOM
Lifestyle Drugs
are Excluded
01/01/2014
BOTOX
onabotulinumtoxina
ADD TO FORMULARY
Non-Formulary
01/01/2014
BOTOX
onabotulinumtoxina
ADD UM: CUSTOM
Specialty Drug
01/01/2014
BOTOX
onabotulinumtoxina
ADD UM: AUTHORIZATION
PA applies
01/01/2014
BOTOX
onabotulinumtoxina
ADD TO FORMULARY
Preferred Brands
01/01/2014
BOTOX,BOTOX onabotulinumtoxina
COSMETIC
CHANGE UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 193
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
BOTOX,BOTOX onabotulinumtoxina
COSMETIC
01/01/2014
CAPRELSA
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
vandetanib
ADD UM: CUSTOM
Specialty Drug
CAPRELSA
vandetanib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
CAPRELSA
vandetanib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CAPRELSA
vandetanib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
bicalutamide,cas bicalutamide
odex
ADD TO FORMULARY
Non-Formulary
01/01/2014
bicalutamide,cas bicalutamide
odex
ADD UM: CUSTOM
Specialty Drug
01/01/2014
bicalutamide,cas bicalutamide
odex
ADD UM: AUTHORIZATION
PA applies
01/01/2014
bicalutamide
bicalutamide
ADD TO FORMULARY
Generics
01/01/2014
CAYSTON
aztreonam lysine
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CAYSTON
aztreonam lysine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
CHEMET
succimer
ADD TO FORMULARY
Preferred Brands
01/01/2014
CHEMET
succimer
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CHEMET
succimer
ADD UM: AUTHORIZATION
PA applies
01/01/2014
CIMZIA
certolizumab pegol
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CIMZIA
certolizumab pegol
ADD UM: AUTHORIZATION
PA applies
01/01/2014
CIMZIA
certolizumab pegol
ADD TO FORMULARY
Preferred Brands
01/01/2014
CIMZIA
certolizumab pegol
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CIMZIA
certolizumab pegol
ADD UM: AUTHORIZATION
PA applies
01/01/2014
COMETRIQ
cabozantinib s-malate
ADD TO FORMULARY
Non-Formulary
01/01/2014
COMETRIQ
cabozantinib s-malate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
COMETRIQ
cabozantinib s-malate
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 194
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
COMETRIQ
cabozantinib s-malate
ADD TO FORMULARY
Non-Formulary
01/01/2014
COMETRIQ
cabozantinib s-malate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
COMETRIQ
cabozantinib s-malate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
COMETRIQ
cabozantinib s-malate
ADD TO FORMULARY
Non-Formulary
01/01/2014
COMETRIQ
cabozantinib s-malate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
COMETRIQ
cabozantinib s-malate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
COPAXONE
glatiramer acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
COPAXONE
glatiramer acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
COPAXONE
glatiramer acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
cortrosyn,cosyntr cosyntropin
opin
ADD TO FORMULARY
Non-Formulary
01/01/2014
cortrosyn,cosyntr cosyntropin
opin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
cortrosyn,cosyntr cosyntropin
opin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
cosyntropin
cosyntropin
ADD TO FORMULARY
Non-Formulary
01/01/2014
cosyntropin
cosyntropin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
cosyntropin
cosyntropin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
CUROSURF
poractant alfa
ADD TO FORMULARY
Non-Formulary
01/01/2014
CUROSURF
poractant alfa
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CUROSURF
poractant alfa
ADD TO FORMULARY
Non-Formulary
01/01/2014
CUROSURF
poractant alfa
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CUROSURF
poractant alfa
ADD UM: AUTHORIZATION
PA applies
01/01/2014
desferal
deferoxamine mesylate
mesylate,deferox
amine mesylate
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 195
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
desferal
deferoxamine mesylate
mesylate,deferox
amine mesylate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
desferal
deferoxamine mesylate
mesylate,deferox
amine mesylate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
desferal,deferoxa deferoxamine mesylate
mine mesylate
ADD TO FORMULARY
Preferred Brands
01/01/2014
desferal,deferoxa deferoxamine mesylate
mine mesylate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
desferal,deferoxa deferoxamine mesylate
mine mesylate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
DYSPORT
abobotulinumtoxina
ADD UM: CUSTOM
Specialty Drug
01/01/2014
DYSPORT
abobotulinumtoxina
ADD UM: AUTHORIZATION
PA applies
01/01/2014
DYSPORT
abobotulinumtoxina
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EGRIFTA
tesamorelin acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
EGRIFTA
tesamorelin acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EGRIFTA
tesamorelin acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EGRIFTA
tesamorelin acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
EGRIFTA
tesamorelin acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EGRIFTA
tesamorelin acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ELSPAR
asparaginase
ADD TO FORMULARY
Non-Formulary
01/01/2014
ELSPAR
asparaginase
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ELSPAR
asparaginase
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EMCYT
estramustine phosphate
sodium
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EMCYT
estramustine phosphate
sodium
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 196
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ENBREL
etanercept
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ENTEREG
alvimopan
ADD TO FORMULARY
Non-Formulary
01/01/2014
ENTEREG
alvimopan
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ENTEREG
alvimopan
ADD UM: AUTHORIZATION
PA applies
01/01/2014
epivir
hbv,lamivudine
hbv
lamivudine
ADD TO FORMULARY
Preferred Brands
01/01/2014
epivir
hbv,lamivudine
hbv
lamivudine
ADD UM: CUSTOM
Specialty Drug
01/01/2014
epivir
hbv,lamivudine
hbv
lamivudine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EPIVIR HBV
lamivudine
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ERIVEDGE
vismodegib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ERIVEDGE
vismodegib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ERWINAZE
asparaginase (erwinia
chrysanthemi)
ADD TO FORMULARY
Non-Formulary
01/01/2014
ERWINAZE
asparaginase (erwinia
chrysanthemi)
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ERWINAZE
asparaginase (erwinia
chrysanthemi)
ADD UM: AUTHORIZATION
PA applies
01/01/2014
etoposide
etoposide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
etoposide
etoposide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EXJADE
deferasirox
ADD TO FORMULARY
Preferred Brands
01/01/2014
EXJADE
deferasirox
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EXJADE
deferasirox
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EXJADE
deferasirox
ADD TO FORMULARY
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 197
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
EXJADE
deferasirox
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EXJADE
deferasirox
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EXJADE
deferasirox
ADD TO FORMULARY
Preferred Brands
01/01/2014
EXJADE
deferasirox
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EXJADE
deferasirox
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EXTAVIA,BETAS interferon beta-1b
ERON
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EXTAVIA,BETAS interferon beta-1b
ERON
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EXTAVIA,BETAS interferon beta-1b
ERON
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EXTAVIA,BETAS interferon beta-1b
ERON
ADD UM: AUTHORIZATION
PA applies
01/01/2014
FARESTON
toremifene citrate
ADD TO FORMULARY
Preferred Brands
01/01/2014
FARESTON
toremifene citrate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
FARESTON
toremifene citrate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
FASLODEX
fulvestrant
ADD UM: CUSTOM
Specialty Drug
01/01/2014
FASLODEX
fulvestrant
ADD UM: AUTHORIZATION
PA applies
01/01/2014
letrozole,femara
letrozole
ADD UM: CUSTOM
Specialty Drug
01/01/2014
letrozole,femara
letrozole
ADD UM: AUTHORIZATION
PA applies
01/01/2014
FERRIPROX
deferiprone
ADD UM: CUSTOM
Specialty Drug
01/01/2014
FERRIPROX
deferiprone
ADD UM: AUTHORIZATION
PA applies
01/01/2014
FIRAZYR
icatibant acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
FIRAZYR
icatibant acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
FIRMAGON
degarelix acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
FIRMAGON
degarelix acetate
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 198
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
flutamide
flutamide
ADD TO FORMULARY
Generics
01/01/2014
flutamide
flutamide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
FORTEO
teriparatide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
FORTEO
teriparatide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
GALZIN
zinc acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
GALZIN
zinc acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
GALZIN
zinc acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
GALZIN
zinc acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
gammagard sd,gammagard
liquid,gamastan
s-d,carimune nf
nanofiltered,privig
en,hizentra,biviga
m,flebogamma
dif,gammaplex
immune
globulin,gamm(igg)/glycine/g
lucose/iga 0 to 50
mcg/ml,immune
globulin,gamm(igg)/glycine/i
ga greater than 50
mcg/ml,immune
globulin,gamma(igg)/glycine,
immune
globulin,gamm(igg)/sucrose/
iga greater than 50
mcg/ml,immune
globulin,gamma
(igg)/proline/iga 0 to 50
mcg/ml,immune
globulin,gamma
(igg)/sorbitol/iga 0 to 50
mcg/ml,immune
globul,gamma(igg)/sorbitol/i
ga greater than 50
mcg/ml,immune
globulin,gamm(igg)/sorbitol/
glycin/iga 0 to 50 mcg/ml
ADD UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 199
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
01/01/2014
gammagard sd,gammagard
liquid,gamastan
s-d,carimune nf
nanofiltered,privig
en,hizentra,biviga
m,flebogamma
dif,gammaplex
01/01/2014
GAMASTAN S-D immune
globulin,gamma(igg)/glycine
ADD TO FORMULARY
Preferred Brands
01/01/2014
GAMUNEX,GAM immune
UNEXglobulin,gamm(igg)/glycine/i
C,GAMMAKED ga greater than 50 mcg/ml
ADD UM: CUSTOM
Specialty Drug
01/01/2014
GAMUNEX,GAM immune
ADD UM: AUTHORIZATION
UNEXglobulin,gamm(igg)/glycine/i
C,GAMMAKED ga greater than 50 mcg/ml
01/01/2014
GAMUNEX
immune
ADD UM: AUTHORIZATION
globulin,gamm(igg)/glycine/g
lucose/iga 0 to 50
mcg/ml,immune
globulin,gamm(igg)/glycine/i
ga greater than 50
mcg/ml,immune
globulin,gamma(igg)/glycine,
immune
globulin,gamm(igg)/sucrose/
iga greater than 50
mcg/ml,immune
globulin,gamma
(igg)/proline/iga 0 to 50
mcg/ml,immune
globulin,gamma
(igg)/sorbitol/iga 0 to 50
mcg/ml,immune
globul,gamma(igg)/sorbitol/i
ga greater than 50
mcg/ml,immune
globulin,gamm(igg)/sorbitol/
glycin/iga 0 to 50 mcg/ml
immune
globulin,gamm(igg)/glycine/i
ga greater than 50 mcg/ml
ADD TO FORMULARY
New Value
PA applies
PA applies
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 200
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
GAMUNEXC,GAMMAKED
immune
globulin,gamm(igg)/glycine/i
ga greater than 50 mcg/ml
ADD TO FORMULARY
Preferred Brands
01/01/2014
GAMUNEXC,GAMMAKED
immune
globulin,gamm(igg)/glycine/i
ga greater than 50 mcg/ml
ADD TO FORMULARY
Preferred Brands
01/01/2014
GAMUNEXC,GAMMAKED
immune
globulin,gamm(igg)/glycine/i
ga greater than 50 mcg/ml
ADD TO FORMULARY
Preferred Brands
01/01/2014
GAMUNEXC,GAMMAKED
immune
globulin,gamm(igg)/glycine/i
ga greater than 50 mcg/ml
ADD TO FORMULARY
Preferred Brands
01/01/2014
GAMUNEXC,GAMMAKED
immune
globulin,gamm(igg)/glycine/i
ga greater than 50 mcg/ml
ADD TO FORMULARY
Preferred Brands
01/01/2014
HUMATROPE,G somatropin
ENOTROPIN,NO
RDITROPIN
NORDIFLEX,NO
RDITROPIN
FLEXPRO,OMNI
TROPE,SEROST
IM,SAIZEN,ZOR
BTIVE,NUTROPI
N,NUTROPIN
AQ,NUTROPIN
AQ
NUSPIN,TEVTROPIN
ADD UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 201
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
HUMATROPE,G somatropin
ENOTROPIN,NO
RDITROPIN
NORDIFLEX,NO
RDITROPIN
FLEXPRO,OMNI
TROPE,SEROST
IM,SAIZEN,ZOR
BTIVE,NUTROPI
N,NUTROPIN
AQ,NUTROPIN
AQ
NUSPIN,TEVTROPIN
01/01/2014
GILENYA
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
fingolimod hcl
ADD TO FORMULARY
Non-Formulary
GILENYA
fingolimod hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
GILENYA
fingolimod hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
GILOTRIF
afatinib dimaleate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
GILOTRIF
afatinib dimaleate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
GRANIX
tbo-filgrastim
ADD UM: CUSTOM
Specialty Drug
01/01/2014
GRANIX
tbo-filgrastim
ADD UM: AUTHORIZATION
PA applies
01/01/2014
H.P. ACTHAR
corticotropin
ADD TO FORMULARY
Preferred Brands
01/01/2014
H.P. ACTHAR
corticotropin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
H.P. ACTHAR
corticotropin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
hecoria,tacrolimu tacrolimus
s,prograf
ADD TO FORMULARY
Generics
01/01/2014
tacrolimus
tacrolimus
ADD TO FORMULARY
Generics
01/01/2014
PROGRAF
tacrolimus
ADD TO FORMULARY
Non-Formulary
01/01/2014
PROGRAF
tacrolimus
ADD TO FORMULARY
Non-Formulary
01/01/2014
PROGRAF
tacrolimus
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 202
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
tacrolimus
tacrolimus
ADD TO FORMULARY
Generics
01/01/2014
hecoria
tacrolimus
ADD TO FORMULARY
Generics
01/01/2014
hecoria
tacrolimus
ADD TO FORMULARY
Generics
01/01/2014
HEPAGAM B
hepatitis b immune
globulin/maltose
ADD TO FORMULARY
Preferred Brands
01/01/2014
HEPAGAM B
hepatitis b immune
globulin/maltose
ADD UM: CUSTOM
http://4d.adaptive
rx.com/webSearc
h/index?key=cnh
mbGV4LnBsYW4
uUGxhblBkZlR5c
GUtOTE=
01/01/2014
HEPAGAM B
hepatitis b immune
globulin/maltose
ADD UM: AUTHORIZATION
PA applies
01/01/2014
HUMIRA,HUMIR adalimumab
A PEN,HUMIRA
PEN CROHNUC-HS
STARTER,HUMI
RA PEN
PSORIASISUVEITIS
ADD UM: CUSTOM
Specialty Drug
01/01/2014
HEPAGAM B
hepatitis b immune
globulin/maltose
ADD TO FORMULARY
Preferred Brands
01/01/2014
HEPAGAM B
hepatitis b immune
globulin/maltose
ADD UM: CUSTOM
Specialty Drug
01/01/2014
HEPAGAM B
hepatitis b immune
globulin/maltose
ADD UM: AUTHORIZATION
PA applies
01/01/2014
HEPAGAM B
hepatitis b immune
globulin/maltose
CHANGE UM: CUSTOM
http://4d.adaptive
rx.com/webSearc
h/index?key=cnh
mbGV4LnBsYW4
uUGxhblBkZlR5c
GUtOTE=
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 203
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
HYCAMTIN
topotecan hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
HYCAMTIN
topotecan hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
HYCAMTIN
topotecan hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
HYCAMTIN
topotecan hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
HYCAMTIN
topotecan hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
HYCAMTIN
topotecan hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
HYPERHEP B S- hepatitis b immune globulin
D,NABI-HB
ADD TO FORMULARY
Preferred Brands
01/01/2014
HYPERHEP B S- hepatitis b immune globulin
D,NABI-HB
ADD UM: CUSTOM
Specialty Drug
01/01/2014
HYPERHEP B S- hepatitis b immune globulin
D,NABI-HB
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ICLUSIG
ponatinib hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
ICLUSIG
ponatinib hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ICLUSIG
ponatinib hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ICLUSIG
ponatinib hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
ICLUSIG
ponatinib hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ICLUSIG
ponatinib hcl
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
ILARIS
canakinumab/pf
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ILARIS
canakinumab/pf
ADD UM: AUTHORIZATION
PA applies
01/01/2014
IMBRUVICA
ibrutinib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
IMBRUVICA
ibrutinib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
imiquimod,aldara imiquimod
ADD UM: CUSTOM
Specialty Drug
01/01/2014
INFERGEN
interferon alfacon-1
ADD UM: CUSTOM
Specialty Drug
01/01/2014
INLYTA
axitinib
ADD UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 204
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
INLYTA
axitinib
01/01/2014
INTRON A
interferon alfa-2b,recomb.
01/01/2014
IPRIVASK
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
ADD UM: CUSTOM
Specialty Drug
desirudin
ADD TO FORMULARY
Preferred Brands
IPRIVASK
desirudin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
IPRIVASK
desirudin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
JAKAFI
ruxolitinib phosphate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
JAKAFI
ruxolitinib phosphate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
JUXTAPID
lomitapide mesylate
ADD TO FORMULARY
Non-Formulary
01/01/2014
JUXTAPID
lomitapide mesylate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
JUXTAPID
lomitapide mesylate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
KALBITOR
ecallantide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
KALBITOR
ecallantide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
KALYDECO
ivacaftor
ADD UM: CUSTOM
Specialty Drug
01/01/2014
KALYDECO
ivacaftor
ADD UM: AUTHORIZATION
PA applies
01/01/2014
KINERET
anakinra
ADD UM: CUSTOM
Specialty Drug
01/01/2014
KINERET
anakinra
ADD UM: AUTHORIZATION
PA applies
01/01/2014
MIFEPREX,KOR mifepristone
LYM
ADD UM: CUSTOM
Specialty Drug
01/01/2014
MIFEPREX,KOR mifepristone
LYM
ADD UM: AUTHORIZATION
PA applies
01/01/2014
kuvan,tetrahydro sapropterin dihydrochloride
biopterin dihcl,tetrahydro-lbiopterin di-hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
kuvan,tetrahydro sapropterin dihydrochloride
biopterin dihcl,tetrahydro-lbiopterin di-hcl
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 205
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
KYNAMRO
mipomersen sodium
ADD UM: CUSTOM
Specialty Drug
01/01/2014
KYNAMRO
mipomersen sodium
ADD UM: AUTHORIZATION
PA applies
01/01/2014
lamivudine hbv
lamivudine
01/01/2014
LETAIRIS
ambrisentan
01/01/2014
CHANGE TIER
Preferred Brands
Generics
ADD UM: CUSTOM
Specialty Drug
eligard,lupron
leuprolide acetate
depot-ped,lupron
depot,leuprolide
acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
eligard,lupron
leuprolide acetate
depot-ped,lupron
depot,leuprolide
acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
leuprolide acetate leuprolide acetate
ADD TO FORMULARY
Generics
01/01/2014
CEENU,LOMUST lomustine
INE
ADD TO FORMULARY
Preferred Brands
01/01/2014
CEENU,LOMUST lomustine
INE
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CEENU,LOMUST lomustine
INE
ADD UM: AUTHORIZATION
PA applies
01/01/2014
CEENU,LOMUST lomustine
INE
ADD TO FORMULARY
Preferred Brands
01/01/2014
CEENU,LOMUST lomustine
INE
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CEENU,LOMUST lomustine
INE
ADD UM: AUTHORIZATION
PA applies
01/01/2014
CEENU,LOMUST lomustine
INE
ADD TO FORMULARY
Preferred Brands
01/01/2014
CEENU,LOMUST lomustine
INE
ADD UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 206
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
CEENU,LOMUST lomustine
INE
01/01/2014
LUPANETA
PACK
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
leuprolide
acetate/norethindrone
acetate
ADD UM: CUSTOM
Specialty Drug
LUPANETA
PACK
leuprolide
acetate/norethindrone
acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
LYSODREN
mitotane
ADD TO FORMULARY
Preferred Brands
01/01/2014
LYSODREN
mitotane
ADD UM: CUSTOM
Specialty Drug
01/01/2014
LYSODREN
mitotane
ADD UM: AUTHORIZATION
PA applies
01/01/2014
MAKENA
hydroxyprogesterone
caproate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
MAKENA
hydroxyprogesterone
caproate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
MATULANE
procarbazine hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
MATULANE
procarbazine hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
MEKINIST
trametinib dimethyl sulfoxide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
MEKINIST
trametinib dimethyl sulfoxide ADD UM: AUTHORIZATION
01/01/2014
MESNEX
mesna
ADD UM: CUSTOM
Specialty Drug
01/01/2014
MESNEX
mesna
ADD UM: AUTHORIZATION
PA applies
01/01/2014
micrhogam ultra- rho(d) immune globulin
filtered
plus,hyperrho s-d
ADD TO FORMULARY
Preferred Brands
01/01/2014
micrhogam ultra- rho(d) immune globulin
filtered
plus,hyperrho s-d
ADD UM: CUSTOM
Specialty Drug
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 207
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
micrhogam ultra- rho(d) immune globulin
filtered
plus,hyperrho s-d
01/01/2014
MONOVISC
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
hyaluronate sodium,
stabilized
ADD UM: CUSTOM
Specialty Drug
MONOVISC
hyaluronate sodium,
stabilized
ADD UM: AUTHORIZATION
PA applies
01/01/2014
MYOBLOC
rimabotulinumtoxinb
ADD UM: CUSTOM
Specialty Drug
01/01/2014
MYOBLOC
rimabotulinumtoxinb
CHANGE UM:
AUTHORIZATION
PA applies
01/01/2014
NEUPOGEN
filgrastim
ADD TO FORMULARY
Preferred Brands
01/01/2014
NEUPOGEN
filgrastim
ADD UM: CUSTOM
Specialty Drug
01/01/2014
NEUPOGEN
filgrastim
ADD UM: AUTHORIZATION
PA applies
01/01/2014
NEUMEGA
oprelvekin
ADD TO FORMULARY
Preferred Brands
01/01/2014
NEUMEGA
oprelvekin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
NEUMEGA
oprelvekin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
NEULASTA
pegfilgrastim
ADD UM: CUSTOM
Specialty Drug
01/01/2014
NEULASTA
pegfilgrastim
ADD UM: AUTHORIZATION
PA applies
01/01/2014
NEXAVAR
sorafenib tosylate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
NEXAVAR
sorafenib tosylate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
sandostatin,sand octreotide acetate,octreotide
ostatin
acetate, microspheres
lar,octreotide
acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
sandostatin,sand octreotide acetate,octreotide ADD UM: AUTHORIZATION
ostatin
acetate, microspheres
lar,octreotide
acetate
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 208
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
sandostatin,octre octreotide acetate
otide acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
sandostatin,octre octreotide acetate
otide acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
octreotide
acetate
octreotide acetate
ADD TO FORMULARY
Generics
01/01/2014
sandostatin,octre octreotide acetate
otide acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
sandostatin,octre octreotide acetate
otide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
sandostatin,octre octreotide acetate
otide acetate
ADD TO FORMULARY
Generics
01/01/2014
octreotide
acetate
octreotide acetate
ADD TO FORMULARY
Generics
01/01/2014
octreotide
acetate
octreotide acetate
ADD TO FORMULARY
Generics
01/01/2014
octreotide
acetate
octreotide acetate
ADD TO FORMULARY
Generics
01/01/2014
SANDOSTATIN
octreotide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
SANDOSTATIN
octreotide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
octreotide
acetate
octreotide acetate
ADD TO FORMULARY
Generics
01/01/2014
SANDOSTATIN
octreotide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
octreotide
acetate
octreotide acetate
ADD TO FORMULARY
Generics
01/01/2014
SANDOSTATIN
octreotide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
octreotide
acetate
octreotide acetate
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 209
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
octreotide
acetate
octreotide acetate
ADD TO FORMULARY
Generics
01/01/2014
octreotide
acetate
octreotide acetate
ADD TO FORMULARY
Non-Formulary
01/01/2014
OLYSIO
simeprevir sodium
ADD UM: CUSTOM
Specialty Drug
01/01/2014
OLYSIO
simeprevir sodium
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ONCASPAR
pegaspargase
ADD TO FORMULARY
Preferred Brands
01/01/2014
ONCASPAR
pegaspargase
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ONCASPAR
pegaspargase
ADD UM: AUTHORIZATION
PA applies
01/01/2014
OPSUMIT
macitentan
ADD TO FORMULARY
Non-Formulary
01/01/2014
OPSUMIT
macitentan
ADD UM: CUSTOM
Specialty Drug
01/01/2014
OPSUMIT
macitentan
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ORENCIA
abatacept
CHANGE TIER
Preferred Brands
01/01/2014
ORENCIA
abatacept
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ORENCIA
abatacept
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ORENCIA
abatacept/maltose
01/01/2014
ORENITRAM ER treprostinil diolamine
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ORENITRAM ER treprostinil diolamine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ORFADIN
nitisinone
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ORFADIN
nitisinone
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ORTHOVISC
hyaluronate sodium
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ORTHOVISC
hyaluronate sodium
ADD UM: AUTHORIZATION
PA applies
01/01/2014
OTEZLA
apremilast
CHANGE TIER
Preferred Brands
01/01/2014
OTEZLA
apremilast
ADD UM: CUSTOM
Specialty Drug
01/01/2014
OTEZLA
apremilast
ADD UM: AUTHORIZATION
PA applies
CHANGE TIER
Preferred Brands
Not Covered
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 210
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
OTEZLA
apremilast
ADD UM: CUSTOM
Specialty Drug
01/01/2014
OTEZLA
apremilast
ADD UM: AUTHORIZATION
PA applies
01/01/2014
OXSORALENULTRA
methoxsalen, rapid
ADD UM: CUSTOM
Specialty Drug
01/01/2014
OXSORALENULTRA
methoxsalen, rapid
ADD UM: AUTHORIZATION
PA applies
01/01/2014
PANRETIN
alitretinoin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
PANRETIN
alitretinoin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
PEGASYS,PEGA peginterferon alfa-2a
SYS PROCLICK
ADD UM: CUSTOM
Specialty Drug
01/01/2014
PEGINTRON,SY peginterferon alfa-2b
LATRON,SYLAT
RON 4PACK,PEGINTR
ON REDIPEN
ADD UM: CUSTOM
Specialty Drug
01/01/2014
POMALYST
pomalidomide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
POMALYST
pomalidomide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
EPOGEN,PROC epoetin alfa
RIT
ADD UM: CUSTOM
Specialty Drug
01/01/2014
EPOGEN,PROC epoetin alfa
RIT
ADD UM: AUTHORIZATION
PA applies
01/01/2014
hecoria,tacrolimu tacrolimus
s,prograf,protopic
,astagraf xl
01/01/2014
PROLIA,XGEVA denosumab
ADD UM: CUSTOM
Specialty Drug
01/01/2014
PROLIA,XGEVA denosumab
ADD UM: AUTHORIZATION
PA applies
01/01/2014
PROMACTA
eltrombopag olamine
ADD UM: CUSTOM
Specialty Drug
01/01/2014
PROMACTA
eltrombopag olamine
ADD UM: AUTHORIZATION
PA applies
REMOVE UM: CUSTOM
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 211
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
PROTOPAM
CHLORIDE
pralidoxime chloride
ADD TO FORMULARY
Preferred Brands
01/01/2014
PROTOPAM
CHLORIDE
pralidoxime chloride
ADD UM: CUSTOM
Specialty Drug
01/01/2014
PROTOPAM
CHLORIDE
pralidoxime chloride
ADD UM: AUTHORIZATION
PA applies
01/01/2014
PULMOZYME
dornase alfa
ADD UM: CUSTOM
Specialty Drug
01/01/2014
mercaptopurine,p mercaptopurine
urinethol
ADD UM: CUSTOM
Specialty Drug
01/01/2014
mercaptopurine,p mercaptopurine
urinethol
ADD UM: AUTHORIZATION
PA applies
01/01/2014
QUELICIN,ANEC succinylcholine chloride
TINE
ADD TO FORMULARY
Preferred Brands
01/01/2014
QUELICIN,ANEC succinylcholine chloride
TINE
ADD UM: CUSTOM
Specialty Drug
01/01/2014
QUELICIN,ANEC succinylcholine chloride
TINE
ADD UM: AUTHORIZATION
PA applies
01/01/2014
QUELICIN
succinylcholine chloride
ADD UM: CUSTOM
Specialty Drug
01/01/2014
QUELICIN
succinylcholine chloride
ADD UM: AUTHORIZATION
PA applies
01/01/2014
QUTENZA
capsaicin/skin cleanser
ADD UM: CUSTOM
Specialty Drug
01/01/2014
QUTENZA
capsaicin/skin cleanser
ADD UM: AUTHORIZATION
PA applies
01/01/2014
RADIOGARDAS prussian blue (insoluble)
E
ADD TO FORMULARY
Non-Formulary
01/01/2014
RADIOGARDAS prussian blue (insoluble)
E
ADD UM: CUSTOM
Specialty Drug
01/01/2014
RADIOGARDAS prussian blue (insoluble)
E
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 212
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
copegus,rebetol,r ribavirin
ibavirin,virazole,ri
batab,ribasphere,
ribasphere
ribapak,moderiba
ADD UM: CUSTOM
Specialty Drug
01/01/2014
RELISTOR
methylnaltrexone bromide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
RELISTOR
methylnaltrexone bromide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
REMODULIN
treprostinil sodium
ADD UM: CUSTOM
Specialty Drug
01/01/2014
REMODULIN
treprostinil sodium
ADD UM: AUTHORIZATION
PA applies
01/01/2014
REVLIMID
lenalidomide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
REVLIMID
lenalidomide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
RHOGAM
rho(d) immune globulin
ULTRAFILTERED
PLUS,HYPERRH
O S-D
ADD TO FORMULARY
Preferred Brands
01/01/2014
RHOGAM
rho(d) immune globulin
ULTRAFILTERED
PLUS,HYPERRH
O S-D
ADD UM: CUSTOM
Specialty Drug
01/01/2014
RHOGAM
rho(d) immune globulin
ULTRAFILTERED
PLUS,HYPERRH
O S-D
ADD UM: AUTHORIZATION
PA applies
01/01/2014
rilutek,riluzole
riluzole
ADD TO FORMULARY
Preferred Brands
01/01/2014
rilutek,riluzole
riluzole
ADD UM: CUSTOM
Specialty Drug
01/01/2014
rilutek,riluzole
riluzole
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SABRIL
vigabatrin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SABRIL
vigabatrin
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 213
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
SAMSCA
tolvaptan
ADD TO FORMULARY
Preferred Brands
01/01/2014
SAMSCA
tolvaptan
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SAMSCA
tolvaptan
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SAMSCA
tolvaptan
ADD TO FORMULARY
Preferred Brands
01/01/2014
SAMSCA
tolvaptan
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SENSIPAR
cinacalcet hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SENSIPAR
cinacalcet hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SIGNIFOR
pasireotide diaspartate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SIGNIFOR
pasireotide diaspartate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SIMPONI,SIMPO golimumab
NI ARIA
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SIMPONI ARIA
golimumab
01/01/2014
SOMATULINE
DEPOT
lanreotide acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SOMATULINE
DEPOT
lanreotide acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SOMAVERT
pegvisomant
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SOMAVERT
pegvisomant
ADD UM: AUTHORIZATION
PA applies
01/01/2014
soriatane,acitretin acitretin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
soriatane,acitretin acitretin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
soriatane,acitretin acitretin
ADD TO FORMULARY
Preferred Brands
01/01/2014
soriatane,acitretin acitretin
ADD TO FORMULARY
Preferred Brands
01/01/2014
SPRYCEL
dasatinib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SPRYCEL
dasatinib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
STELARA
ustekinumab
ADD UM: CUSTOM
Specialty Drug
01/01/2014
STELARA
ustekinumab
ADD UM: AUTHORIZATION
PA applies
CHANGE TIER
Preferred Brands
Not Covered
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 214
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
STIVARGA
regorafenib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
STIVARGA
regorafenib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SUCRAID
sacrosidase
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SUCRAID
sacrosidase
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SURFAXIN
lucinactant
ADD TO FORMULARY
Non-Formulary
01/01/2014
SURFAXIN
lucinactant
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SURFAXIN
lucinactant
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SURVANTA
beractant
ADD TO FORMULARY
Non-Formulary
01/01/2014
SURVANTA
beractant
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SURVANTA
beractant
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SUTENT
sunitinib malate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SUTENT
sunitinib malate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SYNAGIS
palivizumab
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SYNRIBO
omacetaxine mepesuccinate
ADD TO FORMULARY
Non-Formulary
01/01/2014
SYNRIBO
omacetaxine mepesuccinate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SYNRIBO
omacetaxine mepesuccinate ADD UM: AUTHORIZATION
01/01/2014
SYNVISC
hylan g-f 20
ADD TO FORMULARY
Preferred Brands
01/01/2014
SYNVISC
hylan g-f 20
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SYNVISC
hylan g-f 20
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SYNVISC-ONE
hylan g-f 20
ADD TO FORMULARY
Preferred Brands
01/01/2014
SYNVISC-ONE
hylan g-f 20
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SYNVISC-ONE
hylan g-f 20
ADD UM: AUTHORIZATION
PA applies
01/01/2014
SYPRINE
trientine hcl
ADD TO FORMULARY
Preferred Brands
01/01/2014
SYPRINE
trientine hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
SYPRINE
trientine hcl
ADD UM: AUTHORIZATION
PA applies
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 215
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
TACHOSIL
fibrinogen/thrombin (human
plasma derived)
ADD TO FORMULARY
Preferred Brands
01/01/2014
TACHOSIL
fibrinogen/thrombin (human
plasma derived)
ADD UM: CUSTOM
Specialty Drug
01/01/2014
TACHOSIL
fibrinogen/thrombin (human ADD UM: AUTHORIZATION
plasma derived)
01/01/2014
TAFINLAR
dabrafenib mesylate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
TAFINLAR
dabrafenib mesylate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
TARCEVA
erlotinib hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
TARCEVA
erlotinib hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
TARGRETIN
bexarotene
ADD UM: CUSTOM
Specialty Drug
01/01/2014
TARGRETIN
bexarotene
ADD UM: AUTHORIZATION
PA applies
01/01/2014
TASIGNA
nilotinib hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
tecfidera,dimethyl dimethyl fumarate
fumarate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
tecfidera,dimethyl dimethyl fumarate
fumarate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
temodar,temozol temozolomide
omide
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
temodar,temozol temozolomide
omide
CHANGE TIER
Preferred Brands
Generics
01/01/2014
temodar,temozol temozolomide
omide
CHANGE TIER
Preferred Brands
Generics
01/01/2014
temodar,temozol temozolomide
omide
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
TEMODAR
temozolomide
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
temodar,temozol temozolomide
omide
CHANGE TIER
Generics
Non-Formulary
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 216
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
temodar,temozol temozolomide
omide
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
temodar,temozol temozolomide
omide
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
temodar,temozol temozolomide
omide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
temodar,temozol temozolomide
omide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
TESTRED,ANDR methyltestosterone
OID
ADD UM: CUSTOM
Specialty Drug
01/01/2014
TESTRED,ANDR methyltestosterone
OID
ADD UM: AUTHORIZATION
PA applies
01/01/2014
THALOMID
thalidomide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
THALOMID
thalidomide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
tobi,tobramycin
tobramycin in 0.225 %
sodium chloride
ADD TO FORMULARY
Non-Formulary
01/01/2014
TOBI
PODHALER
tobramycin
CHANGE TIER
01/01/2014
BETHKIS
tobramycin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
BETHKIS
tobramycin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
TRACLEER
bosentan
ADD UM: CUSTOM
Specialty Drug
01/01/2014
TRELSTAR
triptorelin pamoate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
TRELSTAR
triptorelin pamoate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
tretinoin
tretinoin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
tretinoin
tretinoin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
TYKERB
lapatinib ditosylate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
TYKERB
lapatinib ditosylate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
UVADEX
methoxsalen
ADD UM: CUSTOM
Specialty Drug
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 217
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
UVADEX
methoxsalen
01/01/2014
VELCADE
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
bortezomib
ADD TO FORMULARY
Preferred Brands
VELCADE
bortezomib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
VELCADE
bortezomib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
VENTAVIS
iloprost tromethamine
ADD TO FORMULARY
Preferred Brands
01/01/2014
VENTAVIS
iloprost tromethamine
ADD UM: CUSTOM
Specialty Drug
01/01/2014
VENTAVIS
iloprost tromethamine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
VENTAVIS
iloprost tromethamine
ADD TO FORMULARY
Preferred Brands
01/01/2014
VENTAVIS
iloprost tromethamine
ADD UM: CUSTOM
Specialty Drug
01/01/2014
VENTAVIS
iloprost tromethamine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
VICTRELIS
boceprevir
ADD UM: CUSTOM
Specialty Drug
01/01/2014
VICTRELIS
boceprevir
ADD UM: AUTHORIZATION
PA applies
01/01/2014
VOTRIENT
pazopanib hcl
ADD UM: CUSTOM
Specialty Drug
01/01/2014
VOTRIENT
pazopanib hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2014
WINRHO SDF
rho(d) immune
globulin/maltose
ADD UM: CUSTOM
Specialty Drug
01/01/2014
WINRHO SDF
rho(d) immune
globulin/maltose
ADD UM: AUTHORIZATION
PA applies
01/01/2014
WINRHO SDF
rho(d) immune
globulin/maltose
ADD TO FORMULARY
Preferred Brands
01/01/2014
WINRHO SDF
rho(d) immune
globulin/maltose
ADD TO FORMULARY
Preferred Brands
01/01/2014
WINRHO SDF
rho(d) immune
globulin/maltose
ADD TO FORMULARY
Preferred Brands
01/01/2014
WINRHO SDF
rho(d) immune
globulin/maltose
ADD TO FORMULARY
Preferred Brands
01/01/2014
XALKORI
crizotinib
ADD UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 218
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
XALKORI
crizotinib
01/01/2014
XELJANZ
01/01/2014
XELJANZ
01/01/2014
xeloda,capecitabi capecitabine
ne
01/01/2014
XENAZINE
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
tofacitinib citrate
ADD UM: CUSTOM
Specialty Drug
tofacitinib citrate
ADD UM: AUTHORIZATION
PA applies
ADD UM: CUSTOM
Specialty Drug
tetrabenazine
ADD TO FORMULARY
Non-Formulary
XENAZINE
tetrabenazine
ADD UM: CUSTOM
Specialty Drug
01/01/2014
XENAZINE
tetrabenazine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XENAZINE
tetrabenazine
ADD TO FORMULARY
Non-Formulary
01/01/2014
XENAZINE
tetrabenazine
ADD UM: CUSTOM
Specialty Drug
01/01/2014
XENAZINE
tetrabenazine
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XEOMIN
incobotulinumtoxina
ADD TO FORMULARY
Non-Formulary
01/01/2014
XEOMIN
incobotulinumtoxina
ADD UM: CUSTOM
Specialty Drug
01/01/2014
XEOMIN
incobotulinumtoxina
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XEOMIN
incobotulinumtoxina
ADD TO FORMULARY
Non-Formulary
01/01/2014
XEOMIN
incobotulinumtoxina
ADD UM: CUSTOM
Specialty Drug
01/01/2014
XEOMIN
incobotulinumtoxina
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XIAFLEX
collagenase clostridium
histolyticum
ADD UM: CUSTOM
Specialty Drug
01/01/2014
XIAFLEX
collagenase clostridium
histolyticum
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XIFAXAN
rifaximin
CHANGE TIER
Preferred Brands
01/01/2014
XIFAXAN
rifaximin
ADD UM: CUSTOM
Specialty Drug
01/01/2014
XIFAXAN
rifaximin
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XIFAXAN
rifaximin
ADD TO FORMULARY
Preferred Brands
01/01/2014
XIFAXAN
rifaximin
ADD UM: CUSTOM
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 219
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
XIFAXAN
rifaximin
01/01/2014
XOLAIR
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
omalizumab
ADD UM: CUSTOM
Specialty Drug
XOLAIR
omalizumab
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XTANDI
enzalutamide
ADD UM: CUSTOM
Specialty Drug
01/01/2014
XTANDI
enzalutamide
ADD UM: AUTHORIZATION
PA applies
01/01/2014
XYREM
sodium oxybate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
XYREM
sodium oxybate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZAVESCA
miglustat
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZAVESCA
miglustat
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZELBORAF
vemurafenib
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZELBORAF
vemurafenib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZELBORAF
vemurafenib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZOLADEX
goserelin acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZOLADEX
goserelin acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZOLADEX
goserelin acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZOLADEX
goserelin acetate
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZOLADEX
goserelin acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZOLADEX
goserelin acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZOLINZA
vorinostat
CHANGE TIER
01/01/2014
ZOLINZA
vorinostat
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZOLINZA
vorinostat
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZORTRESS
everolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZORTRESS
everolimus
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZORTRESS
everolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZORTRESS
everolimus
ADD UM: AUTHORIZATION
PA applies
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 220
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ZORTRESS
everolimus
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZORTRESS
everolimus
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZYCLARA
imiquimod
ADD TO FORMULARY
Preferred Brands
01/01/2014
ZYCLARA
imiquimod
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZYCLARA
imiquimod
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZYCLARA
imiquimod
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZYCLARA
imiquimod
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZYCLARA
imiquimod
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZYCLARA
imiquimod
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZYKADIA
ceritinib
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZYKADIA
ceritinib
ADD UM: AUTHORIZATION
PA applies
01/01/2014
ZYTIGA
abiraterone acetate
ADD UM: CUSTOM
Specialty Drug
01/01/2014
ZYTIGA
abiraterone acetate
ADD UM: AUTHORIZATION
PA applies
01/01/2014
INCIVEK
telaprevir
ADD UM: CUSTOM
Specialty Drug
01/01/2014
CORVITE FE
iron,carbonyl/ferrous asparto
glycinate/folic acid/mvmin27,iron,carbonyl/methylt
etrahydrofolate gluc,fa/mv,
min no.40
ADD UM: CUSTOM
Vitamin Rider
may be required
01/01/2014
CORVITE FE
iron,carbonyl/ferrous asparto
glycinate/folic acid/mvmin27,iron,carbonyl/methylt
etrahydrofolate gluc,fa/mv,
min no.40
REMOVE UM: GENDER
01/01/2014
CORVITE 150
iron,carbonyl/methyltetrahyd
rofolate gluc,fa/mv, min
no.41
ADD UM: CUSTOM
Vitamin Rider
may be required
01/01/2014
arixtra,fondaparin fondaparinux sodium
ux sodium
ADD UM: CUSTOM
Specialty Drug
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 221
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
arixtra,fondaparin fondaparinux sodium
ux sodium
01/01/2014
fluoritab
sodium fluoride
01/01/2014
AUBAGIO
01/01/2014
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
ADD UM: QUANTITY
50 / 30 days
teriflunomide
ADD UM: AUTHORIZATION
PA applies
AUBAGIO
teriflunomide
REMOVE UM: STEP
01/01/2014
breeze 2
blood-glucose meter, disctype
ADD TO FORMULARY
Preventative
01/01/2014
contour next ez
blood-glucose meter
ADD TO FORMULARY
Preventative
01/01/2014
ACTEMRA
tocilizumab
ADD UM: QUANTITY
4 / 28 days
01/01/2014
CIMZIA
certolizumab pegol
ADD UM: QUANTITY
1 / 28 days
01/01/2014
CIMZIA
certolizumab pegol
ADD UM: QUANTITY
1 / 180 days
01/01/2014
HUMIRA
adalimumab
CHANGE UM: QUANTITY
4 / 28 days
2 / 28 days
01/01/2014
HUMIRA
adalimumab
CHANGE UM: QUANTITY
4 / 28 days
2 / 28 days
01/01/2014
HUMIRA PEN
adalimumab
CHANGE UM: QUANTITY
4 / 28 days
2 / 28 days
01/01/2014
HUMIRA PEN
CROHN-UC-HS
STARTER
adalimumab
CHANGE UM: QUANTITY
4 / 28 days
1 / 180 days
01/01/2014
HUMIRA PEN
PSORIASISUVEITIS
adalimumab
CHANGE UM: QUANTITY
4 / 28 days
1 / 180 days
01/01/2014
KINERET
anakinra
ADD UM: QUANTITY
30 / 30 days
01/01/2014
ORENCIA
abatacept
ADD UM: QUANTITY
4 / 28 days
01/01/2014
SIMPONI
golimumab
ADD UM: QUANTITY
1 / 28 days
01/01/2014
SIMPONI
golimumab
ADD UM: QUANTITY
1 / 28 days
01/01/2014
SIMPONI
golimumab
ADD UM: QUANTITY
1 / 28 days
01/01/2014
SIMPONI
golimumab
ADD UM: QUANTITY
1 / 28 days
01/01/2014
STELARA
ustekinumab
ADD UM: QUANTITY
1 / 84 days
ST applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 222
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
STELARA
ustekinumab
ADD UM: QUANTITY
1 / 84 days
01/01/2014
XELJANZ
tofacitinib citrate
ADD UM: QUANTITY
60 / 30 days
01/01/2014
ENBREL
etanercept
REMOVE UM: CUSTOM
01/01/2014
ENBREL
etanercept
ADD UM: SPECIALTY
Specialty Drug
01/01/2014
depotestosterone cypionate
testosterone,test
osterone
cypionate
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
AVEED
testosterone undecanoate
ADD TO FORMULARY
Non-Formulary
01/01/2014
AVEED
testosterone undecanoate
ADD UM: CUSTOM
OTC Benefit
Rider REQUIRED
01/01/2014
OXYCONTIN
oxycodone hcl
CHANGE UM: QUANTITY
30 / 30 days
60 / 30 days
01/01/2014
OXYCONTIN
oxycodone hcl
CHANGE UM: QUANTITY
30 / 30 days
60 / 30 days
01/01/2014
OXYCONTIN
oxycodone hcl
CHANGE UM: QUANTITY
30 / 30 days
60 / 30 days
01/01/2014
etoposide,toposa etoposide
r
01/01/2014
MONOCLATE-P antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
KOATE-DVI
antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
CINRYZE
c1 esterase inhibitor
ADD TO FORMULARY
Non-Formulary
01/01/2014
MIRENA
levonorgestrel
ADD TO FORMULARY
Non-Formulary
01/01/2014
BCG (TICE
STRAIN)
bcg live
ADD TO FORMULARY
Non-Formulary
01/01/2014
ZEMPLAR
paricalcitol
01/01/2014
hectorol,doxercal doxercalciferol
ciferol
CHANGE TIER
01/01/2014
revonto,dantrium dantrolene sodium
CHANGE TIER
Specialty Drug
ADD TO FORMULARY
CHANGE TIER
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 223
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
agalsidase beta
Type of Change
Previous Value
New Value
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
FABRAZYME
01/01/2014
zometa,zoledroni zoledronic acid
c acid
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALDURAZYME
laronidase
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ondansetron
hcl,zofran
ondansetron hcl
CHANGE TIER
01/01/2014
GAMUNEX
immune
globulin,gamm(igg)/glycine/i
ga greater than 50 mcg/ml
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALPHANINE SD factor ix
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
FABRAZYME
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
hycamtin,topotec topotecan hcl
an hcl
ADD TO FORMULARY
Non-Formulary
01/01/2014
EDEX
alprostadil
ADD TO FORMULARY
Preferred Brands
01/01/2014
HECTOROL
doxercalciferol
ADD TO FORMULARY
Non-Formulary
01/01/2014
VANTAS
histrelin acetate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
TYSABRI
natalizumab
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
FEIBA VH
anti-inhibitor coagulant
IMMUNO,FEIBA complex
NF
CHANGE TIER
01/01/2014
FEIBA NF
anti-inhibitor coagulant
complex
CHANGE TIER
01/01/2014
KOGENATE
FS,HELIXATE
FS,RECOMBINA
TE
antihemophilic factor (fviii)
recomb,full length (albfree),antihemophilic factor
viii, human recombinant
ADD TO FORMULARY
Non-Formulary
01/01/2014
KOGENATE
FS,HELIXATE
FS,RECOMBINA
TE
antihemophilic factor (fviii)
recomb,full length (albfree),antihemophilic factor
viii, human recombinant
ADD TO FORMULARY
Non-Formulary
agalsidase beta
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 224
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
KOGENATE
FS,HELIXATE
FS,RECOMBINA
TE
antihemophilic factor (fviii)
recomb,full length (albfree),antihemophilic factor
viii, human recombinant
01/01/2014
KOATE-DVI
antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
KOATE-DVI
antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
PROFILNINE
factor ix complex,
prothrombin cplx conc(pcc)
no.4, 3-factor
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
PROFILNINE
factor ix complex,
prothrombin cplx conc(pcc)
no.4, 3-factor
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
BEBULIN VH
factor ix complex,
IMMUNO,BEBUL prothrombin complex conc.
IN
(pcc) comb. 6,factor ix
complex, prothrombin cplx
conc(pcc) no.6, 3-factor
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
PROFILNINE
factor ix complex,
prothrombin cplx conc(pcc)
no.4, 3-factor
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
KOATE-DVI
antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
BENEFIX
factor ix human recombinant
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
BENEFIX
factor ix human recombinant
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
BENEFIX
factor ix human recombinant
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
cleocin
clindamycin phosphate
phosphate,clinda
mycin phosphate
ADD TO FORMULARY
Non-Formulary
01/01/2014
ceftriaxone
ADD TO FORMULARY
Non-Formulary
ceftriaxone sodium
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 225
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
ADD TO FORMULARY
Previous Value
New Value
01/01/2014
ampicillinsulbactam
ampicillin sodium/sulbactam
sodium
Non-Formulary
01/01/2014
ORENCIA
abatacept/maltose
CHANGE TIER
Not Covered
Non-Formulary
01/01/2014
FEIBA NF
anti-inhibitor coagulant
complex
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
boniva,ibandrona ibandronate sodium
te sodium
CHANGE TIER
01/01/2014
HUMATE-P
antihemophilic factor,
human/von willebrand
factor,human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
HUMATE-P
antihemophilic factor,
human/von willebrand
factor,human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
HUMATE-P
antihemophilic factor,
human/von willebrand
factor,human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
heparin sodium in heparin sodium,porcine in
0.45% nacl
0.45 % sodium chloride
CHANGE TIER
Generics
Non-Formulary
01/01/2014
heparin sodium in heparin sodium,porcine in
0.45% nacl
0.45 % sodium chloride
CHANGE TIER
Generics
Non-Formulary
01/01/2014
heparin sodium in heparin sodium,porcine in
0.45% nacl
0.45 % sodium chloride
CHANGE TIER
Generics
Non-Formulary
01/01/2014
HEMOFIL M
antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
HEMOFIL M
antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
KOGENATE
FS,HELIXATE
FS,RECOMBINA
TE
antihemophilic factor (fviii)
recomb,full length (albfree),antihemophilic factor
viii, human recombinant
Non-Formulary
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 226
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
MYOZYME,LUMI alglucosidase alfa
ZYME
CHANGE TIER
Non-Formulary
01/01/2014
ZYVOX
linezolid
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ZYVOX
linezolid
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ACTEMRA
tocilizumab
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ACTEMRA
tocilizumab
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ACTEMRA
tocilizumab
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
FLUORESCITE,
AK-FLUOR
fluorescein sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
AK-FLUOR
fluorescein sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
ARZERRA
ofatumumab
ADD TO FORMULARY
Non-Formulary
01/01/2014
WILATE
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Non-Formulary
01/01/2014
WILATE
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 227
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
PROVENGE
sipuleucel-t/lactated ringers
solution
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NOVOSEVEN
RT
coagulation factor viia
(recombinant)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
topotecan hcl
topotecan hcl
01/01/2014
argatroban-0.9% argatroban in 0.9 % sodium
nacl
chloride
01/01/2014
azithromycin
azithromycin
CHANGE TIER
01/01/2014
ARZERRA
ofatumumab
ADD TO FORMULARY
Non-Formulary
01/01/2014
WILATE
antihemophilic factor,
human/von willebrand
factor,human
ADD TO FORMULARY
Non-Formulary
01/01/2014
HEMOFIL M
antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
HEMOFIL M
antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ADCETRIS
brentuximab vedotin
ADD TO FORMULARY
01/01/2014
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
EYLEA
aflibercept
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
BENEFIX
factor ix human recombinant
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
BERINERT
c1 esterase inhibitor
ADD TO FORMULARY
Non-Formulary
ADD TO FORMULARY
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 228
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
provisc
hyaluronate sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
AMVISC
hyaluronate sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
AMVISC PLUS
hyaluronate sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
BERINERT
c1 esterase inhibitor
ADD TO FORMULARY
Non-Formulary
01/01/2014
euflexxa,hyalgan, hyaluronate sodium
supartz
ADD TO FORMULARY
Non-Formulary
01/01/2014
HYALGAN
hyaluronate sodium
ADD TO FORMULARY
Non-Formulary
01/01/2014
ADVATE
antihemophilic factor (fviii)
recomb,full length (alb-free)
01/01/2014
DEXFERRUM
iron dextran complex
ADD TO FORMULARY
Non-Formulary
01/01/2014
DEXFERRUM
iron dextran complex
ADD TO FORMULARY
Non-Formulary
01/01/2014
KADCYLA
ado-trastuzumab emtansine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
KADCYLA
ado-trastuzumab emtansine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
RIXUBIS
factor ix human recombinant
ADD TO FORMULARY
Non-Formulary
01/01/2014
RIXUBIS
factor ix human recombinant
ADD TO FORMULARY
Non-Formulary
01/01/2014
RIXUBIS
factor ix human recombinant
ADD TO FORMULARY
Non-Formulary
01/01/2014
RIXUBIS
factor ix human recombinant
ADD TO FORMULARY
Non-Formulary
01/01/2014
RIXUBIS
factor ix human recombinant
ADD TO FORMULARY
Non-Formulary
01/01/2014
SIMPONI ARIA
golimumab
CHANGE TIER
Not Covered
Non-Formulary
01/01/2014
ALPROLIX
factor ix recombinant, fc
fusion protein
CHANGE TIER
Preferred Brands
Non-Formulary
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 229
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ALPROLIX
factor ix recombinant, fc
fusion protein
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALPROLIX
factor ix recombinant, fc
fusion protein
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALPROLIX
factor ix recombinant, fc
fusion protein
ADD TO FORMULARY
01/01/2014
MONOVISC
hyaluronate sodium,
stabilized
01/01/2014
ELOCTATE
antihemophilic factor (fviii)
recombinant, fc fusion
protein
ADD TO FORMULARY
Non-Formulary
01/01/2014
ELOCTATE
antihemophilic factor (fviii)
recombinant, fc fusion
protein
ADD TO FORMULARY
Non-Formulary
01/01/2014
ELOCTATE
antihemophilic factor (fviii)
recombinant, fc fusion
protein
ADD TO FORMULARY
Non-Formulary
01/01/2014
ELOCTATE
antihemophilic factor (fviii)
recombinant, fc fusion
protein
ADD TO FORMULARY
Non-Formulary
01/01/2014
ELOCTATE
antihemophilic factor (fviii)
recombinant, fc fusion
protein
ADD TO FORMULARY
Non-Formulary
01/01/2014
ELOCTATE
antihemophilic factor (fviii)
recombinant, fc fusion
protein
ADD TO FORMULARY
Non-Formulary
01/01/2014
ELOCTATE
antihemophilic factor (fviii)
recombinant, fc fusion
protein
ADD TO FORMULARY
Non-Formulary
01/01/2014
ATRYN
antithrombin iii, human
recombinant
ADD TO FORMULARY
Non-Formulary
CHANGE TIER
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 230
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2014
ALPHANATE
antihemophilic factor,
human/von willebrand
factor,human
01/01/2014
alkeran,melphala melphalan hcl
n hcl
01/01/2014
mesnex,mesna
01/01/2014
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Non-Formulary
CHANGE TIER
Non-Formulary
mesna
ADD TO FORMULARY
Non-Formulary
flebogamma
dif,gammaplex
immune globulin,gamma
(igg)/sorbitol/iga 0 to 50
mcg/ml,immune
globulin,gamm(igg)/sorbitol/
glycin/iga 0 to 50 mcg/ml
ADD TO FORMULARY
Non-Formulary
01/01/2014
carimune nf
nanofiltered
immune
globulin,gamm(igg)/sucrose/
iga greater than 50 mcg/ml
ADD TO FORMULARY
Non-Formulary
01/01/2014
carimune nf
nanofiltered
immune
globulin,gamm(igg)/sucrose/
iga greater than 50 mcg/ml
ADD TO FORMULARY
Non-Formulary
01/01/2014
GAMMAGARD S- immune
D
globulin,gamm(igg)/glycine/g
lucose/iga 0 to 50 mcg/ml
ADD TO FORMULARY
Non-Formulary
01/01/2014
GAMMAGARD S- immune
D
globulin,gamm(igg)/glycine/g
lucose/iga 0 to 50 mcg/ml
ADD TO FORMULARY
Non-Formulary
01/01/2014
GAMMAGARD S- immune
D
globulin,gamm(igg)/glycine/g
lucose/iga 0 to 50 mcg/ml
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 231
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
gammagard
liquid,privigen,bivi
gam,flebogamma
dif
immune
globulin,gamm(igg)/glycine/i
ga greater than 50
mcg/ml,immune
globulin,gamma
(igg)/proline/iga 0 to 50
mcg/ml,immune
globul,gamma(igg)/sorbitol/i
ga greater than 50 mcg/ml
ADD TO FORMULARY
Non-Formulary
01/01/2014
carimune nf
nanofiltered
immune
globulin,gamm(igg)/sucrose/
iga greater than 50 mcg/ml
ADD TO FORMULARY
Non-Formulary
01/01/2014
CELLCEPT
mycophenolate mofetil hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ZEMPLAR
paricalcitol
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
zithromax,azithro azithromycin
mycin
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
levocarnitine,carn levocarnitine
itor
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
MONOCLATE-P antihemophilic factor,
human
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALPHANINE SD factor ix
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ALPHANINE SD factor ix
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
calcitriol
calcitriol
ADD TO FORMULARY
Non-Formulary
01/01/2014
lidocaine hcl
lidocaine hcl/pf
ADD TO FORMULARY
Non-Formulary
01/01/2014
sandimmune,cycl cyclosporine
osporine
CHANGE TIER
Non-Formulary
01/01/2014
BENEFIX
factor ix human recombinant
CHANGE TIER
01/01/2014
KOGENATE
FS,HELIXATE
FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
ADD TO FORMULARY
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 232
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
ADVATE
UH,ADVATE
antihemophilic factor (fviii)
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ADVATE,ADVAT antihemophilic factor (fviii)
E SH
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ADVATE,ADVAT antihemophilic factor (fviii)
EM
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ADVATE,ADVAT antihemophilic factor (fviii)
EH
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ADVATE,ADVAT antihemophilic factor (fviii)
EL
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
ADVATE
antihemophilic factor (fviii)
recomb,full length (alb-free)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NOVOSEVEN
RT
coagulation factor viia
(recombinant)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NOVOSEVEN
RT
coagulation factor viia
(recombinant)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
NOVOSEVEN
RT
coagulation factor viia
(recombinant)
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XYNTHA
antihemophilic factor (factor
viii) recomb,b-domain
deleted
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XYNTHA
antihemophilic factor (factor
viii) recomb,b-domain
deleted
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XYNTHA
antihemophilic factor (factor
viii) recomb,b-domain
deleted
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
XYNTHA
antihemophilic factor (factor
viii) recomb,b-domain
deleted
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 233
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
VIAGRA
sildenafil citrate
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
VIAGRA
sildenafil citrate
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
VIAGRA
sildenafil citrate
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
CIALIS
tadalafil
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
CIALIS
tadalafil
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
LEVITRA
vardenafil hcl
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
LEVITRA
vardenafil hcl
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
LEVITRA
vardenafil hcl
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
LEVITRA
vardenafil hcl
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
prostin vr
alprostadil
pediatric,caverjec
t,muse,alprostadil
,edex,prostaglan
din e1
ADD UM: CUSTOM
Benefit Rider
REQUIRED
01/01/2014
VIAGRA
sildenafil citrate
ADD UM: GENDER
Male
01/01/2014
VIAGRA
sildenafil citrate
ADD UM: GENDER
Male
01/01/2014
VIAGRA
sildenafil citrate
ADD UM: GENDER
Male
01/01/2014
QNASL
beclomethasone
dipropionate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
COREG CR
carvedilol phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
COREG CR
carvedilol phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 234
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2014
COREG CR
carvedilol phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2014
COREG CR
carvedilol phosphate
CHANGE TIER
Preferred Brands
Not Covered
01/01/2014
arava,leflunomide leflunomide
ADD UM: SPECIALTY
Specialty Drug
01/01/2014
leflunomide
leflunomide
ADD TO FORMULARY
Generics
01/01/2014
leflunomide
leflunomide
ADD TO FORMULARY
Generics
01/01/2014
APRISO
mesalamine
CHANGE TIER
01/01/2015
REGIMEX
benzphetamine hcl
01/01/2015
BELVIQ
lorcaserin hcl
01/01/2015
QSYMIA
01/01/2015
Preferred Brands
Non-Formulary
ADD UM: AUTHORIZATION
PA applies
ADD UM: CUSTOM
Anorexiant Rider
May be required
phentermine hcl/topiramate
ADD UM: AUTHORIZATION
PA applies
phentermine
hcl,suprenza
odt,adipex-p
phentermine hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2015
BELVIQ
lorcaserin hcl
ADD UM: AUTHORIZATION
PA applies
01/01/2015
AURYXIA
ferric citrate
CHANGE TIER
01/01/2015
TAMIFLU
oseltamivir phosphate
CHANGE TIER
Preferred Brands
01/01/2015
TAMIFLU
oseltamivir phosphate
CHANGE TIER
Preferred Brands
01/01/2015
microurine albumin test
bumintest,albusti
x
reagent,chemstri
p micral
CHANGE TIER
Non-Formulary
01/01/2015
LESCOL
fluvastatin sodium
ADD TO FORMULARY
Non-Formulary
01/01/2015
digitek
digoxin
ADD TO FORMULARY
01/01/2015
aspirin ec
aspirin
CHANGE TIER
Preventative
01/01/2015
aspirin ec
aspirin
CHANGE UM: QUANTITY
30 / 30 days
01/01/2015
aspirin ec
aspirin
CHANGE UM: AGE
45 to 79 yrs old
Generics
Non-Formulary
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 235
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Non-Formulary
Generics
01/01/2015
digitek
digoxin
01/01/2015
theophylline
theophylline anhydrous
CHANGE TIER
Generics
01/01/2015
theophylline
theophylline anhydrous
CHANGE TIER
Generics
01/01/2015
URSO
ursodiol
ADD TO FORMULARY
Non-Formulary
01/01/2015
nitroglycerin
patch
nitroglycerin
ADD TO FORMULARY
Generics
01/01/2015
NITRO-DUR
nitroglycerin
ADD TO FORMULARY
Non-Formulary
01/01/2015
CARDENE SR
nicardipine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
PROCARDIA XL nifedipine
ADD TO FORMULARY
Non-Formulary
01/01/2015
PROCARDIA
nifedipine
ADD TO FORMULARY
Non-Formulary
01/01/2015
ANTABUSE
disulfiram
ADD TO FORMULARY
Non-Formulary
01/01/2015
nicoderm cq
nicotine
ADD TO FORMULARY
Preventative
01/01/2015
nicoderm cq
nicotine
ADD TO FORMULARY
Preventative
01/01/2015
k-sol
potassium chloride
ADD TO FORMULARY
Generics
01/01/2015
PRILOSEC
omeprazole
ADD TO FORMULARY
Non-Formulary
01/01/2015
ELOCON
mometasone furoate
ADD TO FORMULARY
Non-Formulary
01/01/2015
CARAFATE
sucralfate
ADD TO FORMULARY
Non-Formulary
01/01/2015
DIOVAN HCT
valsartan/hydrochlorothiazid
e
ADD TO FORMULARY
Non-Formulary
01/01/2015
CARAFATE
sucralfate
ADD TO FORMULARY
Non-Formulary
01/01/2015
anti-diarrheal
loperamide hcl
CHANGE TIER
Generics
01/01/2015
BILTRICIDE
praziquantel
ADD TO FORMULARY
Non-Formulary
01/01/2015
trospium chloride trospium chloride
CHANGE TIER
Generics
01/01/2015
DIOVAN HCT
valsartan/hydrochlorothiazid
e
ADD TO FORMULARY
Non-Formulary
01/01/2015
DDAVP
desmopressin acetate
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 236
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
REMOVE FROM
FORMULARY
Not Covered
Non-Formulary
01/01/2015
added strength
pain reliever
aspirin/acetaminophen/caffei
ne
01/01/2015
CORDARONE
amiodarone hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
PACERONE
amiodarone hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
OVCON-35
norethindrone-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
01/01/2015
HUMULIN R
insulin regular, human
ADD TO FORMULARY
Preferred Brands
01/01/2015
HUMULIN R
insulin regular, human
ADD TO FORMULARY
Preferred Brands
01/01/2015
sensorcaine
bupivacaine hcl
ADD TO FORMULARY
01/01/2015
MICARDIS HCT
telmisartan/hydrochlorothiazi
de
ADD TO FORMULARY
Non-Formulary
01/01/2015
MICARDIS HCT
telmisartan/hydrochlorothiazi
de
ADD TO FORMULARY
Non-Formulary
01/01/2015
nateglinide
nateglinide
CHANGE TIER
Generics
01/01/2015
STARLIX
nateglinide
ADD TO FORMULARY
Non-Formulary
01/01/2015
VANIQA
eflornithine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
PACERONE
amiodarone hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
REMERON
mirtazapine
ADD TO FORMULARY
Non-Formulary
01/01/2015
mirtazapine
mirtazapine
ADD TO FORMULARY
Generics
01/01/2015
mirtazapine
mirtazapine
ADD TO FORMULARY
Generics
01/01/2015
REMERON
mirtazapine
ADD TO FORMULARY
Non-Formulary
01/01/2015
LOPROX
ciclopirox
ADD TO FORMULARY
Non-Formulary
01/01/2015
EVOXAC
cevimeline hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
desloratadine
desloratadine
CHANGE TIER
Generics
01/01/2015
NEXIUM
esomeprazole magnesium
ADD TO FORMULARY
Non-Formulary
01/01/2015
NEXIUM 24HR
esomeprazole magnesium
ADD TO FORMULARY
Not Covered
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 237
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2015
NEXIUM 24HR
esomeprazole magnesium
01/01/2015
fluoxetine dr
01/01/2015
Type of Change
Previous Value
New Value
ADD UM: CUSTOM
OTC Not
Covered
fluoxetine hcl
CHANGE TIER
Generics
PROZAC
WEEKLY
fluoxetine hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
TOPROL XL
metoprolol succinate
ADD TO FORMULARY
Non-Formulary
01/01/2015
mirtazapine
mirtazapine
ADD TO FORMULARY
Generics
01/01/2015
REMERON
mirtazapine
ADD TO FORMULARY
Non-Formulary
01/01/2015
zarah
ethinyl
estradiol/drospirenone
ADD TO FORMULARY
Non-Formulary
Preventative
01/01/2015
syeda
ethinyl
estradiol/drospirenone
ADD TO FORMULARY
Non-Formulary
Preventative
01/01/2015
drospirenoneethinyl estradiol
ethinyl
estradiol/drospirenone
ADD TO FORMULARY
Non-Formulary
Preventative
01/01/2015
VOLTAREN-XR
diclofenac sodium
ADD TO FORMULARY
Non-Formulary
01/01/2015
GEODON
ziprasidone hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
GEODON
ziprasidone hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
GEODON
ziprasidone hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
bpo
benzoyl peroxide
ADD TO FORMULARY
Generics
01/01/2015
ipratropiumalbuterol
ipratropium
bromide/albuterol sulfate
CHANGE TIER
Generics
01/01/2015
VALTREX
valacyclovir hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
VALTREX
valacyclovir hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
ACEON
perindopril erbumine
ADD TO FORMULARY
Non-Formulary
01/01/2015
TACLONEX
calcipotriene/betamethason
e dipropionate
ADD TO FORMULARY
Non-Formulary
01/01/2015
RESTORIL
temazepam
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 238
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Non-Formulary
Generics
01/01/2015
temazepam
temazepam
ADD TO FORMULARY
01/01/2015
allergy d-12
cetirizine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Generics
01/01/2015
allergy d-12
cetirizine
hcl/pseudoephedrine hcl
ADD UM: CUSTOM
OTC Rider May
Be Required
01/01/2015
cetirizinecetirizine
pseudoephedrine hcl/pseudoephedrine hcl
er
ADD TO FORMULARY
01/01/2015
cetirizinecetirizine
pseudoephedrine hcl/pseudoephedrine hcl
er
ADD UM: CUSTOM
OTC Rider may
be required
01/01/2015
all day allergy-d
cetirizine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Generics
01/01/2015
all day allergy-d
cetirizine
hcl/pseudoephedrine hcl
ADD UM: CUSTOM
OTC Rider may
be required
01/01/2015
aller-tec d
cetirizine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Generics
01/01/2015
aller-tec d
cetirizine
hcl/pseudoephedrine hcl
ADD UM: CUSTOM
OTC Rider may
be required
01/01/2015
wal-zyr d
cetirizine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Generics
01/01/2015
wal-zyr d
cetirizine
hcl/pseudoephedrine hcl
ADD UM: CUSTOM
OTC Rider may
be required
01/01/2015
allergy relief-d
cetirizine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Generics
01/01/2015
allergy relief-d
cetirizine
hcl/pseudoephedrine hcl
ADD UM: CUSTOM
OTC Rider may
be required
01/01/2015
allergy-d
cetirizine
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Generics
01/01/2015
allergy-d
cetirizine
hcl/pseudoephedrine hcl
ADD UM: CUSTOM
OTC Rider may
be required
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 239
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2015
allergy complete- cetirizine
d
hcl/pseudoephedrine hcl
ADD TO FORMULARY
Generics
01/01/2015
allergy complete- cetirizine
d
hcl/pseudoephedrine hcl
ADD UM: CUSTOM
OTC Rider may
be required
01/01/2015
SANDIMMUNE
cyclosporine
ADD TO FORMULARY
Non-Formulary
01/01/2015
SANDIMMUNE
cyclosporine
ADD TO FORMULARY
Non-Formulary
01/01/2015
NEORAL
cyclosporine, modified
ADD TO FORMULARY
Non-Formulary
01/01/2015
NEORAL
cyclosporine, modified
ADD TO FORMULARY
Non-Formulary
01/01/2015
NEORAL
cyclosporine, modified
ADD TO FORMULARY
Non-Formulary
01/01/2015
potassium citrate- potassium citrate/citric acid
citric acid
ADD TO FORMULARY
01/01/2015
potass cit-sod cit- sodium/potassium/potassiu
citric acid
m citrate/sodium citrate/cit
ac
ADD TO FORMULARY
Generics
01/01/2015
virtrate-3
sodium/potassium/potassiu
m citrate/sodium citrate/cit
ac
ADD TO FORMULARY
Generics
01/01/2015
potassium citrate- potassium citrate/citric acid
citric acid
ADD TO FORMULARY
Generics
01/01/2015
FAMVIR
famciclovir
ADD TO FORMULARY
Non-Formulary
01/01/2015
FAMVIR
famciclovir
ADD TO FORMULARY
Non-Formulary
01/01/2015
REBETOL
ribavirin
ADD TO FORMULARY
Non-Formulary
01/01/2015
QUESTRAN
cholestyramine (with sugar)
ADD TO FORMULARY
Non-Formulary
01/01/2015
KEPPRA XR
levetiracetam
ADD TO FORMULARY
Non-Formulary
01/01/2015
virt-care one
prenatal vit with calcium
no.37/iron,aspg/folic
acid/omega-3
ADD TO FORMULARY
Generics
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 240
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/01/2015
virt-care one
prenatal vit with calcium
no.37/iron,aspg/folic
acid/omega-3
01/01/2015
VIDEX EC
01/01/2015
Type of Change
Previous Value
New Value
ADD UM: GENDER
Female
didanosine
ADD TO FORMULARY
Non-Formulary
VIDEX EC
didanosine
ADD TO FORMULARY
Non-Formulary
01/01/2015
VIDEX EC
didanosine
ADD TO FORMULARY
Non-Formulary
01/01/2015
VIDEX EC
didanosine
ADD TO FORMULARY
Non-Formulary
01/01/2015
albuterol sulfate
albuterol sulfate
CHANGE TIER
Generics
01/01/2015
albuterol sulfate
albuterol sulfate
CHANGE TIER
Generics
01/01/2015
ADDERALL XR
dextroamphetamine sulfsaccharate/amphetamine
sulf-aspartate
ADD TO FORMULARY
Non-Formulary
01/01/2015
ADDERALL XR
dextroamphetamine sulfsaccharate/amphetamine
sulf-aspartate
ADD TO FORMULARY
Non-Formulary
01/01/2015
ADDERALL XR
dextroamphetamine sulfsaccharate/amphetamine
sulf-aspartate
ADD TO FORMULARY
Non-Formulary
01/01/2015
nicotine lozenge
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2015
nicorelief
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2015
quit 4
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2015
nicotine
nicotine polacrilex
lozenge,nicorette,
nicorelief,stop
smoking aid,quit
2
CHANGE TIER
Generics
01/01/2015
NICORETTE
nicotine polacrilex
REMOVE FROM
FORMULARY
Non-Formulary
01/01/2015
nicorelief
nicotine polacrilex
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 241
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2015
quit 2
nicotine polacrilex
ADD TO FORMULARY
Preventative
01/01/2015
COZAAR
losartan potassium
ADD TO FORMULARY
Non-Formulary
01/01/2015
COZAAR
losartan potassium
ADD TO FORMULARY
Non-Formulary
01/01/2015
HYZAAR
losartan
potassium/hydrochlorothiazi
de
ADD TO FORMULARY
Non-Formulary
01/01/2015
COZAAR
losartan potassium
ADD TO FORMULARY
Non-Formulary
01/01/2015
HYZAAR
losartan
potassium/hydrochlorothiazi
de
ADD TO FORMULARY
Non-Formulary
01/01/2015
promethazine hcl promethazine hcl
ADD TO FORMULARY
01/01/2015
ZYPREXA
olanzapine
ADD TO FORMULARY
Non-Formulary
01/01/2015
ZYPREXA
olanzapine
ADD TO FORMULARY
Non-Formulary
01/01/2015
PRAVACHOL
pravastatin sodium
ADD TO FORMULARY
Non-Formulary
01/01/2015
URAMAXIN
urea
ADD TO FORMULARY
Non-Formulary
01/01/2015
levalbuterol hcl
levalbuterol hcl
CHANGE TIER
Generics
01/01/2015
UNIRETIC
moexipril
hcl/hydrochlorothiazide
ADD TO FORMULARY
Non-Formulary
01/01/2015
RITALIN
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
RITALIN
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
RITALIN
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
01/01/2015
DILAUDID
hydromorphone hcl/pf
ADD TO FORMULARY
Non-Formulary
01/01/2015
DILAUDID
hydromorphone hcl/pf
ADD TO FORMULARY
Non-Formulary
01/01/2015
DILAUDID
hydromorphone hcl/pf
ADD TO FORMULARY
Non-Formulary
01/01/2015
TRILIPIX
fenofibric acid (choline)
ADD TO FORMULARY
Non-Formulary
01/01/2015
TRILIPIX
fenofibric acid (choline)
ADD TO FORMULARY
Non-Formulary
01/01/2015
DILAUDID
hydromorphone hcl
ADD TO FORMULARY
Non-Formulary
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 242
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2015
DILAUDID
hydromorphone hcl
ADD TO FORMULARY
01/01/2015
OLYSIO
simeprevir sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2015
SOVALDI
sofosbuvir
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2015
STRIBILD
elvitegravir/cobicistat/emtrici REMOVE UM: SPECIALTY
tabine/tenofovir disoproxil
01/01/2016
VIEKIRA PAK
ombitasvir/paritaprevir/ritona
vir/dasabuvir sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
OLYSIO
simeprevir sodium
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
INCRUSE
ELLIPTA
umeclidinium bromide
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
DAKLINZA
daclatasvir dihydrochloride
ADD UM: SPECIALTY
Specialty Drug
01/01/2016
ENVARSUS XR
tacrolimus
ADD UM: SPECIALTY
Specialty Drug
01/01/2016
ENVARSUS XR
tacrolimus
ADD UM: SPECIALTY
Specialty Drug
01/01/2016
ENVARSUS XR
tacrolimus
ADD UM: SPECIALTY
Specialty Drug
01/01/2016
ENVARSUS XR
tacrolimus
ADD UM: QUANTITY
30 / 30 days
01/01/2016
ENVARSUS XR
tacrolimus
ADD UM: QUANTITY
1 / 1 days
01/01/2016
ENVARSUS XR
tacrolimus
ADD UM: QUANTITY
1 / 1 days
01/01/2016
ENVARSUS XR
tacrolimus
ADD UM: QUANTITY
1 / 1 days
01/01/2016
ODOMZO
sonidegib phosphate
ADD UM: QUANTITY
1 / 1 days
01/01/2016
DAKLINZA
daclatasvir dihydrochloride
ADD UM: QUANTITY
1 / 1 days
01/01/2016
DAKLINZA
daclatasvir dihydrochloride
ADD UM: QUANTITY
1 / 1 days
01/01/2016
TECHNIVIE
ombitasvir/paritaprevir/ritona
vir
ADD UM: QUANTITY
56 / 30 days
01/01/2016
ENTRESTO
sacubitril/valsartan
01/01/2016
REXULTI
brexpiprazole
01/01/2016
APTENSIO XR
methylphenidate hcl
CHANGE UM: QUANTITY
Non-Formulary
30 / 30 days
ADD UM: QUANTITY
CHANGE UM: QUANTITY
2 / 1 days
1 / 1 days
30 / 30 days
6 / 1 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 243
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2016
APTENSIO XR
methylphenidate hcl
CHANGE UM: QUANTITY
30 / 30 days
4 / 1 days
01/01/2016
APTENSIO XR
methylphenidate hcl
CHANGE UM: QUANTITY
30 / 30 days
3 / 1 days
01/01/2016
APTENSIO XR
methylphenidate hcl
CHANGE UM: QUANTITY
30 / 30 days
2 / 1 days
01/01/2016
APTENSIO XR
methylphenidate hcl
CHANGE UM: QUANTITY
30 / 30 days
1 / 1 days
01/01/2016
APTENSIO XR
methylphenidate hcl
CHANGE UM: QUANTITY
30 / 30 days
1 / 1 days
01/01/2016
APTENSIO XR
methylphenidate hcl
CHANGE UM: QUANTITY
30 / 30 days
1 / 1 days
01/01/2016
APTENSIO XR
methylphenidate hcl
ADD UM: CUSTOM
Max. 60mg per
day
01/01/2016
NATESTO
testosterone
ADD UM: QUANTITY
3 / 1 days
01/01/2016
NATESTO
testosterone
ADD UM: CUSTOM
Max. 3 pumps
per day
01/01/2016
VIBERZI
eluxadoline
ADD UM: QUANTITY
2 / 1 days
01/01/2016
REPATHA
SURECLICK
evolocumab
ADD UM: QUANTITY
0.07 / 1 days
01/01/2016
REPATHA
SYRINGE
evolocumab
ADD UM: QUANTITY
0.07 / 1 days
01/01/2016
PRALUENT PEN alirocumab
ADD UM: QUANTITY
0.07 / 1 days
01/01/2016
PRALUENT
SYRINGE
alirocumab
ADD UM: QUANTITY
0.07 / 1 days
01/01/2016
PROAIR
RESPICLICK
albuterol sulfate
ADD UM: QUANTITY
0.067 / 1 days
01/01/2016
INCRUSE
ELLIPTA
umeclidinium bromide
ADD UM: QUANTITY
1 / 1 days
01/01/2016
PULMICORT
budesonide
CHANGE UM: QUANTITY
120 / 30 days
01/01/2016
accu-chek
compact
blood sugar diagnostic,
drum-type
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
accu-chek
compact plus
blood sugar diagnostic,
drum-type
ADD TO FORMULARY
Non-Formulary
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 244
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2016
accu-chek
comfort curve
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
accu-chek aviva
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
accu-chek aviva
plus
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
accu-chek
smartview
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
accu-chek active blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ORKAMBI
lumacaftor/ivacaftor
REMOVE UM:
AUTHORIZATION
PA applies
01/01/2016
glucose test
strip,blood
glucose
test,premium
blood glucose
test,blood
glucose test
strip,test strips
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
01/01/2016
glucose test
strip,blood
glucose
test,premium
blood glucose
test,blood
glucose test
strip,test strips
blood sugar diagnostic
CHANGE UM: QUANTITY
100 / 30 days
01/01/2016
clever choice talk blood sugar diagnostic
REMOVE UM: GENDER
01/01/2016
true metrix
blood sugar diagnostic
glucose test strip
ADD TO FORMULARY
Non-Formulary
01/01/2016
true metrix
blood sugar diagnostic
glucose test strip
ADD UM: QUANTITY
100 / 3 days
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 245
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2016
fortiscare glucose blood sugar diagnostic
test strips
ADD UM: QUANTITY
100 / 30 days
01/01/2016
fortiscare glucose blood sugar diagnostic
test strips
ADD TO FORMULARY
Non-Formulary
01/01/2016
evencare mini
glucose test str
ADD TO FORMULARY
Non-Formulary
blood sugar diagnostic
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 246
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
01/01/2016
Brand Name
Generic Name
contour,contour blood sugar diagnostic
next,bgstar,advance test
strips,assure
pro,assure
platinum,assure
3,assure
4,glucocard
expression,pocke
tchem ez,relion
prime test
strips,micro,relion
confirmmicro,glucocard
01 sensor
plus,glucocard xsensor,glucocard
vital,glucocard
vital
sensor,evencare
g2,evencare,eve
ncare
g3,easygluco test
strips,easy gluco
g2,control
g3,control ast test
strip,control,g4,maxima,infinity
test strips,acura
test
strips,easygluco
plus,easy pro
plus,prodigy,prodi
gy eject,prodigy
no coding,prodigy
autocode,prodigy
voice,easy touch
test
strip,eclipse,envis
Type of Change
Previous Value
CHANGE UM: QUANTITY
New Value
100 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 247
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ion,evolution test
strips,element
test
strips,smartdiabet
es xpres,element
plus,glucolab,sm
artest
test,glucocom
glucose,glucose
test strip,rightest
gs300 test
strips,rightest
gs100 test
strips,rightest
gs550 test
strips,ge100
blood glucose
test strip,nova
max glucose test
strips,keynote,wa
vesense
jazz,wavesense
presto,agamatrix
amp,blood
glucose
test,liberty test
strips,ultratrak,ult
ratrak
ultimate,solus v2
test
strips,caresens
n,smart caresens
n,reveal test
strip,truetest test
strips,truetrack
test
strip,premium
blood glucose
test,foracare
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 248
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
gd20,fora
v10,choicedm
g20,fora g20,fora
test strip,fora
g71a,foracare
gd40,premium
v10,fora
v12,refuah
plus,surechek
test strips,sure
edge test
strips,vocal
point,ultratrak
pro,truetrack
smart
system,easymax,
easymax
15,easyplus,mygl
ucohealth,accuchek comfort
curve,accu-chek
active,microdot,m
icrodot xtra,ez
smart,ez smart
plus,one touch
verio,fast
take,surestep,on
e touch test
strips,onetouch
ultra test
strips,onetouch
verio,surestep
pro,glucostix,free
style test
strips,test
strips,test
strip,prestige test
strips,prestige
smart
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 249
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
system,precision
pcx
plus,precision
point of
care,optium
ez,precision q-id,precision
pcx,optium,precis
ion xtra,neutek
2tek test
strips,telcare,sure
-test easyplus
mini,accu-chek
aviva,accutrend
glucose,accuchek aviva
plus,accu-chek
smartview,ultima,
on call plus test
strip,on call vivid
test strip,gmate
test strips,gluco
navii,choicedm
clarus test
strips,quintet,quin
tet ac,easy
step,easy
plus,easy
trak,easy
talk,easy plus
ii,easy check test
strip,fifty50 test
strip,embrace,vict
ory,advocate test
strip,advocate
redicode,advocate
redi-code+,clever
choice test
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 250
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
strips,clever
choice voice+ tst
strip,clever
choice
pro,pharmacist
choice,clever
choice micro test
strip,clever
choice talk,fora
d10,fora
d15c,fora
d15z,fora
v20,fora v22,fora
g30a,fora
d15g,fora
d20,fora g90,fora
v30a,freestyle lite
strips,freestyle
lite test
strips,freestyle
insulinx test
strips,freestyle
insulinx,test
n'go,optumrx,ele
ment
compact,blood
glucose test
strip,diatrue
plus,td gold test
strip,rightest
gs260 test
strips,rightest
gs250s test
strips,smart
sense test
strips,ascensia
elite,quicktek,eas
ypro,duocare,accu-chek
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 251
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
instant plus,accuchek instant,one
touch ultra test
strips,accu-chek
advantage,exacte
ch,exactech
rsg,precision softact,unicheck,glucoleade
r,valustrip test
strips,sof-tact,one
touch ii test
strips,genstrip,uni
strip1,embrace
evo,embrace
pro,on call
express test
strip,healthpro
test
strips,advanced
glucose test
strips,true metrix
glucose test
strip,fora gd50
test strips,fora
test n'go test
strips,fortiscare
glucose test
strips,assure
prism
multi,glucocard
shine,genultimate
test,evencare
mini glucose test
str,fora tn'g voice
test strips
01/01/2016
DAKLINZA
daclatasvir dihydrochloride
ADD UM: AUTHORIZATION
01/01/2016
DAKLINZA
daclatasvir dihydrochloride
REMOVE UM: QUANTITY
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 252
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2016
TECHNIVIE
ombitasvir/paritaprevir/ritona REMOVE UM: QUANTITY
vir
01/01/2016
DAKLINZA
daclatasvir dihydrochloride
01/01/2016
pioglitazonepioglitazone hcl/metformin
metformin,actopl hcl
us met,actoplus
met xr
01/01/2016
CORDARONE
amiodarone hcl
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COUMADIN
warfarin sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COUMADIN
warfarin sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COUMADIN
warfarin sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COUMADIN
warfarin sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COUMADIN
warfarin sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COUMADIN
warfarin sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COUMADIN
warfarin sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COUMADIN
warfarin sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COUMADIN
warfarin sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
DEPAKOTE ER
divalproex sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
DEPAKOTE ER
divalproex sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
DEPAKOTE
SPRINKLE
divalproex sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
testosterone
testosterone
ADD UM: QUANTITY
01/01/2016
ANDROGEL
testosterone
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
ANDROGEL
testosterone
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ANDROGEL
testosterone
ADD TO FORMULARY
Non-Formulary
Preferred Brands
ADD TO FORMULARY
56 / 30 days
Non-Formulary
Preferred Brands
CHANGE TIER
Preferred Brands
60 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 253
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2016
BEYAZ
drospirenone/ethinyl
estradiol/levomefolate
calcium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ANDRODERM
testosterone
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ANDRODERM
testosterone
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
APIDRA
insulin glulisine
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
APIDRA
SOLOSTAR
insulin glulisine
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ATROVENT
ipratropium bromide
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
ATROVENT
ipratropium bromide
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
comtan,entacapo entacapone
ne
CHANGE TIER
Generics
Non-Formulary
01/01/2016
COREG CR
carvedilol phosphate
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COREG CR
carvedilol phosphate
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COREG CR
carvedilol phosphate
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
COREG CR
carvedilol phosphate
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
DETROL
tolterodine tartrate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
DETROL
tolterodine tartrate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
DETROL LA
tolterodine tartrate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
DILANTIN
phenytoin
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ENJUVIA
estrogens,conj.,synthetic b
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ENJUVIA
estrogens,conj.,synthetic b
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ENJUVIA
estrogens,conj.,synthetic b
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ENJUVIA
estrogens,conj.,synthetic b
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ENJUVIA
estrogens,conj.,synthetic b
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
GLYSET
miglitol
ADD TO FORMULARY
Non-Formulary
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 254
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2016
GLYSET
miglitol
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
GLYSET
miglitol
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
STENDRA
avanafil
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
STENDRA
avanafil
REMOVE UM:
AUTHORIZATION
PA applies
01/01/2016
AZILECT
rasagiline mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
AZASAN
azathioprine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
AZASAN
azathioprine
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
BUPHENYL
sodium phenylbutyrate
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
CELONTIN
methsuximide
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
clorpres
clonidine hcl/chlorthalidone
CHANGE TIER
Generics
Non-Formulary
01/01/2016
elixophyllin
theophylline anhydrous
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
FLUORABON
sodium fluoride
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
FLUOR-A-DAY
sodium fluoride/xylitol
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
FLUOR-A-DAY
sodium fluoride/xylitol
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
FLUOR-A-DAY
sodium fluoride/xylitol
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
FLUOR-A-DAY
sodium fluoride
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
HEMANGEOL
propranolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
XIGDUO XR
dapagliflozin
propanediol/metformin hcl
01/01/2016
ASMANEX HFA
01/01/2016
ADD TO FORMULARY
Non-Formulary
mometasone furoate
ADD UM: QUANTITY
1 / 30 days
ASMANEX HFA
mometasone furoate
ADD UM: QUANTITY
1 / 30 days
01/01/2016
TEGRETOL XR
carbamazepine
REMOVE UM:
AUTHORIZATION
PA applies
01/01/2016
TEGRETOL XR
carbamazepine
REMOVE UM:
AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 255
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ADD UM: QUANTITY
30 / 30 days
01/01/2016
TRIBENZOR
olmesartan
medoxomil/amlodipine
besylate/hydrochlorothiazide
01/01/2016
ZECUITY
sumatriptan succinate
ADD TO FORMULARY
Preferred Brands
01/01/2016
ZECUITY
sumatriptan succinate
ADD UM: QUANTITY
9 / 30 days
01/01/2016
CIMZIA
certolizumab pegol
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
ORENCIA
abatacept
CHANGE TIER
Preferred Brands
Non-Formulary
01/01/2016
EXTAVIA,BETAS interferon beta-1b
ERON
ADD TO FORMULARY
01/01/2016
REBIF,REBIF
interferon beta-1a/albumin
REBIDOSE,AVO human
NEX
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
AVONEX,AVON interferon beta-1a
EX PEN
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
ADCIRCA
tadalafil
REMOVE UM: GENDER
Male
01/01/2016
FORTEO
teriparatide
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
euflexxa
hyaluronate sodium
ADD TO FORMULARY
Non-Formulary
Preferred Brands
01/01/2016
euflexxa
hyaluronate sodium
ADD UM: AUTHORIZATION
PA applies
01/01/2016
GLEEVEC
imatinib mesylate
ADD UM: SPECIALTY
Specialty Drug
01/01/2016
eligard,lupron
leuprolide acetate
depot-ped,lupron
depot,leuprolide
acetate,lupron
CHANGE TIER
Preferred Brands
01/01/2016
ZOLADEX
goserelin acetate
CHANGE TIER
01/01/2016
CERDELGA
eliglustat tartrate
ADD UM: AUTHORIZATION
PA applies
01/01/2016
SUTENT
sunitinib malate
CHANGE UM: QUANTITY
30 / 30 days
01/01/2016
SUTENT
sunitinib malate
CHANGE UM:
AUTHORIZATION
PA applies
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 256
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/01/2016
ipratropium
bromide
ipratropium bromide
CHANGE TIER
Preferred Brands
Generics
01/01/2016
ipratropium
bromide
ipratropium bromide
CHANGE TIER
Preferred Brands
Generics
01/06/2015
SITAVIG
acyclovir
ADD TO FORMULARY
Non-Formulary
01/06/2015
ZENPEP
lipase/protease/amylase
ADD TO FORMULARY
Preferred Brands
01/06/2015
eligen b12
cyanocobalamin/salcaprozat
e sodium
ADD UM: CUSTOM
Vitamin Rider
may be required
01/06/2015
LYNPARZA
olaparib
ADD UM: SPECIALTY
Specialty Drug
01/06/2015
PKU EASY
nutritional therapy for pku,
combination no.56
ADD TO FORMULARY
Non-Formulary
01/06/2015
REYATAZ
atazanavir sulfate
ADD TO FORMULARY
Preferred Brands
01/06/2015
VIEKIRA PAK
ombitasvir/paritaprevir/ritona
vir/dasabuvir sodium
ADD UM: SPECIALTY
Specialty Drug
01/09/2016
norgestimateethinyl estradiol
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/09/2016
tri-lo-estarylla
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/09/2016
vienva
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/09/2016
genvisc 850
hyaluronate sodium
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
trinessa lo
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/09/2016
trinessa lo
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/09/2016
blisovi fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 257
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/09/2016
blisovi fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
01/09/2016
aerovent plus
inhaler, assist devices
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
droplet pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
01/09/2016
droplet pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
01/09/2016
droplet pen
needle
pen needle, diabetic
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
easy touch unislip
syringe w-o needl,insulin,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
easy touch unislip
syringe w-o needl,insulin,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
easy touch
fliplock syringes
syringe,safety with needle,5
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
glyceryl
distearate
glyceryl distearate
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
glyceryl
distearate
glyceryl distearate
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
nature's tears
dextran 70/hypromellose
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
mucus relief dm
guaifenesin/dextromethorph
an hbr
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
mucus relief dm
guaifenesin/dextromethorph
an hbr
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
nicotine patch
nicotine
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
sodium
bicarbonate
sodium bicarbonate
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 258
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/09/2016
oyster shell
calcium-vit d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
oyster shell
calcium-vit d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
oyster shell
calcium
calcium carbonate
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
oyster shell
calcium
calcium carbonate
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
PRADAXA
dabigatran etexilate
mesylate
ADD TO FORMULARY
Preferred Brands
01/09/2016
STRAVIX
human regenerative tissue
matrix
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
STRAVIX
human regenerative tissue
matrix
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
BRIDION
sugammadex sodium
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
BRIDION
sugammadex sodium
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
BRIDION
sugammadex sodium
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
ENSTILAR
calcipotriene/betamethason
e dipropionate
ADD TO FORMULARY
Non-Formulary
01/09/2016
ENSTILAR
calcipotriene/betamethason
e dipropionate
ADD TO FORMULARY
Non-Formulary
01/09/2016
OB COMPLETE
GOLD
prenatal vitamins
no.106/iron,carbonyl/folate
no.6/dha
ADD TO FORMULARY
Non-Formulary
01/09/2016
ASPERGILLUS
FUMIGATUS
allergenic extract-aspergillus
fumigatus
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 259
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/09/2016
AUREOBASIDIU allergenic extractM
aureobasidium pullulans
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
CANDIDA
ALBICANS
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
CLADOSPORIU allergenic extractM
cladosporium
CLADOSPORIOI cladosporioides
DES
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
DRECHSLERA
allergenic extract-drechslera
sorokiniana
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
DRECHSLERA
allergenic extract-drechslera
sorokiniana
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
EPICOCCUM
allergenic extract-epicoccum
nigrum
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
MUCOR
allergenic extract-mucor
plumbeus
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
MUCOR
allergenic extract-mucor
plumbeus
REMOVE FROM
FORMULARY
Non-Formulary
01/09/2016
PHOMA
allergenic extract-phoma
herbarum
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
MICROGESTIN
24 FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Non-Formulary
01/11/2016
MICROGESTIN
24 FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Non-Formulary
01/11/2016
STRAVIX
human regenerative tissue
matrix
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
b-donna
phenobarbital/hyoscyamine
sulf/atropine
sulf/scopolamine hb
ADD TO FORMULARY
Generics
allergenic extract-candida
albicans
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 260
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/11/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Preferred Brands
01/11/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Preferred Brands
01/11/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Preferred Brands
01/11/2016
droplet pen
needle
pen needle, diabetic
ADD TO FORMULARY
Preferred Brands
01/11/2016
droplet pen
needle
pen needle, diabetic
ADD TO FORMULARY
Preferred Brands
01/11/2016
droplet pen
needle
pen needle, diabetic
ADD TO FORMULARY
Preferred Brands
01/11/2016
blood lancets
lancets
ADD TO FORMULARY
Preferred Brands
01/11/2016
ONCCOR
multivitamin with
minerals/folic
acid/lycopene/lutein
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
COATS ALOE
MOISTURIZING
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
COATS ALOE
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
COATS ALOE
MOISTURIZING
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
COATS ALOE
MOISTURIZING
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
COATS ALOE
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
COATS ALOE
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
COATS ALOE
ANALGESIC
methyl salicylate/aloe vera
extract/menthol/eucalyptus
oil
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 261
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/11/2016
COATS ALOE
ANALGESIC
methyl salicylate/aloe vera
extract/menthol/eucalyptus
oil
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
COATS ALOE
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
menstrual
complete
acetaminophen/pyrilamine
maleate/caffeine
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
adult dm
maximum
guaifenesin/dextromethorph
an hbr
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD TO FORMULARY
Non-Formulary
01/11/2016
menstrual
acetaminophen/pyrilamine
relief,midol,midol maleate/caffeine
complete,menstr
ual complete
REMOVE FROM
FORMULARY
Non-Formulary
01/11/2016
UPTRAVI
selexipag
ADD UM: SPECIALTY
Specialty Drug
01/11/2016
MICROGESTIN
24 FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
01/12/2016
RISPERDAL
risperidone
CHANGE TIER
Generics
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 262
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/12/2016
RISPERDAL
risperidone
CHANGE TIER
Generics
Non-Formulary
01/12/2016
VIBRAMYCIN
doxycycline hyclate
CHANGE TIER
Generics
Non-Formulary
01/12/2016
garamycin
gentamicin sulfate
ADD TO FORMULARY
01/12/2016
ORTHO TRICYCLEN LO
norgestimate-ethinyl
estradiol
CHANGE TIER
Preferred Brands
Non-Formulary
01/12/2016
tri-lo-sprintec
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Non-Formulary
Preventative
01/12/2016
tri-lo-sprintec
norgestimate-ethinyl
estradiol
ADD UM: GENDER
Female
01/12/2016
junel fe,gildess
fe,loestrin
fe,microgestin
fe,larin fe,blisovi
fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE UM: GENDER
Female
01/12/2016
OB COMPLETE
GOLD
prenatal vitamins
no.106/iron,carbonyl/folate
no.6/dha
ADD UM: GENDER
Female
01/12/2016
lessina,aviane,or levonorgestrel-ethinyl
sythia,falmina,lut estradiol
era,sronyx,levono
rgestrel-eth
estradiol,aubra,d
elyla,vienva
CHANGE UM: GENDER
Female
01/12/2016
ortho tri-cyclen
norgestimate-ethinyl
lo,tri-loestradiol
sprintec,norgesti
mate-ethinyl
estradiol,tri-loestarylla,trinessa
lo
CHANGE UM: GENDER
Female
01/13/2015
sinelee
capsaicin/menthol
ADD TO FORMULARY
Generics
01/13/2015
captracin
capsaicin/menthol
ADD TO FORMULARY
Generics
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 263
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/13/2015
valsartan
valsartan
ADD TO FORMULARY
Non-Formulary
Generics
01/13/2015
valsartan
valsartan
ADD TO FORMULARY
Non-Formulary
Generics
01/13/2015
valsartan
valsartan
ADD TO FORMULARY
Non-Formulary
Generics
01/13/2015
valsartan
valsartan
ADD TO FORMULARY
Non-Formulary
Generics
01/13/2015
QNASL
CHILDREN
beclomethasone
dipropionate
ADD TO FORMULARY
Non-Formulary
01/13/2015
REVESTA
cholecalciferol (vit d3)/folic
acid
ADD TO FORMULARY
Non-Formulary
01/13/2015
REVESTA
cholecalciferol (vit d3)/folic
acid
ADD UM: CUSTOM
Vitamin Rider
may be required
01/13/2015
LIDOVEX
lidocaine
ADD TO FORMULARY
Non-Formulary
01/13/2015
solaice
capsaicin/menthol
ADD TO FORMULARY
Generics
01/15/2016
lincomycin hcl
lincomycin hcl
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
lincomycin hcl
lincomycin hcl
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
lincomycin hcl
lincomycin hcl
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
inflammacin
diclofenac sodium/capsicum
oleoresin
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
virt-nate dha
prenatal vitamins
no.11/ferrous fumarate/folic
acid/omega-3
ADD TO FORMULARY
Generics
01/15/2016
droplet pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
01/15/2016
droplet pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
01/15/2016
droplet pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 264
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/15/2016
easy touch
fliplock syringes
syringe,safety with needle,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy touch
fliplock syringes
syringe,safety with needle,3
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy touch
fliplock syringes
syringe,safety with needle,3
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy touch
fliplock syringes
syringe,safety with needle,3
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy touch
fliplock syringes
syringe,safety with needle,5
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy touch
fliplock syringes
syringe,safety with needle,5
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy touch
fliplock syringes
syringe,safety with needle,5
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy touch
fliplock syringes
syringe,safety with needle,5
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy touch
fliplock syringes
syringe,safety with
needle,10 ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy touch
fliplock syringes
syringe,safety with
needle,10 ml
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
pampers
swaddlers
diaper/brief,infant-toddler,
disposable
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
linktemp
thermometer, infrared, noncontact
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
pyrazinamide
pyrazinamide
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
easy comfort
insulin syringe
syringe with
needle,disposable,insulin 1
ml
ADD TO FORMULARY
Generics
01/15/2016
freestyle
precision neo
blood sugar diagnostic
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 265
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/15/2016
freestyle
precision neo
blood sugar diagnostic
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
freestyle
precision neo
meter
blood-glucose meter
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
ONE DAILY
PLUS IRON
multivitamin/ferrous
fumarate/folic acid
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
b-100 complex
vit b complex 100 combo
no.2
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
b-100 complex
vit b complex 100 combo
no.2
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
calcium
carbonate
calcium carbonate
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
PENICILLIUM
NOTATUM
allergenic extract-penicillium
notatum
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
PENICILLIUM
NOTATUM
allergenic extract-penicillium
notatum
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
RHIZOPUS
allergenic extract-rhizopus
oryzae
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
NYATA
nystatin/emollient
combination no.88
ADD TO FORMULARY
Non-Formulary
01/15/2016
PHOXILLUM
phosphate hemodialysis
solution no.2 without
dextrose
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
PHOXILLUM
phosphate hemodialysis
solution no.3 without ca and
dextrose
REMOVE FROM
FORMULARY
Non-Formulary
01/15/2016
SALIVAMAX
saliva substitute
combination no.11
ADD TO FORMULARY
Non-Formulary
01/15/2016
BRIDION
sugammadex sodium
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 266
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/15/2016
lincomycin hcl
lincomycin hcl
REMOVE FROM
FORMULARY
01/21/2015
EPIVIR HBV
lamivudine
01/21/2015
CERENX
citicoline sodium
ADD TO FORMULARY
Non-Formulary
01/21/2015
EMBEDA
morphine sulfate/naltrexone
hcl
ADD TO FORMULARY
Non-Formulary
01/21/2015
EMBEDA
morphine sulfate/naltrexone
hcl
ADD TO FORMULARY
Non-Formulary
01/21/2015
EMBEDA
morphine sulfate/naltrexone
hcl
ADD TO FORMULARY
Non-Formulary
01/21/2015
EMBEDA
morphine sulfate/naltrexone
hcl
ADD TO FORMULARY
Non-Formulary
01/21/2015
EMBEDA
morphine sulfate/naltrexone
hcl
ADD TO FORMULARY
Non-Formulary
01/21/2015
OBREDON
guaifenesin/hydrocodone
bitartrate
ADD TO FORMULARY
Non-Formulary
01/21/2015
SAVAYSA
edoxaban tosylate
ADD TO FORMULARY
Non-Formulary
01/21/2015
SAVAYSA
edoxaban tosylate
ADD TO FORMULARY
Non-Formulary
01/21/2015
SAVAYSA
edoxaban tosylate
ADD TO FORMULARY
Non-Formulary
01/21/2016
MIRCERA
methoxy polyethylene
glycol-epoetin beta
ADD UM: AUTHORIZATION
PA applies
01/21/2016
MIRCERA
methoxy polyethylene
glycol-epoetin beta
ADD UM: SPECIALTY
Specialty Drug
01/21/2016
kitabis
pak,tobramycin
tobramycin/nebulizer
ADD UM: SPECIALTY
Specialty Drug
01/21/2016
tobi,tobramycin
tobramycin in 0.225 %
sodium chloride
ADD UM: SPECIALTY
Specialty Drug
01/21/2016
VENTAVIS
iloprost
tromethamine,iloprost
ADD TO FORMULARY
CHANGE TIER
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 267
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
01/21/2016
SUTENT
sunitinib malate
ADD TO FORMULARY
Non-Formulary
01/21/2016
SUTENT
sunitinib malate
REMOVE UM: SPECIALTY
Specialty Drug
01/21/2016
SUTENT
sunitinib malate
ADD UM: QUANTITY
30 / 30 days
01/25/2016
antifungal cream tolnaftate
REMOVE FROM
FORMULARY
Non-Formulary
01/25/2016
clindamycin
phosphate
clindamycin phosphate
REMOVE FROM
FORMULARY
Non-Formulary
01/25/2016
tri-lo-marzia
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/25/2016
tri-lo-marzia
norgestimate-ethinyl
estradiol
ADD TO FORMULARY
Preventative
01/25/2016
kaitlib fe
norethindrone-ethinyl
estradiol/ferrous fumarate
ADD TO FORMULARY
Preventative
01/25/2016
kaitlib fe
norethindrone-ethinyl
estradiol/ferrous fumarate
ADD TO FORMULARY
Preventative
01/25/2016
imatinib mesylate imatinib mesylate
ADD TO FORMULARY
Generics
01/25/2016
easy touch
fliplock syringes
syringe,safety with needle,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/25/2016
fora d40
blood-glucose and blood
pressure meter with adult
cuff
REMOVE FROM
FORMULARY
Non-Formulary
01/25/2016
fora d40-g31 test blood sugar diagnostic
strips
ADD TO FORMULARY
Non-Formulary
01/25/2016
CHILDREN'S
DELSYM
COUGH
dextromethorphan polistirex
REMOVE FROM
FORMULARY
Non-Formulary
01/25/2016
mucus relief dm
max
guaifenesin/dextromethorph
an hbr
REMOVE FROM
FORMULARY
Non-Formulary
01/25/2016
NUFERA
iron,carbonyl/folate combo
no.9/vit c/vit d3/vit b6/vit b12
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 268
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
01/25/2016
DYANAVEL XR
01/25/2016
Generic Name
amphetamine
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Non-Formulary
imatinib mesylate imatinib mesylate
ADD TO FORMULARY
Generics
01/25/2016
imatinib mesylate imatinib mesylate
CHANGE TIER
01/25/2016
tri-lo-marzia
norgestimate-ethinyl
estradiol
01/25/2016
freestyle
precision neo
blood sugar diagnostic
01/25/2016
virt-nate dha
prenatal vitamins
no.11/ferrous fumarate/folic
acid/omega-3
01/26/2015
ARAVA
01/26/2015
Generics
Not Covered
ADD UM: GENDER
Female
ADD UM: QUANTITY
100 / 30 days
ADD UM: GENDER
Female
leflunomide
ADD UM: SPECIALTY
Specialty Drug
ARAVA
leflunomide
ADD UM: SPECIALTY
Specialty Drug
01/27/2015
pain relief
capsaicin/menthol
ADD TO FORMULARY
Generics
01/27/2015
amantadine
amantadine hcl
CHANGE TIER
Generics
01/27/2015
isosource 1.5
cal,resource with
fiber,isosource
1.5 cal tube
feed,ensure with
fiber,promote
with fiber,jevity
1.2 cal
lactose-reduced
food/fiber,lactose-free
food/fiber,nutritional
supplement/fiber
ADD TO FORMULARY
Non-Formulary
01/27/2015
GRAFIX CORE
human regenerative tissue
matrix
ADD TO FORMULARY
Non-Formulary
01/27/2015
GRAFIX PRIME
human regenerative tissue
matrix
ADD TO FORMULARY
Non-Formulary
01/27/2015
GRAFIX PRIME
human regenerative tissue
matrix
ADD TO FORMULARY
Non-Formulary
01/27/2015
GRAFIX CORE
human regenerative tissue
matrix
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 269
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/27/2015
NEULASTA
pegfilgrastim
ADD TO FORMULARY
Preferred Brands
01/27/2015
NEULASTA
pegfilgrastim
ADD UM: AUTHORIZATION
PA applies
01/27/2015
ONEXTON
clindamycin
phosphate/benzoyl peroxide
ADD TO FORMULARY
Non-Formulary
01/27/2015
ADAZIN
lidocaine
hcl/benzocaine/methyl
salicylate/capsaicin
ADD TO FORMULARY
Non-Formulary
01/27/2015
RYTARY
carbidopa/levodopa
ADD TO FORMULARY
Non-Formulary
01/27/2015
RYTARY
carbidopa/levodopa
ADD TO FORMULARY
Non-Formulary
01/27/2015
RYTARY
carbidopa/levodopa
ADD TO FORMULARY
Non-Formulary
01/27/2015
RYTARY
carbidopa/levodopa
ADD TO FORMULARY
Non-Formulary
01/27/2015
SCAR
lidocaine/allantoin/petrolatu
m,white
ADD TO FORMULARY
Non-Formulary
01/27/2016
COAGADEX
coagulation factor x
ADD TO FORMULARY
Non-Formulary
01/27/2016
COAGADEX
coagulation factor x
ADD TO FORMULARY
Non-Formulary
01/27/2016
NINLARO
ixazomib citrate
ADD UM: AUTHORIZATION
PA applies
01/27/2016
gleevec,imatinib
mesylate
imatinib mesylate
CHANGE TIER
Generics
01/27/2016
gleevec,imatinib
mesylate
imatinib mesylate
CHANGE UM: SPECIALTY
Specialty Drug
01/27/2016
imatinib mesylate imatinib mesylate
CHANGE TIER
01/27/2016
imatinib mesylate imatinib mesylate
ADD UM: AUTHORIZATION
PA applies
01/27/2016
imatinib mesylate imatinib mesylate
ADD UM: SPECIALTY
Specialty Drug
01/27/2016
GLEEVEC
imatinib mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
01/27/2016
GLEEVEC
imatinib mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
01/27/2016
imatinib mesylate imatinib mesylate
ADD UM: AUTHORIZATION
PA applies
01/27/2016
ALECENSA
ADD UM: AUTHORIZATION
PA applies
alectinib hcl
Not Covered
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 270
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/27/2016
ALECENSA
alectinib hcl
01/27/2016
TAGRISSO
01/27/2016
Type of Change
Previous Value
New Value
ADD UM: SPECIALTY
Specialty Drug
osimertinib mesylate
ADD UM: AUTHORIZATION
PA applies
COTELLIC
cobimetinib fumarate
ADD UM: AUTHORIZATION
PA applies
01/27/2016
COTELLIC
cobimetinib fumarate
ADD UM: SPECIALTY
Specialty Drug
01/27/2016
STRENSIQ
asfotase alfa
ADD UM: AUTHORIZATION
PA applies
01/27/2016
STRENSIQ
asfotase alfa
ADD UM: SPECIALTY
Specialty Drug
01/30/2016
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
XYNTHA
SOLOFUSE
antihemophilic factor (factor
viii) recomb,b-domain
deleted
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
tegaderm + pad
adhesive bandage
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock needle
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock needle
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock needle
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 271
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/30/2016
easy touch
fliplock needle
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock needle
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock needles
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock needle
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock needles
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock needle
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock needles
needles, safety
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringes
syringe,safety with needle,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringes
syringe,safety with needle,3
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringes
syringe,safety with needle,3
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringe
syringe,safety with needle,3
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringe
syringe,safety with needle,3
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringe
syringe,safety with needle,3
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringe
syringe,safety with needle,3
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringes
syringe,safety with needle,5
ml
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 272
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/30/2016
easy touch
fliplock syringe
syringe,safety with needle,5
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringe
syringe,safety with needle,5
ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringe
syringe,safety with
needle,10 ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringe
syringe,safety with
needle,10 ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringes
syringe,safety with
needle,10 ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringes
syringe,safety with
needle,10 ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringes
syringe,safety with
needle,10 ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringes
syringe,safety with
needle,10 ml
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
advanced healing hydrocolloid dressing
bandage
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
easy touch
fliplock syringe
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
advanced healing hydrocolloid dressing
pad
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
itraconazole
micronized
itraconazole, micronized
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
polyoxyl 40
stearate nf
polyoxyl 40 stearate
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
potassium
chlorate
potassium chlorate
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
vacustim black
foam/gauze
bandage/lidocaine/chlorhexi
dine/isopropyl alcohol
REMOVE FROM
FORMULARY
Non-Formulary
syringe,safety with needle,3
ml
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 273
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/30/2016
CALADRYL
pramoxine hcl/calamine
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
DURAPREP
iodine povacrylex/isopropyl
alcohol
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
DURAPREP
iodine povacrylex/isopropyl
alcohol
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
MOVE FREE
JOINT HEALTH
glucosamine/chondroitin/hya
luronic acid/calcium
fructoborate
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
3-DAY VAGINAL clotrimazole
CREAM
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
despec dm-g
guaifenesin/dextromethorph
an hbr/phenylephrine
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
24 hour allergy
relief
fluticasone propionate
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
nac
acetylcysteine
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
glucosamine
daily complex
glucosamine
hcl/d3/boswellia serrata
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
melatonin
melatonin
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
advanced
exfoliating
cleanser
benzoyl peroxide
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
guaifenesin er
guaifenesin
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
biotin
biotin
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
benzoyl peroxide benzoyl peroxide
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 274
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
01/30/2016
benzoyl peroxide benzoyl peroxide
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
STANDARDIZED allergenic extract,grass
TIMOTHY
pollen-timothy,standard
GRASS
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
STANDARDIZED allergenic extract, grass
ORCHARD
pollen-orchard grass,
GRASS
standard
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
STANDARDIZED allergenic extract,grass
JUNE GRASS
pollen-june(kentucky
POLLEN
blue),standard
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
ALTERNARIA
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
CLADOSPORIU allergenic extractM
cladosporium
SPHAEROSPER sphaerospermum
MUM
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
SACCHAROMYC allergenic extractES CEREVISIAE saccharomyces cerevisiae
REMOVE FROM
FORMULARY
Non-Formulary
01/30/2016
DS PREP PAK
ADD TO FORMULARY
Non-Formulary
01/30/2016
QUILLICHEW ER methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
01/30/2016
QUILLICHEW ER methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
01/30/2016
QUILLICHEW ER methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
01/30/2016
KOSHER
PRENATAL
PLUS IRON
prenatal vitamins combo
no.108/iron,carbonyl/folic
acid
ADD TO FORMULARY
Non-Formulary
01/30/2016
KOSHER
PRENATAL
PLUS IRON
prenatal vitamins combo
no.108/iron,carbonyl/folic
acid
ADD TO FORMULARY
Non-Formulary
allergenic extract-alternaria
alternata
diclofenac
sodium/benzalkonium
chloride
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 275
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
01/30/2016
morphine sulfate morphine sulfate/pf
01/30/2016
EVICEL
thrombin(human plasma
der)/fibrinogen/calcium
chloride
01/30/2016
easy touch
fliplock syringe
syringe,safety with needle,3
ml
Type of Change
Previous Value
New Value
REMOVE FROM
FORMULARY
Non-Formulary
ADD TO FORMULARY
Generics
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 276
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
February, 2016
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/01/2016
COATS ALOE
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
02/01/2016
COATS ALOE
MOISTURIZING
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
02/01/2016
COATS ALOE
MOISTURIZING
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
02/01/2016
COATS ALOE
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
02/01/2016
COATS ALOE
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
02/01/2016
COATS ALOE
aloe vera extract/allantoin
REMOVE FROM
FORMULARY
Non-Formulary
02/01/2016
QUILLICHEW ER methylphenidate hcl
ADD UM: QUANTITY
30 / 30 days
02/01/2016
QUILLICHEW ER methylphenidate hcl
ADD UM: QUANTITY
60 / 30 days
02/01/2016
QUILLICHEW ER methylphenidate hcl
ADD UM: QUANTITY
30 / 30 days
02/01/2016
KOSHER
PRENATAL
PLUS IRON
prenatal vitamins combo
no.108/iron,carbonyl/folic
acid
ADD UM: GENDER
Female
02/02/2015
HARVONI
ledipasvir/sofosbuvir
ADD TO FORMULARY
Non-Formulary
02/02/2015
HARVONI
ledipasvir/sofosbuvir
REMOVE UM:
AUTHORIZATION
PA applies
02/02/2015
VIEKIRA PAK
ombitasvir/paritaprevir/ritona
vir/dasabuvir sodium
ADD TO FORMULARY
Non-Formulary
02/02/2015
VIEKIRA PAK
ombitasvir/paritaprevir/ritona
vir/dasabuvir sodium
REMOVE UM:
AUTHORIZATION
PA applies
02/02/2015
GLEOSTINE
lomustine
ADD TO FORMULARY
Non-Formulary
02/02/2015
GLEOSTINE
lomustine
ADD TO FORMULARY
Non-Formulary
Preferred Brands
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 277
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/02/2015
GLEOSTINE
lomustine
ADD TO FORMULARY
Non-Formulary
02/02/2015
gildess 24 fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
02/02/2015
LOESTRIN 24
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
02/02/2015
gildess 24 fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
02/02/2015
lamotrigine odt
lamotrigine
ADD TO FORMULARY
Generics
02/02/2015
NEPTAZANE
methazolamide
ADD TO FORMULARY
Generics
02/02/2015
PAIN RELIEF
lidocaine hcl/menthol
ADD TO FORMULARY
Non-Formulary
02/02/2015
EVEKEO
amphetamine sulfate
ADD TO FORMULARY
Non-Formulary
02/02/2015
EVEKEO
amphetamine sulfate
ADD TO FORMULARY
Non-Formulary
02/02/2015
OCUVEL
folic acid/vit c/vit
e/zinc/cupric
oxide/lutein/zeaxanthin
ADD TO FORMULARY
Non-Formulary
02/02/2015
VITEKTA
elvitegravir
ADD TO FORMULARY
Non-Formulary
02/02/2015
VITEKTA
elvitegravir
ADD TO FORMULARY
Non-Formulary
02/02/2015
lamotrigine odt
lamotrigine
ADD TO FORMULARY
Non-Formulary
02/03/2015
NEULASTA
pegfilgrastim
ADD UM: SPECIALTY
Specialty Drug
02/06/2016
GARDASIL
human papillomavirus
vaccine, quadrivalent/pf
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
urogesicblue,uryl,uroblue,urolet
mb,me-naphosmb-hyo 1
methenamine/sodium
phosphate,monobasic/meth
blue/hyosc sul
ADD TO FORMULARY
Generics
Preventative
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 278
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/06/2016
naftin,naftifine hcl naftifine hcl
ADD TO FORMULARY
Generics
02/06/2016
COubiquinol/mecobalamin/folic
VERATROL,CO- acid/resveratrol
BALAMIN
ADD TO FORMULARY
Generics
02/06/2016
cyclobenzaprine
hcl
cyclobenzaprine hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
glumetza,metfor
min hcl er
metformin hcl
ADD TO FORMULARY
Generics
02/06/2016
delsym,cough dm dextromethorphan
er,dextromethorp polistirex,dextromethorphan
han
hbr
polistirex,children'
s cough dm
er,children's
delsym cough
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
ultracin m
menthol
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
BENEFIBER
wheat dextrin
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
GLYTACTIN 10
PE COMPLETE
nutritional therapy for pku
no.62
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
black cohosh
black cohosh root
extract,black cohosh
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
mucinex
guaifenesin/pseudoephedrin
d,guaifenesine hcl
pseudoephedrine
er
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
STANDARDIZED allergenic extract,grass
RED TOP
pollen-redtop, standard
GRASS
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 279
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/06/2016
STANDARDIZED allergenic extract-grass
MEADOW
pollen-meadow fescue,
FESCUE
standardized
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
FUSARIUM
allergenic extract-fusarium
oxysporum
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
ACREMONIUM
allergenic extractacremonium strictum
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
XEOMIN
incobotulinumtoxina
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
ZEPATIER
elbasvir/grazoprevir
ADD TO FORMULARY
Non-Formulary
02/06/2016
TICANASE
fluticasone
propionate/sodium
chloride/sodium bicarbonate
ADD TO FORMULARY
Non-Formulary
02/06/2016
neurontin,gabape gabapentin
ntin
ADD TO FORMULARY
Generics
02/06/2016
hydrochlorothiazi hydrochlorothiazide
de
CHANGE TIER
Generics
02/06/2016
adalat
cc,nifedipine
er,nifediac
cc,afeditab
cr,nifedipine
nifedipine
ADD TO FORMULARY
Generics
02/06/2016
adalat cc,nifediac nifedipine
cc,nifedipine
er,afeditab
cr,nifedipine
ADD TO FORMULARY
Generics
02/06/2016
labetalol
hcl,trandate
CHANGE TIER
Generics
02/06/2016
valium,diazepam diazepam
ADD TO FORMULARY
Generics
02/06/2016
labetalol
labetalol hcl
hcl,trandate,norm
odyne
CHANGE TIER
Generics
labetalol hcl
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 280
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/06/2016
oxycodoneoxycodone
acetaminophen,p hcl/acetaminophen
ercocet,endocet
CHANGE TIER
Generics
02/06/2016
oxycodoneoxycodone
acetaminophen,o hcl/acetaminophen
xycodone hclacetaminophen,p
ercocet,endocet
CHANGE TIER
Generics
02/06/2016
remeron,mirtazap mirtazapine
ine
ADD TO FORMULARY
Generics
02/06/2016
depakene,valproi valproic acid
c acid
ADD TO FORMULARY
Generics
02/06/2016
metoprolol
tartrate
CHANGE TIER
Generics
02/06/2016
oxybutynin
oxybutynin chloride
chloride,oxybutyn
in chloride
er,ditropan
CHANGE TIER
Generics
02/06/2016
lopressor,metopr metoprolol tartrate
olol tartrate
ADD TO FORMULARY
Generics
02/06/2016
carbamazepine
er,carbatrol
CHANGE TIER
Generics
02/06/2016
lopressor,metopr metoprolol tartrate
olol tartrate
ADD TO FORMULARY
Generics
02/06/2016
anastrozole,arimi anastrozole
dex
CHANGE TIER
Generics
02/06/2016
baraclude,enteca entecavir
vir
ADD TO FORMULARY
Generics
02/06/2016
baraclude,enteca entecavir
vir
ADD TO FORMULARY
Generics
metoprolol tartrate
carbamazepine
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 281
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/06/2016
vsl#3,visbiome
lactobacillus combination
no.2/s.thermophl/bif cmb
no.1,lactobacillus
no.2/s.thermophilus/bifidoba
cterium no.1
ADD TO FORMULARY
Generics
02/06/2016
vsl#3,visbiome
lactobacillus combination
no.2/s.thermophl/bif cmb
no.1,lactobacillus
no.2/s.thermophilus/bifidoba
cterium no.1
ADD TO FORMULARY
Not Covered
02/06/2016
abilify,aripiprazol aripiprazole
e
ADD TO FORMULARY
Generics
02/06/2016
gianvi,loryna,yaz, ethinyl
vestura,nikki,dros estradiol/drospirenone
pirenone-ethinyl
estradiol
CHANGE TIER
Preventative
02/06/2016
naproxen
sodium,aleve
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
camrese,seasoni levonorgestrel/ethinyl
que,amethia,days estradiol and ethinyl
ee,ashlyna,levon estradiol
org-eth estrad eth
estrad
CHANGE TIER
Preventative
02/06/2016
enfamil
infant formula with
newborn,tugaboo iron/docosahexanoic
premium infant
acid/arachidonic ac
formula,premium
infant
formula,enfamil
newborn nongmo
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
diprolene
betamethasone
af,betamethason dipropionate/propylene
e dipropionate
glycol
ADD TO FORMULARY
Generics
naproxen sodium
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 282
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/06/2016
flonase allergy
fluticasone propionate
relief,fluticasone
propionate,24
hour allergy
relief,children's
flonase allergy rlf
ADD TO FORMULARY
Generics
02/06/2016
dermacinrx
dimethyl sulfoxide/ethyl
topical,dermacinr alcohol/glycerin
x tss,tdm
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
imdur,isosorbide isosorbide mononitrate
mononitrate
er,isosorbide
mononitrate
ADD TO FORMULARY
Generics
02/06/2016
imdur,isosorbide isosorbide mononitrate
mononitrate
er,isosorbide
mononitrate
ADD TO FORMULARY
Generics
02/06/2016
erythromycin,eryt erythromycin
hromycin
base,erythromycin stearate
stearate
CHANGE TIER
Generics
02/06/2016
XAQUIL XR
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
clarithromycin,bia clarithromycin
xin
CHANGE TIER
Generics
02/06/2016
clarithromycin,bia clarithromycin
xin
CHANGE TIER
Generics
02/06/2016
analpram
hydrocortisone
hc,hydrocortisone acetate/pramoxine hcl
-pramoxine
ADD TO FORMULARY
Generics
methyltetrahydrofolate
glucosamine
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 283
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/06/2016
tylenol pm extra acetaminophen/diphenhydra
strength,headach mine hcl,simethicone
e pm,pain relief
pm,pain reliever
pm,acetaminoph
en pm xtra
strength,acetami
nophen
pm,acetaminoph
endiphenhydramine
,mapap pm,nonaspirin pm exstrength,nonaspirin pm,pain &
sleep,pm pain
relief,non-aspirin
sleep
aid,acetadryl,hea
dache pm
formula,gas
relief,meditabs,medi-tabs
pm,wal-nadol
pm,tylenol cold
relief,pain
medicine,acetami
nophen-sleep aid
pm,night time
pain
medicine,eazzze
the pain
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
amantadine hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
estriol
estriol micronized
micronized,estriol
REMOVE FROM
FORMULARY
Non-Formulary
amantadine hcl
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 284
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
02/06/2016
humapen
memoir,humapen
luxura hd,adriaoncoline,triaminic
flowing
vapors,unisol 4
preservative
free,ortho allflex,optifree,soaclens,sys
tane
contacts,clerz
plus,opti-free
replenish,irrigatio
n administration
set,schirmer tear
test,opti-free
express,secondar
y set,spinal-22 wbupiv-epiephed,spinal
anesthesia
tray,ivex-rf filter
set,evacuated
container,ls plum
primary setol,plumset
primary setol,dial-a-flo iv
extension
set,dial-a-flo
microdrip
set,venoset
secondary,soluse
t with cair
clamp,transfer
set,decanting
set,nonvented iv
set 100 w-
insulin admin. supplies,iv
equipment,vaporizer,soft
lens rinse-store
solution,diaphragms, arcspring,diaphragm fitting
set,arc-spring,gas
permeable lens cleaner,hard
lens clean-soak
solution,wetting soln
gas,hard and soft,soft lens
adjunctive
solutions,irrigation set,tear
test,iv piggyback
adminstration set,anesthesia
tray,iv administration setfilter,container,empty,iv
administration set,iv admin
extension set-filter,iv admin
extension set,iv
administration setclamp,transfer sets,iv
infusion pump
accessory,blood
administration set,iv
administration set,nonvent,hyperalimentation
equipment,miscellaneous
medical supply,iv catheter
kit,nerve stimulator
device,blood administration
equipment,iv infusion
pump,in-line burette
set,procedural tray,iv
venipuncture needle set,iv
catheter,dialysis (peritoneal)
kits,blood collection
set,vial,empty,feeder
container with pump
set,irrigation piercing pin
REMOVE FROM
FORMULARY
Previous Value
New Value
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 285
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
clamp,nitroglyceri
n patient
line,soluset
150x15 i.v. setsl,screw cap
set,iv pump setivex-hp,blood ytype pump
set,hema blood
secondary
pump,venoset
piggyback,air
filter,extension
set with
stopcock,anesthe
sia extension
set,syringe
filter,cvp
universal
set,blood
set,backcheck
extension
set,venoset with
cair
clamp,nonvented
primary pg-bk wcair,blood set 78sl, y-type,blood
set 82-sl,venoset
t-type w-cair
clamp,venoset
secondary
piggybk
set,venoset sec
piggyback,nutrimi
x,abbott counting
tray,cont epidural
w-bupiv-epi,veniprep ii kit,veni-
set,nv,calamine/zinc
gelatin,inhaler, assist
devices,inhaler, assist
devices, accessories,facialbody sponge,n95 respirator,
disposable,pen needle,
diabetic,pen needle,
diabetic, safety,syringe
accessory,syr biopsyaspiration
reusable,gloves,bloodglucose meter, disctype,blood glucose
calibration control solution,
normal,blood glucose
calibration control solution,
low,blood glucose
calibration control solution,
high,blood glucose
calibration control high and
low,lancets,lancing
device,lancing
device/lancets,bloodglucose meter,bloodglucose meter,
wireless,jejunostomy
tube,gastrostomy
tube,dental plaque
indicator,needleless
dispensing pin,diaphragms,
wide seal,heating
pad,adhesive remover,gum
mastic/storax/methyl
salicylate/alcohol,syringe
with
needle,disposable,insulin 1
ml,syringe with
needle,insulin,0.5
ml,condoms, latex,
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 286
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
prep iii-site-care
dresng,ivex-2
filterset with ysite,veni-prep i
kit,reliefband,twoway transfer
device,venoset
78 w-mb piercing
pin,hema access
port,extension
set,three-way
stopcock ext
20in-sl,three-way
stopcock ext
36,three-way
stopcock,threeway stopcock wluer lock,threeway stopcock ext
20-sl,lifecare
plum set,pca
mini-bore
set,pharmacy
additive transfer
set,y-type
connecting
set,extension set
int-sl,brachial
plexus tray,in-line
burette
set,venoset 78 wivex-2
nonvented,amnio
centesis tray,4
leg vented
transfer set,4 leg
nonvented
transfer set,3 leg
vented transfer
lubricated,activated
charcoal/iron/sodium/water,s
uppository mold,breast
shield,adhesive,silver na
hydrogen zirconium
phos/hydrocolloid heel
dressing,silver na hydrogen
zirconium phos/hydrocolloid
toe dressing,silver na
hydrogen zircon
phos/hydrocolloid
heel&toe/cream59,nasal
airflow strips,ear
syringe,denture
cleanser,adhesive
tape,transparent
dressing,facial mask,elastic
bandage,pads for
bedsores,nebulizer,peak
flow meter/inhaler, assist
devices,peak flow
meter,condoms, latex, nonlubricated,sanitary
pads,incontinence
pad,liner,disp,ostomy
supply,catheter,syringe
disposable, irrigation,70
ml,urinary bag,urinary bag
accessories,catheter
male,external,drainage
bag,gel
dressing,catheterization
tray,syringe disposable
irrigation,colostomy
bags,foam bandage,gauze
bandage/elastic
bandage,non-adherent
bandage,ostomy
adhesive,alginate
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 287
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
set,nutrimix iv
empty
container,extensi
on tube,butterfly
infusion
set,platelet
concentrate
infusion,ivex h.p.
filterset,s-a-i-f set
1 micron,clearcath,20g,2
in,clearcath,16g,1-1/4
in,clearcath,clearcath(subclav),abb
ocath-t,abbocatht with
syringe,butterfly,e
xtension setlocking luer
t,thoracentesis
set,blood
warming coil,y
connector,inpers
ol peritoneal cath.
11fr,blood
collection
set,doubleneedle transfer
device,cont
epidural wlidocaineepi,additive hinge
cap,lifecare
additive cap,male
adapter
plug,sterile empty
vial,quik lok luer
dressing,hydrocolloid
dressing,zinc
oxide,adhesive
bandage,gauze
bandage,syringe,
disposable, 60 ml,syringe
with needle,disposable, 3
ml,ostomy kit,syringe,
disposable, 1
ml,underpads,diaper,brief,ad
ult, disposable,syringe,
disposable, 140 ml,syringe
w-needle,disposab,1
ml,undercast padding,facialbody wipes,enema bag,
disposable,wadding,syringe,
disposable, 20 ml,syringe,
disposable, 12 ml,needles,
blood collection,syringe with
needle, 12
ml,polyhexamethylene
biguanide/gauze
bandage,feeder
container,eye patch,syringe,
disposable, 3 ml,surgical
suction tubing,compression
stocking,thigh high,regular
length,small,compression
stocking,thigh high,short
length,small,compression
stocking,thigh high,regular
length,medium,compression
stocking,thigh high,regular
length,large,compression
stocking,thigh high,long
length,small,compression
stocking,thigh high,regular
length,x-small,compression
stocking,thigh high,short
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 288
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
lock
adapter,sterile
empty vial&
injector,nv
cardiac catheter
set,microbore
extension setsl,manifold 111sl,plum lc 5000
enteral set,pca
extension set,pca
set-long mini
bore ol,pca cont
inf mini-bore,pca
set-cont inf mini
bore ol,access
set,catheter wcair clamp nonvent,cystomanom
eter
set,secondary
irrigation set,t-u-r
system w-flow
pouch
2000,nonvented
t-u-r
set,cystoscopyirrigation set,nv
large bore yirrigation
set,pentothal
dispensing
pin,empty 3-in-1
mixing
container,nutrimix
-macro
ferrules,ferrules,n
utriclamp,container
length,
medium,compression
stocking,thigh high,long
length,x-small,wet
dressing,compression
stocking,thigh high,long
length,medium,compression
stocking,thigh high,long
length,large,compression
stocking,thigh high,short
length,large,compression
stocking,thigh high,regular
length,x-large,compression
stocking,thigh high,long
length,xlarge,petrolatum,white,comp
ression stocking, knee high,
regular length,
small,compression stocking,
knee high, regular length,
medium,compression
stocking, knee high, regular
length, large,compression
stocking, knee high, regular
length, x-large,compression
stocking, knee high, long
length, small,compression
stocking, knee high, long
length,
medium,compression
stocking, knee high,long
length, large,compression
stocking, knee high, long
length, x-large,bismuth
tribromophenate/petrolatum,
white,syringe, disposable,
35 ml,syringe wneedle,disposb,0.5ml,syring
e, disposable, 6 ml,syringe
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 289
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
with ytransfer,lifecare
flex
container,lifecare
flex container
1000ml,adi sterile
empty vial,snap
lock device,veni
loop
connector,venose
t 100-sl
piggyback
nv,burette 100ml
hemoset nv,blood
set w-pumpsl,pediatric
microaggr blood
filt,hema blood
set,hema y-type
blood
set,microdrip
micro pump setfiltr,soluset iv
micro pump
set,lifecare 5000
secondary
cntnr,plum lc
5000
minipole,domepaste
bandage,inspirea
se,buf
bodymate,actiprotect
uf,novofine
32,novopen
3,novofine,novop
en
jr,innovo,novofine
w-needle,disposab,6
ml,swab,syringe disposable
irrig,60 ml,burn
dressing,diaper/brief,infanttoddler,
disposable,diaper,brief,yout
h,disposable,feeder
container w-gravity
set,nasogastric
tube,iodoform,needles,
disposable,urinary
bag/catheterization
tray,calcium
alginate,dressing,
hydropolymer,porcine acell
submucosa,meshed,porcine
submucosa,
fenestrated,peripheral nerve
diagnostic device,nerve test
monofilament,diabetic
supplies,miscell,vacuum
erection device
system,penile constriction
ring systm,needles, insulin
disposable,neurological
exam pin,syringe, needle,
safety,self-contained
disposal unit,1.5 ml,syringe
with needle, insulin,1 ml and
sharps container,syring wndl,disp,insul,0.3
ml/container,empty,syringeneedle,insulin,0.5
ml/container,empty,syringe
with needle,insulin,0.3
ml,syringe with
needle,insulin
disposable,0.3 ml,syringe,
disposable, 5 ml,syringe,
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 290
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
autocover,novotw
ist,nordipen
5,nordipen
15,astra selfaspirating
dental,cartridge
dispenser
dental,astrapro,br
eeze 2,autodisc
normal,ascensia
autodisc,fingersti
x,glucolet
2,contour
link,didget,contou
r next
link,microlet,singl
e-let,microlet
2,contour,contour
next ez,contour
next control
solution,contour
next,contour
usb,contour next
usb,compat
gravity delivery
set,compat
enteral delivery
pump,vivonex
jejunostomy
kit,compat,compa
t select flo
pump,compat
container wpump set,compat
select flo
case,compat
select flo baggle
cage,compat
yset,iv
disposable, 10 ml,syringe,
disposable, 30 ml,syringe,
disposable, 50 ml,needles,
safety huber,
disposable,needles, huber
disposable,needles,
reusable,needles, huber
reuse,needles, spinalanesthetic,needles,
biopsy,bone,aspirate,syringe
reusable, 0.25 ml,syringe
reusable, 1 ml,syringe
reusable, 2 ml,syringe
reusable, 5 ml,syringe
reusable, 10 ml,syringe
reusable, 20 ml,syringe
reusable, 30 ml,syringe
reusable, 50 ml,syringe
reusable, 3 ml,syringe
reusable,syring w-needl 0.5
ml,kit-tray,syringe with
needle 1 ml, disposable kittray,syringe with needle, 0.5
ml,syringe, irrigation,
reusable,iv catheter kit
accessory,syringe wcannula,disp, 3 ml,syringe
w-cannula, disp, 5
ml,syringe w-cannula,disp,
10 ml,syringe with
needle/cannula,disposable
10 ml,blunt needle,
disposable,needles,
filter,oral dosing
devices,syringe, disposable,
2.5 ml,syringe,safety with
needle,3 ml,syringe,safety
with needle,1
ml,syringe,safety with
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 291
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
administration
set,solution
transfer
device,beutlich
ph test,hurricaine
dispenser,hurrivie
w,hurricaine luerlock,hurriview
ii,hurricaine spry
extension
tube,pro-ception
fertility pak,wide
seal
diaphragm,liqua
spen,precise pain
relieving,aerocha
mber plus flowvu,detachol
adhesive
remover,mastisol,
mastisol
adhesive,boules
quies
earplugs,insulin
syringe,ultra
comfort,easytouch insulin
syringe,condoms,
thermacare,pump
for liquagel,suppository
mold,o-calette,pedi-skin
adherent #2,pedipre,pedi-pre tape
spray,hydro
armor ag,hydro
armor ag blister
care,e-z ject
needle,5 ml,syringe,safety
with needle,10 ml,needles,
safety,syringe with needle,
10 ml,syringe w-o
needl,insulin,1 ml,syringe wneedle,disposab,5
ml,syringe with
needle,insulin 0.3 ml (half
unit mark),needle clipping
and storage device,syringe
with needle,insulin
disposable,0.5 ml,needles,
insulin disposable,
safety,pen needle, diabetic
disposable, safety,blade
lancet, safety,thermometer,
glass mercury
(oral),thermometer, glass
mercury (rectal),iv catheter
kit/iv catheter kit
accessory,myelogram
tray,pregnancy test
kit,syringe with needle,
insulin, safety, 1 ml,syringe
with needle, insulin, safety,
0.5 ml,blood glucose
calibration control solution,
high and normal,bloodglucose calib. control,ringers
solution,lactated/gel
dressing,silver,dressing,
odor absorbent,
hydropolymer,mucus
clearing device,compressor,
for
nebulizer,nebulizer/compres
sor, for nebulizer,nebulizer
accessories,spirometers and
accessories,ostomy
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 292
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
lancets,major
comfort,nasal
strips,ear
syringe,denture
cleanser,micropo
re first aid
paper,micropore
first aid
skintone,micropor
e first aid
plastic,micropore
first aid
waterproof,micro
pore first aid
cloth,tegaderm,m
icropore air
wrming fltr
mask,micropore
pollen filter
mask,micropore
germ filter
mask,coban,resto
n,durex avanti
bare,aeroeclipse
ii,aerotrach
plus,aerochambe
r z-stat
plus,aerochambe
r with
flowsignal,aeroge
ar asthma action
kit,truzone peak
flow
meter,aerochamb
er
mv,aerochamber
mini,relion
prime,relion
confirm,trustex
cap,colostomy
washer,colostomy
belt,ostomy
disinfectant,karaya
gum,urostomy
pouch,colostomy bag, nonsterile,colostomy-ileostomy
sets, non-sterile,colostomyileostomy sets,
sterile,urostomy sets, nonsterile,urostomy sets,
sterile,ostomy lubricating
deodorant,condoms,
female,sub-q administration
set,sub-q infusion pump
accessory,cervical
cap,biosynthetic
bandage,biosynthetic
glove,syring wndl,disp,insul,0.5
ml/container,empty,ovulation
test kit,blood-glucose meter
& wrist blood pressure
monitor,insulin pump
cartridge,subcutaneous
insulin pump,injection
ports,insulin pump syringe, 3
ml,insulin pump syringe, 1.8
ml,blood ketone
test,strips,blood glucose and
ketone control, normal,sub-q
insulin delivery device, 40
unit, disposable,sub-q
insulin delivery device, 30
unit, disposable,sub-q
insulin delivery device, 20
unit,disposable,middle ear
inflation device,head
support, infant, small,head
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 293
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
condom,trustexria,trustex latex
condom,trustex,f
antasy,stayfree
surefit,stayfree
maxipad,stayfree ultra
thin,carefree
panty shield,tena
serenity,serenity
ultra
plus,drain,bardic
adaptertubing,cunningha
m incontinence
clamp,catheter,fe
male intermittent
catheter,toomey
syringe,urethral
catheter,reliaseal
disc,dispoz-a-bag
leg bag
small,dispoz-abag leg bag
medium,dispoza-bag leg bag
large,leg bag
holder,uro sheath
disposable
bulk,bardic uro
sheath vinyl,male
external
catheter,deluxe
fabric leg
straps,catheter
strap holder,twosided adhesive
strips,latex
extension
support, infant,
medium,head support,
infant, large,silver
sulfate/non-adherent
bandage,silver sulfate/foam
bandage,foam heel
dressing,dressing, foam
matrix/activated
charcoal,silver/calcium
alginate,adhesive
bandage/adhesive
tape/benzalkonium
chloride,adhesive
bandage/adhesive remover
comb. no.1,hydrocolloid
dressing/adhesive remover
comb. no.1,medical
information identification
tag,nasal exhalation
resistance device,syringe,
safety, self-contained
disposal unit, 3 ml,syringe,
safety, self-contained
disposal unit, 5
ml,syringe,needle,insulin,saf
ety,disposal unit,0.3
ml,insulin syringeneedle,safety,disposal
unit,0.5
ml,syringe,needle,insulin,saf
ety,disposal unit, 1
ml,syringe with needle,
safety, self-cont disposal
unit, 1 ml,syringe with
needle, safety, self-cont
disposal unit, 3 ml,syringe
with needle, safety, self-cont
disposal unit, 5 ml,syringe,
safety, self-contained
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 294
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
tubing,latex leg
straps,bard
center entry close
system,urinary
drainage
bag,infection
control bag,leg
bag
straps,bardex
silicone foley
catheter,rubber
utility
catheter,cleancath,protective
barrier
film,adhesive
remover
wipes,vigilon
wound
dressing,irrigation
tray,basic
irrigation
tray,urethral
catheter
tray,bardex
urethral catheter
tray,universal
foley catheter
tray,davol
complete foley
kit,davol urinary
drainage
bag,bardia
urinary drainage
bag,davol foley
cath insert
tray,davol
universal catheter
tray,davol clsd
disposal unit, 10
ml,syringe,safety,disp
unit,10 ml,conception
assistance supplies
combination no.1,bloodglucose transmitter,bloodglucose
meter,continuous,bloodglucose sensor,bloodglucose
meter,continuous/bloodglucose transmitter,syringe,
disposable,syringe wcannula,disp, 1 ml,syringe
w-cannula,disp, 6
ml,needles, pharmacy
compound,syrng w-ndl,dsp
kit-tray,0.5ml,syrng wndl,disp. kit-tray,1ml,syringe
with
needle,disposable,insulin,sy
ringe wneedle,disposab,3ml,syringe
wneedle,disposab,6ml,syringe
,safety with needle,12
ml,syringe with
cannula,disposable 12
ml,syringe wneedle,disposable,syringe
with needle, insulin, safety,
0.3 ml,feeder irrigation kit,yport adapter-extension
set,pump set,calcium
alginate/honey,soft lens
surfactant cleanser,soft lens
chemical disinfectnt,hard
lens cleaner,gum/polyvinyl
alcohol/dental
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 295
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
sys foley cath
tray,davol
irrigation
syringe,davol
irrigation
tray,davol
urethral catheter
tray,davol
silicone foley
catheter,bardex
closed system
cath tray,infection
control
tray,bardex
lubricath foley
tray,extra
colostomy
pouch,stoma
urine bag,extra
security
pouch,extra
open-end
drain,scanpor
tape,opsite
flexifix,allevyn,all
evyn
heel,profore,exudry,skin-bond
cement,iv
3000,uni-solve
adhes remover
wipes,uni-solve
adhesive
remover,remove
wipes,remove
liquid,urikleen,skinprep,no sting skin
prep,hypafix,opsit
adhesive,dental
adhesive,toothpaste,dental
polishvarnishes,polymerized rosin
resin,ovulation and
pregnancy test kit,sodium
chloride,thermometer probe
covers,thermometer,
electronic,oral,corn/callus
cushion,dental floss,syringe
w/needle,insulin disposable
0.3 ml (half unit
mark),toothbrush,thermomet
er, tape,ostomy accessories,
filters and bridges,ice
bag,cold-hot pack,finger
splint,dental gingival
products,hot water
bottle,fountain syringes
applicator,footcare,miscellan
eous,thermometer,
electronic,otic,hearing aid
accessory,gloves,
latex,blood pressure test kitmedium,blood pressure test
kit,ear plugs,contact lens
case,thermometer, basal
electronic,tubular
gauze/tub.rubbr dressing
protector,blood pressure test
kit-wrist,incontinence pants,
reusable,blood pressure test
kit medium and large
cuffs,walker,silicone
adhesive,infusion set for
insulin pump,pharmacy
dispensing adm
set,pharmacy compounding
access.,catheter
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 296
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
e postop,solosite,opsite
flexigrid
dressing,algisite
m,transigel,replic
are,viscopaste
pb7,opsite
adhesive
dressing,flexigel,
cicacare,primapore
iv,primapore,covr
site,covrsite
plus,intrasite,alle
vyn cavity
dressing,allevyn
tracheostomy
dressing,unlabele
d refill bottle
240ml,spray
pump,microspon
ge,monoject,mon
oject
syringe,sharpsafe
ty
container,nutripor
t balloon,dover
advantage,dover
premium,dover
pediatric
urine,dover
advantage
drainage,monoje
ct tb
syringe,monoject
luer lock tb
syringe,curity
lumbar puncture
tray,durasorb,sim
accessories,external,syringe
filter,enteral feeding
dispenser, 20 ml,enteral
feeding dispenser, 35
ml,enteral feeding
dispenser, 60 ml,enteral
feeding dispenser,1
ml,enteral feeding
dispenser,3 ml,enteral
feeding dispenser,5
ml,enteral feeding
dispenser,10 ml,dental
suction device/chlorhexidine
gl/dental swab comb
no.1,dental suction
device/chlorhexidine/dental
swab #1/mouthwash,eye
pressure monitor,injector
device,spray applicator kit,
sterile,humidifier,thermomet
er, temple
electronic,disinfectant,glycin
e/sodium
hydroxide,ultrasonic
cleaner/holding
solution,protease-amylase
medical equipment
cleaner,transfer device,
closed system,needle
injector, luer, closed
system,needle injector, luer
lock, closed
system,connector luer lock,
closed system,infusion
adapter, closed system,ysite line connector, closed
system,assembly system,
vial to transfer device,
closed system,clamp, iv
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 297
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
plicity
liner,telfa,maxicar
e,rondic,presenc
e,telfa
clear,curity,kerlix,
sure care
protective
underwear,monoj
ect tb,curity
maternity
pad,curity
ultramer 2-way
catheter,webril,to
uch-trol,curity
cleaners
medium,sharpsa-gator,enema
bag,handicare,su
recare,versalon,t
enderskin,kendall
paper tape,sure
care protective
undergmnt,curity
foley catheter
kit,curity cleaners
large,dressing
change-pov-iod
tray,curity
universal w-o
drainage,suretys,
monoject blood
collection,confor
m,monoject luer
adapter,curity
ureth cath closed
systm,curity
amd,curity
urethral
catheter,precision
tubing,diaper,brief,adult,disp
osable,blood pressure test
kitlarge,cane,wheelchair,smoki
ng deterrent filter,cane
tips,crutch
accessories,crutch,thermom
eter, basal glass
mercury,neck collar,feminine
syringe,vaporizer-humidifier
supply,rectal syringe,nasal
syringe,vehicle base no.
13,topical cream metereddose device,adapter cap for
bottle,rectal, vaginal
applicator tip,troche
mold,silver/hydrocolloid
dressing,fecal collector with
charcoal filter,hard lens
wetting solution,hard contact
lens enzymatic
cleanser/pf,arm brace,leg
brace,back
brace,compression socks,
medium,compression socks,
large,blood glucose
calibration control solutions
high,normal,low,aloe
vera/gloves, latex,nonadherent
bandage/petrolatum,white,fir
st aid kit,dressing
holder,blood-glucose meter,
drum-type,prothrombin time
test strips,amniotic fluid
detection test,vaginal cream
applicator,suppository
container, empty,vaginal
suppository applicator,filter,
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 298
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
200 catheter
tray,argyle,nursin
g pads
(breast),webril
ii,curity ultramer
irrg 3way
cath,curity o-b
sponges,vistec,ar
gyle connecting
tubes,wings
underpad,t.e.d.
anti-embolism
stocking,lisco,curi
ty bedside
drainage set,wetpruf,sharps a
gator,curity ureth
cath open
system,tensor,ker
lix amd
bandage,urinary
leg medium
bag,kenguard,ad
d-a-foley
tray,foley
catheter,curity
irrigation
tray,heavy
drainage
dressing
steril,robinson
clear vinyl
catheter,specipan
collection
unit,vaseline
petrolatum
gauze,xeroform
petrolatum
dressing,xerofor
disposable ptfe
membrane,benzalkonium
chloride,allantoin,mineral
oil/aloe
vera/petrolatum,white/sodiu
m lauryl
sulfate,acemannan/alginate
dressing,alginate
dressing/carboxymethylcellu
lose,needleless accessory
device, insulin,blood sugar
diagnostic test strips with
disposable meter,safety
seal, for bags,safety seal,
for vials,safety seal, for
syringes,defibrillator,automa
tic,external,gel dressing/zinc
acetate/meadowsweet/oak,c
ellulose,oxidized/collagen,ac
tivated charcoal/silver,gelmatrix pad dressing,
silicone/benzalk chl/vit e/min
oil,cholesterol calibration
controls - high and
low,cholesterol test,
strips,cholesterol & blood
glucose meter,prothrombin
time/inr test meter,gel
dressing,
fenestrated,collagen,bovine,
fecal collector w-charcoal
filter/catheter/syringe,
dispos,ostomy
irrigator,activated
charcoal/alginate
dressing/hydrocolloid
dressing,gravity feeding
set,feeding
pump,stethoscope,dental
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 299
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
m,dermacea,der
macea nonwoven,dermacea
stretch,flexwrap,aquaflo,curit
y thoracentesis
trays,monoject
pharmacy
tray,curity
thoracentesiscath tray,kenline
add-a-foley tray
30cc,add-a-foley
cath-pre-fill
syrn,curity spng
counter bag
strips,curity spng
counter rackscale,curad,curity
surgical,clean
catch-benzalkon
towelets,clean
catch-soap
towelettes,t.e.d.
sequnt compress
device,copa
hydrophilic
foam,argyle
trocar,unigard,wi
ngs classic youth
briefs,wings
classic adult
briefs,wings
classic,wings
choice plus youth
briefs,wings
choice plus adult
briefs,wings
choice adult
preparation, o.u.,bloodglucose transmitter/bloodglucose sensor,needles,
subcutaneous set,iv
administration set/needles,
reusable,ring,cath male
external-starter
kit,transcutaneous electrical
nerve stimulators (tens
units),tens unit
electrodes,blood pressure
kit-extra large,propylene
glycol,toe splint,disinfectant
liquid soap cmb4,mineral
oil/non-adherent
bandage/petrolatum,hydrop
hilic,weigh scale,blood
pressure test kitsmall,compression socks, xlarge,blood-glucose and
blood pressure meter with
adult cuff,isopropyl
alcohol,infusion set with
insulin pump body,insulin
pump controller,insulin
pump/infusion set/bloodglucose meter,bacitracin
zinc/polymyxin b
sulfate,safety syringe with
needle, disposable kit-tray, 1
ml,polyhexamethylene
biguanide/non-adherent
bandage,sub-q
administration set,
bifurcated,sub-q
administration set,
trifurcated,sub-q
administration set, quadfurcated,alcohol swab
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 300
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
brief,foley
catheter
tray,dover foley
catheter,curity
strmlin cath wmono-flo,curity
premium catheter
tray,add-a-foley
cath-mono-flo
drng,curity
bedside-mono-flo
drange,monoflo,tenderol,curity
ureteral drain
set,curity bedside
drainage
bag,simplicity
adult
poly,simplicity,ver
salon
washcloth,curity
washcloths,curity
urine meter,dover
red rubber
robibson
cath,dover
catheter,kendall,p
olyskin ii,kerlix
amd,dover bulb
syringe,wings,ker
lix burn
pack,monoject
safety syr tip
cap,curity
detectable
lap,simplicity
adult flat fold
xl,dover latex
foley
cap,tubular bandage
applicator,diaphragms, coil
spring,diaphragms, flat
spring,cholesterol test
kit,multiple test strip
device,syringe, disposable,
1ml,syringe wneedle,disposab,12ml,rib
belt,abdominal
brace,compression
pantyhose,
small,compression
pantyhose,
medium,compression
pantyhose,
large,compression
pantyhose,x-large,athletic
support,bed
pan,urinal,cushion,thermom
eter, electronic (rectal),blunt
filter cannula, disp.,soft lens
enzymatic cleanser,transfer
needle,hard lens soaking
solution,incont
device,muscle
toner,elt,alginate
dressing/hydrocolloid
dressing,incontinence bed
sheets,covers,venous flow
controller,home hiv test
kit,wetting soln gas,hard &
soft,acne scrub pad,lumbar
supports,contracept barrier
dev, vented,gas perm. lens
soaking soln,eye cup,plastic
bags,chemo
gowns,smocks,chemo spill
clean-up kit,incontinence
alarms,breast pump,iv
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 301
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
catheter,simplicit
y pants,curity run
arounds,curity
runarounds,curity
sleep
pants,kangaroo
gravity
set,excilon,tender
sorb,kangaroo
nasogastric feed
tube,curasilk,diap
ers-disppolyethylene
back,dover urine
leg bag,telfa
amd,kangaroo
epump set,curity
iodoform,curity
ultra
fits,tenderwrap
unna boot,kerlix
lite,monoject
insulin
syringe,curity
8000 urine
meter,hypodermi
c needle,curity
abdominal,curity
ultramer
catheter,rcra
hazardous
waste,kendall
container,dover
coated latex
foley,curafil,kend
all cloth,maxicare
underpads,wings
supreme,staput,wings
equipment/container,empty,
sterile field,chlorhexidine
gluconate,ring pessary,hard
lens soak-wet
solution,mercury spill cleanup kit,polyvinyl
alcohol/gentian
violet/methylene
blue,silver/foam
bandage,dressing,collagen/s
ilver/sod
alginate/carboxymethylcellul
ose,dressing,
collagen/sodium
alginate/carboxymethylcellul
ose,silver sulfadiazine/foam
bandage,transcutaneous
electrical nerve
stimulators(tens)/electrodes,
blood-glucose meter,for
mobile device,transfer
set/syringe,
disposable/bandages,compr
ession/tubing,gauze
bandage/lanolin alc/min
oil/petrolat/ceresin,zinc
oxide/gauze
bandage,polyquaternium6/gauze
bandage,polyquaternium6/non-adherent
bandage,polyquaternium6/adhesive
bandage,honey/hydrocolloid
dressing,eye drops
dispenser,sub-q insulin
pump, continuous glucose
monitoring (cgm)
syst,methylene blue/gentian
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 302
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
maxima,wings
fluff and
polymer,curistrip,bandaid,non-stick
pads,first aid
tape,first aid cloth
tape,first aid hurtfree
wrap,mirasorb,ba
nd-aid flexible
fabric,gauze
pads,rolled
gauze,soothing
non-stick,kling
rolls,ultraheal,spe
ctragel,lancets,co
mfort
lancets,super thin
lancets,polymem,
polywic,oasis
ultra,curasol
gel,curasol
hydrogel,wound
matrix,burn
matrix,neuropen,
neuropen
monofilaments,ca
reone,kinney
brand lancets,thin
lancets,ultra thin
lancets,incontrol
ultra thin
lancets,unilet
lancets,autolet
mini,lancing
device,advanced
lancing
device,unifine
violet/foam
bandage,diaphragms,
contoured,spirometer with
drug delivery adapters,pen
injector device,lancets with
blood glucose test
strips,thermometer, infrared,
non-contact,foam/gauze
bandage/lidocaine/chlorhexi
dine/isopropyl alcohol
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 303
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pentips,pen
needle,incontrol
pen needle,pen
needles,healthy
accents unifine
pentip,autolet
platforms,unifine
pentips
plus,unilet
lancet,unilet gp
lancet,alternate
site lancets,unilet
comfortouch,adv
anced travel
lancets,unilet
excelite,unilet
excelite ii,autolet
lite
clinisafe,unistik,a
urora super thin
lancets,incontrol
super thin
lancets,healthy
accents unilet
lancet,unistik
2,incontrol
lancing
device,autolet
lancing
device,healthy
accents
autolet,autolet
mkii
clinisafe,unistik
3,autoject
2,rapport vacuum
therapy,amielle
vaginal
trainer,rapport
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 304
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ring loading
system,autopen,n
eurotips,autodrop
,autosqueeze,ulti
care
syringe,ulticare,ul
ticare pen
needle,lancets
thin,lancets ultra
thin,fine 30
universal
lancets,medlance
plus,adjustable
lancing
device,insumed,i
nsupen,glucosour
ce,exel insulin
syringe,insulin
pen
needle,tuberculin
syringeneedle,exel tb
with needle,exel
tuberculin
syringe,exel
allergy
syringe,allergy
syringe,exel
syringe,exel
hypodermic
needle,exel mti
drawing
needle,psv set,iv
catheter,exel
huber,exel huber
needle,yale
needle regular
bevel,yale
needle,yale
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 305
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
needle short
bevel,special
needle,intraveno
us,arterial &
blood,yale needle
huber
bevel,pudendal &
parasympathetic,
whitacre spinal
needle,rosenthal,
osgood,security
bead needle,
local,klatskin,yale
glass tb
syringe,yale
syringe,syringe,c
ornwall syringes
luer-lok tip,plastic
adapter kit for
busher,cornwall
accessories &
parts,cornwall
metal pipeting
holder,tempaway
thermometer
sheath,yale
spinal
needle,quince
spinal
needle,allergist
syringe,allergist
syringe with
needle,allergist
tray,allergist
syringe
tray,tuberculin
syringe,yale
cleaner,asepto
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 306
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
bulb syringe
glass tip,pipette
30ml catheter
tip,pipette 45ml
catheter
tip,asepto bulb
syringe cath
tip,pipette 90ml
catheter
tip,pipette 120ml
catheter
tip,plastic adapter
for busher,bulk
syringe,syringe
bulk,luer-lok
syringe,needle,ca
nnula,interlink
syringe,lever lock
cannula,twinpak
dual
cannula,interlink
syringe wcannula,specialty
use
needles,regular
bevel
needles,needles,
precisionglide,yal
e needles,short
bevel
needles,blunt
needle,thin wall
needles,filter
needle,tampertuf,oral
syringe,nokor
needle,nokor
admix
needle,cornwall
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 307
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
syringe tip
connector,glaspa
k,integra
syringe,integra
needle,sharps
collector,onepiece sharps
collectors,sharps
container,safetylok safety
syringes,safetylok safety
syringe,medsaver
,syringe storage
bin,eclipse
needle,syringeneedle,eclipse
syringe,eclipse
syringeneedle,eclipse
luer-lok
syringe,safety
syringeneedle,syringe tip
cap,safetyglide
needle,safetyglid
e
syringe,safetyglid
e insulin
syringe,safetyglid
e tb
syringe,safetyglid
e allergy
syringe,safetyglid
e allergy,syringeluer tip cap,luerlok syringeneedle,safety-lok
syringes,syringeBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 308
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
precisionglide
needle,syringe
catheter tip,tb
syringe,luer-lok
tip
syringe,luerslip
syringe,bd ultrafine pen
needle,bd ultrafine,bd ultra-fine
ii,lancet
device,magniguide
magnifier,safeclip,auto
injector,autoshiel
d pen
needle,autoshield
duo pen
needle,paradigm
link blood
glucose,vacutain
er blood
transfer,luer-lok
access device,bd
microtainer
lancets,microtain
er lancets,safetylok collection
set,vacutainer
collection
set,brite sight
thermometer,insy
te
autoguard,insyte
iv
catheter,angiocat
h iv
catheter,angiocat
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 309
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
h,saf-t-intima iv
catheter,saf-tintima,nexiva,intr
osyte
autoguard,qsyte,e-z set
winged infusion
set,saf-t e-z
collection set,saft e-z
set,myelogram
tray,precise,ibgstar,haemolance,
retractable,assur
e id insulin
safety,hypolance,
advance
intuition,assure
pro,assure
platinum,assure
dose,assure
3,assure
4,glucocard
expression,pocke
tchem ez,multilancet
device,micro,relio
n micro,glucocard
01,glucocard 01
control,glucocard
01-mini,glucocard
x-meter
control,glucocard
xmeter,glucocard
vital,techlite
lancets,techlite
blood
lancet,techlite,ha
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 310
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
emolance,assure
haemolance
plus,assure
lance,haemolanc
e plus,ultilet
safety,ultilet
classic,ultilet
lancets,publix
lancet,ultilet
insulin
syringe,ultilet pen
needle,ultilet
basic,suresite
matrix,tenderwet
active,tenderwet
active
cavity,evencare
g2,safety
lancets,pressure
activated
lancets,silvasorb,
silvasorb
cavity,exuderm
odorshield,evenc
are,skintegrity,me
dfix
ez,stratasorb,bor
dered
gauze,exuderm
satin,evencare
g3,medigrip,carra
syn hydrogel
wound,blenderm,
transpore,microfo
am,micropore,dur
apore,steristrip,3m
nexcare,tegader
m i.v.,tegaderm
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 311
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
i.v.
advanced,medipo
re h,medipore
dressit,medipore,soft
cloth,medipore
plus pad,steristrip wound
closure
syst,tegaderm
hydrocolloid,tega
derm hydrocolloid
thin,tegasorb
thin,tegagen
hi,tegagen
hg,tegaderm ag
mesh,tegaderm
absorbent,tegade
rm
hp,primeaire,qua
ke,liteaire,mistern
eb
compressor,inspir
ation
elite,inspiration,si
destream,mistern
eb pediatric
compressor,innos
pire
elegance,mistern
eb
nebulizer,sidestre
am
mask,innospire
essence,micro
elite replacement
filter,minielite,mic
ro elite,pflex
trainer,assess,ast
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 312
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
hmapack
i,asthmapack
ii,asthmapack
iii,asthmapack
children's,thresho
ld imt,threshold
pep,asthma
check,asthmame
ntor,personal
best,optihaler,opti
chamber,pediatri
c
mask,sidestream
plus,inspiration
elite filter,micro
plus,innospire
replacement
filter,sidestream
nebulizer,sami
the
seal,litetouch,sa
mi the seal
filter,sami the
seal
mask,sidestream
pediatric,optionho
me,mini plus
nebulizer,mini
elite filter
replacement,optic
hamber
diamond,procha
mber,lo-profile
urostomy
pouch,contour
i,filter security
closed
pouch,stoma cap
w-micropore
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 313
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
adhesive,karaya
drainable ostomy
pouch,karaya
seal closed
stoma
pouch,centerpoin
tlock closed
pouch,stoma cap
w-deodor fltrflange,stoma cap
w/deodor
fltr/flange,karaya
5 drainable
pouch,premium
drainable
pouch,skin
barrier w-floating
flange,convex
syn barr w-float
flange,pouchkins
skin
barrier,pouchkins
pediatric
belt,pouchkins
pouch,pouchkins
drain
tube,pouchkins
drainable
pouch,pouchkins
urostomy
pouch,drainable
pouch with
flange,stoma
irrigator drain wflange,drain
pouch-filterflange,drainable
pouch w-filtrflange,drainable
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 314
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
mini-pouch wflange,cpl
drainable
pouch,drainable
pouch,urostomy
pouch with
flange,ostomy
belt,urostomy
drain tube
adapter,hollihesiv
e skin
barrier,stoma
combo cone-tube
irrg kit,stoma
cone w-connector
unit,stoma combo
cone,tube irrg
drn,medical
adhesive,adhesiv
e remover,odor
eliminator,m9clea
nerdecrystallizer,sto
ma
lubricant,adhesiv
e-barrier remover
wipes,filter
replacement,loop
ostomy bridge,
sterile,premium
skin barrier,adapt
barrier
ring,softflex skin
barrier,karaya,ad
apt stoma
powder,karaya
paste tube,skin
gel protective
dressing,premier
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 315
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
drainable
pouch,premier
urostomy
pouch,premier
lock n roll,premier
drainable minipouch,centerpoin
tlock flextend
skin,drainable
pouch
clamp,flextend
skin
barrier,premier
urostomy
pouch/flange,eve
ryday male
catheter,extende
d male
catheter,extensio
n tubing wconnector,urinary
leg bag,bag-strap
system,bagtubing
system,vent urin
leg bag
sys,combo
pk,wound
drainage
collector,universa
l catheter access
port,drain-tube
sterile clamp,horz
drain-tube attach
device,vertical
drain-tube attach
dev,suction tube
attachment
device,feeding
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 316
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
tube attachment
device,replaceme
nt
neckband,retract
ed penis
pouch,fecal
collector,
drainable,bedside
drainage
collection,female
urinary
pouch,vented
urinary leg bag
system,fecal
collector,new
image skin
barrier,new
image
flexwear,new
image skin
barrierflange,new image
flextend,new
image drainable
pouch,new image
irrigation
sleeve,new
image drainable
mini-pouch,new
image closed
pouch,new image
closed minipouch,new
image,new image
urostomy,new
image urostomy
pouch,new image
colostomy-ileo
kit,new image
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 317
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
kit,new image
drainable kit,new
image urostomy
kit,adapt,adapt
paste,adapt
barrier,adapt
convex
barrier,premier
closed minipouch,premier
pre-sized minipouch,premier
closed
pouch,premier
skn barr w-float
flang,premier
colostomyileostomy,premier
urostomy,advanc
e plus
intermittent,incar
e,fc condom,
female,two-piece
stoma
caps,closed-end
pouch,adhesive
barriers,adhesive
barrier,irrigation
sleeve,microskin
barrier,system
pouch,microderm
plus,one-piece
drainable
pouch,mini
drainable
pouch,urostomy
pouch,platinum
urostomy
pouch,mini
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 318
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
urostomy
pouch,one-piece
urostomy
pouch,microderm
,cymed seal,ilesorb,night drain
adapter,microskin
applicator,draina
ble pouch
closure,microhesi
ve stoma
paste,clickfine,reli
on pen
needles,thalaset,
neria,insuflon,tub
eguard,mouthpie
ce,expiratory,piko
1,pocket
peak,pocket
chamber,pediatri
c panda
mask,panda
mask,femcap,bio
brane,biobrane
dressing,biobran
e-l,biobrane-l
dressing,biobran
e gloves,pillow
mask,pillow mask
for
children,splash
shield full,splash
shield flex,splash
shield short,co
monitor
replacement t,co
monitor,disposabl
e paper
mouthpiece,miniBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 319
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
wright peak flow
meter,airzone &
miniwright afs,incheck oral,incheck nasal with
mask,in-check
dial,windmill
trainer,one way
mouthpiece,pedismall mouth
adaptor,pediatric
mouthpieces,airz
one peak flow
meter,one flow
fvc,one flow
spirometer,one
flow
mouthpiece,filtere
d mouthpiece
attachment,silico
ne
mask,breathrite,n
ose clip,rubber
mouthpiece,all
flow 1000,all flow
2000,all flow
3000 pft,all flow
3000 kit,all flow
4000,all flow
5000,all flow
6000,all flow
7000,easygluco
meter starter
kit,easygluco,con
trol,g-4,control
solution,infinity,inf
inity control
solution,acura
starter kit,acura
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 320
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
control solution
normal,acura
meter kit,acura
control
solution,acura
control solution
low,acura
plus,easygluco
plus,easygluco
plus control
normal,compact
ultrasonic
nebulizer,compac
t compressor
nebulizer,autolet
impression,autole
t plus,unistik
czt,unistik 3
extra,unistik 3
comfort,unistik 3
neonatal,ultraco
mfort,orsini
insulin
syringe,clearblue,
easy pro
plus,prodigy
count-adose,prodigy
mini-mist,prodigy
pocket,prodigy,pr
odigy
eject,prodigy
voice,prodigy
duo,prodigy
control
solution,prodigy
preferred,prodigy
autocode
pro,prodigy
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 321
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pocket
pro,prodigy voice
pro,prodigy twist
top lancet,prodigy
lancets,prodigy
lancing
device,prodigy
pen
needle,prodigy
insulin
syringe,actilance,droplet
lancets,easy
touch glucose
monitor,easy
touch lancing
device,easy
touch control
solution,easy
touch,easy touch
insulin
syringe,easy
touch pen
needle,omnipod,
1st choice
lancets,1st tier
unilet
comfortouch,1st
tier unifine
pentips,1st tier
unifine pentips
plus,iport,thinset,fifty50
safety seal
lancets,fifty50
reservoir,infusion
set,eclipse,eclips
e control
solution,envision,
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 322
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
evolution blood
glucose
meter,evolution
control
solution,element
blood glucose
meter,element
control
solution,smartdia
betes
xpres,smartdiabe
tes
vantage,element
plus,xpres,eleme
nt plus control
solution,glucolab
control,glucolab,s
martest,smartest
lancet,smartest
eject,smartest
protege,smartest
smart
code,smartest
talking,smartest
pronto,smartest
persona,glucoco
m blood
glucose,glucoco
m lancets,blood
glucose
meter,glucocom
control
solution,glucoco
m,glucocom
autolink,glucose
control
solution,glucose
control,bloodglucose
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 323
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
control,rightest
gm300
system,bionime
rightest gm300
system,rightest
control
solution,rightest
gd500,rightest
gm100
system,rightest
gm550
system,rightest
gl300
lancets,ge100
blood glucose
system,ge100
control solution
normal,nova
sureflex,sureflex,
nova max blood
glucose
meter,nova max
glucose control
soln,novamax
plus,novamax
plus glu-ket,nova
safety
lancets,keynote,
wavesense
control
solution,agamatri
x control,jazz
wireless
2,wavesense
presto,keynote
pro,wavesense
amp,presto
pro,liberty blood
glucose
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 324
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
meter,liberty
control
solution,vgo
40,vgo 30,vgo
20,ear
popper,sterilance
tl,cinis preemie
halo,restore
contact
layer,restore
contact layer
silver,restore,rest
ore trio,restore
duo,restore foam
heel
dressing,restore
odorabsorbent,restore
ex thin
hydrocolloid,resto
re hydrocolloid
dressing,restore
calcium
alginate,restore
hydrogel,restore
hydrogel
gauze,ultraflex,burns-scaldsabrasions,skin
closure,blister
care,bandages,m
edical id for
bracelet,medical
id for
necklace,riteflo,pr
ovent hr,provent
sr,provent,ultratra
k
pro,ultratrak,ultral
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 325
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ance,ultratrak
ultimate,safesnap
syringe,safesnap
insulin
syringe,safesnap
tuberculin
syringe,safesnap
allergy
syringe,conceptio
n,needle-pro
edge,solus
v2,solus v2
lancets,solus v2
lancing
device,solus v2
control
solution,caresens
n,caresens,smart
caresens
n,invacare
lancets,gdrive,de
xcom g4,seven
plus,seven
system
sensor,droplet
lancing
device,syringe
without
needle,filter
connector,lifeshie
ld blunt
cannula,transfer
needle,bone
marrow aspir
needle,filter
aspirator
needle,allergist
tray syr-perm
needle,monoject
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 326
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
allergy trayneedle,monoject
tuberculin
syringe,allergist
tray syr-detach
ndl,monoject
insulin safety
syrng,monoject
tuberculin safety
syr,monoject
control
syringe,monoject
syringe pharmacy
tray,monoject
safety
syringe,safety
syringe with
shield,monoject
smartip
cannula,monolet
lancets,monoject
or lancet
device,monolet
thin
lancets,sharps
container
accessory,glove
box,monoject
magellan,finger
grip
extender,magella
n tuberculin
syringe,monoject
megellan tb
syringe,magellan
insulin safety
syrng,magellan
insulin
syringe,oral
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 327
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
medication
syringe,extender
caps,kangaroo
pet carrying
case,kangaroo
pet pump
frame,kangaroo
pet charging
cord,petrolatum
gauze,xeroflo
gauze
dressing,viasorb,
blisterfilm,ultec,qtips wood stick
applicator,interso
rb,expandover,ka
ngaroo enteralfeed-irrig
kt,kangaroo
pump extension
set,kangaroo
500ml pump
set,kangaroo
deluxe pump
set,kangaroo
pump
set,kangaroo
1000ml gravity
bag,kangaroo
1200ml deluxe
pump
st,kangaroo
proximal spike
pmp st,kangaroo
screw cap pump
set,kangaroo
1600ml deluxe
pump
st,kangaroo y-site
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 328
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
extension
set,kangaroo
1200ml rigid
containr,kangaro
o rigid
container,kangar
oo plyurethane
feed
tube,kangaroo
100ml rigid
burette,texas
catheter,elastic
foam strap,uridrain,two-sided
adhesive
strap,catheter
with
strap,vaseline
constant
care,rob-nel pvc
catheter,terumo
insulin
syringe,terumo
surguard2,thinpro
insulin
syringe,terumo
surguard,terumo
allergy
syringe,terumo
syringe,terumo
hypodermic
needlesyrin,medihoney,
premier skn barr
w/float
flang,sensitive
eyes
saline,sensitive
eyes
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 329
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
drops,sensitive
eyes plus
saline,sensitive
eyes daily
cleaner,renu
multi-purpose,bio
true,renu
rewetting
drops,renu
multiplus,boston
advance
cleaner,boston
conditioning
solution,boston
simplus
solution,re-nu
fresh,boston
cleaner,smoker's
polident,polident,
super poligrip,sensodyne,d
entucreme,dentugel,super
wernet's
denture,ctub,gallon jug
with pump,jetcospray
cannula,dee
fog,zarosen,varn
al,release,mixing
container with
lid,reveal
pregnancy
test,reveal
ovulation
predictor,stik
it,reveal blood
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 330
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
glucose
meter,reveal get
pregnant
quick,reveal
ovulation
test,mesalt,mepil
ex,tendra mepilex
border,probe
covers,digital
thermometer,und
erpad,bladder
control pad,water
shield
bandages,antibac
terial
bandages,foam
bandages,gauze
bandage,stretch
gauze
bandage,shield,u
ndergarment,brief
,lamb's
wool,fabric
bandage,adhesiv
e pads,clear
bandages,flexible
bandages,plastic
bandages,banda
ges sheer,callus
pads,sheer
bandages,sterile
pads,adhesive
tape,dental
adhesive,hypoallergenic
bandages,cotton
swabs,color
lancets,cosmetic
puffs,cosmetic
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 331
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
squares,dental
floss,flexible
bandage,elastic
bandage,baby
wipes,pregnancy
test,strong
strips,waterproof
strong
strips,multipurpos
e contact lens
soln,saline
solution,saline
sensitive
eyes,fever flash
thermometer,dent
ure,combine
abd,toothbrush
precision
head,toothpaste,
cotton
balls,bandage,cot
ton
squares,cosmetic
balls,toothbrush
adult deluxe,lens
lustre eyeglass
cleaner,toothbrus
h, total,pill box,pill
planner,pill
divider with pill
box,medicine
dropper,medicine
spoon,forehead
thermometer,ther
mometer,thermo
meter probe
covers,brief,
medium,ep
brief,heatwraps,b
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 332
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
andage
roll,breatherite,o.
a.d.,woun'dres,co
mfeel
plus,comfeel plus
clear,comfeel
plus
triangle,comfeel
plus
contour,comfeel
plus pressure
relief,comfeel
ulcer
care,comfeel,com
feel film,female
self catheter,selfcath,coloplast
skin
barrier,coloplast
paste,ostomy
paste,coloplast
barrier
ring,coloplast,col
oplast drainable
pouch,coloplast
closed
pouch,irrigation
set,assura
irrigation face
plate,assura 2pc
irrigation
sleeve,filtrodor
pouch filter,pouch
clamp,assura
flange,assura
wound
manager,assura,
assura flange
convex,assura
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 333
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ostomy
belt,comfeel
seasorb,assura
2pc
drainable,assura
pouch,assura
standard
wear,assura
pediatric
pouch,comfeel
purilon,conveen
coude intermtnt
cath,conveen drip
collector,assura
easiclose,assura
non-convex
drainable,urosto
my night
bag,biatain,assur
a extra,assura
two-piece uro
minicap,assura
light easiclose
drain,assura
ac,urostomy
multichamber,urostom
y multi-chamber
pouch,urostomy
micropouch,easiclose
wide
outlet,coloplast
paste
strip,sensura
easiclose wide
outlet,sensura
click ostomy
pouch,sensura
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 334
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
flex ostomy base
plate,sensura
ostomy base
plate,sensura flex
ostomy pouch,ice
bag,overnites,sur
e choice
pantiliners,belted
undergarment,wi
pes,diapers,sensi
tive baby
wipes,bladder
control pads for
women,briefs for
men & women,ezject
lancets,panty
shields,tugaboos
diapers,maxi
pads,panty
liners,hot-cold
compress,multiuse cold
pad,back & neck
cold pad,cloth
first aid
tape,selfgrip,finge
r splints,finger
sleeves,rewetting
,super strip
bandages,flexible
fabric
bandage,flexible
fabric
bandages,tugabo
os
overnights,under
wear for
men,premium
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 335
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
baby wipes,clear
spot
bandages,ovulati
on predictor,kid
pants,protective
underwear,surec
hoice,pantiliners,
dental travel
pack,briefs xlarge,cotton,
sterile,sheer
plastic
strip,disposable
razor,adhesive
bandage,fabric
strip extra
large,pro sports
tape,ice
cap,water
bottle,water
bottle-fountain
syringe,foam
insole,cushion
insole,super
moleskin,over
nites,instant ear
thermometer,viny
l gloves,multipurpose
solution,eye
patch,instant heat
therapy,hearing
aid batteries,latex
gloves,true2go
blood glucose
system,self
grip,cotton
gloves,underpads
,soft touch pill
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 336
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
reminder,linen
fresh,hot & cold
therapy
brace,instant
heat,heat therapy
patches,moist
towelettes,ultra
fine cut n
crush,tablet
cutter,nail
clip,toenail
clip,nail
nippers,disposabl
e probe
covers,alkaline
batteries,toenail
nipper,finger
splint,tubular
gauze,non-slip
underpads,delux
e
underpads,blood
pressure
monitor,underwe
ar for
women,foam ear
plugs,guards for
men,underwear
menwomen,blood
pressure cuff
monitor,boxers
for men,surgical
dressing,contact
lens cases,paper
tape,cleaning &
disinfecting
lens,callus
cushions,plantar
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 337
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
fasciitis arch
sleeve,gel bunion
cushion,clear
bandage,pain
free tape,flexible
foam pad,push n
pop pill
reminder,medicin
e dropper &
spoon,am-pm
locking pill
reminder,soft-tip
thermometer,und
erwear for men &
women,tugaboos
training
pants,quiet
please foam ear
plugs,blood
glucose
monitor,flexible
foam
bandage,disposa
ble brief,daily
cleaner,rewetting
drops,one step
ovulation
test,truetrack
smart
system,gauze,bla
dder control,heat
wraps,basal
thermometer,hyp
o-allergenic
bandage,blood
pressure
kit,tender
tape,skin closure
strips,flex fabric
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 338
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
bandage,comfortstretch,premium
comfortstretch,gauze
dressing,one step
pregnancy
test,comfortsmooth,fitted
briefs,fitted
brief,blister
relief,ultra-soft
gloves,premium
nitrile
gloves,quick
read,adult
wash,certainty,to
e separators,gel
toe spacers,gel
toe protector,arch
bandage,gel corn
protectors,sleep
pants,truetrack
blood glucose
system,trueresult
blood glucose
systm,flight ear
plugs,sterile
bandage
roll,gentle
adhesive
bandages,plastic
adhesive
bandages,sheer
adhesive
bandages,confor
ming rolled
gauze,deluxe
arm bp
monitor,premium
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 339
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
arm bp
monitor,premium
baby
diaper,premium
training
pants,flushable
cleansing
cloths,face
mask,non-stick
pad,micro thin
lancets,ultra-light
rollator,scar
treatment,cloth
tape,trueplus
lancets,pain free
wrap,self
adherent
wrap,gel bunion
guard,sorespot,al
l gel bunion toe
spreader,well
beginnings sleep
pants,e.p.t.,e.p.t.
digital,e-z
spacer,vanishpoi
nt,syringe with
needle disp,sheer
spot
bandages,blood
glucose
monitoring,premi
um blood
glucose,accuchek spirit,sew-in
pocket,accu-chek
tender,accu-chek
rapid d,accuchek,d-tronplus
adapter,accuBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 340
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
chek
ultraflex,accuchek ultraflex
ii,sport belt,accuchek d-tron
plus,flexlink plus
infusion
set,foracare
gd20,choicedm
g20,fora
v30a,fora
g71a,foracare
gd40a,foracare
gd40b,premium
v10,fora
v12,kimono,kimo
no maxx,kimono
microthin,kimono
microthin aqua
lube,kimono
textured,digitex
gold,rid,devilbiss
pulmomate,pulm
o-aide,devilbiss
pulmoaide,devilbiss
disposable
nebulizer,devilbis
s
compact,sunrise
compressornebulizer,devilbis
s
traveler,cytosafe
dipensing
pin,exactamed,dual rate
syringe
infuser,bifurcated
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 341
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
fluid tran tube
set,exactamix,elbow
inlet,gravity
mixing set,luer
lock-to-bag,fluid
transfer
extension set,vial
adapter,bag
spike,oral liquid
transfer tube
set,micro volume
inlet,fluid transfer
set,calibration
bag,dual rate syr
infuser
tubing,minibore,
microfuse
minibore,pole
clamp,em2400
valve set,exactamix
calibration,exacta
-mix
eva,micromacro,s
terl fluid transfer
tube set,topical
tip cap,topical
cream
dispenser,topical
dispenser,sterile
fluid tran tube
set,syringe filling
fixture,oral liq
bag-tube set
combo,repeater
pump
stand,pharmacy
pump stand,0.2
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 342
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
micron filter
attachment,gel
bag & tube set
non-sterile,sterile
exacta-med
dispenspin,tamperresistant bag
cap,sterile top fill
bag,sterile empty
collection
bags,adaptacap,microfuse,trif
urcate fluid tran
tube
set,pharmacy
pack liquid
dispenser,repeat
er pump,vaginal
cream
dispenser,luer to
urethral tip
adapter,luer to
catheter tip
adapter,sterile
rapid fill
connector,sterile
gel bag,sterile
two-fer
needle,exactamed tip
extender,supor,la
bels, 1.5" x
1.5",kwikvial,kwik-vial
filling
extension,kwikvial plug
dispenser,t.i. seal
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 343
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
non-sterile
foil,bottle
adapter,3-way
oral port
stopcock,rapid fill
adapter,sterile
rapid fill
adapter,oral-tooral rapid fill
connec,mark-adose,oral
labels,shrinksafe,
port saver sterile
inject port,vaginal
dispenser tip
cap,tip caps, nonsterile,exactamed tip cap,luer
lock tip cap,luer
lock tip caps,
sterile,sterile luer
slip tip caps,luer
slip tip caps,selfrighting luer slip
tip,catheter tip
cap,locking,selfrighting luer tip
cap,self-righting
luer lock
tip,bedside pack
liquid
dispenser,ward
pack liquid
dispenser,neothri
ve,rapidfill,comfort
bath,toothette,qcare rx,reality,first
aid paper
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 344
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
tape,first aid
skintone
paper,first aid
plastic tape,first
aid waterproof
tape,air warming
mask,dust &
pollen filter
mask,germ filter
protective
mask,cold
comfort,trueplus
insulin
syringe,brush 'n
floss,proview eye
pressure
monitor,autolancet mini,injectease,insuleze,insulcap,insultray,reconstitube,
deluxe tablet
cutter,zymogeneti
cs spray
applicator,vicks
warm steam
vaporizer,health
mist,vicks cool
mist,vicks warm
mist,vaporizer,vic
ks digital
thermometer,vick
s forehead
thermometer,ther
moscan,cetylcide
g,hyde-out,power
cleaner,cetylzyme,replacemen
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 345
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
t j-4
cannula,mepilex
border,mepilex
ag,mepilex
border
sacrum,mefix,lite
touch,medilance,aurora
healthcare
lancets,phaseal
protector,phaseal
injector
luer,phaseal
connector
luer,phaseal
adapter,phaseal
y-site,phaseal
assembly
fixture,phaseal
infusion,phaseal
secondary
set,saline,kotex
fresh & dry,kotex
overnight,depend
,huggies,huggies
pull-ups,huggies
baby
wipes,goodnites,
depend
silhouette,depend
real fit,poise
pads,depend
guards for
men,kotex
security,poise
liners,depend
overnite,depend
protection,huggie
s
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 346
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
goodnites,goodnit
es sleep
shorts,huggies
ultratrim,lavender
nitrile exam
glove,huggies
overnites,topcare
belted
shield,topcare
underpad,topcare
maxi
overnight,topcare
pantiliner,topcare
male
guard,topcare
liners,topcare
pads,topcare
maxi
pads,luvs,pamper
s
premium,pamper
s ultra dry
thin,pampers
babydry,pampers
unisex,pampers
cruisers,underja
ms,pampers easy
ups,pampers
extra
protection,pampe
rs swaddlers
sensitive,pamper
s
preemie,pampers
swaddlers,pampe
rs,newborn babydry,washcloth,pa
mpers
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 347
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
premature,pampe
rs ultra
dry,pampers
newborn,pamper
s rash
care,pampers
premie,luvs
overnight,pamper
s nonelasticized,pamp
ers ultra
phases,ultra +
pampers,pamper
s thick
phases,pads,refu
ah plus,refuah
plus glucose
control,sleep
overs,cuties,cutie
pants,glucopro,a
migo insulin
pump,hugo
cane,hugo rolling
walker,hugo
transport,hugo
folding
walker,airgo
rolling
walker,universal
1,smart sense
lancets,topcare
universal1 thin
lancet,ultra thin
plus,smart
sense,ultra thin
plus
lancets,topcare
ultra
comfort,renew
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 348
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
advanced microlancets,renew
advanced lancing
system,topcare
clickfine,bullseye
mini safety
lancets,sms
glucose
control,safetylet,safety seal
lancets,aqua
lance lancing
device,easy twist
& cap
lancets,surechek
glucose
control,sure edge
blood glucose
meter,sure edge
glucose control
soln,alternate site
lancing
device,vocalpoint
glucose
control,vocal
point glucose
control,one step
at a time,cane
tips,cane,crutch
tip,hand
grips,crutch
accessory
kit,underwear,hu
midifier,crutch,co
ol mist,super
underpad,regular
pad,super
pad,cervical
collar,oral
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 349
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
thermometer,bab
y
thermometer,femi
nine combination
syringe,fountain
syringe,feminine
folding
syringe,feminine
bulb
syringe,vaporizer
inhalant,vaporizer
cleaning
tablets,feminine
compact travel
syrnge,attachme
nt set,enema
syringe,nasal
aspirator,rectal
syringe,wheelcha
ir,acapella,lipo
cream
base,shrink
band,plastic
white hdpe
bottle,amber
round glass
bottle,topiclick,bottletop
dispenser
adapter,unguator
lid,syringe filter,
millexgp,precisedose
dispenser tip
cap,megapump
mezzo,megapum
p airless,rectalvaginal
perforation
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 350
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
tip,sterile clear
glass vial,amber
glass serum
bottle,topi-click
filling
nozzle,enema
bottle,adapter
cap,glass
graduated
cylinder,precised
ose dispenser
syringe,posidyne
eld,suppository
shell,syringe
filter, millexgs,adapter pressin bottle,troche
mold,thermophor
e,thermophore
maxheat,ice
it!,thermophore
arthritis,opsite iv
3000,no-sting
skin-prep
swab,exu-dry slit
tube,conformant
2,drynet,replicare
ultra,replicare
ultra
sacrum,acticoat,a
cticoat 7,acticoat
absorbent,aquap
hor gauze,hot &
cold
compress,sports
tape,ear
thermometer,non
adherent
pads,nonBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 351
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
adherent,adhesiv
e
bandages,adhesi
ve foam
bandages,baby
darlings
wipes,baby
darlings
diapers,combinati
on water
bottle,thong
liners,tampons,ex
tra absorbent
undergarment,pu
re
cotton,feminine
cleansing
cloths,lice
removal
comb,heating
pad,personal
washcloths,traini
ng
pants,compmist
compressor
nebulizer,minico
mp compressor
nebulizer,earloop
masks,cone
masks,instant
cold
pack,transport
chair,selfgrip,deluxe
instant,lubricating
&
rewetting,everyda
y long
pantiliners,sheer
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 352
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
strips,clear
strips,plastic
strips,personal
confidence
pads,beltless
undergarments,p
ersonal
confidence
briefs,overnight
brief,personal
confidence
underpad,flexible
foam strips,slipon
undergarments,b
aby basics,basics
for kids,butterfly
closures,heavy
duty fabric
strips,personal
confidence
liners,overnight
protective,clear
waterproof
strips,natural
care
bandages,camo
bandages,person
al confidence
underwear,protec
tive barrier
wipes,reliamed,re
liamed mini
lancing
device,reliamed
safety seal
lancets,transpare
nt thin film
dressing,transpar
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 353
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ent i.v. site
dressing,ostomy
protective
powder,incontrol
bp
monitor,microlife
peak
flow,stomahesive
protective,flexiseal
fecal,surepress,ul
ti-lance,lc d
nebulizer set,lc
plus,baby
nebulizer,lc
star,sinustar,pari
lc plus
nebulizer,lc sprint
nebulizer,pari
sinus aerosol
system,pari lc
sprint sinus,vios
aerosol delivery
system,filter,
valve set for ll &
lc,filter pad,filters
replacement,bab
y conversion
pack 1,baby
conversion pack
2,mask set with
y-piece,mask
vortex,vortex,bub
bles the fish
ii,wing tip
tubing,adult
aerosol
mask,vortex
ladybug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 354
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
mask,vortex frog
mask,trek s
portable pwr
kit,trek s combo
pack,trek s
compact
compressor,alter
a nebulizer,eflow
scf,eflow scf
aerosol
head,eflow scf
nebulizer
handset,smartma
sk kids,proneb
ultra,proneb ultra
ii,proneb ultra ii
deluxe,elasto-gel
hot & cold
wrap,elastogel,elasto-gel
plus,toe aid
dressing,elastogel circle
dressing,elastogel cast-splint
padding,boston
rewetting
drops,boston one
step,microspacer,
microchamber,ea
symax v
speaking,easyma
x v,easymax
speaking,easyma
x v2,easymax
l,easymax
n,easymax,easy
max ng,easymax
15,easyplus
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 355
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
r13n,easyplus
v,anti-embolism
stockings,truform
compression
stocking,puralin,s
urgilance
lancets,cut n
crush,moist
wipes,cold
wrap,cold pack
back pad,tennis
elbow
brace,ankle
brace,elbow
support,knee
brace,ace back
support,knee
stabilizer,elbow
strap,wrist
support,ankle
support,ace ankle
support,arm
sling,elbow
brace,knee
support,deluxe
laced ankle
brace,backshoulder ice &
heat wrap,multipurpose ice &
heat wrap,wrist
brace,deluxe
ankle
brace,contoured
back
support,back
stabilizer,deluxe
back
stabilizer,maxi
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 356
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
super,maxi
deodorant,maxi
regular,thumb
stabilizer,deluxe
wrist
stabilizer,hand
support,warm
steam
vaporizer,selfadhering,flushabl
e moist
wipes,ankle
stabilizer,ace
aerosol cloud
enhancer,easiven
t,daily pill box,hot
& cold
pack,medilice,sheer
adhesive,medico
ol's
diasox,thermipaq,
myglucohealth,m
yglucohealth
lancets,myglucoh
ealth control
solution,nessi
spacer,protective
pads,jumbo
diapers,supreme
diapers,diapers
mega,kidpant,abs
orbent cotton
balls,stretch
bandage,sheer
strip,blood
glucose monitor
kit,bladder control
pad ultra,guard
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 357
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
male,plastic
swabs,diaper,inst
ant cold therapy
wrap,sleep
comforts,gentle
tape,gloves,nonadhesive
pad,overnight
briefs,cleansing
wipes,saline
sensitive,aloe
vera latex
gloves,flexible
dressing,gauze
sponges,eye
pad,adhesive
dressing,selfadherent gentle
wrap,blood
pressure
cuff,contact lens
relief,flex
bandage,ear
plugs,suresite
window,procedur
al face
masks,advanced
non-stick
dressings,nonstick
dressings,surgica
l dressings,allpurpose
dressings,dressin
g sponges,cold
pack,x-abs
underwear,foam
toe bandages,all
purpose cloth
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 358
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
tape,corn
cushion,flex
finger
bandage,callus
cushion,moleskin
plus,first aid
kit,nitrile exam
gloves,portable
sharps
disposal,triple
layer non-stick
pad,qwikstrip,premium
adult wash
cloths,peas cold
therapy,arthritis
heatwraps,calciu
m
alginate,hydrogel
dressing,hydrocol
loid
dressing,contact
lens
case,household
burn kit,reusable
instant heat
pack,elastic
stretch
net,women's
underwear,men's
underwear,weekl
y vitamin
planner,saline
4,disposable
latex-free
gloves,overnites
diaper,adhesive
gauze
pad,needle
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 359
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
collection &
disposal,rolled
absorbent
cotton,iv prep
antiseptic,coverle
t o.r.,allevyn
plus,blairex
sterile saline
soln,assess peak
flow
meter,personal
best peak flow
meter,coaguchek
,accu-chek safet-pro
plus,chemstrip bg
diary,soft
touch,accu-chek
voicemate,accuchek safe-tpro,softclix,accuchek
softclix,microdot,
3m nexcare
stomaseal,microp
ore paper
surgical
tape,blenderm
surgical
tape,durapore
cloth surgical
tape,opticlude,sto
maseal,nexcare
gentle paper
tape,3m nexcare
durapore,nexcare
all purpose
mask,futuro
restoring,futuro
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 360
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
antiembolism,nexcar
e tegaderm,paper
first aid
tape,amniscreen,
metercheck,normject,aimsco,aimsc
o ultra thin
ii,aimsco mini
ultra-thin ii,ultrathin ii,ultra thin
ii,ultra-thin ii
lancets,pcca
accupen15,supposistrip,u
niversal
sleeve,vaginal
cream
applicator,suppos
itory box,filter,
millex-or
syringe,boston
round
natural,vaginal
suppository
applicator,bottle,l
uer lock
adapter,filter,
millex-fg
0.2um,suppositor
y shell,
small,suppository
shell,
medium,syringe
tip rectalvaginal,freedom
precision
airless,advanced
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 361
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
antibacterial
bandage,antibact
erial
bandage,antibact
erial pad,temple
thermometer,fast
read
thermometer,chil
d ear
syringe,infant ear
syringe,watchhal
er,carra sorb
h,carra sorb
m,carra
film,diab,pump
for whirlpool
solution,shampoo
& body wash
dispenser,radiafd
g,carrasyn
gel,gauze
packing
strip,wound
dressing,gel
pad,carrasyn
spray gel,carra
gauze
strips,carra
gauze,carrasyn
v,carracolloid,ultr
a-klenz,dermal
wound
gel,primary
dressing,incontin
ence skin
care,carrasmart,c
arradres,radiadre
s,carraginate,sur
esite
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 362
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
iv,suresite,suresit
e
flexigrid,arglaes,a
rglaes
film,arglaes
island,optifoam,e
xuderm
rcd,exuderm,exu
derm lp,exuderm
ultra,exuderm
sacrum,dermagel,medfix,maxor
b,maxorb
extra,tenderwet,e
z smart,ez smart
lancets,ez smart
plus,onetouch
ultra control
soln,one touch
delica,onetouch
verio iq,one touch
verio,onetouch
delica,onetouch
finepoint
lancets,onetouch
suresoft,onetouc
h
ultramini,onetouc
h ultra
system,one touch
glucose control
soln,onetouch
verio,one touch
basic
system,surestep,
penlet plus blood
sampler,onetouc
h
lancets,onetouch
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 363
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ultra2,onetouch
ultra
smart,onetouch
ultralink,surestep
control
solution,surestep
pro,grx wound
gel,alligator
spoon,pre-moist
pads,replacemen
t
pads,aerochamb
er,one touch
lancets,ultra fine
lancets,opsite
flexigrid,opsite,all
evyn cavity
wound
dress,algisite,unif
lex,needle free
syringe kit
a,medi-jector
vision,needle free
syringe kit
b,needle free
syringe kit
c,medi-jector
needle-free syr
a,medi-jector
needle-free syr
b,medi-jector
needle-free syr
c,truedraw,starter
kit,life medical
starter,diabetic.co
m starter,prestige
meter,prestige,pr
estige value
pack,truetrack,tru
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 364
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
econtrol,truetest
glucose
control,sidekick,p
restige smart
system,prestige
smart system
iq,liberty lev 1
glucose
control,liberty lev
2 glucose
control,liberty
monitor,breathe
right,medisense
thin
lancets,medisens
e glucose
ketone,medisens
e glucose ketone
contr,medisense,
precision
xtra,optium,precis
ion,unistik 2
normal,unistik 2
extra,steritamp,elon nail
care
system,flutter,2te
k,e-z spacer
pedspak,wonderp
ants,up & up
maxi pads,up &
up baby
diaper,telcare,telc
are control
solution,sure-ject
insulin
syringe,surelance,sure-fine
pen
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 365
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
needles,sure-test
easyplus
mini,suretouch,surepen,heartstream
fr2,deltec
cozmo,infusion,in
sulin
cartridge,adapter,
belt clip,gripper
plus,deltec
cozmo cleo
infusion
set,amerigel,der
mafilmhd,dermasyn,der
magauze,dermav
iew,dermaview
ii,dermafilm,derm
aginate,dermadre
ss,dermalevin,fle
xzan adhesive
dressing,hydrocol
ii,sorbsan,vial,ste
rile,empty,maxifill
transfer set,iv
transfer
spike,steri-tamp
seal,chemo
transfer pin,floweze,mini transfer
pin,hi-volume
pumping
chamber,transfer
pin,universal
syringe tip
adaptor,promogr
an
prisma,promogra
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 366
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
n,actisorb,silverc
el,tear flo,scar
care,accu-chek
aviva
plus,coaguchek
xs,accutrend
cholesterol,accutr
end
glucose,accutren
d plus,accu-chek
fastclix,accu-chek
compact blue
control,coaguche
k xs pro,accuchek nano
smartview,accuchek
smartview,comfor
t,cartridge
pump,contact
detach infusion
set,cartridge
stamped,onetouc
h ping,insulin
pump,cartridge,in
set infusion
set,animas
2020,inset 30
tubing,infusion
pump,comfort
short,inset 30
infusion
set,ultima,gelpad,
woundgard
gauze,coolmagic,
triple helix
collagen,foam
dressing,sanizone ostomy
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 367
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
deodorant,primab
ella,flexi-seal
fms,little ones
active life
pouch,active life
drainable
pouch,active life
urostomy
pouch,sur-fit
natura
stomahesive,acti
ve life
convex,kaltostat,
kaltostat
fortex,active life
stoma cap,active
life closed-end
pouch,duoderm
cgf,combiderm
acd,sur-fit
autolock
stomahesive,surfit autolock
durahesive,sur-fit
autolock drain
pouch,sur-fit
autolock
pouch,sur-fit
natura drainable
pouch,sur-fit
natura closedend pch,sur-fit
natura minipouch,sur-fit
natura urostomy
pouch,sur-fit
natura pouch,surfit natura high
output,sur-fit
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 368
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
autolock,sur-fit
natura
durahesive,sur-fit
natura flange
cap,visi-flow
irrigation
sleeve,visi-flow
irrig starter
set,sur-fit nat irrig
faceplate,sur-fit
natura little
ones,little ones
drainable
pouch,little ones
urostomy
pouch,little ones
closed-end
pouch,visi-flow
irrigator stoma
cone,carboflex,aq
uacel-ag,esteem
synergy,stomahe
sive,durahesive
moldable
convex,esteem
drainable
pouch,little ones
skin
barrier,duoderm
hydroactive,duod
erm,visi-flow
sleeve tail
closures,visi-flow
stoma
cone,convatec
night drainage
tubing,sur-fit
natura convex
inserts,ostomy
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 369
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
appliance
belt,sur-fit-act
life-tail
closures,aquacel,
duoderm
signal,versiva,ver
siva xc,allkare
adhesive
remover
wipes,allkare
protect barrier
wipe,flexi-trak
anchoring
device,unnaflex,saf-gel,sur-fit
autolock
inserts,sur-fit
natura
adaptor,sur-fit
natura lowpressure,duolock
curved tail
closure,eakin
cohesive
seals,convatec
night drain
container,esteem
+ closed
pouch,esteem
closed
pouch,natura
closed
pouch,esteem
synergy closed
pouch,flexi-seal
signal
fms,stomahesive
skin barrier,eakin
cohesive
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 370
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
slims,aquacel
foam,natura
durahesive skin
barrier,natura
stomahesive skn
barrier,aquacel
extra,harmonie,dr
y comfort
extra,tena,dry
comfort,tena
pants,tena
classic,tena
stretch ultra,tena
classic plus,tena
protective
underwear,flexiflo
,y-port
connector,flexiflo
top-fill,flexiflo
feeding
tube,flexiflo topfill bag,enteralite
infinity,flexiflo
magnaport,magnaport,flexiflo overtheguidewire,flexiflo
easy-feed
500,flexiflo top-fill
enteral
bag,flexiflo
quantum,compan
ion pump,durag,nasoenteric
tube,embrace,em
brace
adapter,embrace
bag set,flexiflo
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 371
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
toptainer,flexiflo
feeding
bag,embrace
pole
clamp,quantum
pump,patrol,gravi
ty feeding
set,tranquility
premium
underwear,atn
brief,select
underwear,select
disposable
briefs,select
underpads,diaper
booster
pad,tranquility
topliner
pads,select kids
briefs,self-taking
blood
pressure,a.i.r.s.
nebulizer,airs
disposable
nebulizer,airs
adult aerosol
mask,airs
pediatric
disposable
mask,comp-air
elite compressor
syst,reusable
nebulizer kit,air
tube with air
plugs,micro
air,comp-air
nebulizer
compressor,peak
-air,women's
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 372
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
advanced bp
monitor,stethosco
pe,visine for
contacts,bengay
moist heat
therapy,ezo,avog
el,sofsensor,guardian
transmitter
tape,guardian rt
starter
kit,paradigm realtime,guardian
realtime,guardian rt
system,replacem
ent pediatric
monitor,minimed
reservoir,1.5 volt
batteries
#357,polyfin,sofset,paradigm
insulin pump
pathway,polyfin
qr,sofserter,paradigm
infusion,quick
release soft
teflon,sof-set
micro,paradigm,p
aradigm
silhouette,silhoue
tte,silserter,quick-set
paradigm,minime
d,guardian test
plug,minimed
infusion,medtroni
c remote
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 373
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
control,paradigm
remote
control,paradigm
insulin
pump,revel
programmable
pump,guardian rt
charger,minilink
real-time
transmitter,suret,sure-t
paradigm,mio
infusion set,senserter,supreme,te
na
underwear,carefr
ee
pantiliners,bulkee
ii,day & night
brief,thermometer
tip
covers,urological
catheter,active
cath,3 step skin
care,step 2moisture
cream,step 3moisture
barrier,step 1incontinent
cleanser,ultrafresh,sleeve
closure
clamp,irrigation
syringe,enema
bag with
catheter,mountin
g ring,elastic
belt,shut off for
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 374
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
5000 enema
bag,lubriwipe,compact
irrigator,colostokit
irrigator,hospital
pack
irrigator,colostom
y barium enema
kit,female
specimen
catheter,tubing
for irrigator,shut
off for
tubing,quick
disconnectconnector,insertio
n tube
catheter,shield
for insertion
tube,travel
case,laird
tip,freedom t-tap
leg bag
kit,freedom leg
bag,tube &
connector
kit,freedom twist
port leg bag
kit,colostotip,colo
stotip w-quick
disconnect,freedo
m pak
seven,freedom
cath,response
ii,touch ii,piston
ii,economy
pouch,mini-drain
open end
pouch,doubleBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 375
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
hesive,e-z
hold,gizmo foam
straps,uro-san
plus,clear
advantage,contin
ent urinary
catheter,colostop
ads,cone
tip,dermaguard,uro-san leg
bag,plastic
connector,deluxe
leg bag
straps,comfort
leg bag
straps,freedom
drainage
bag,gizmo,bandaid activ flex,seal
tight,on call plus
meter,on call plus
control,on call
plus lancing
device,on call
plus lancet,on
call lancet,on call
lancing device,on
call vivid
meter,on call
vivid control,tens
502,tens
504,neurostimula
tion
electrodes,mask
set,erapid
nebulizer,erapid
nebulizer
handset,baby
conversion
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 376
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
kit,vortex vhc
ladybug
mask,vortex vhc
frog mask,sure
comfort,poly hub
needle,sure
comfort
lancets,sure
comfort lancing
pen,securely
yours,quickables
washcloths,ezsorb,attends,atte
nds
undergarments,at
tends
insert,attends
underwear,attend
s
guards,tissuepak,
attends light
insert,attends
booster,attends
disposable
underpads,gmate
control
solution,gmate
voice
starter,gmate
voice meter,gluco
navii,lancing
system,choicedm
clarus control
soln,choicedm
clarus,quintet,blo
od glucose
control,quintet
ac,nasoneb nasal
nebulizer,aeroecli
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 377
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pse,aerochamber
plus z
stat,monaghan z
stat,easy check
control
solution,easy
step,easy
plus,easy
trak,easy
talk,easy plus
ii,maxicomfort,mini
ultra-thin ii,mini
lancing
device,inject
ease
lancets,affirm
underwear,affirm
pads,snap
pants,mesh
pants,adult
brief,prevail
bladder
control,cuties
baby wipes,cuties
wash
cloths,prevail,was
hcloths,prevail
wet wipes,prevail
premium
washcloths,ameri
can star
washcloths,proca
re
washcloths,perso
nal cloths,pant
liner large
plus,pant liner
large,prevail
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 378
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
underwear,nu-fit
brief,breezers,per
-fit brief,value
buy,prevail
brief,prevail
stretch fit,nufit
underwear,prevai
l simply stretch
fit,prevail
boxers,procare,pr
evail full
coverage
undrwear,nufit
brief,per-fit
underwear,perfit
brief,prevail perfit,ben-efit,prevail
breezers,prevail
extra
underwear,prevai
l bariatric,prevail
super plus,prevail
protective
underwear,prevai
l
adjustable,prevail
classic fit
underwear,prevai
l pm,prevail ultra
plus,prevail ultra
bladder,prevail
panty liner,prevail
extra plus
bladder,prevail
extra
bladder,prevail
guards for
men,prevail
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 379
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pads,prevail male
guard,easy
check,easy
comfort,easy
click,easy
comfort insulin
syringe,propylene
glycol,easy touch
lancets,toe
straightener,up &
up
pantiliners,agiegrx,erase,erase
ras-pouri,geridyne,hydrophor
gauze,karaya
gum,hydrocollgrx,calalgingrx,calalgin-grx
rope,island gardgrx,grx hydrogel
gauze,grx foam
dressing,bloodglucose
meter,profit,quick
response,freestyl
e insulinx,ultratlc
lancets,medisens
e
control,precision
glucose
control,embrace
glucose control
soln,victory,advo
cate control
solution,advocate
blood glucose
monitor,advocate
rapidBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 380
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
safe,advocate
lancing
device,advocate
lancet,advocate
redicode,advocate
lancets,advocate
redi-code
duo,advocate
duo,advocate
redicode+,advocate
redi-code+ ctrl
soln,advocate
syringes,advocat
e pen
needles,fabric
bandages,neopre
ne ankle
support,neoprene
knee
stabilizer,neopren
e knee
support,neoprene
wrist splint,new
generation,sterile
bandages,droppe
r,ankle supportelastic,elbow
supportelastic,wrist splint
support,diabetic
socks,pulmoneb
lt compressor
nebul,clever
choice control
solution,clever
choice hd
glucose
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 381
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
syst,clever choice
blood gluc
sys,clever chek
blood glucose
syst,clever chek
lancets,clever
choice pro,clever
chek,clever
choice,pharmacis
t choice,clever
choice
micro,clever
choice
talk,comfort
ez,fora d10,fora
control
solution,fora
v10,fora v20,fora
v22,fora
g30a,fora
g20,fora d15,fora
d20,fora g90,fora
lancing
device,foracare
lancets,freestyle
system,freestyle
sidekick
ii,freestyle
lancets,freestyle
control
solution,freestyle
flash
system,freestyle
unistik 2,freestyle
navigator,freestyl
e lite
meter,freestyle
freedom,freestyle
freedom
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 382
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lite,freestyle
precision,alcohwipe,alcohglove,t:slim,e.p.t,
e.p.t
digital,gmate,earl
y pregnancy
test,test n'go,cleo
90 infusion
set,snap insulin
pump-infusion
set,snap insulin
pump
controller,dover
universal,caresen
sn
voice,gentlecath,
agamatrix
amp,ezvac,natura
drainable
pouch,esteem
synergy drainable
pouch,sterile
nitrile
gloves,aquacelag extra,amber
glass bottle,clear
glass serum
bottle,luer lock
syringe,silverseal
hydrogel,optumrx
,trueresult blood
glucose
meter,options
liners,options
pads,early
ovulation
test,options ultra
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 383
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
thins,little
darlings,band-aid
plus
antibiotic,medlan
ce plus special
blade,easy touch
fluringe,easy
touch insulin
safety,kangaroo
924 safety
screw,easy touch
syr allergy
tray,easy touch
fluringe flu
tray,prevail
curve,prevail
smooth fit,excilon
amd,element
compact control
soln,eakin
cohesive,easy
comfort pen
needles,neria
multi,element
compact,depend
shields for
men,gmate
lancing
device,kendall
disinfectant
cap,huggies slipon,on-thego,huggies snug
and dry,on call
vivid pal,diatrue
plus,diatrue,uroc
are urinary
drainage,uro-con
catheter,eyelid
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 384
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
cleansing pads,td
gold blood
glucose
monitor,td gold
voice glucose
monitor,td gold
level 1 control
sol,td gold level 2
control sol,td gold
level 3 control
sol,sheer
bandage,rightest
gc250s control
soln,rightest
gm250s
meter,rightest
gm260
meter,enlite
glucose
sensor,minimed
530g,smart
sense monitoring
system,relion
thin,enlite
serter,dexcom
g5-g4
sensor,gentle
touch
system,gentle
touch loop
ostomy
sys,tubigrip,tubul
ar bandage
applicator,tubipad
,lyofoam,lyofoam
c,lyofoam
a,lyofoam
t,lyofoam
extra,sur-fit
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 385
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
natura post
op,eakin skin
barrier,eakin
fistula & wound
pouch,pliagel,orth
odiaphragm,advan
ce pregnancy
test,advanced
care cholesterol
test,opti-one,opticlean ii daily
cleaner,opti-free
lens case,nutriclamp w-transfer
set,ascensia
elite,omnitrope
pen 5,personal
biometric test
kit,drainable
adhesive
pouch,baby urine
collector,sharpsa-gator disposal
system,insertion
tray with
pvp,excilon
washcloth,curity
maternity
belts,curagel,nurs
ing
pads,dermicel,wa
terproof
tape,topper
dressing
sponge,surgipad,
ulcer
dressing,proxistrip,healthcare
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 386
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
gloves,nu-gauze
sponge,elastikon,
adaptic,sof-band
bulky
bandage,bioclusi
ve,sof-wick,sofwick drain
sponge,johnson
& johnson filter
mask,johnson's
health care
gloves,steripak,g
auze
sponge,rescue
blanket,antiseptic
wipes,triangular
bandage,j & j first
aid
kit,swabs,cotton
rounds,steripad,nugauze,dentotape
ribbon
floss,dental floss
waxed,stim-udent,cartridge
filling aid,arm
belt,d-tron,h-tron
power
pack,autolet
lite,back
support,rib
belt,pouch arm
sling,wrist brace
reversible,wrist
brace
splint,surgical
binder abdom
support,sacroiliac
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 387
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
brace,herniaaid,surgical
stockings,compre
ssion
stockings,beyond
support,super
socks,compressi
on
pantyhose,athleti
c supporter,cup
supporter wprotector
cup,suspensory,k
nee
comforter,curity
curad flexible
bandages,curity
curad flexible
fabric,curad
ultralite,curad kid
size
bandages,curity
underpads,bedpa
n,sitz
bath,urinal,cervic
al pillow,cervical
traction
kit,wheelchair
invalid
ring,wheelchair
cushion,crutch
pad,walker
tips,sport
polartec,sport
neoprene,tennis
elbow
support,curity
curad adhesive
bandages,curity
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 388
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
telfa non-stick
pads,curity
nursing
pads,curity telfa
adhesive
pads,curity wetpruf adhesive
tape,curad super
soft puffs,curad
gauze
pads,curad
stretch gauze
bandage,fever
thermometer,ace
rubber elastic
bandage,trutouch
gloves,durall,sus
pensory with leg
straps,suspensor
y w-o leg
straps,adult
supporter,compre
ssion
shorts,swimmer
supporter,ace
neoprene wrist
brace,ace
neoprene thigh
brace,ace
neoprene elbow
brace,ace
neoprene ankle
brace,ace
neoprene knee
brace,ace
neoprene plus
knee brace,ace
neoprene ankle
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 389
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
wrap,ace tennis
elbow brace,ace
ankle brace,ace
knee brace,ace
wrist brace,ace
elastic
bandage,ace
elbow brace,ace
plus rigid wrist
brace,ace
unibody
supporter,ace
athletic
supporter,ace
swim
supporter,ace
cup
supporter,ace
plus knee
brace,ace sports
underwrap,ace
knee strap,ace
elbow strap,ace
bandage
clips,ace athletic
bandage,ace
sports tape,ace
instant cold
compress,ace
reusable cold
compress,ace
hot-cold
compress,ace
hot-cold
compression
wrap,ace velcro
bandage,fever
thermometerimprinted,sensica
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 390
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
re,tru-fit knee
support,ace
plastic
gloves,sentinel
thermometer,quic
ktek,advance
microdraw,advance,sel
ect-lite,anti-stick
insulin,anti-stick
tuberculin,ventstr
eam
nebulizer,zoey,fir
stchoice
drainable
pouch,everyday
self-adhes
catheter,firstchoic
e postop drain
pouch,selfadhesive
catheter,advance
hydro,seaband,sea-band
for
children,easypro,
compressor
nebulizer,replace
ment
nebulizer,replace
ment air
filter,healthy
living,duocare,sharps
disposal by
mail,monoject
blunt filter
cannula,saline
solution,sterile
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 391
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
presrv,renu
saline,sensitive
eyes
enzymatic,lens
carrying
case,crayon
bandage,easy
read,sudacare
advanced,pediac
are gentle
vapors,efferdent
plus,efferdent,fre
sh'n
brite,effergrip,oha
us scout sc,iv
transfer
needles,venting
pin,ez-lets,insultote,dermagran,la
dy lite,hard
contact lens
cleaner,hard
contact lens
soak,hard contact
lens
wet,kotex,kotex
lightdays,new
freedom
lightdays,kotex
new freedom,lil
swimmer small
pant,lil swimmer
medium pant,lil
swimmer large
pant,poise,depen
d belted
shields,huggies
overnite,huggies
newborn,huggies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 392
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
convertibles,pelvi
c muscle
trainer,babytherm
pacifier
thermometer,inco
ntinent
liner,dignity
regular,dignity
extra-duty,dignity
regular
duty,dignity
natural
extra,dignity
diaper,dignity
underpad,free &
active
super,dignity,dign
ity plus,dignity
plus
liners,briefmates,
prevent
plus,dignity plus
fitted brief,dignity
plus regular
brief,lady dignity
plus brief,sir
dignity plus
brief,inhaler
companions,asth
ma
control,interlink,w
rist
immobilizer,delux
e wrist brace,ultra
thin,water-proof
bandages,plastic
strip,heartstart,cli
p&
stor,fibracol,kling
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 393
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
fluff,sofkling,sheet
protector,precisio
n link,elta
dermal,actis,rese
rvoir,brief
youth,promise
pad,coverlet eye
occlusor,real-time
starter kit,ultrasoft plus,ultra-soft
classic,protection
plus
underpad,protecti
on plus,protection
plus classic,home
access hiv-1 test
system,ultima
tuckables,cairpad
,ultima
incontinence,adh
eres,tuffsorb,tuck
ables,attends
washcloths,preva
il fits to a t,youth
brief,adult frontal
tape brief,prevail
pre-moist bath
cloth,pant
liners,xtremefit
brief,ultrathin,sto
mahesive sterile
wafer,sur-fit
drainage
container,sur-fit
night drainage
tubing,allkare
adhesive
remover
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 394
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
wipe,active
life,little ones surfit ped belt,sur-fit
tail
closures,active
life
pouch,optipore,s
etopress high
compression,surfit natura irrig
sleeve,flexiseal,active life
one-piece,sur-fit
natura visi-flow
set,unna-flex
plus,clerz-2
lubricatingrewetting,clerz2,mirasept,miras
ept step
1,mirasept step
2,unisol 25 day pf saline,unisol
plus,opti-one
multipurpose,opticlean daily
cleaner,preflex,sa
line for sensitive
eyes,alcon
enzymatic,flexcare,opti-soak
conditioning,optitears,opti-soak
daily,opti-soak
soothing
drops,fact plus
pregnancy
test,primary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 395
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pump set,nylon
epidural
catheter,ls plum
secondary setol,ivex-hp
administration
set,venoset-100
prim pigbk-ivexhp,screw cap set
38mm,fat
emulsion iv
set,primary iv setsl,soluset wpediatric ivex
sl,venoset 100
piggyback wclamp,lifecare
controller model
1000,lifecare
pump set,lifecare
model 4 macro
pump,pca
pump,nonvented
iv set 100 with
cair,venoset
microdrip,lifecare
1025 controller,lc
1050
controller,flow
detector
30inch,flow
detector
54inch,lifecare
pump,lifecare
micro pump
1a,lifecare micro
pump,controller
lifecare model
75,pca plus
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 396
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
2,lifecare 75 flow
detector,solusetivex-2 filter &
cair,dual i.v.
stand adapter,i.v.
stabilizer bar,i.v.
clip adapter,i.v.
stand-pole
assembly,i.v.
stand-base
assembly,blood
set 64 with cair
clamp,blood set
78 with cair
clamp,blood ytype set wpump,single shot
epidurallidocaine,lifecare
1050 drop
detector,enteral
set with
container,inpersol
w-o auto shutoff
valv,inpersol-auto
shutoff
valve,plumset
speciality pump
set-ol,plum
lifecare 5000
infuser,site-care
kit,ivex h.p.
pediatric exten
set,nonvented
secondary iv
set,venoset
piggyback-mb
pin-clmp,pca
miniBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 397
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
bore,batteries, six
volt (pair),primary
iv set-sl with ivexhp,500ml
pressure infusion
cuff,pressure
infusion
cuff,burette nv inline set wport,venoset
dual-rate pgbkivex-2,cvc
kit,venoset
piggyback w-ivex
filtr,lifecare shelf
storage
tray,primary
piggyback nv ib
set-sl,cvp
manometer,drum
-cartridge
catheter,provider
pump
set,butterfly s.t.
19x7/8.31/2tbg,pca
injector,flip-top
additive
cap,pump set wproximal male
adapt,butterfly
st,venous
cannulation
tray,blood set wcair clamp,tidal
joint irrigation
tray,cont epidural
tray w-drugs,cont
epidural-lido-epi
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 398
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
t-dose,cont
epidural
tray,spinal-22bupiv-dex-ephedepi,spinal-25bupiv-dex-ephedepi,spinalanesthesia
tray,cont
epidural-bupivlidocaine,inpersol
peritoneal
tray,caudal wlidocaineepinephrine,spina
l-22-tet-ephedepi-iodine,nerve
block tray wlidocaine,local
infiltration wlidocaine,spinal25 w-tetra-ephedepi,saddle block
anesthesia
tray,saddleblock
anesthesia
tray,spinal-22
whitacre w-lidodext,spinal
whitacre
anesthesia,cont
epidural w-poviodine,lumbar
puncture
adult,lifecare
adds
rack,primary
piggybackconv,d
ual injection
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 399
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
site,male adapter
plug w-inj
site,male luer
cap,dual luer
cap,plum lc 5000
primary setsl,plum microdrip
soluset,extension
set with luer
lock,plum lc 5000
primary set,plum
lc 5000 microdrip
set-nv,plum lc
5000 with
ivex,pca set-long
minibore,venoset 100
soluset,pentothal
dispensing
cap,catheter
adapter-luer
plug,venoset nv
piggybk
micrdrp,crimping
tool,transfer
lok,blood set 64
w-cair &
needle,hemoset
100x10 with cair
clamp,blood set
w-pump & cair
clamp,blood
surgical y-type
set-clmp,blood ytype set 66-cair
clamp,continuous
pediatric
caudal,cont
epidural w-lidoBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 400
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
epi-iodin,lifecare
microdrip pump
set,nitroglycerin
micro pump
set,screw cap
(40mm)
set,lifecare 5000
syringe
adapter,lifecare
5000 vial
adapter,hema
blood 30 set,bufpuf,buf-puf
bodymate,buf-puf
sponge,buf-puf
gentle,microlet
vaculance,accus
ure,opti-zyme
enzymatic
cleaner,bard
irrigation tray,3m
cold-hot
pack,home care
underpads,takeoff,conform
stretch
bandage,coets,d
ermilite-ii paper
tape,dermicel
hypo-allergenic
tape,dermilite ii
hypoallergenic,dermicl
ear,kling
bandage,waterga
rd,insertion tray
with bzk,foley
cath silicone
retn,curity foley
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 401
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
2-way ped
cath,folding
walker,walker
wheels,cervical
soft
collar,molicare
classic brief,ultra
soft,dry time
diaper,protection
plus
liner,economy
underpad,peg
elastic
bandage,reston2,iamin,osmocyte
,dressing,digital
therm probe
cover,hypotherm
thermometer,bd
genie lancet,ace
wrist brace with
splint,ace lumbar
support,statlet,disgard sharps
pad,kangaroo
1000ml pump
set,glucoleader,le
a's shield,saline
solution,
unpreserved,hyp
o-clear,lens
lubricant,disinfect
ing solution,quiksept,renu weekly
cleaner,concentr
ated
cleaner,wetting &
soaking
solution,super
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 402
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
denture
adhesive,disinfec
ting unit,compact
disinfecting
unit,fashion
case,lens
cup,snug denture
cushions,thermod
ent,contact lens
conditioning,niteti
me,interdental
stimulators,extra
absorbent
shield,wild hot
strips,napkin
hospital
tabbed,foot and
shoe
padding,bed
pad,sudacare,chil
dren's
sudacare,rgp
wetting and
soaking,rigid gas
permeable
cleaner,lubricatin
g drops,htronplus
adapter,h-tron
plus-piston rod,htron plus,catheter
tip
cap,winged,chem
oplus dispensing
pin,p2 hi-risk,p2
safety plus,p2
safety plus
powder free,p2
hi-risk powder
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 403
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
free,pro star
powder
free,oncology
plus,chemoplus
powder
free,chemoplus,d
ust-mist
respirator
mask,chemosafet
y container,u.v.
protection
bags,spill proof
prep mat,safelock
bags,chemowast
e
bags,chemolinen
waste
bags,chemolinen
hamper
stand,chemowast
e hamper
stand,chemosafet
y prep
admin,personnel
protection,multimix,designer,che
mo plus,chemo
spill kit,trudent,wetstop,dermastat,n
utrastat,dermacol
,nutracol,dermasi
te,sanitizer
bottle,autolancet,sensitive
teeth,tartar
control,depend
elastic leg
undergarmnt,dep
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 404
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
end fitted
brief,goodnite,hu
ggies
snuggems,huggie
s convertible clip
strip,huggies
supreme,first
choice thin
lancets,slipon,entrust plus
undergarment,br
east
pump,nebulizer,fil
ters,mask,sphyg
momanometer,ad
apter w-disp
mouthpiece,mout
hpiece for
truzone peak
fl,mask,
pediatric,proneb,
pep pressure
monitor,bubbles
the fish,pep
nebulizer,lc
nebulizer,nite
train'r,empty
viaflex-y-transfer
set,sub-q
set,empty viaflex
container,bed
underpads,contro
l pads,clear
spots,7 day pill
box,fancy pill
box,pill pal,one
weektoday,rubber
finger,dosage
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 405
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
spoon,dosage
syringe,dosage
dropper,hot &
cold wrap,super
absorbent
underwear,ultrathin
underwear,polyrayon,3m paper
pre-cut tape
strips,clear first
aid tape,active
strips,waterproof
adhesive,foam
sports tape,3m
non-stick
pads,heat
comfort,e.p.t.
stick test,barrier
sterile
field,biopatch,nubrede,topper,tiell
e,bioclusive
select,bioclusive
select
mvp,bioclusive
mvp select,nu-gel
collagen,algosteri
l,nu-gel,raytec,soffoam,band-aid
island
surgical,zonas,de
rmiview,dermifor
m,tielle plus,kling
conforming
gauze
bandage,dynaflex,ultralon
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 406
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pf,maxxus
pf,micro-touch
pf,allergard,neutr
alon
50,maxxus,neutr
alon,microtouch,microtouch xp,sofloop,surgine,barri
er,surgine
ii,barrier n95,protectivw,protectiv plusw,biovue,protecti
v,lister's suture
removal
kit,barrier
fenestrated strl
field,preptic
shave
prep,preptic 2
shave
prep,chix,sofnet,d
aylee,preptic,prevac
are,autolancet
device wlancets,ultratlc
lancetsdevice,pocketcar
e irrigator,e-z
spacer mask,e-z
spacer &
mask,supreme
glucose
control,supreme
meter,simplechoi
ce,simplechoice
quick,md
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 407
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
turbo,aerochamb
er plus,airs
pediatric aerosol
mask,continuous
glucose
sensor,evacare
pessary,relion
blood pressure
cuff,muppet
strips,cleaning
solution,wetting
solution for hard
lens,nonpreserved
saline,oragrip,ho
me pregnancy
test,absorbent
shield,poison first
aid kit,facial
cleansing
sponge,pill
divider,shave
cream,blade
double
edge,lady's
shaver plus lube
strip,weekly pill
planner,effervesc
ent denture
cleansr,effervesc
ent
denture,premier
adult brief,safe
klean,one-step
blood pressure
monitr,precision
sof-tact,precision
q-i-d,dental floss
unwaxed,mercury
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 408
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
klean
kit,enlite,well
beginnings
diapers,novopen
echo,filtered
extension set,rate
flow regulator iv
set,aerobika,accu
-chek compact
plus
control,soothene
b mesh
nebulizer,onetouc
h verio
sync,unistrip,iport
advance,hydrofer
a blue,foracare
gdh,acticoat
site,acticoat
moisture
control,acticoat
flex 7,acticoat
flex 3,allevyn
life,embrace
pro,embrace
evo,kendall foam
border,luer slip
tip cap,luer-lock
syringe,amber
oral-topical
syringe,slip-tip
syringe,caresens
prem lancing
device,carelance
ult lancing
device,acticoat
surgical,luer slip
tip syringe
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 409
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
tray,md pump
actuator b,md
pump actuator
a,on call express
meter,on call
express control
soln,athletic
tape,healthpro
glucose
monitor,healthpro
glucose control
soln,md pump
bottle airless,md
pen airless,md
syringe
airless,md jar
airless,biostep
ag,space
chamber
plus,compact
space chamber
plus,ems antiembolism
stocking,allevyn
adhesive,biostep,
allevyn
sacrum,allevyn
ag adhesive,icy
hot smart relief
tens,icy hot smart
relief tens
pads,ear-loop
mask,temple
touch mini
thermometer,pur
ple nitrile
gloves,allevyn ag
gentle,allevyn
ag,prevail
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 410
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
breezers
360,allevyn
gentle
border,temple
touch prem
thermometer,adv
anced glucose
meter,allevyn
gentle border
lite,carefine pen
needle,allevyn
gentle border
sacrum,allevyn
gentle border
heel,allevyn
gentle border
multisit,microbore
extension
set,prevail per-fit
360,clear
tape,transparent
film
dressing,gmate
smart
starter,gmate
smart meter,true
metrix blood
glucose mtr,true
metrix,vascuderm
hydrogel
wound,huggies
pure &
natural,varithena
administration
pack,band-aid
gauze
pads,band-aid
rolled
gauze,band-aid
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 411
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
non-stick
pads,band-aid
mirasorb gauze
sponge,band-aid
surgipad
dressing,bandaid cloth
tape,band-aid
paper tape,bandaid waterproof
tape,sterile
amber glass
vial,aeroneb
go,slip on
knee,band-aid
hurt-free,bandaid tough
pads,band-aid
secureflex,innospire
deluxe,band-aid
waterproof
pad,innospire
mini,novofine
plus,fora test n'go
voice,cuticerin,m
egapumpblue,fora
gd50,primer
modified unna
boot,fortiscare
blood glucose
syst,fortiscare,tel
care
bgm,nighttime
underpants,allevy
n
tracheostomy,cuti
nova
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 412
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
hydro,durafiber,re
plicare
thin,allevyn
thin,surgical
pads,iv3000
frame
delivery,md pump
actuator c,bardex
lubricath
foley,inspiracham
ber,mepitel,aeron
eb go
nebulizer,lanzo,al
gicell ag,bioguard
gauze,bioguard
packing,bioguard
nonadherent,bioguar
d island,fc2
female
condom,hydress,
aquacel ag
foam,element
compact v,fora
test n'go
bp,aquacel ag
foam
heel,aquacel ag
foam
sacral,aquacel
foam
sacral,devilbiss
pulmoneb lt
compneb,prodigy
autocode,assure
prism
multi,glucocard
shine,assure
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 413
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lance
plus,esteem
synergy+,sterile
droptainers,assur
e prism,animas
vibe,sensi-care
adhes remover
wipes,relief knee
open toe,apogee
hc
intermittent,unisti
k safety,true
metrix air glucose
meter,hydrofera
blue ready,push
button safety
lancets,t:flex,well
beginnings
training
pants,caya
contoured,estee
m+ durahesive
plus,esteem+
drainable
pouch,urocare
fabric leg
straps,drymax
extra,pentips,acc
u-chek aviva
connect,thumb
support,tegaderm
hydrogel,flexicha
mber,goodnites
tru-fit,medihoney
hcs,dermagran
hydrophilic
wound,cool mist
humidifier,mistas
sist
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 414
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
kit,humatropen,m
istassist,dexcom
g5,fora v10-v12d10d20,evencare
mini monitor
system,evencare
mini glucose
control,tens
replacement back
pads,tens
replacement
body pads,luer tip
cap
tray,t:90,t:slim
g4,dry time
training
pants,bioguard
conforming,jobst
anti-embolism
stocking,jobst
ultrasheer,fora
tn'g voice,capri
bladder control
pads,prevail
purseready,oneto
uch verio flex,fora
lancets,droplet
pen needle,blood
lancets,easy
touch unislip,easy touch
fliplock
syringes,aerovent
plus,linktemp,free
style precision
neo meter,fora
d40,easy touch
fliplock
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 415
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
needle,easy
touch fliplock
needles,easy
touch fliplock
syringe,vacustim
black,tegaderm +
pad,advanced
healing
bandage,advanc
ed healing
pad,easy touch
sheathlock
syringe
02/06/2016
naturethyroid,pork,thyroid
throid,westhroid,
westhroid-p,wp
thyroid,thyroid
CHANGE TIER
Non-Formulary
02/06/2016
SILAZONE-II
triamcinolone
acetonide/silicones
REMOVE FROM
FORMULARY
Non-Formulary
02/06/2016
visbiome
lactobacillus
no.2/s.thermophilus/bifidoba
cterium no.1
ADD TO FORMULARY
Non-Formulary
02/06/2016
BOTRYTIS
allergenic extract-botrytis
cinerea
ADD TO FORMULARY
Non-Formulary
02/06/2016
MIXED
ASPERGILLUS
allergenic extractaspergillus,mixed
ADD TO FORMULARY
Non-Formulary
02/06/2016
XURIDEN
uridine triacetate
ADD TO FORMULARY
Non-Formulary
02/06/2016
XURIDEN
uridine triacetate
ADD TO FORMULARY
Non-Formulary
02/08/2016
cetirizine hcl
cetirizine hcl
ADD TO FORMULARY
Generics
02/08/2016
cetirizine hcl
cetirizine hcl
ADD TO FORMULARY
Generics
02/08/2016
cetirizine hcl
cetirizine hcl
ADD TO FORMULARY
Generics
02/08/2016
cetirizine hcl
cetirizine hcl
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 416
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
02/08/2016
cetirizine hcl
cetirizine hcl
02/08/2016
ZEPATIER
02/08/2016
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Generics
elbasvir/grazoprevir
ADD UM: CUSTOM
Harvoni, Sovaldi
are covered
ZEPATIER
elbasvir/grazoprevir
ADD UM: STEP
ST applies
02/08/2016
drospirenoneethinyl estradiol
ethinyl
estradiol/drospirenone
ADD UM: GENDER
Female
02/08/2016
ZEPATIER
elbasvir/grazoprevir
ADD UM: SPECIALTY
Specialty Drug
02/10/2015
GRANIX
tbo-filgrastim
ADD TO FORMULARY
Non-Formulary
02/10/2015
GRANIX
tbo-filgrastim
CHANGE UM: SPECIALTY
Specialty Drug
02/10/2015
GRANIX
tbo-filgrastim
CHANGE UM:
AUTHORIZATION
PA applies
02/10/2015
GRANIX
tbo-filgrastim
ADD TO FORMULARY
Non-Formulary
02/10/2015
GRANIX
tbo-filgrastim
ADD UM: SPECIALTY
Specialty Drug
02/10/2015
GRANIX
tbo-filgrastim
ADD UM: AUTHORIZATION
PA applies
02/10/2015
neuvaxin
capsaicin/menthol
ADD TO FORMULARY
Generics
02/10/2015
aflexeryl-mc
capsaicin/menthol
ADD TO FORMULARY
Generics
02/10/2015
ZUBSOLV
buprenorphine hcl/naloxone
hcl
ADD TO FORMULARY
Non-Formulary
02/10/2015
SINELEE
capsaicin/menthol
ADD TO FORMULARY
Non-Formulary
02/10/2015
MINIVELLE
estradiol
02/10/2015
EVOTAZ
atazanavir sulfate/cobicistat
ADD TO FORMULARY
Non-Formulary
02/10/2015
DUOPA
carbidopa/levodopa
ADD TO FORMULARY
Non-Formulary
02/10/2015
PREZCOBIX
darunavir
ethanolate/cobicistat
ADD TO FORMULARY
Preferred Brands
02/10/2015
MOVANTIK
naloxegol oxalate
ADD TO FORMULARY
Non-Formulary
02/10/2015
MOVANTIK
naloxegol oxalate
ADD TO FORMULARY
Non-Formulary
02/10/2015
GLYXAMBI
empagliflozin/linagliptin
ADD TO FORMULARY
Non-Formulary
CHANGE TIER
Generics
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 417
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/10/2015
GLYXAMBI
empagliflozin/linagliptin
ADD TO FORMULARY
Non-Formulary
02/10/2015
IBRANCE
palbociclib
ADD TO FORMULARY
Preferred Brands
02/10/2015
IBRANCE
palbociclib
ADD TO FORMULARY
Non-Formulary
02/10/2015
IBRANCE
palbociclib
ADD TO FORMULARY
Non-Formulary
02/10/2015
COSENTYX
secukinumab
SYRINGE,COSE
NTYX (2
SYRINGES)
ADD TO FORMULARY
Non-Formulary
02/10/2015
COSENTYX
secukinumab
SYRINGE,COSE
NTYX (2
SYRINGES)
ADD UM: SPECIALTY
Specialty Drug
02/10/2015
COSENTYX
secukinumab
SYRINGE,COSE
NTYX (2
SYRINGES)
ADD UM: AUTHORIZATION
PA applies
02/10/2015
COSENTYX PEN secukinumab
(2
PENS),COSENT
YX PEN
ADD TO FORMULARY
Non-Formulary
02/10/2015
COSENTYX PEN secukinumab
(2
PENS),COSENT
YX PEN
ADD UM: SPECIALTY
Specialty Drug
02/10/2015
COSENTYX PEN secukinumab
(2
PENS),COSENT
YX PEN
ADD UM: AUTHORIZATION
PA applies
02/10/2015
FOCALIN XR
02/10/2015
TRICARE
pnv no.20/iron
PRENATAL DHA fumarate/fa/docusate na/fish
ONE
oil conc/dha/epa
dexmethylphenidate hcl
CHANGE TIER
Preferred Brands
ADD TO FORMULARY
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 418
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/10/2015
DONNATAL
phenobarbital/hyoscyamine
sulf/atropine
sulf/scopolamine hb
ADD TO FORMULARY
Non-Formulary
02/10/2015
DONNATAL
phenobarbital/hyoscyamine
sulf/atropine
sulf/scopolamine hb
ADD TO FORMULARY
Non-Formulary
02/11/2015
dexmethylphenid dexmethylphenidate hcl
ate hcl er
ADD TO FORMULARY
Generics
02/11/2015
dexmethylphenid dexmethylphenidate hcl
ate hcl er
ADD TO FORMULARY
Generics
02/11/2015
lanzo
lancing device/lancets
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
adapter cap
adapter cap for bottle
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
adapter cap
adapter cap for bottle
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
adapter cap
adapter cap for bottle
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
adapter cap
adapter cap for bottle
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
adapter cap
adapter cap for bottle
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
adapter cap
adapter cap for bottle
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
adapter cap
adapter cap for bottle
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
adapter cap
adapter cap for bottle
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
easy comfort pen pen needle, diabetic
needles
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 419
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/11/2015
RELAGESIC
acetaminophen/phenyltoloxa
mine citrate
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
ONE-A-DAY
TEEN HIM
VITACRAVES
pediatric multivitamin
no.89/cholecalciferol/phyton
adione
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
antacid
calcium
carbonate/magnesium
hydroxide
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
despec-dm
guaifenesin/dextromethorph
an hbr/pseudoephedrine hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
biotin plus keratin biotin/keratin
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
antacid
calcium
carbonate/magnesium
hydroxide
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
antacid
calcium
carbonate/magnesium
hydroxide
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
children's allergy fexofenadine hcl
relief
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 420
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/11/2015
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
daily vitamin
formula + iron
multivitamin/ferrous
fumarate/folic acid
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
daily vitamin
formula + iron
multivitamin/ferrous
fumarate/folic acid
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
little remedies
stuffy nose
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
CYKLOKAPRON tranexamic acid
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
CYKLOKAPRON tranexamic acid
REMOVE FROM
FORMULARY
Non-Formulary
02/11/2015
PRECEDEX
dexmedetomidine hcl in 0.9
% sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
lido-k
lidocaine hcl
ADD TO FORMULARY
Generics
02/13/2016
multi-lancet
lancing device/lancets
ADD TO FORMULARY
Generics
02/13/2016
topcare
lancets
universal1 lancet
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 421
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
02/13/2016
FUSARIUM
02/13/2016
Generic Name
allergenic extract-fusarium
oxysporum
Type of Change
Previous Value
New Value
REMOVE FROM
FORMULARY
Non-Formulary
albumin (human) albumin human
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
CLAFORANDEXTROSE
cefotaxime sodium/dextrose,
iso-osmotic
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
CLAFORANDEXTROSE
cefotaxime sodium/dextrose,
iso-osmotic
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
amitriptyline hcl
amitriptyline hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
amitriptyline hcl
amitriptyline hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
amitriptyline hcl
amitriptyline hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
amitriptyline hcl
amitriptyline hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
cyclobenzaprine
hcl
cyclobenzaprine hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
cyclobenzaprine
hcl
cyclobenzaprine hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
cyclobenzaprine
hcl
cyclobenzaprine hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
cyclobenzaprine
hcl
cyclobenzaprine hcl
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
gabapentin
gabapentin
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
gabapentin
gabapentin
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
gabapentin
gabapentin
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 422
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/13/2016
gabapentin
gabapentin
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
bupivacaine hclepinephrine
bupivacaine
hcl/epinephrine/pf
REMOVE FROM
FORMULARY
Generics
Non-Formulary
02/13/2016
bupivacaine hclepinephrine
bupivacaine
hcl/epinephrine/pf
REMOVE FROM
FORMULARY
Generics
Non-Formulary
02/13/2016
calcium citrate-vit calcium
d3
citrate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
PREVNAR 13
pneumococcal 13-valent
conjugate vaccine
(diphtheria crm)/pf
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
nighttime cough
dextromethorphan
hbr/doxylamine succinate
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
BETADINE
povidone-iodine
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
BETADINE
povidone-iodine
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
CARTICEL
autologous cult.
chondrocytes
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
chorionic
gonadotropin
chorionic gonadotropin,
human
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
butylene glycol
1,3-butanediol
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
butylene glycol
1,3-butanediol
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
butylene glycol
1,3-butanediol
REMOVE FROM
FORMULARY
Non-Formulary
02/13/2016
butylene glycol
1,3-butanediol
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
SOTYLIZE
sotalol hcl
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 423
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/16/2015
SOTYLIZE
sotalol hcl
ADD TO FORMULARY
Non-Formulary
02/16/2015
OTEZLA
apremilast
ADD TO FORMULARY
Non-Formulary
02/16/2015
pramipexole er
pramipexole di-hcl
ADD TO FORMULARY
Generics
02/16/2015
pramipexole er
pramipexole di-hcl
ADD TO FORMULARY
Generics
02/16/2015
idealbase
cream base no.186
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
algicell ag
silver/calcium alginate
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
BIOGAIA
PROTECTIS
lactobacillus
reuteri/cholecalciferol (vit
d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
ALIVIO
capsaicin/menthol
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
ALKA-SELTZER dextromethorphan/pseudoe
PLUS
phrine
COLD+FLU
hcl/acetaminophen/doxylami
ne
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
peg3350
polyethylene glycol 3350
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
probioticdigestive
enzymes
lactobacillus
acidophilus/digestive
enzymes combo no.5
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
men's
multivitamin
multivitamin with
minerals/folic acid
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
women's
multivitamin
multivitamin with
minerals/folic acid
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
remedy phytoplex miconazole nitrate
antifungal
REMOVE FROM
FORMULARY
Non-Formulary
02/16/2015
remedy phytoplex miconazole nitrate
antifungal
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 424
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/16/2015
MIRAPEX
pramipexole di-hcl
ADD TO FORMULARY
Non-Formulary
02/16/2015
MIRAPEX
pramipexole di-hcl
ADD TO FORMULARY
Non-Formulary
02/16/2015
MIRAPEX
pramipexole di-hcl
ADD TO FORMULARY
Non-Formulary
02/16/2015
MIRAPEX
pramipexole di-hcl
ADD TO FORMULARY
Non-Formulary
02/16/2015
MIRAPEX
pramipexole di-hcl
ADD TO FORMULARY
Non-Formulary
02/20/2016
diazepam
diazepam
ADD TO FORMULARY
Generics
02/20/2016
diazepam
diazepam
ADD TO FORMULARY
Generics
02/20/2016
cyclopentolate
hcl
cyclopentolate hcl
ADD TO FORMULARY
Generics
02/20/2016
bitterness
reducing agent
flavoring agent
REMOVE FROM
FORMULARY
Non-Formulary
02/20/2016
bitterness
reducing agent
flavoring agent
REMOVE FROM
FORMULARY
Non-Formulary
02/20/2016
bitterness
reducing agent
flavoring agent
REMOVE FROM
FORMULARY
Non-Formulary
02/20/2016
formoterol
fumarate
formoterol fumarate
dihydrate, micronized
REMOVE FROM
FORMULARY
Non-Formulary
02/20/2016
UROAV-81
methenamine/methylene
blue/sod
phos/p.salicylate/hyoscyami
ne
ADD TO FORMULARY
Non-Formulary
02/20/2016
cool glucose test blood sugar diagnostic
strip
ADD TO FORMULARY
Non-Formulary
02/20/2016
cool blood
glucose meter
blood-glucose meter
ADD TO FORMULARY
Non-Formulary
02/20/2016
KIDSTART
pediatric multivitamin
combination no.121
REMOVE FROM
FORMULARY
Non-Formulary
02/20/2016
b-12
cyanocobalamin (vitamin b12)
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 425
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/20/2016
VRAYLAR
cariprazine hcl
ADD TO FORMULARY
Non-Formulary
02/20/2016
VRAYLAR
cariprazine hcl
ADD TO FORMULARY
Non-Formulary
02/20/2016
VRAYLAR
cariprazine hcl
ADD TO FORMULARY
Non-Formulary
02/20/2016
VRAYLAR
cariprazine hcl
ADD TO FORMULARY
Non-Formulary
02/20/2016
OTIPRIO
ciprofloxacin
ADD TO FORMULARY
Non-Formulary
02/20/2016
VRAYLAR
cariprazine hcl
ADD TO FORMULARY
Non-Formulary
02/20/2016
ALLZITAL
butalbital/acetaminophen
ADD TO FORMULARY
Non-Formulary
02/20/2016
cardioplegia del
nido formula
cardioplegic solution no.16
REMOVE FROM
FORMULARY
Non-Formulary
02/23/2015
OTEZLA
apremilast
ADD UM: AUTHORIZATION
PA applies
02/23/2015
OTEZLA
apremilast
ADD UM: SPECIALTY
Specialty Drug
02/23/2015
OTEZLA
apremilast
CHANGE TIER
Preferred Brands
Non-Formulary
02/23/2015
OTEZLA
apremilast
CHANGE TIER
Preferred Brands
Non-Formulary
02/24/2015
LENVIMA
lenvatinib mesylate
ADD TO FORMULARY
Non-Formulary
02/24/2015
LENVIMA
lenvatinib mesylate
ADD UM: SPECIALTY
Specialty Drug
02/27/2016
CEFOTAN
cefotetan disodium
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
CEFOTAN
cefotetan disodium
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
CEFOTAN
cefotetan disodium
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
fyavolv
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
02/27/2016
fyavolv
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
02/27/2016
fyavolv
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 426
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/27/2016
fyavolv
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
02/27/2016
fyavolv
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
02/27/2016
fyavolv
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Preventative
02/27/2016
benzphetamine
hcl
benzphetamine hcl
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
unilet lancets
lancets
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 427
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/27/2016
easy touch
sheathlock
syringe
syringe, disposable, 3 ml
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
dipropylene
glycol
dipropylene glycol
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
dipropylene
glycol
dipropylene glycol
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
dipropylene
glycol
dipropylene glycol
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
dipropylene
glycol
dipropylene glycol
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
easy touch
hypodermic
needle
needles, disposable
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
easy touch
hypodermic
needle
needles, disposable
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
easy touch
hypodermic
needle
needles, disposable
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
easy touch
hypodermic
needle
needles, disposable
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
hexylene glycol
hexylene glycol
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
hexylene glycol
hexylene glycol
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
hexylene glycol
hexylene glycol
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
hexylene glycol
hexylene glycol
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 428
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/27/2016
easy touch
fliplock insulin
syringe with needle, insulin,
safety, 1 ml
ADD TO FORMULARY
Generics
02/27/2016
easy touch
fliplock insulin
syringe with needle, insulin,
safety, 1 ml
ADD TO FORMULARY
Generics
02/27/2016
easy touch
fliplock insulin
syringe with needle, insulin,
safety, 1 ml
ADD TO FORMULARY
Generics
02/27/2016
easy touch
fliplock insulin
syringe with needle, insulin,
safety, 1 ml
ADD TO FORMULARY
Generics
02/27/2016
window
bandages
transparent dressing
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
testosterone
micronized
testosterone micronized
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
testosterone
micronized
testosterone micronized
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
testosterone
micronized
testosterone micronized
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
testosterone
micronized
testosterone micronized
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
testosterone
micronized
testosterone micronized
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
testosterone
micronized
testosterone micronized
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
omega-3
flaxseed oil
flaxseed oil
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 429
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
techlite pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
02/27/2016
easy touch luer
lock insulin
syringe w-o needl,insulin,1
ml
ADD TO FORMULARY
Generics
02/27/2016
FIBER 6
bran/guar
gum/fiber/cellulose/psyllium
seed/kelp/apple pectn
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
LACTO-PECTIN lactobacillus combo
no.33/bifidobacterium breve
and longum
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
RHINOCORT
ALLERGY
budesonide
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
RHINOCORT
ALLERGY
budesonide
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
RHINOCORT
ALLERGY
budesonide
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
RHINOCORT
ALLERGY
budesonide
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
PURAMINO
TODDLER
nutritional therapy for
impaired digestive function
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
SIMILAC
ALIMENTUM
infant form. iron, lactose
free/dha/arachidonic acid
(ara)
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 430
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
02/27/2016
SIMILAC
ALIMENTUM
infant form. iron, lactose
free/dha/arachidonic acid
(ara)
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
EYEPROTECT
beta-carotene/ascorbic
ac/vite ac (d,toco)/zinc
ox/cupric ox
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
vitamin d3
cholecalciferol (vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
vitamin d3
cholecalciferol (vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
melatonin + ltheanine
melatonin/herbal complex
no.184
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
joint health
cartilage/collagen type
ii/boron
glycinate/hyaluronate sod
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
STANDARD
allergenic extract-sweet
SWEET VERNAL vernal, standardized
GRASS
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
VISTOGARD
uridine triacetate
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
VISTOGARD
uridine triacetate
REMOVE FROM
FORMULARY
Non-Formulary
02/27/2016
FLORIVA PLUS
pediatric multivitamin
combination no.130/sodium
fluoride
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 431
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
March, 2016
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Non-Formulary
03/01/2016
CYCLOGYL
cyclopentolate hcl
CHANGE TIER
03/01/2016
cyclopentolate
hcl
cyclopentolate hcl
ADD TO FORMULARY
03/03/2015
trandolaprilverapamil er
trandolapril/verapamil hcl
ADD TO FORMULARY
03/03/2015
trandolaprilverapamil er
trandolapril/verapamil hcl
ADD UM: QUANTITY
03/03/2015
trandolaprilverapamil er
trandolapril/verapamil hcl
ADD TO FORMULARY
03/03/2015
trandolaprilverapamil er
trandolapril/verapamil hcl
ADD UM: QUANTITY
03/03/2015
trandolaprilverapamil er
trandolapril/verapamil hcl
ADD TO FORMULARY
03/03/2015
trandolaprilverapamil er
trandolapril/verapamil hcl
ADD UM: QUANTITY
03/03/2015
trandolaprilverapamil er
trandolapril/verapamil hcl
ADD TO FORMULARY
03/03/2015
trandolaprilverapamil er
trandolapril/verapamil hcl
ADD UM: QUANTITY
30 / 30 days
03/05/2016
fentanyl citrate0.9% nacl
fentanyl citrate in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
fentanylbupivacaine0.9% nacl
fentanyl citrate/bupivacaine
hcl in 0.9 % sodium
chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
ephedrine
ephedrine sulfate in 0.9 %
sulfate-0.9% nacl sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
phenylephrine
hcl-0.9% nacl
REMOVE FROM
FORMULARY
Non-Formulary
phenylephrine hcl in 0.9 %
sodium chloride/pf
Generics
Non-Formulary
Generics
30 / 30 days
Non-Formulary
Generics
30 / 30 days
Non-Formulary
Generics
30 / 30 days
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 432
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/05/2016
ephedrine
ephedrine sulfate in 0.9 %
sulfate-0.9% nacl sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
magnesium
magnesium sulfate in 0.9 %
sulfate-0.9% nacl sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
phenohytro
phenobarbital/hyoscyamine
sulf/atropine
sulf/scopolamine hb
ADD TO FORMULARY
Non-Formulary
03/05/2016
ure-k
urea
ADD TO FORMULARY
Non-Formulary
03/05/2016
coal tar
coal tar
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
medi-first
isopropyl alcohol
isopropyl alcohol
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
DOC-Q-LACE
docusate sodium
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
DOC-Q-LACE
docusate sodium
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
TYLENOL SINUS guaifenesin/phenylephrine
SEVERE
hcl/acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
MEDI-FIRST
BURN
lidocaine hcl
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
MEDI-FIRST
ANTISEPTIC
benzocaine/benzalkonium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
medi-first
hydrogen
peroxide
hydrogen peroxide
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
glucosaminechondroitin-uc ii
glucosamine hcl/chondro
sulfate a/cartilage/collagen
type ii
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
guaifenesin
guaifenesin
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 433
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
03/05/2016
guaifenesin
03/05/2016
Generic Name
guaifenesin
Type of Change
Previous Value
New Value
REMOVE FROM
FORMULARY
Non-Formulary
guaifenesinguaifenesin/dextromethorph
dextromethorpha an hbr
n
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
guaifenesinguaifenesin/dextromethorph
dextromethorpha an hbr
n
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
lice complete kit
1-2-3
piperonyl
butoxide/pyrethrins/permethr
in
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
children's coldcough day
dextromethorphan
hbr/phenylephrine hcl
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
formula 3
tolnaftate
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
ensure compact
lactose-reduced food
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
ensure compact
lactose-reduced food
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
fluticasone
propionate
fluticasone propionate
ADD TO FORMULARY
Generics
03/05/2016
HYMOVIS
hyaluronate sodium,
modified, non-crosslinked
REMOVE FROM
FORMULARY
Non-Formulary
03/05/2016
HUMULIN R U500 KWIKPEN
insulin regular, human
ADD TO FORMULARY
Preferred Brands
03/05/2016
HUMULIN R U500 KWIKPEN
insulin regular, human
ADD TO FORMULARY
Preferred Brands
03/05/2016
ODEFSEY
emtricitabine/rilpivirine
hcl/tenofovir alafenamide
fumarate
ADD TO FORMULARY
Non-Formulary
03/05/2016
XELJANZ XR
tofacitinib citrate
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 434
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
03/05/2016
fentanylfentanyl citrate/ropivacaine
ropivacaine-0.9% hcl/sodium chloride 0.9%/pf
nacl
03/05/2016
metoprolol
tartrate
03/05/2016
Type of Change
Previous Value
New Value
REMOVE FROM
FORMULARY
Non-Formulary
metoprolol tartrate
ADD TO FORMULARY
Generics
metoprolol
tartrate
metoprolol tartrate
ADD TO FORMULARY
Generics
03/05/2016
metoprolol
tartrate
metoprolol tartrate
ADD TO FORMULARY
Generics
03/05/2016
metoprolol
tartrate
metoprolol tartrate
ADD TO FORMULARY
Generics
03/09/2015
fentanyl
fentanyl
ADD TO FORMULARY
Generics
03/09/2015
fentanyl
fentanyl
ADD TO FORMULARY
Generics
03/09/2015
fentanyl
fentanyl
ADD TO FORMULARY
Generics
03/09/2015
ROSULA
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Non-Formulary
03/10/2015
TOUJEO
SOLOSTAR
insulin glargine,human
recombinant analog
ADD TO FORMULARY
Non-Formulary
03/10/2015
NUVESSA
metronidazole
ADD TO FORMULARY
Non-Formulary
03/10/2015
NUVESSA
metronidazole
ADD UM: GENDER
Female
03/10/2015
FARYDAK
panobinostat lactate
ADD TO FORMULARY
Non-Formulary
03/10/2015
FARYDAK
panobinostat lactate
ADD UM: SPECIALTY
Specialty Drug
03/11/2016
morphine sulfate- morphine sulfate in 0.9 %
0.9% nacl
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
morphine sulfate- morphine sulfate in 0.9 %
0.9% nacl
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
oxiconazole
nitrate
oxiconazole nitrate
ADD TO FORMULARY
Generics
03/11/2016
oxiconazole
nitrate
oxiconazole nitrate
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 435
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/11/2016
oxiconazole
nitrate
oxiconazole nitrate
ADD TO FORMULARY
Generics
03/11/2016
doxepin hcl
doxepin hcl
ADD TO FORMULARY
Generics
03/11/2016
midazolam hcl0.9% nacl
midazolam hcl in 0.9 %
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
vancomycin hcl0.9% nacl
vancomycin in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
oxytocin-0.9%
nacl
oxytocin in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
oxytocin-lactated oxytocin/ringers
ringers
solution,lactated
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
ketamine hcl0.9% nacl
ketamine hcl in 0.9 %
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
norepinephrine
bitar-0.9% nacl
norepinephrine bitartrate in
0.9 % sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
norepinephrine
bitartrate-d5w
norepinephrine
bitartrate/dextrose 5 % in
water
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
hydromorphone
hcl-0.9% nacl
hydromorphone hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
vancomycin hcl0.9% nacl
vancomycin in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
vancomycin hcl0.9% nacl
vancomycin in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
vancomycin hcl0.9% nacl
vancomycin in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
vancomycin hcl0.9% nacl
vancomycin in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
amikacin sulfate
amikacin sulfate
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 436
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/11/2016
midazolam-0.9% midazolam hcl in 0.9 %
nacl
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
vancomycin hcld5w
vancomycin hcl/dextrose 5
% in water
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
amiodarone hcld5w
amiodarone hcl/dextrose 5
% in water
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
amiodarone hcld5w
amiodarone hcl/dextrose 5
% in water
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
hydromorphone
hcl-0.9% nacl
hydromorphone hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
hydromorphone
hcl-0.9% nacl
hydromorphone hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
phenylephrine
hcl-0.9% nacl
phenylephrine hcl in 0.9 %
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
dynamic plus pak lidocaine hcl/glycerin
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
vancomycin hcl0.9% nacl
vancomycin in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
dermawerx sds
triamcinolone
acetonide/dimethicone/silico
ne, adhesive
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
unistik touch
lancets
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
unistik touch
lancets
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
unistik touch
lancets
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
unistik touch
lancets
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
unistik touch
lancets
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 437
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/11/2016
unistik touch
lancets
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
cool control
solution
blood glucose calibration
control solution, normal
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
cool control
solution
blood glucose calibration
control solution, high
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
rasagiline
mesylate
rasagiline mesylate
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
true metrix air
glucose meter
blood-glucose meter
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
true metrix air
glucose meter
blood-glucose meter
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
MAPAP
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
MTERYTI
prenatal vit no.6/iron
fum/folic acid/vit
b12/calcium/vit d3
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
all day relief
naproxen sodium
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
DIABETIC
VITAMIN
multivitamin with
minerals/folic acid/a lipoic
acid/ubidecar
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
duo fusion
famotidine/calcium
carbonate/magnesium
hydroxide
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
duo fusion
famotidine/calcium
carbonate/magnesium
hydroxide
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
duo fusion
famotidine/calcium
carbonate/magnesium
hydroxide
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 438
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/11/2016
duo fusion
famotidine/calcium
carbonate/magnesium
hydroxide
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
IDELVION
factor ix
recombinant,albumin fusion
protein
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
IDELVION
factor ix
recombinant,albumin fusion
protein
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
IDELVION
factor ix
recombinant,albumin fusion
protein
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
IDELVION
factor ix
recombinant,albumin fusion
protein
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
DOUBLEDEX
dexamethasone sodium
phosphate/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
heparin sodium0.9% nacl
heparin sodium,porcine in
0.9 % sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
hydromorphone
hcl-0.9% nacl
hydromorphone hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/11/2016
alprostadil
alprostadil
REMOVE FROM
FORMULARY
03/15/2016
SPRITAM
levetiracetam
ADD TO FORMULARY
Non-Formulary
03/15/2016
SPRITAM
levetiracetam
ADD TO FORMULARY
Non-Formulary
03/15/2016
SPRITAM
levetiracetam
ADD TO FORMULARY
Non-Formulary
03/15/2016
SPRITAM
levetiracetam
ADD TO FORMULARY
Non-Formulary
03/16/2015
methylphenidate methylphenidate hcl
hcl
ADD TO FORMULARY
Generics
03/16/2015
methylphenidate methylphenidate hcl
hcl
ADD TO FORMULARY
Generics
Not Covered
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 439
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/16/2015
methylphenidate methylphenidate hcl
hcl
ADD TO FORMULARY
Generics
03/16/2015
naproxen sodium naproxen sodium
cr
ADD TO FORMULARY
Generics
03/16/2015
niva-fol
cyanocobalamin/folic
acid/pyridoxine
ADD TO FORMULARY
Generics
03/16/2015
niva-fol
cyanocobalamin/folic
acid/pyridoxine
ADD UM: CUSTOM
Vitamin Rider may be required
for coverage
03/16/2015
zenatane
isotretinoin
ADD TO FORMULARY
Generics
03/16/2015
amnesteem,clara isotretinoin
vis,absorica,zena
tane,myorisan,iso
tretinoin
03/16/2015
NATESTO
testosterone
ADD TO FORMULARY
Non-Formulary
03/16/2015
NATESTO
testosterone
ADD UM: GENDER
Male
03/16/2015
NOVOEIGHT
antihemophilic factor viii
recombinant, b-domain
truncated
ADD TO FORMULARY
Non-Formulary
03/16/2015
NOVOEIGHT
antihemophilic factor viii
recombinant, b-domain
truncated
ADD UM: SPECIALTY
Specialty Drug
03/18/2016
hygel
hyaluronate
sodium/hydroxyethylcellulos
e/polyethylene glycol
ADD TO FORMULARY
Non-Formulary
03/19/2016
tramadol hcl er
tramadol hcl
ADD TO FORMULARY
03/19/2016
sulfacetamide
sodium
sulfacetamide sodium
ADD TO FORMULARY
Generics
03/19/2016
fentanylfentanyl citrate/ropivacaine
ropivacaine-0.9% hcl/sodium chloride 0.9%/pf
nacl
REMOVE FROM
FORMULARY
Non-Formulary
REMOVE UM:
AUTHORIZATION
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 440
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/19/2016
bupivacaine hcl0.9% nacl
bupivacaine hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
fentanylbupivacaine0.9% nacl
fentanyl citrate/bupivacaine
hcl in 0.9 % sodium
chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
darifenacin er
darifenacin hydrobromide
ADD TO FORMULARY
Generics
03/19/2016
darifenacin er
darifenacin hydrobromide
ADD TO FORMULARY
Generics
03/19/2016
darifenacin er
darifenacin hydrobromide
ADD TO FORMULARY
Generics
03/19/2016
darifenacin er
darifenacin hydrobromide
ADD TO FORMULARY
Generics
03/19/2016
darifenacin er
darifenacin hydrobromide
ADD TO FORMULARY
Generics
03/19/2016
darifenacin er
darifenacin hydrobromide
ADD TO FORMULARY
Generics
03/19/2016
darifenacin er
darifenacin hydrobromide
ADD TO FORMULARY
Generics
03/19/2016
darifenacin er
darifenacin hydrobromide
ADD TO FORMULARY
Generics
03/19/2016
fentanylfentanyl citrate/ropivacaine
ropivacaine-0.9% hcl/sodium chloride 0.9%/pf
nacl
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
fentanyl citrate
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
morphine sulfate- morphine sulfate in 0.9 %
0.9% nacl
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
oxycodone hcl er oxycodone hcl
ADD TO FORMULARY
Generics
03/19/2016
oxycodone hcl er oxycodone hcl
ADD TO FORMULARY
Generics
03/19/2016
oxycodone hcl er oxycodone hcl
ADD TO FORMULARY
Generics
03/19/2016
emverm
mebendazole
ADD TO FORMULARY
Non-Formulary
03/19/2016
grape flavor
grape flavor
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
grape flavor
grape flavor
REMOVE FROM
FORMULARY
Non-Formulary
fentanyl citrate/pf
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 441
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
03/19/2016
unifine pentips
plus
pen needle, diabetic
03/19/2016
methyl 5aminolevulinate
hcl
03/19/2016
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Generics
methyl aminolevulinate hcl
REMOVE FROM
FORMULARY
Non-Formulary
easy touch
hypodermic
needle
needles, disposable
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
easy touch
hypodermic
needle
needles, disposable
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
easy touch
hypodermic
needle
needles, disposable
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
easy touch
hypodermic
needle
needles, disposable
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
easy touch
hypodermic
needle
needles, disposable
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
adhesive pad
adhesive bandage
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
tiopronin
tiopronin
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
retinaldehyde
retinal
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
adhesive pad
adhesive bandage
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
easy touch
syringe with needle, insulin,
sheathlock insulin safety, 1 ml
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
easy touch
syringe with needle, insulin,
sheathlock insulin safety, 1 ml
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 442
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/19/2016
mango flavor
flavoring agent
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
mango flavor
flavoring agent
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
strawberry cream flavoring agent
flavor
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
strawberry cream flavoring agent
flavor
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
easy touch
syringe,safety with
sheathlock syrg- needle,10 ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
easy touch
syringe,safety with
sheathlock syrg- needle,10 ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
easy touch
syringe,safety with
sheathlock syrg- needle,10 ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
bitterness
suppressor
bitter mask flavoring
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
bitterness
suppressor
bitter mask flavoring
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
vanilla flavor
flavoring agent
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
vanilla flavor
flavoring agent
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
base, pcca
xematop
cream base no.208
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
ebase controller
compressor, for nebulizer
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
coenzyme q-10
ubidecarenone
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 443
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/19/2016
coenzyme q-10
ubidecarenone
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
afrin
oxymetazoline hcl
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
no drip nasal
spray
oxymetazoline hcl
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
nasal allergy
triamcinolone acetonide
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
kids mini enema
docusate sodium
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
mucus-er max
guaifenesin
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
BABYBIG
botulism immune globulin,
human
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
CERAMAX
emollient combination
no.101
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
MAKENA
hydroxyprogesterone
caproate
REMOVE FROM
FORMULARY
Non-Formulary
03/19/2016
KLOR-CON M20 potassium chloride
ADD TO FORMULARY
Generics
03/19/2016
KLOR-CON M20 potassium chloride
ADD TO FORMULARY
Generics
03/24/2015
FRAGMIN
dalteparin sodium,porcine
CHANGE TIER
Preferred Brands
03/24/2015
acetaminophencodeine
acetaminophen with codeine
phosphate
CHANGE TIER
Generics
03/24/2015
acetaminophencodeine
acetaminophen with codeine
phosphate
CHANGE TIER
Generics
03/24/2015
ANIMI-3 WITH
VITAMIN
D,ANIMI-3
omega3/dha/epa/d3/b12/folic
acid/pyridox hcl/phytosterol
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 444
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/24/2015
bp vit 3 plus
omega3/dha/epa/d3/b12/folic
acid/pyridox hcl/phytosterol
ADD TO FORMULARY
Generics
03/24/2015
bp vit 3 plus
omega3/dha/epa/d3/b12/folic
acid/pyridox hcl/phytosterol
ADD UM: CUSTOM
Vitamin Rider
May Be Required
03/24/2015
niva-plus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
ADD TO FORMULARY
Generics
03/24/2015
niva-plus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
03/24/2015
KALYDECO
ivacaftor
ADD TO FORMULARY
Preferred Brands
03/24/2015
KALYDECO
ivacaftor
ADD UM: SPECIALTY
Specialty Drug
03/24/2015
KALYDECO
ivacaftor
ADD UM: AUTHORIZATION
PA applies
03/24/2015
KALYDECO
ivacaftor
ADD TO FORMULARY
Preferred Brands
03/24/2015
KALYDECO
ivacaftor
ADD UM: SPECIALTY
Specialty Drug
03/24/2015
KALYDECO
ivacaftor
ADD UM: AUTHORIZATION
PA applies
03/24/2015
METHYLIN
methylphenidate hcl
CHANGE TIER
Non-Formulary
03/24/2015
EDEX
alprostadil
CHANGE TIER
Preferred Brands
03/24/2015
CAVERJECT
alprostadil
CHANGE TIER
Non-Formulary
03/24/2015
CAVERJECT
alprostadil
CHANGE TIER
03/24/2015
MUSE
alprostadil
CHANGE TIER
Non-Formulary
03/24/2015
MUSE
alprostadil
CHANGE TIER
Non-Formulary
03/24/2015
MUSE
alprostadil
CHANGE TIER
Non-Formulary
03/24/2015
MUSE
alprostadil
CHANGE TIER
Non-Formulary
03/24/2015
DIVIGEL
estradiol
CHANGE TIER
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 445
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/24/2015
DEPOPROVERA
medroxyprogesterone
acetate
CHANGE TIER
Non-Formulary
03/24/2015
MYOBLOC
rimabotulinumtoxinb
CHANGE TIER
Preferred Brands
Non-Formulary
03/24/2015
ZORBTIVE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
03/24/2015
FOCALIN
dexmethylphenidate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
03/24/2015
dexmethylphenid dexmethylphenidate hcl
ate hcl
CHANGE TIER
Preferred Brands
Generics
03/24/2015
FOCALIN
dexmethylphenidate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
03/24/2015
dexmethylphenid dexmethylphenidate hcl
ate hcl
CHANGE TIER
Preferred Brands
Generics
03/24/2015
PARNATE
tranylcypromine sulfate
ADD TO FORMULARY
Non-Formulary
03/24/2015
tranylcypromine
sulfate
tranylcypromine sulfate
CHANGE TIER
Generics
03/24/2015
PAXIL CR
paroxetine hcl
ADD TO FORMULARY
Non-Formulary
03/24/2015
paroxetine
paroxetine hcl
er,paroxetine
hcl,paroxetine cr
CHANGE TIER
Generics
03/24/2015
dantrolene
sodium
dantrolene sodium
CHANGE TIER
Generics
03/24/2015
DANTRIUM
dantrolene sodium
CHANGE TIER
Non-Formulary
03/24/2015
dantrolene
sodium
dantrolene sodium
CHANGE TIER
Generics
03/24/2015
DANTRIUM
dantrolene sodium
ADD TO FORMULARY
Non-Formulary
03/24/2015
dantrolene
sodium
dantrolene sodium
CHANGE TIER
Generics
03/24/2015
DANTRIUM
dantrolene sodium
ADD TO FORMULARY
Non-Formulary
03/24/2015
SOLU-MEDROL methylprednisolone sodium
succinate
CHANGE TIER
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 446
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/24/2015
CARDIZEM LA
diltiazem hcl
ADD TO FORMULARY
Non-Formulary
03/24/2015
diltiazem 24hr
er,diltiazem er
diltiazem hcl
CHANGE TIER
Generics
03/24/2015
matzim la
diltiazem hcl
CHANGE TIER
Generics
03/24/2015
PENNSAID
diclofenac sodium
CHANGE TIER
Non-Formulary
03/24/2015
desloratadine
desloratadine
CHANGE TIER
03/24/2015
methamphetamin methamphetamine hcl
e hcl
03/24/2015
DESOXYN
methamphetamine hcl
03/24/2015
ciprofloxacin er
03/24/2015
Preferred Brands
Generics
CHANGE TIER
Generics
ADD TO FORMULARY
Non-Formulary
ciprofloxacin/ciprofloxacin
hcl
CHANGE TIER
Generics
CIPRO XR
ciprofloxacin/ciprofloxacin
hcl
ADD TO FORMULARY
Non-Formulary
03/24/2015
RITALIN LA
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
03/24/2015
methylphenidate methylphenidate hcl
er,methylphenida
te la
CHANGE TIER
Generics
03/24/2015
RITALIN LA
ADD TO FORMULARY
Non-Formulary
03/24/2015
methylphenidate methylphenidate hcl
er,methylphenida
te la
CHANGE TIER
Generics
03/24/2015
RITALIN LA
ADD TO FORMULARY
Non-Formulary
03/24/2015
methylphenidate methylphenidate hcl
er,methylphenida
te la
CHANGE TIER
Generics
03/24/2015
ELESTAT
epinastine hcl
ADD TO FORMULARY
Non-Formulary
03/24/2015
epinastine hcl
epinastine hcl
CHANGE TIER
Generics
03/24/2015
alendronate
sodium
alendronate sodium
CHANGE TIER
methylphenidate hcl
methylphenidate hcl
Preferred Brands
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 447
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/24/2015
SORIATANE
acitretin
ADD TO FORMULARY
Non-Formulary
03/24/2015
acitretin
acitretin
CHANGE TIER
Generics
03/24/2015
l-alanine,alanine alanine
CHANGE TIER
Preferred Brands
03/24/2015
alprazolam odt
alprazolam
CHANGE TIER
Generics
03/24/2015
alprazolam odt
alprazolam
CHANGE TIER
Generics
03/24/2015
CAVERJECT
alprostadil
CHANGE TIER
03/24/2015
KOGENATE FS
antihemophilic factor (fviii)
recomb,full length (alb-free)
ADD TO FORMULARY
Non-Formulary
03/24/2015
KOATE-DVI
antihemophilic factor,
human
ADD TO FORMULARY
Non-Formulary
03/24/2015
KOATE-DVI
antihemophilic factor,
human
ADD TO FORMULARY
Non-Formulary
03/24/2015
azelastine hcl
azelastine hcl
CHANGE TIER
Generics
03/24/2015
ASTEPRO
azelastine hcl
ADD TO FORMULARY
Non-Formulary
03/24/2015
vp-zel
niacinamide/azelaic
acid/zinc oxide/vit
b6/copper/fa
CHANGE TIER
Generics
03/24/2015
BECONASE AQ beclomethasone
dipropionate
CHANGE TIER
Non-Formulary
03/24/2015
benzoyl peroxide benzoyl peroxide
CHANGE TIER
Generics
03/24/2015
BENZEFOAM
benzoyl peroxide
ADD TO FORMULARY
Non-Formulary
03/24/2015
benzepro
benzoyl peroxide
CHANGE TIER
Generics
03/24/2015
bp foam
benzoyl peroxide
CHANGE TIER
Generics
03/24/2015
benzoyl peroxide benzoyl peroxide
CHANGE TIER
Generics
03/24/2015
BENZEFOAM
ULTRA
benzoyl peroxide
ADD TO FORMULARY
Non-Formulary
03/24/2015
benzepro
benzoyl peroxide
CHANGE TIER
Generics
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 448
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/24/2015
bp foam
benzoyl peroxide
CHANGE TIER
Generics
03/24/2015
bromfenac
sodium
bromfenac sodium
CHANGE TIER
Generics
03/24/2015
butalbitalacetaminophencaffe
butalbital/acetaminophen/caf
feine
CHANGE TIER
03/24/2015
ORTHO-NESIC
capsaicin/camphor/menthol
CHANGE TIER
03/24/2015
QUTENZA
capsaicin/skin cleanser
CHANGE TIER
03/24/2015
COREG CR
carvedilol phosphate
CHANGE TIER
Non-Formulary
03/24/2015
cefpodoxime
proxetil
cefpodoxime proxetil
CHANGE TIER
Generics
03/24/2015
cefpodoxime
proxetil
cefpodoxime proxetil
CHANGE TIER
Generics
03/24/2015
cefpodoxime
proxetil
cefpodoxime proxetil
CHANGE TIER
Generics
03/24/2015
ceftibuten
ceftibuten
CHANGE TIER
Generics
03/24/2015
CEDAX
ceftibuten
dihydrate,ceftibuten
ADD TO FORMULARY
Non-Formulary
03/24/2015
CIMZIA
certolizumab pegol
CHANGE TIER
Preferred Brands
Non-Formulary
03/24/2015
poly-tussin d
chlorcyclizine
hcl/pseudoephedrine
hcl/codeine phosphate
CHANGE TIER
Preferred Brands
Generics
03/24/2015
poly-tussin
chlorcyclizine hcl/codeine
phosphate
CHANGE TIER
Preferred Brands
Generics
03/24/2015
CATAPRES-TTS clonidine
1
CHANGE TIER
Preferred Brands
Non-Formulary
03/24/2015
clonidine
clonidine
CHANGE TIER
Generics
03/24/2015
CATAPRES-TTS clonidine
2
CHANGE TIER
Non-Formulary
Preferred Brands
Generics
Not Covered
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 449
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/24/2015
clonidine
clonidine
CHANGE TIER
Generics
03/24/2015
clonidine
clonidine
CHANGE TIER
Generics
03/24/2015
CATAPRES-TTS clonidine
3
CHANGE TIER
03/24/2015
clonidine hcl er
clonidine hcl
CHANGE TIER
Generics
03/24/2015
clorpres
clonidine hcl/chlorthalidone
CHANGE TIER
Generics
03/24/2015
clorpres
clonidine hcl/chlorthalidone
CHANGE TIER
Generics
03/24/2015
clorpres
clonidine hcl/chlorthalidone
CHANGE TIER
Generics
03/24/2015
COLESTID
colestipol hcl
ADD TO FORMULARY
Non-Formulary
03/24/2015
colestipol hcl
colestipol hcl
CHANGE TIER
Generics
03/24/2015
colestipol hcl
colestipol hcl
CHANGE TIER
Generics
03/24/2015
COLESTID
colestipol hcl
ADD TO FORMULARY
Non-Formulary
03/24/2015
COLESTID
colestipol hcl
ADD TO FORMULARY
Non-Formulary
03/24/2015
COLESTID
colestipol hcl
CHANGE TIER
Non-Formulary
03/24/2015
XALKORI
crizotinib
CHANGE TIER
Preferred Brands
Non-Formulary
03/24/2015
XALKORI
crizotinib
CHANGE TIER
Preferred Brands
Non-Formulary
03/24/2015
EURAX
crotamiton
03/24/2015
COMFORT PAC- cyclobenzaprine hcl/irritants
CYCLOBENZAP counter-irritants combo #2
RINE
03/24/2015
cyclopentolate
hcl
cyclopentolate hcl
CHANGE UM:
AUTHORIZATION
PA applies
03/24/2015
demeclocycline
hcl
demeclocycline hcl
CHANGE TIER
Generics
03/24/2015
demeclocycline
hcl
demeclocycline hcl
CHANGE TIER
Generics
03/24/2015
PROLIA
denosumab
CHANGE TIER
Preferred Brands
ADD TO FORMULARY
CHANGE TIER
Non-Formulary
Non-Formulary
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 450
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
CHANGE TIER
Preferred Brands
Generics
03/24/2015
desloratadine
desloratadine
03/24/2015
DESONATE
desonide
ADD TO FORMULARY
Non-Formulary
03/25/2015
ANALPRAM E
hydrocortisone
acetate/pramoxine/emollient
/pramoxine comb#1
ADD TO FORMULARY
Non-Formulary
03/25/2015
hydrocortisonepramoxine
hydrocortisone
acetate/pramoxine/emollient
/pramoxine comb#1
CHANGE TIER
Generics
03/25/2015
hydrocortisonepramoxine
hydrocortisone
acetate/pramoxine/emollient
/pramoxine comb#1
CHANGE TIER
Generics
03/25/2015
ANALPRAM E
hydrocortisone
acetate/pramoxine/emollient
/pramoxine comb#1
ADD TO FORMULARY
Non-Formulary
03/25/2015
PICATO
ingenol mebutate
CHANGE TIER
Preferred Brands
Non-Formulary
03/25/2015
PICATO
ingenol mebutate
CHANGE TIER
Preferred Brands
Non-Formulary
03/25/2015
APIDRA
SOLOSTAR
insulin glulisine
CHANGE TIER
Preferred Brands
Non-Formulary
03/25/2015
BETASERON
interferon beta-1b
ADD TO FORMULARY
Non-Formulary
03/25/2015
EXTAVIA
interferon beta-1b
ADD TO FORMULARY
Non-Formulary
03/25/2015
PROCARDIA XL nifedipine
ADD TO FORMULARY
Non-Formulary
03/25/2015
ARICEPT
donepezil hcl
CHANGE UM:
AUTHORIZATION
PA applies
03/25/2015
ARICEPT
donepezil hcl
CHANGE UM:
AUTHORIZATION
PA applies
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 451
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
KOVALTRY
antihemophilic factor (fviii)
recomb,full length (alb-free)
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
carbamazepine
er
carbamazepine
ADD TO FORMULARY
Generics
03/26/2016
frovatriptan
succinate
frovatriptan succinate
ADD TO FORMULARY
Non-Formulary
03/26/2016
mometasone
furoate
mometasone furoate
ADD TO FORMULARY
Generics
03/26/2016
sodium
sulfacetamidesulfur
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Generics
03/26/2016
sodium
sulfacetamidesulfur
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Generics
03/26/2016
diclofenac
sodium
diclofenac sodium
ADD TO FORMULARY
Generics
03/26/2016
zolpidem tartrate zolpidem tartrate
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 452
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/26/2016
zolpidem tartrate zolpidem tartrate
ADD TO FORMULARY
Generics
03/26/2016
diphenhydramine diphenhydramine hcl in 0.9
-0.9% nacl
% sodium chloride
ADD TO FORMULARY
Generics
03/26/2016
alogliptin
alogliptin benzoate
ADD TO FORMULARY
Generics
03/26/2016
alogliptinpioglitazone
alogliptin
benzoate/pioglitazone hcl
ADD TO FORMULARY
Generics
03/26/2016
alogliptinpioglitazone
alogliptin
benzoate/pioglitazone hcl
ADD TO FORMULARY
Generics
03/26/2016
alogliptinpioglitazone
alogliptin
benzoate/pioglitazone hcl
ADD TO FORMULARY
Generics
03/26/2016
alogliptinpioglitazone
alogliptin
benzoate/pioglitazone hcl
ADD TO FORMULARY
Generics
03/26/2016
alogliptinpioglitazone
alogliptin
benzoate/pioglitazone hcl
ADD TO FORMULARY
Generics
03/26/2016
alogliptin
alogliptin benzoate
ADD TO FORMULARY
Generics
03/26/2016
alogliptinmetformin
alogliptin
benzoate/metformin hcl
ADD TO FORMULARY
Generics
03/26/2016
alogliptinmetformin
alogliptin
benzoate/metformin hcl
ADD TO FORMULARY
Generics
03/26/2016
alogliptinpioglitazone
alogliptin
benzoate/pioglitazone hcl
ADD TO FORMULARY
Generics
03/26/2016
alogliptin
alogliptin benzoate
ADD TO FORMULARY
Generics
03/26/2016
diclotral
diclofenac sodium/capsicum
oleoresin
ADD TO FORMULARY
Generics
03/26/2016
klofensaid ii
diclofenac sodium
ADD TO FORMULARY
Generics
03/26/2016
unilet lancets
lancets
ADD TO FORMULARY
Generics
03/26/2016
easy touch
syringe,safety with needle,5
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 453
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/26/2016
easy touch
syringe,safety with needle,5
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
easy touch
syringe,safety with needle,5
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
relizorb
enteral pump accessory for
fat hydrolysis
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
cool blood
glucose
blood-glucose meter
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
depend fit-flex
diaper,brief,adult,
disposable
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
tetrahydrobiopteri sapropterin dihydrochloride
n hcl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
easy mini eject
lancing device
lancing device
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
vitamin c
ascorbic acid
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
vitamin c
ascorbic acid
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
MURINE EAR
DROPS
carbamide peroxide
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
GALAXTRA
galactose
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
CLEAR EYES
COOLING
COMFORT
naphazoline hcl/glycerin
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
CLEAR EYES
MAX REDNESS
RELIEF
naphazoline hcl/glycerin
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 454
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
03/26/2016
CLEAR EYES
MAX REDNESS
RELIEF
03/26/2016
Generic Name
naphazoline hcl/glycerin
Type of Change
Previous Value
New Value
REMOVE FROM
FORMULARY
Non-Formulary
arthritis pain relief acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
arthritis pain relief acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
melatonin
melatonin
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
nu-mag
magnesium chloride
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
relhist dmx
guaifenesin/dextromethorph
an hbr/phenylephrine
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
relcof dm
brompheniramine
maleate/phenylephrine
hcl/dextromethorphan
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
prenatal vitamins prenatal vits with
calcium#133/ferrous
fumarate/folic acid
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
mucus d
guaifenesin/pseudoephedrin
e hcl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
mucus d
guaifenesin/pseudoephedrin
e hcl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
ALPROLIX
factor ix recombinant, fc
fusion protein
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
ADZENYS XRODT
amphetamine
ADD TO FORMULARY
Non-Formulary
03/26/2016
ADZENYS XRODT
amphetamine
ADD TO FORMULARY
Non-Formulary
03/26/2016
ADZENYS XRODT
amphetamine
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 455
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/26/2016
ADZENYS XRODT
amphetamine
ADD TO FORMULARY
Non-Formulary
03/26/2016
ADZENYS XRODT
amphetamine
ADD TO FORMULARY
Non-Formulary
03/26/2016
ADZENYS XRODT
amphetamine
ADD TO FORMULARY
Non-Formulary
03/26/2016
ZEMBRACE
SYMTOUCH
sumatriptan succinate
ADD TO FORMULARY
Non-Formulary
03/26/2016
ZEMBRACE
SYMTOUCH
sumatriptan succinate
ADD TO FORMULARY
Non-Formulary
03/26/2016
epinephrine hcl0.9% nacl
epinephrine hcl in 0.9 %
sodium chloride
ADD TO FORMULARY
Generics
03/26/2016
SMARTRX
GABAKIT
gabapentin/lidocaine
hcl/menthol
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
easy touch
syringe,safety with needle,3
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
easy touch
syringe,safety with needle,3
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
easy touch
syringe,safety with needle,3
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
easy touch
syringe,safety with needle,3
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
easy touch
syringe,safety with needle,3
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
easy touch
syringe,safety with needle,3
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 456
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
03/26/2016
easy touch
syringe,safety with needle,3
sheathlock syrg- ml
ndl
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
NOURISH
lactose-reduced food/fiber
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
vcf
nonoxynol 9
REMOVE FROM
FORMULARY
Non-Formulary
03/26/2016
vcf
nonoxynol 9
REMOVE FROM
FORMULARY
Non-Formulary
03/30/2015
MIRCERA
methoxy polyethylene
glycol-epoetin beta
ADD TO FORMULARY
Non-Formulary
03/30/2015
NORDITROPIN
FLEXPRO
somatropin
ADD TO FORMULARY
Preferred Brands
03/30/2015
NORDITROPIN
FLEXPRO
somatropin
ADD UM: SPECIALTY
Specialty Drug
03/30/2015
NORDITROPIN
FLEXPRO
somatropin
ADD UM: AUTHORIZATION
PA applies
03/30/2015
CRESEMBA
isavuconazonium sulfate
ADD TO FORMULARY
Non-Formulary
03/30/2015
CRESEMBA
isavuconazonium sulfate
ADD TO FORMULARY
Not Covered
03/30/2015
AVENOVA
hypochlorous acid/sodium
chloride
ADD TO FORMULARY
Non-Formulary
03/30/2015
recedo
polydimethylsiloxanes/silico
n dioxide
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 457
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
April, 2014
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
Specialty Drug
04/01/2014
AUBAGIO
teriflunomide
REMOVE UM: CUSTOM
04/01/2014
AUBAGIO
teriflunomide
ADD UM: SPECIALTY
04/01/2015
PROMACTA
eltrombopag olamine
04/01/2015
INVOKAMET
canagliflozin/metformin hcl
ADD TO FORMULARY
04/01/2015
INVOKANA
canagliflozin
ADD TO FORMULARY
04/01/2015
INVOKAMET
canagliflozin/metformin hcl
04/01/2015
isradipine
CHANGE TIER
New Value
Specialty Drug
Preferred Brands
Non-Formulary
Preferred Brands
Non-Formulary
Preferred Brands
ADD UM: QUANTITY
30 / 30 days
isradipine
CHANGE TIER
Generics
04/01/2015
clindamycinclindamycin
benzoyl peroxide phosphate/benzoyl peroxide
ADD TO FORMULARY
04/01/2015
MONOCLATE-P antihemophilic factor,
human
ADD TO FORMULARY
Non-Formulary
04/01/2015
KOATE-DVI
antihemophilic factor,
human
ADD TO FORMULARY
Non-Formulary
04/01/2015
MENEST
estrogens,esterified
CHANGE TIER
Non-Formulary
04/01/2015
MENEST
estrogens,esterified
CHANGE TIER
04/01/2015
MICRONOR,ORT norethindrone
HO MICRONOR
CHANGE TIER
04/01/2015
SAIZEN
somatropin
CHANGE TIER
04/01/2015
SANDIMMUNE
cyclosporine
ADD UM: AUTHORIZATION
PA applies
04/01/2015
SANDIMMUNE
cyclosporine
ADD UM: AUTHORIZATION
PA applies
04/01/2015
FAMVIR
famciclovir
ADD TO FORMULARY
Non-Formulary
04/01/2015
REBETOL
ribavirin
ADD UM: AUTHORIZATION
PA applies
04/01/2015
SPECTRACEF
cefditoren pivoxil
CHANGE TIER
Non-Formulary
Non-Formulary
Preventative
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 458
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/01/2015
dexmethylphenid dexmethylphenidate hcl
ate hcl
CHANGE TIER
Preferred Brands
Generics
04/01/2015
FOCALIN
dexmethylphenidate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
04/01/2015
fondaparinux
sodium
fondaparinux sodium
CHANGE TIER
Preferred Brands
Generics
04/01/2015
se bpo
benzoyl peroxide
microspheres
ADD TO FORMULARY
Non-Formulary
Generics
04/01/2015
metadate er
methylphenidate hcl
CHANGE TIER
Generics
04/01/2015
RITALIN-SR
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
morphine sulfate morphine sulfate
er
04/01/2015
ROXICODONE
oxycodone hcl
CHANGE TIER
Non-Formulary
04/01/2015
SARAFEM
fluoxetine hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
SARAFEM
fluoxetine hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
REMERON
mirtazapine
ADD TO FORMULARY
Non-Formulary
04/01/2015
REMERON
mirtazapine
ADD TO FORMULARY
Non-Formulary
04/01/2015
REMERON
mirtazapine
ADD TO FORMULARY
Non-Formulary
04/01/2015
INOVA 8-2
salicylic acid/benzoyl
peroxide/vitamin e mixed
CHANGE TIER
Preferred Brands
Non-Formulary
04/01/2015
INOVA 4-1
salicylic acid/benzoyl
peroxide/vitamin e mixed
CHANGE TIER
Preferred Brands
Non-Formulary
04/01/2015
EFFIENT
prasugrel hcl
CHANGE TIER
04/01/2015
morphine sulfate morphine sulfate
er
04/01/2015
STAVZOR
valproic acid
04/01/2015
DEPAKOTE
divalproex sodium
ADD TO FORMULARY
Non-Formulary
04/01/2015
DEPAKOTE
divalproex sodium
ADD TO FORMULARY
Non-Formulary
ADD TO FORMULARY
Non-Formulary
Generics
Non-Formulary
ADD TO FORMULARY
Non-Formulary
Generics
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 459
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/01/2015
DEPAKOTE
divalproex sodium
ADD TO FORMULARY
Non-Formulary
04/01/2015
DEPAKOTE
SPRINKLE
divalproex sodium
ADD TO FORMULARY
Non-Formulary
04/01/2015
ZARONTIN
ethosuximide
ADD TO FORMULARY
Non-Formulary
04/01/2015
ZARONTIN
ethosuximide
ADD TO FORMULARY
Non-Formulary
04/01/2015
REMODULIN
treprostinil sodium
CHANGE TIER
Preferred Brands
Non-Formulary
04/01/2015
REMODULIN
treprostinil sodium
CHANGE TIER
Preferred Brands
Non-Formulary
04/01/2015
REMODULIN
treprostinil sodium
CHANGE TIER
Preferred Brands
Non-Formulary
04/01/2015
REMODULIN
treprostinil sodium
CHANGE TIER
Preferred Brands
Non-Formulary
04/01/2015
RETIN-A MICRO tretinoin microspheres
ADD TO FORMULARY
Non-Formulary
04/01/2015
ADDERALL XR
dextroamphetamine sulfsaccharate/amphetamine
sulf-aspartate
ADD TO FORMULARY
Non-Formulary
04/01/2015
ADDERALL XR
dextroamphetamine sulfsaccharate/amphetamine
sulf-aspartate
ADD TO FORMULARY
Non-Formulary
04/01/2015
ADDERALL XR
dextroamphetamine sulfsaccharate/amphetamine
sulf-aspartate
ADD TO FORMULARY
Non-Formulary
04/01/2015
VFEND
voriconazole
ADD TO FORMULARY
Non-Formulary
04/01/2015
LOTREL
amlodipine
besylate/benazepril hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
URSO FORTE
ursodiol
ADD TO FORMULARY
Non-Formulary
04/01/2015
UTA
methenamine/methylene
blue/salicylate/sodium
phos/hyoscy
ADD TO FORMULARY
Non-Formulary
04/01/2015
DEPAKOTE ER
divalproex sodium
ADD TO FORMULARY
Non-Formulary
04/01/2015
XYREM
sodium oxybate
REMOVE UM:
AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 460
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/01/2015
URECHOLINE
bethanechol chloride
ADD TO FORMULARY
Non-Formulary
04/01/2015
URECHOLINE
bethanechol chloride
ADD TO FORMULARY
Non-Formulary
04/01/2015
URECHOLINE
bethanechol chloride
ADD TO FORMULARY
Non-Formulary
04/01/2015
URECHOLINE
bethanechol chloride
ADD TO FORMULARY
Non-Formulary
04/01/2015
DEPAKOTE ER
divalproex sodium
ADD TO FORMULARY
Non-Formulary
04/01/2015
CARDIZEM LA
diltiazem hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
CARDIZEM LA
diltiazem hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
CARDIZEM LA
diltiazem hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
DURAGESIC
fentanyl
CHANGE TIER
Non-Formulary
04/01/2015
DURAGESIC
fentanyl
CHANGE TIER
Non-Formulary
04/01/2015
DURAGESIC
fentanyl
CHANGE TIER
Non-Formulary
04/01/2015
DURAGESIC
fentanyl
CHANGE TIER
Non-Formulary
04/01/2015
LOPROX
ciclopirox
ADD TO FORMULARY
Non-Formulary
04/01/2015
MAXALT
rizatriptan benzoate
ADD TO FORMULARY
Non-Formulary
04/01/2015
MAXALT
rizatriptan benzoate
ADD TO FORMULARY
Non-Formulary
04/01/2015
MAXALT MLT
rizatriptan benzoate
ADD TO FORMULARY
Non-Formulary
04/01/2015
MAXALT MLT
rizatriptan benzoate
ADD TO FORMULARY
Non-Formulary
04/01/2015
DIDREX
benzphetamine hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
ZOFRAN
ondansetron hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
ZOFRAN
ondansetron hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
ZOFRAN
ondansetron hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
ZOFRAN ODT
ondansetron
ADD TO FORMULARY
Non-Formulary
04/01/2015
ZOFRAN ODT
ondansetron
ADD TO FORMULARY
Non-Formulary
04/01/2015
CLIMARA
estradiol
CHANGE TIER
Non-Formulary
04/01/2015
CLIMARA
estradiol
CHANGE TIER
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 461
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/01/2015
oxycodone
oxycodone hcl
hcl,oxycodone
hydrochloride,oxy
contin,roxicodone
,oxecta,oxycodon
e
concentrate,roxic
odone
intensol,ethoxydose,oxyir,da
zidox,oxycodone
hcl er
CHANGE TIER
Generics
04/01/2015
ROXICODONE
oxycodone hcl
CHANGE TIER
Non-Formulary
04/01/2015
ROXICODONE
oxycodone hcl
CHANGE TIER
Non-Formulary
04/01/2015
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
04/01/2015
DILAUDID
hydromorphone hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
ACULAR LS
ketorolac tromethamine
ADD TO FORMULARY
Non-Formulary
04/01/2015
METADATE CD
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
METADATE CD
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
METADATE CD
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
04/01/2015
DILAUDID-HP
hydromorphone hcl/pf
ADD TO FORMULARY
Non-Formulary
04/01/2015
TOPROL XL
metoprolol succinate
ADD TO FORMULARY
Non-Formulary
04/01/2015
TOPROL XL
metoprolol succinate
ADD TO FORMULARY
Non-Formulary
04/01/2015
TOPROL XL
metoprolol succinate
ADD TO FORMULARY
Non-Formulary
04/01/2015
KEPPRA XR
levetiracetam
ADD TO FORMULARY
Non-Formulary
04/01/2016
DYMISTA
azelastine hcl/fluticasone
propionate
ADD TO FORMULARY
Non-Formulary
Preferred Brands
04/01/2016
TRULICITY
dulaglutide
ADD TO FORMULARY
Non-Formulary
Preferred Brands
04/01/2016
TRULICITY
dulaglutide
ADD TO FORMULARY
Non-Formulary
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 462
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/01/2016
EMBEDA
morphine sulfate/naltrexone
hcl
ADD TO FORMULARY
Non-Formulary
Preferred Brands
04/01/2016
NUEDEXTA
dextromethorphan
hbr/quinidine sulfate
ADD TO FORMULARY
Non-Formulary
Preferred Brands
04/01/2016
GENVOYA
elvitegravir/cobicistat/emtrici
tabine/tenofovir alafenamide
ADD UM: SPECIALTY
Specialty Drug
04/01/2016
NUWIQ
antihemophilic factor viii rec
hek cell, b-domain deleted
ADD TO FORMULARY
Non-Formulary
04/01/2016
NUWIQ
antihemophilic factor viii rec
hek cell, b-domain deleted
ADD UM: SPECIALTY
Specialty Drug
04/01/2016
KEVEYIS
dichlorphenamide
ADD UM: SPECIALTY
Specialty Drug
04/01/2016
glucophage,gluco metformin hcl
phage
xr,metformin
hcl,metformin hcl
er,riomet,glumetz
a,metformin
hydrochloride,fort
amet
ADD UM: AUTHORIZATION
PA applies
04/01/2016
glumetza,metfor
min hcl er
04/01/2016
PH 12 DILUENT diluent for epoprostenol
FOR FLOLAN
sodium (glycine)
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
dicyclomine hcl
dicyclomine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
dicyclomine hcl
dicyclomine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
fentanyl citrate0.9% nacl
fentanyl citrate in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
cefazolin sodium- cefazolin sodium/water for
sterile water
injection,sterile
REMOVE FROM
FORMULARY
Non-Formulary
metformin hcl
CHANGE TIER
Generics
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 463
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/01/2016
sure result tac
pak
triamcinolone
acetonide/dimethicone/silico
ne, adhesive
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
sure result dss
premium pack
diclofenac sodium/capsicum
oleoresin
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
dexamethasone- dexamethasone sodium
0.9% nacl
phosphate in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
dexamethasone- dexamethasone sodium
0.9% nacl
phosphate in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
diphenhydramine diphenhydramine hcl in 0.9
-0.9% nacl
% sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
norepinephrine
bitartrate-d5w
norepinephrine
bitartrate/dextrose 5 % in
water
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
magnesium
sulfate-d5w
magnesium sulfate/dextrose
5 % in water
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
oxytocin-0.9%
nacl
oxytocin in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
epinephrine hcl0.9% nacl
epinephrine hcl in 0.9 %
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
oxytocin-lactated oxytocin/ringers
ringers
solution,lactated
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
fentanyl citrate
fentanyl citrate/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
easy touch
fluringe fliplock
syringe,safety with needle,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
easy touch
fluringe
sheathlock
syringe,safety with needle,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 464
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/01/2016
easy touch
tuberculin
sheathlk
syringe,safety with needle,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
easy touch
tuberculin
sheathlk
syringe,safety with needle,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
easy touch
tuberculin
sheathlk
syringe,safety with needle,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
alcohol prep pads alcohol antiseptic pads
ADD TO FORMULARY
Generics
04/01/2016
NEXIUM 24HR
esomeprazole magnesium
ADD TO FORMULARY
Generics
04/01/2016
KETOVIE
PEPTIDE 4:1
nutritional tx,
ketogenic,whey
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
MTERYTI FOLIC prenatal vit no.6/iron
5
fum/folic acid/vit
b12/calcium/vit d3
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
day time cold-flu dextromethorphan
relief
hbr/phenylephrine
hcl/acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
nighttime cold-flu dextromethorphan
relief
hbr/acetaminophen/doxylam
ine
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
famotidine
famotidine
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
calcium 600-vit
d3
calcium
carbonate/cholecalciferol
(vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
famotidine
famotidine
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
relcof ir
guaifenesin/phenylephrine
hcl
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 465
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
04/01/2016
relhist bp
04/01/2016
Generic Name
brompheniramine
maleate/phenylephrine hcl
Type of Change
Previous Value
New Value
REMOVE FROM
FORMULARY
Non-Formulary
day time cold-flu dextromethorphan
relief
hbr/phenylephrine
hcl/acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
severe cold
cough-flu
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
nighttime cold-flu dextromethorphan
relief
hbr/acetaminophen/doxylam
ine
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
lubricating tears
propylene
glycol/polyethylene glycol
400
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
severe cold
cough-flu
diphenhydramine
hcl/phenylephrine
hcl/acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
lubricating tears
propylene
glycol/polyethylene glycol
400
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
famotidine
famotidine
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
famotidine
famotidine
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
TALTZ
ixekizumab
AUTOINJECTOR
(3 PACK)
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
TALTZ
ixekizumab
AUTOINJECTOR
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
TALTZ
ixekizumab
AUTOINJECTOR
(2 PACK)
REMOVE FROM
FORMULARY
Non-Formulary
diphenhydramine
hcl/phenylephrine
hcl/acetaminophen
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 466
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/01/2016
TALTZ SYRINGE ixekizumab
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
TALTZ SYRINGE ixekizumab
(3 PACK)
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
TALTZ SYRINGE ixekizumab
(2 PACK)
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
TALTZ SYRINGE ixekizumab
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
ACTIVE-PAC
gabapentin/lidocaine
hcl/menthol
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
SERNIVO
betamethasone dipropionate
ADD TO FORMULARY
Non-Formulary
04/01/2016
mupirocin
mupirocin
ADD TO FORMULARY
Generics
04/01/2016
nicardipine hcl
nicardipine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
succinylcholine
chloride
succinylcholine chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
hydromorphone
hcl-0.9% nacl
hydromorphone hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/01/2016
temozolomide
temozolomide
ADD TO FORMULARY
Non-Formulary
Generics
04/01/2016
temozolomide
temozolomide
ADD TO FORMULARY
Non-Formulary
Generics
04/01/2016
temozolomide
temozolomide
ADD TO FORMULARY
Non-Formulary
Generics
04/01/2016
temozolomide
temozolomide
ADD TO FORMULARY
Non-Formulary
Generics
04/01/2016
XELJANZ XR
tofacitinib citrate
04/06/2015
04/06/2015
REMOVE FROM
FORMULARY
Non-Formulary
norethin-eth
norethindrone-ethinyl
estra-ferrous fum estradiol/ferrous fumarate
ADD TO FORMULARY
Preventative
norethin-eth
norethindrone-ethinyl
estra-ferrous fum estradiol/ferrous fumarate
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 467
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/06/2015
LAYOLIS FE
norethindrone-ethinyl
estradiol/ferrous fumarate
ADD TO FORMULARY
Preventative
04/06/2015
LAYOLIS FE
norethindrone-ethinyl
estradiol/ferrous fumarate
ADD UM: GENDER
Female
04/06/2015
adapalene
adapalene
ADD TO FORMULARY
Generics
04/06/2015
CHOLBAM
cholic acid
ADD TO FORMULARY
Non-Formulary
04/06/2015
CHOLBAM
cholic acid
ADD TO FORMULARY
Non-Formulary
04/06/2015
NATPARA
parathyroid hormone
ADD TO FORMULARY
Non-Formulary
04/06/2015
NATPARA
parathyroid hormone
ADD UM: SPECIALTY
Specialty Drug
04/06/2015
OMIDRIA
phenylephrine hcl/ketorolac
tromethamine
ADD TO FORMULARY
Not Covered
04/06/2015
hydroxyzine hcl
hydroxyzine hcl
CHANGE TIER
Generics
04/06/2015
metaxalone
metaxalone
ADD TO FORMULARY
Generics
04/06/2015
SKELAXIN
metaxalone
ADD TO FORMULARY
Non-Formulary
04/07/2016
UROAV-B
methenamine/methylene
blue/sod
phos/p.salicylate/hyoscyami
ne
ADD TO FORMULARY
Non-Formulary
04/07/2016
EVOMELA
melphalan hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
prednisone
prednisone
ADD TO FORMULARY
Generics
04/07/2016
prednisone
prednisone
ADD TO FORMULARY
Generics
04/07/2016
methergine
methylergonovine maleate
ADD TO FORMULARY
Generics
04/07/2016
methergine
methylergonovine maleate
ADD TO FORMULARY
Generics
04/07/2016
magnesiumlactated ringers
magnesium sulfate/ringers
solution,lactated
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
oxytocin-d5lactated ringers
oxytocin/dextrose 5%lactated ringers
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 468
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/07/2016
cefazolin sodium- cefazolin sodium/water for
sterile water
injection,sterile
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
phenylephrine
hcl-0.9% nacl
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
morphine sulfate- morphine sulfate in 0.9 %
0.9% nacl
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
bupivacaine hcl0.9% nacl
bupivacaine hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
bupivacaine hcl0.9% nacl
bupivacaine hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
morphine sulfate- morphine sulfate in 0.9 %
0.9% nacl
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
fentanylbupivacaine0.9% nacl
fentanyl citrate/bupivacaine
hcl in 0.9 % sodium
chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
midazolam hcl0.9% nacl
midazolam hcl in 0.9 %
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
easy touch
syringe,safety with needle,1
tuberculin fliplock ml
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
easy touch
syringe,safety with needle,1
tuberculin fliplock ml
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
easy touch
tuberculin
sheathlk
syringe,safety with needle,1
ml
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
easy touch
syringe,safety with needle,1
tuberculin fliplock ml
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
stevia glycerite
stevioside/glycerin
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
stevia glycerite
stevioside/glycerin
REMOVE FROM
FORMULARY
Non-Formulary
phenylephrine hcl in 0.9 %
sodium chloride
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 469
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/07/2016
ADULT MULTI + multivitamin with min/folic
OMEGA-3
acid/d3/omega3/dha/epa/fish oil
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
HAIR, SKIN AND ascorbic acid/ascorbate
NAILS
sodium/biotin
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
NEOKE MCT70
medium chain triglycerides
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
EMERGEN-C
MSM LITE
ascorbic acid/multivitamin,
minerals/methylsulfonylmeth
ane
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
EMERGEN-C
ascorbic acid/multivitamin
with minerals
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
EMERGEN-C
ascorbic acid/multivitHEART HEALTH min/lycopene/plant sterol
complex
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
EMERGEN-C
VITAMIN DCALCIUM
ascorbic acid/multivitmin/calcium combo
no.27/vitamin d3
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
EMERGEN-C
ascorbic acid/multivitamin
with minerals
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
children's painfever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
12-hour cough
relief
dextromethorphan polistirex
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
juniors'
acetaminophen
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
juniors'
acetaminophen
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
wart remover
salicylic acid
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 470
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/07/2016
antifungal
undecylenic acid
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
children's painfever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
alertness aid
caffeine
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
allergy relief
chlorpheniramine maleate
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
allergy relief
chlorpheniramine maleate
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
alertness aid
caffeine
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
guaifenesin-dm
er
guaifenesin/dextromethorph
an hbr
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
protein nutritional lactose-reduced food
shake
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
ddrops
cholecalciferol (vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
baby ddrops
cholecalciferol (vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
ddrops
cholecalciferol (vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
pain reliever pm
acetaminophen/diphenhydra
mine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
witch hazel
witch hazel
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
pain reliever pm
acetaminophen/diphenhydra
mine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
witch hazel
witch hazel
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 471
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/07/2016
alertness aid
caffeine
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
alertness aid
caffeine
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
allergy relief
chlorpheniramine maleate
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
allergy relief
chlorpheniramine maleate
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
DOG
EPITHELIUM
EXTRACT
allergenic extract-dog
epithelium
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
DOG FENNEL
allergenic extract-weed
pollen-dog fennel
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
HACKBERRY
allergenic extract-tree
pollen-hackberry
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
IV INFUSION
CPI
lidocaine/prilocaine with 0.9
% sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
CINQAIR
reslizumab
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
DESCOVY
emtricitabine/tenofovir
alafenamide fumarate
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
DEFITELIO
defibrotide sodium
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
DEFITELIO
defibrotide sodium
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
NOXIFOL-D3
cholecalciferol (vit d3)/folic
acid
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
ketamine hclsterile water
ketamine hcl in sterile water
REMOVE FROM
FORMULARY
Non-Formulary
04/07/2016
meperidine hcl0.9% nacl
meperidine hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 472
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/08/2015
verapamil er pm
verapamil hcl
CHANGE TIER
Generics
04/08/2015
verapamil
er,verapamil hcl
verapamil hcl
CHANGE TIER
Generics
04/08/2016
lamotrigine er
lamotrigine
CHANGE TIER
04/09/2016
PLEGRIDY PEN peginterferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
PLEGRIDY PEN peginterferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
GILENYA
fingolimod hcl
ADD UM: PS
Preferred
Specialty
04/09/2016
BETASERON
interferon beta-1b
ADD UM: PS
Preferred
Specialty
04/09/2016
AVONEX PEN
interferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
NORDITROPIN
FLEXPRO
somatropin
ADD UM: PS
Preferred
Specialty
04/09/2016
HUMIRA
adalimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
AVONEX PEN
interferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
HUMIRA
PEDIATRIC
CROHN'S
adalimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
HUMIRA
PEDIATRIC
CROHN'S
adalimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
NORDITROPIN
FLEXPRO
somatropin
ADD UM: PS
Preferred
Specialty
04/09/2016
BETASERON
interferon beta-1b
ADD UM: PS
Preferred
Specialty
Generics
Not Covered
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 473
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/09/2016
TECFIDERA
dimethyl fumarate
ADD UM: PS
Preferred
Specialty
04/09/2016
TECFIDERA
dimethyl fumarate
ADD UM: PS
Preferred
Specialty
04/09/2016
BETASERON
interferon beta-1b
ADD UM: PS
Preferred
Specialty
04/09/2016
HUMIRA
adalimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
COPAXONE
glatiramer acetate
ADD UM: PS
Preferred
Specialty
04/09/2016
MAKENA
hydroxyprogesterone
caproate
ADD UM: PS
Preferred
Specialty
04/09/2016
TECFIDERA
dimethyl fumarate
ADD UM: PS
Preferred
Specialty
04/09/2016
SIMPONI
golimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
SIMPONI
golimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
PLEGRIDY
peginterferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
PLEGRIDY
peginterferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
BETASERON
interferon beta-1b
ADD UM: PS
Preferred
Specialty
04/09/2016
AVONEX PEN
interferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
NORDITROPIN
NORDIFLEX
somatropin
ADD UM: PS
Preferred
Specialty
04/09/2016
PLEGRIDY PEN peginterferon beta-1a
ADD UM: PS
Preferred
Specialty
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 474
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/09/2016
AVONEX
interferon beta-1a/albumin
human
ADD UM: PS
Preferred
Specialty
04/09/2016
ENBREL
etanercept
ADD UM: PS
Preferred
Specialty
04/09/2016
COPAXONE
glatiramer acetate
ADD UM: PS
Preferred
Specialty
04/09/2016
ENBREL
etanercept
ADD UM: PS
Preferred
Specialty
04/09/2016
ZYTIGA
abiraterone acetate
ADD UM: PS
Preferred
Specialty
04/09/2016
BETASERON
interferon beta-1b
ADD UM: PS
Preferred
Specialty
04/09/2016
ENBREL
etanercept
ADD UM: PS
Preferred
Specialty
04/09/2016
GILENYA
fingolimod hcl
ADD UM: PS
Preferred
Specialty
04/09/2016
ENBREL
etanercept
ADD UM: PS
Preferred
Specialty
04/09/2016
SIMPONI
golimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
ENBREL
etanercept
ADD UM: PS
Preferred
Specialty
04/09/2016
ENBREL
etanercept
ADD UM: PS
Preferred
Specialty
04/09/2016
PLEGRIDY
peginterferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
AVONEX
interferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
SIMPONI
golimumab
ADD UM: PS
Preferred
Specialty
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 475
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/09/2016
COPAXONE
glatiramer acetate
ADD UM: PS
Preferred
Specialty
04/09/2016
ORTHOVISC
hyaluronate sodium
ADD UM: PS
Preferred
Specialty
04/09/2016
AVONEX
interferon beta-1a/albumin
human
ADD UM: PS
Preferred
Specialty
04/09/2016
GILENYA
fingolimod hcl
ADD UM: PS
Preferred
Specialty
04/09/2016
AVONEX
interferon beta-1a/albumin
human
ADD UM: PS
Preferred
Specialty
04/09/2016
ENBREL
etanercept
ADD UM: PS
Preferred
Specialty
04/09/2016
AVONEX
interferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
NORDITROPIN
FLEXPRO
somatropin
ADD UM: PS
Preferred
Specialty
04/09/2016
HUMIRA
adalimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
NORDITROPIN
FLEXPRO
somatropin
ADD UM: PS
Preferred
Specialty
04/09/2016
SYNVISC-ONE
hylan g-f 20
ADD UM: PS
Preferred
Specialty
04/09/2016
STELARA
ustekinumab
ADD UM: PS
Preferred
Specialty
04/09/2016
SYNVISC
hylan g-f 20
ADD UM: PS
Preferred
Specialty
04/09/2016
AVONEX
interferon beta-1a
ADD UM: PS
Preferred
Specialty
04/09/2016
ENBREL
etanercept
ADD UM: PS
Preferred
Specialty
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 476
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/09/2016
HUMIRA PEN
PSORIASISUVEITIS
adalimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
HUMIRA PEN
adalimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
HUMIRA PEN
CROHN-UC-HS
STARTER
adalimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
HUMIRA PEN
adalimumab
ADD UM: PS
Preferred
Specialty
04/09/2016
STELARA
ustekinumab
ADD UM: PS
Preferred
Specialty
04/13/2015
QUADRACEL
DTAP-IPV
diphtheria,
pertussis(acell),tetanus,polio
vaccine/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
QUADRACEL
DTAP-IPV
diphtheria,
pertussis(acell),tetanus,polio
vaccine/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
sterile
droptainers
eye drops dispenser
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
sterile
droptainers
eye drops dispenser
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
sterile
droptainers
eye drops dispenser
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
genistein
genistein
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
latanoprost
latanoprost
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
scar care base
enhanced
gel base no.184
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 477
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/13/2015
scar care base
enhanced
gel base no.184
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
ANASEPT
sodium hypochlorite
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
melatonin
melatonin
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
acidophilus
lactobacillus
acidophilus/bifidobacterium
longum
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
scrub care
povidone iodine
povidone-iodine
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
probiotic colon
support
lactobacillus acidophilus/l.
gasseri/b. bifidum/b. longum
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
ensure high
protein-muscle
lactose-reduced food
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
scrub care
povidone iodine
povidone-iodine
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
ensure high
protein-muscle
lactose-reduced food
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
MENVEO MENA meningococcal a diphtheriaCOMPONENT
conj vaccine component 1 of
2/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
MENVEO
MENCYW-135
COMPONENT
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
RETIN-A MICRO tretinoin microspheres
PUMP
ADD TO FORMULARY
Non-Formulary
04/13/2015
PENTACEL
diphtheria,
DTAP-IPV
pertussis(acell),tetanus,polio
COMPONENT,Q vaccine/pf
UADRACEL
DTAP-IPV
REMOVE FROM
FORMULARY
Non-Formulary
meningococcal c,y,w135,dip-conj vaccine
component 2 of 2/pf
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 478
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/13/2015
venlafaxine hcl er venlafaxine hcl
ADD TO FORMULARY
Generics
04/13/2015
retin-a micro
pump,tretinoin
microsphere
tretinoin microspheres
ADD TO FORMULARY
Non-Formulary
04/13/2015
ornithine
ornithine
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
comtan,entacapo entacapone
ne
ADD TO FORMULARY
Generics
04/13/2015
fexmid,cyclobenz cyclobenzaprine hcl
aprine hcl
ADD TO FORMULARY
Generics
04/13/2015
ANASEPT SKIN- sodium hypochlorite
WOUND
CLEANSER,ANA
SEPT
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 479
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
04/13/2015
humapen
memoir,humapen
luxura hd,gentle
touch
system,gentle
touch loop
ostomy
sys,tubigrip,tubul
ar bandage
applicator,tubipad
,lyofoam,lyofoam
c,lyofoam
a,lyofoam
t,lyofoam
extra,kaltostat,sur
-fit natura post
op,stomahesive,e
steem
synergy,eakin
skin barrier,eakin
fistula & wound
pouch,little ones
active life
pouch,stomahesi
ve sterile
wafer,active life
closed-end
pouch,visi-flow
stoma
cone,active life
drainable
pouch,stomahesi
ve protective,surfit drainage
container,sur-fit
night drainage
tubing,allkare
protect barrier
wipe,flexi-trak
insulin admin.
supplies,ostomy kit,elastic
bandage,tubular bandage
applicator,foam
bandage,alginate
dressing,ostomy
supply,colostomy
bags,ostomy
adhesive,adhesive
remover,colostomy
belt,ostomy cap,facial-body
sponge,gel
dressing,hydrocolloid
dressing,ostomy
irrigator,colostomy bag, nonsterile,activated
charcoal/alginate
dressing/hydrocolloid
dressing,silver/hydrocolloid
dressing,zinc oxide,nonadherent bandage,irrigation
set,miscellaneous medical
supply,urinary bag,iv
equipment,vaporizer,soft
lens rinse-store
solution,hard lens
cleaner,soft lens adjunctive
solutions,hard lens wetting
solution,contact lens
case,soft lens chemical
disinfectnt,diaphragms, arcspring,diaphragm fitting
set,arc-spring,diaphragms,
coil spring,diaphragms, flat
spring,pregnancy test
kit,cholesterol test kit,gas
permeable lens cleaner,hard
lens clean-soak
solution,wetting soln
REMOVE FROM
FORMULARY
Previous Value
New Value
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 480
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
anchoring
device,allkare
adhesive
remover
wipe,active
life,sur-fit natura
stomahesive,acti
ve life urostomy
pouch,active life
convex,little ones
sur-fit ped
belt,ostomy
appliance
belt,active life
stoma cap,sur-fitact life-tail
closures,sur-fit
tail
closures,duolock
curved tail
closure,active life
pouch,sur-fit
autolock
stomahesive,surfit autolock
durahesive,sur-fit
autolock drain
pouch,sur-fit
autolock
pouch,optipore,s
af-gel,setopress
high
compression,kalt
ostat
fortex,aquacel,du
oderm
hydroactive,duod
erm,combiderm
acd,duoderm
gas,hard and soft,tear
test,soft lens surfactant
cleanser,soft lens enzymatic
cleanser,wetting soln
gas,hard & soft,iv piggyback
adminstration set,anesthesia
tray,iv administration setfilter,container,empty,iv
administration set,iv admin
extension set-filter,iv admin
extension set,iv
administration setclamp,transfer sets,iv
infusion pump
accessory,blood
administration set,iv
administration set,nonvent,hyperalimentation
equipment,iv catheter
kit,nerve stimulator
device,blood administration
equipment,iv infusion
pump,in-line burette
set,procedural tray,iv
venipuncture needle set,iv
catheter,dialysis (peritoneal)
kits,blood collection
set,vial,empty,feeder
container with pump
set,irrigation piercing pin
set,nv,pump set,iv catheter
kit accessory,calamine/zinc
gelatin,inhaler, assist
devices,inhaler, assist
devices, accessories,acne
scrub pad,n95 respirator,
disposable,pen needle,
diabetic,pen needle,
diabetic, safety,syringe
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 481
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
cgf,sur-fit natura
drainable
pouch,sur-fit
natura closedend pch,sur-fit
natura minipouch,sur-fit
natura urostomy
pouch,sur-fit
natura pouch,surfit autolock
inserts,sur-fit
autolock,sur-fit
natura
durahesive,sur-fit
natura flange
cap,sur-fit natura
irrig sleeve,sur-fit
nat irrig
faceplate,sur-fit
natura little
ones,visi-flow
irrigator stoma
cone,sur-fit
natura convex
inserts,durahesiv
e moldable
convex,flexiseal,active life
one-piece,eakin
cohesive
seals,carboflex,v
ersiva,duoderm
signal,aquacelag,unnaflex,surepress,sur
-fit natura visiflow set,unna-flex
plus,adria-
Generic Name
Type of Change
Previous Value
New Value
accessory,needles, insulin
disposable,syr biopsyaspiration
reusable,gloves,bloodglucose meter, disctype,blood glucose
calibration control solution,
normal,blood glucose
calibration control solution,
low,blood glucose
calibration control solution,
high,blood glucose
calibration control high and
low,lancets,lancing
device,lancing
device/lancets,bloodglucose meter,bloodglucose meter,
wireless,jejunostomy
tube,gastrostomy
tube,silver/foam
bandage,silver
sulfadiazine/foam
bandage,gauze
bandage/lanolin alc/min
oil/petrolat/ceresin,silicone
adhesive,transparent
dressing,dental plaque
indicator,needleless
dispensing pin,diaphragms,
wide seal,heating pad,gum
mastic/storax/methyl
salicylate/alcohol,syringe
with
needle,disposable,insulin 1
ml,syringe with
needle,insulin,0.5
ml,condoms, latex,
lubricated,activated
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 482
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
oncoline,triaminic
flowing
vapors,unisol 4
preservative
free,pliagel,clerz2 lubricatingrewetting,clerz2,mirasept,miras
ept step
1,mirasept step
2,unisol 25 day pf saline,unisol
plus,ortho allflex,orthodiaphragm,advan
ce pregnancy
test,advanced
care cholesterol
test,fact plus
pregnancy
test,optifree,soaclens,sys
tane
contacts,clerz
plus,opti-free
replenish,irrigatio
n administration
set,schirmer tear
test,opti-free
express,optione,opti-clean ii
daily cleaner,optifree lens
case,opti-one
multipurpose,opticlean daily
cleaner,preflex,sa
line for sensitive
charcoal/iron/sodium/water,c
old-hot pack,suppository
mold,syringe with
needle,insulin
disposable,0.5 ml,breast
shield,adhesive,silver na
hydrogen zirconium
phos/hydrocolloid heel
dressing,silver na hydrogen
zirconium phos/hydrocolloid
toe dressing,silver na
hydrogen zircon
phos/hydrocolloid
heel&toe/cream59,nasal
airflow strips,ear
syringe,denture
cleanser,adhesive
tape,facial mask,pads for
bedsores,multiple test strip
device,nebulizer,peak flow
meter/inhaler, assist
devices,peak flow
meter,mucus clearing
device,blood pressure test
kit-wrist,thermometer,
electronic,oral,blood
pressure test kitlarge,thermometer,
electronic,otic,condoms,
latex, nonlubricated,sanitary
pads,incontinence
pad,liner,disp,catheter,syrin
ge disposable, irrigation,70
ml,urinary bag
accessories,catheter
male,external,drainage
bag,catheterization
tray,syringe disposable
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 483
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
eyes,alcon
enzymatic,flexcare,opti-soak
conditioning,optitears,opti-soak
daily,opti-soak
soothing
drops,secondary
set,spinal-22 wbupiv-epiephed,spinal
anesthesia
tray,ivex-rf filter
set,evacuated
container,ls plum
primary setol,plumset
primary setol,dial-a-flo iv
extension
set,dial-a-flo
microdrip
set,venoset
secondary,soluse
t with cair
clamp,transfer
set,decanting
set,nonvented iv
set 100 wclamp,nitroglyceri
n patient
line,soluset
150x15 i.v. setsl,screw cap
set,iv pump setivex-hp,blood ytype pump
set,hema blood
secondary
irrigation,needles,
filter,gauze bandage/elastic
bandage,adhesive
bandage,gauze
bandage,syringe,
disposable, 60 ml,syringe
with needle,disposable, 3
ml,syringe, disposable, 1
ml,underpads,diaper,brief,ad
ult, disposable,syringe,
disposable, 140 ml,syringe
w-needle,disposab,1
ml,undercast padding,facialbody wipes,enema bag,
disposable,wadding,syringe,
disposable, 20 ml,syringe,
disposable, 12 ml,needles,
blood collection,syringe with
needle, 12
ml,polyhexamethylene
biguanide/gauze
bandage,feeder
container,eye patch,syringe,
disposable, 3 ml,surgical
suction tubing,compression
stocking,thigh high,regular
length,small,compression
stocking,thigh high,short
length,small,compression
stocking,thigh high,regular
length,medium,compression
stocking,thigh high,regular
length,large,compression
stocking,thigh high,long
length,small,compression
stocking,thigh high,regular
length,x-small,compression
stocking,thigh high,short
length,
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 484
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
pump,venoset
piggyback,air
filter,extension
set with
stopcock,anesthe
sia extension
set,syringe
filter,cvp
universal
set,blood
set,backcheck
extension
set,venoset with
cair
clamp,nonvented
primary pg-bk wcair,blood set 78sl, y-type,blood
set 82-sl,venoset
t-type w-cair
clamp,venoset
secondary
piggybk
set,venoset sec
piggyback,nutrimi
x,abbott counting
tray,cont epidural
w-bupiv-epi,veniprep ii kit,veniprep iii-site-care
dresng,ivex-2
filterset with ysite,veni-prep i
kit,reliefband,twoway transfer
device,venoset
78 w-mb piercing
pin,hema access
port,extension
medium,compression
stocking,thigh high,long
length,x-small,wet
dressing,compression
stocking,thigh high,long
length,medium,compression
stocking,thigh high,long
length,large,compression
stocking,thigh high,short
length,large,compression
stocking,thigh high,regular
length,x-large,compression
stocking,thigh high,long
length,xlarge,petrolatum,white,comp
ression stocking, knee high,
regular length,
small,compression stocking,
knee high, regular length,
medium,compression
stocking, knee high, regular
length, large,compression
stocking, knee high, regular
length, x-large,compression
stocking, knee high, long
length, small,compression
stocking, knee high, long
length,
medium,compression
stocking, knee high,long
length, large,compression
stocking, knee high, long
length, x-large,bismuth
tribromophenate/petrolatum,
white,syringe, disposable,
35 ml,syringe wneedle,disposb,0.5ml,syring
e, disposable, 6 ml,syringe
w-needle,disposab,6
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 485
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
set,three-way
stopcock ext
20in-sl,three-way
stopcock ext
36,three-way
stopcock,threeway stopcock wluer lock,threeway stopcock ext
20-sl,lifecare
plum set,pca
mini-bore
set,pharmacy
additive transfer
set,y-type
connecting
set,extension set
int-sl,brachial
plexus tray,in-line
burette
set,venoset 78 wivex-2
nonvented,amnio
centesis tray,4
leg vented
transfer set,4 leg
nonvented
transfer set,3 leg
vented transfer
set,nutrimix iv
empty
container,extensi
on tube,butterfly
infusion
set,platelet
concentrate
infusion,ivex h.p.
filterset,s-a-i-f set
1 micron,clear-
ml,swab,syringe disposable
irrig,60 ml,burn
dressing,diaper/brief,infanttoddler,
disposable,diaper,brief,yout
h,disposable,feeder
container w-gravity
set,nasogastric
tube,iodoform,needles,
disposable,urinary
bag/catheterization
tray,calcium alginate,sodium
chloride,polyhexamethylene
biguanide/non-adherent
bandage,syringe,
disposable, 1ml,syringe wneedle,disposab,12ml,diape
r,brief,adult,disposable,syrin
ge with needle,insulin
disposable,0.3 ml,syringe wneedle,disposab,3ml,dressin
g, hydropolymer,bacitracin
zinc/polymyxin b
sulfate,gloves, latex,first aid
kit,dental floss,dental
gingival products,sub-q
infusion pump
accessory,porcine acell
submucosa,meshed,porcine
submucosa,
fenestrated,peripheral nerve
diagnostic device,nerve test
monofilament,diabetic
supplies,miscell,vacuum
erection device
system,penile constriction
ring systm,neurological
exam pin,syringe, needle,
safety,self-contained
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 486
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
cath,20g,2
in,clearcath,16g,1-1/4
in,clearcath,clearcath(subclav),abb
ocath-t,abbocatht with
syringe,butterfly,e
xtension setlocking luer
t,thoracentesis
set,blood
warming coil,y
connector,inpers
ol peritoneal cath.
11fr,blood
collection
set,doubleneedle transfer
device,cont
epidural wlidocaineepi,additive hinge
cap,lifecare
additive cap,male
adapter
plug,sterile empty
vial,quik lok luer
lock
adapter,sterile
empty vial&
injector,nv
cardiac catheter
set,microbore
extension setsl,manifold 111sl,plum lc 5000
enteral set,pca
disposal unit,1.5 ml,syringe
with needle, insulin,1 ml and
sharps container,syring wndl,disp,insul,0.3
ml/container,empty,syringeneedle,insulin,0.5
ml/container,empty,syringe
with needle,insulin,0.3
ml,back brace,rib belt,arm
brace,abdominal brace,leg
brace,compression socks,
medium,compression socks,
large,compression socks, xlarge,compression
pantyhose,
small,compression
pantyhose,
medium,compression
pantyhose,
large,compression
pantyhose,x-large,athletic
support,cane,bed
pan,urinal,cushion,crutch
accessories,cane
tips,walker,neck
collar,syringe, disposable, 5
ml,syringe, disposable, 10
ml,syringe, disposable, 30
ml,syringe, disposable, 50
ml,needles, safety huber,
disposable,needles, huber
disposable,needles,
reusable,needles, huber
reuse,needles, spinalanesthetic,needles,
biopsy,bone,aspirate,syringe
reusable, 0.25 ml,syringe
reusable, 1 ml,syringe
reusable, 2 ml,syringe
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 487
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
extension set,pca
set-long mini
bore ol,pca cont
inf mini-bore,pca
set-cont inf mini
bore ol,access
set,catheter wcair clamp nonvent,cystomanom
eter
set,secondary
irrigation set,t-u-r
system w-flow
pouch
2000,nonvented
t-u-r
set,cystoscopyirrigation set,nv
large bore yirrigation
set,pentothal
dispensing
pin,empty 3-in-1
mixing
container,nutrimix
-macro
ferrules,ferrules,n
utriclamp,container
with ytransfer,lifecare
flex
container,lifecare
flex container
1000ml,adi sterile
empty vial,snap
lock device,veni
loop
connector,venose
reusable, 5 ml,syringe
reusable, 10 ml,syringe
reusable, 20 ml,syringe
reusable, 30 ml,syringe
reusable, 50 ml,syringe
reusable, 3 ml,syringe
reusable,syring w-needl 0.5
ml,kit-tray,syringe with
needle 1 ml, disposable kittray,syringe with needle, 0.5
ml,syringe, irrigation,
reusable,syringe wcannula,disp, 3 ml,syringe
w-cannula, disp, 5
ml,syringe w-cannula,disp,
10 ml,syringe with
needle/cannula,disposable
10 ml,blunt needle,
disposable,oral dosing
devices,syringe, disposable,
2.5 ml,syringe,safety with
needle,3 ml,syringe,safety
with needle,1
ml,syringe,safety with
needle,5 ml,syringe,safety
with needle,10 ml,needles,
safety,syringe with needle,
10 ml,syringe w-o
needl,insulin,1 ml,syringe wneedle,disposab,5
ml,syringe with
needle,insulin 0.3 ml (half
unit mark),needle clipping
and storage device,needles,
insulin disposable,
safety,pen needle, diabetic
disposable, safety,blade
lancet, safety,thermometer,
glass mercury
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 488
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
t 100-sl
piggyback
nv,burette 100ml
hemoset nv,blood
set w-pumpsl,pediatric
microaggr blood
filt,hema blood
set,hema y-type
blood
set,microdrip
micro pump setfiltr,soluset iv
micro pump
set,lifecare 5000
secondary
cntnr,plum lc
5000
minipole,nutriclamp w-transfer
set,primary pump
set,nylon epidural
catheter,ls plum
secondary setol,ivex-hp
administration
set,venoset-100
prim pigbk-ivexhp,screw cap set
38mm,fat
emulsion iv
set,primary iv setsl,soluset wpediatric ivex
sl,venoset 100
piggyback wclamp,lifecare
controller model
1000,lifecare
(oral),thermometer, glass
mercury (rectal),iv catheter
kit/iv catheter kit
accessory,myelogram
tray,thermometer, basal
glass mercury,thermometer,
electronic
(rectal),thermometer, basal
electronic,thermometer
probe covers,lumbar
supports,syringe with
needle, insulin, safety, 1
ml,syringe with needle,
insulin, safety, 0.5 ml,blood
glucose calibration control
solution, high and
normal,blood-glucose calib.
control,ringers
solution,lactated/gel
dressing,silver,dressing,
odor absorbent,
hydropolymer,syringe with
needle,disposable,insulin,co
mpressor, for
nebulizer,nebulizer/compres
sor, for nebulizer,nebulizer
accessories,spirometers and
accessories,colostomy
washer,ostomy
disinfectant,karaya
gum,urostomy
pouch,colostomy-ileostomy
sets, non-sterile,colostomyileostomy sets,
sterile,urostomy sets, nonsterile,urostomy sets,
sterile,ostomy lubricating
deodorant,condoms,
female,sub-q administration
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 489
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
pump set,lifecare
model 4 macro
pump,pca
pump,nonvented
iv set 100 with
cair,venoset
microdrip,lifecare
1025 controller,lc
1050
controller,flow
detector
30inch,flow
detector
54inch,lifecare
pump,lifecare
micro pump
1a,lifecare micro
pump,controller
lifecare model
75,pca plus
2,lifecare 75 flow
detector,solusetivex-2 filter &
cair,dual i.v.
stand adapter,i.v.
stabilizer bar,i.v.
clip adapter,i.v.
stand-pole
assembly,i.v.
stand-base
assembly,blood
set 64 with cair
clamp,blood set
78 with cair
clamp,blood ytype set wpump,single shot
epidurallidocaine,lifecare
set,sub-q administration set,
bifurcated,sub-q
administration set,
trifurcated,sub-q
administration set, quadfurcated,cervical
cap,biosynthetic
bandage,biosynthetic
glove,syring wndl,disp,insul,0.5
ml/container,empty,ovulation
test kit,blood-glucose meter
& wrist blood pressure
monitor,safety syringe with
needle, disposable kit-tray, 1
ml,contracept barrier dev,
vented,insulin pump
cartridge,subcutaneous
insulin pump,injection
ports,insulin pump syringe, 3
ml,insulin pump syringe, 1.8
ml,blood ketone
test,strips,blood glucose and
ketone control, normal,sub-q
insulin delivery device, 40
unit, disposable,sub-q
insulin delivery device, 30
unit, disposable,sub-q
insulin delivery device, 20
unit,disposable,middle ear
inflation device,head
support, infant, small,head
support, infant,
medium,head support,
infant, large,silver
sulfate/non-adherent
bandage,silver sulfate/foam
bandage,foam heel
dressing,dressing, foam
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 490
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
1050 drop
detector,enteral
set with
container,inpersol
w-o auto shutoff
valv,inpersol-auto
shutoff
valve,plumset
speciality pump
set-ol,plum
lifecare 5000
infuser,site-care
kit,ivex h.p.
pediatric exten
set,nonvented
secondary iv
set,venoset
piggyback-mb
pin-clmp,pca
minibore,batteries, six
volt (pair),primary
iv set-sl with ivexhp,500ml
pressure infusion
cuff,pressure
infusion
cuff,burette nv inline set wport,venoset
dual-rate pgbkivex-2,cvc
kit,venoset
piggyback w-ivex
filtr,lifecare shelf
storage
tray,primary
piggyback nv ib
set-sl,cvp
matrix/activated
charcoal,silver/calcium
alginate,polyvinyl
alcohol/gentian
violet/methylene
blue,adhesive
bandage/adhesive
tape/benzalkonium
chloride,adhesive
bandage/adhesive remover
comb. no.1,hydrocolloid
dressing/adhesive remover
comb. no.1,medical
information identification
tag,nasal exhalation
resistance device,syringe,
safety, self-contained
disposal unit, 3 ml,syringe,
safety, self-contained
disposal unit, 5
ml,syringe,needle,insulin,saf
ety,disposal unit,0.3
ml,insulin syringeneedle,safety,disposal
unit,0.5
ml,syringe,needle,insulin,saf
ety,disposal unit, 1
ml,syringe with needle,
safety, self-cont disposal
unit, 1 ml,syringe with
needle, safety, self-cont
disposal unit, 3 ml,syringe
with needle, safety, self-cont
disposal unit, 5 ml,syringe,
safety, self-contained
disposal unit, 10
ml,syringe,safety,disp
unit,10 ml,conception
assistance supplies
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 491
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
manometer,drum
-cartridge
catheter,provider
pump
set,butterfly s.t.
19x7/8.31/2tbg,pca
injector,flip-top
additive
cap,pump set wproximal male
adapt,butterfly
st,venous
cannulation
tray,blood set wcair clamp,tidal
joint irrigation
tray,cont epidural
tray w-drugs,cont
epidural-lido-epi
t-dose,cont
epidural
tray,spinal-22bupiv-dex-ephedepi,spinal-25bupiv-dex-ephedepi,spinalanesthesia
tray,cont
epidural-bupivlidocaine,inpersol
peritoneal
tray,caudal wlidocaineepinephrine,spina
l-22-tet-ephedepi-iodine,nerve
block tray wlidocaine,local
combination no.1,bloodglucose transmitter,bloodglucose
meter,continuous,bloodglucose sensor,bloodglucose
meter,continuous/bloodglucose transmitter,syringe,
disposable,syringe wcannula,disp, 1 ml,syringe
w-cannula,disp, 6
ml,needles, pharmacy
compound,syrng w-ndl,dsp
kit-tray,0.5ml,syrng wndl,disp. kit-tray,1ml,syringe
wneedle,disposab,6ml,syringe
,safety with needle,12
ml,syringe with
cannula,disposable 12
ml,syringe wneedle,disposable,syringe
with needle, insulin, safety,
0.3 ml,alcohol swab
cap,blunt filter cannula,
disp.,feeder irrigation kit,yport adapter-extension
set,calcium
alginate/honey,zinc
oxide/gauze
bandage,polyquaternium6/gauze
bandage,polyquaternium6/non-adherent
bandage,polyquaternium6/adhesive
bandage,honey/hydrocolloid
dressing,gum/polyvinyl
alcohol/dental adhesive,gas
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 492
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
infiltration wlidocaine,spinal25 w-tetra-ephedepi,saddle block
anesthesia
tray,saddleblock
anesthesia
tray,spinal-22
whitacre w-lidodext,spinal
whitacre
anesthesia,cont
epidural w-poviodine,lumbar
puncture
adult,lifecare
adds
rack,primary
piggybackconv,d
ual injection
site,male adapter
plug w-inj
site,male luer
cap,dual luer
cap,plum lc 5000
primary setsl,plum microdrip
soluset,extension
set with luer
lock,plum lc 5000
primary set,plum
lc 5000 microdrip
set-nv,plum lc
5000 with
ivex,pca set-long
minibore,venoset 100
soluset,pentothal
dispensing
perm. lens soaking soln,eye
cup,dental
adhesive,toothpaste,dental
polishvarnishes,polymerized rosin
resin,ovulation and
pregnancy test kit,dental
preparation, o.u.,corn/callus
cushion,syringe
w/needle,insulin disposable
0.3 ml (half unit
mark),toothbrush,thermomet
er, tape,thermometer,
temple electronic,ostomy
accessories, filters and
bridges,ice bag,finger
splint,hot water
bottle,fountain syringes
applicator,footcare,miscellan
eous,hearing aid
accessory,blood pressure
test kit-medium,blood
pressure test kit,ear
plugs,benzalkonium
chloride,tubular
gauze/tub.rubbr dressing
protector,incontinence
pants, reusable,blood
pressure test kit medium
and large
cuffs,humidifier,infusion set
for insulin pump,insulin
pump/infusion set/bloodglucose meter,pharmacy
dispensing adm
set,pharmacy compounding
access.,catheter
accessories,external,syringe
filter,enteral feeding
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 493
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
cap,catheter
adapter-luer
plug,venoset nv
piggybk
micrdrp,crimping
tool,transfer
lok,blood set 64
w-cair &
needle,hemoset
100x10 with cair
clamp,blood set
w-pump & cair
clamp,blood
surgical y-type
set-clmp,blood ytype set 66-cair
clamp,continuous
pediatric
caudal,cont
epidural w-lidoepi-iodin,lifecare
microdrip pump
set,nitroglycerin
micro pump
set,screw cap
(40mm)
set,lifecare 5000
syringe
adapter,lifecare
5000 vial
adapter,hema
blood 30
set,dome-paste
bandage,inspirea
se,buf
bodymate,bufpuf,buf-puf
bodymate,buf-puf
sponge,buf-puf
dispenser, 20 ml,enteral
feeding dispenser, 35
ml,enteral feeding
dispenser, 60 ml,enteral
feeding dispenser,1
ml,enteral feeding
dispenser,3 ml,enteral
feeding dispenser,5
ml,enteral feeding
dispenser,10 ml,weigh
scale,transfer needle,dental
suction device/chlorhexidine
gl/dental swab comb
no.1,dental suction
device/chlorhexidine/dental
swab #1/mouthwash,plastic
bags,chemo
gowns,smocks,chemo spill
clean-up kit,eye pressure
monitor,injector
device,incontinence
alarms,spray applicator kit,
sterile,disinfectant,glycine/so
dium hydroxide,ultrasonic
cleaner/holding
solution,protease-amylase
medical equipment
cleaner,transfer device,
closed system,needle
injector, luer, closed
system,needle injector, luer
lock, closed
system,connector luer lock,
closed system,infusion
adapter, closed system,ysite line connector, closed
system,assembly system,
vial to transfer device,
closed system,clamp, iv
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 494
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
gentle,actiprotect
uf,novofine
32,novopen
3,novofine,novop
en
jr,innovo,novofine
autocover,novotw
ist,nordipen
5,nordipen
15,novopen
echo,novofine
plus,astra selfaspirating
dental,cartridge
dispenser
dental,astrapro,br
eeze 2,autodisc
normal,ascensia
autodisc,fingersti
x,glucolet
2,contour
link,didget,contou
r next
link,microlet,singl
e-let,microlet
2,contour,contour
next ez,contour
next control
solution,contour
next,contour
usb,contour next
usb,ascensia
elite,microlet
vaculance,compa
t gravity delivery
set,compat
enteral delivery
pump,vivonex
tubing,hard lens soaking
solution,wheelchair,smoking
deterrent filter,incont
device,muscle
toner,elt,stethoscope,breast
pump,crutch,feminine
syringe,vaporizer-humidifier
supply,rectal syringe,nasal
syringe,vehicle base no.
13,topical cream metereddose device,adapter cap for
bottle,rectal, vaginal
applicator tip,troche
mold,isopropyl alcohol,eye
drops
dispenser,dressing,collagen/
silver/sod
alginate/carboxymethylcellul
ose,dressing,
collagen/sodium
alginate/carboxymethylcellul
ose,transcutaneous
electrical nerve
stimulators(tens)/electrodes,
tens unit electrodes,fecal
collector with charcoal
filter,dressing holder,hard
contact lens enzymatic
cleanser/pf,iv
equipment/container,empty,
blood glucose calibration
control solutions
high,normal,low,aloe
vera/gloves, latex,nonadherent
bandage/petrolatum,white,d
efibrillator,automatic,externa
l,blood-glucose meter, drumtype,prothrombin time test
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 495
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
jejunostomy
kit,compat,compa
t select flo
pump,compat
container wpump set,compat
select flo
case,compat
select flo baggle
cage,compat
yset,acticoat
moisture
control,allevyn
life,acticoat
surgical,allevyn
adhesive,allevyn,
allevyn
sacrum,allevyn
ag
adhesive,allevyn
ag gentle,allevyn
ag,allevyn gentle
border,allevyn
gentle border
lite,allevyn gentle
border
sacrum,allevyn
gentle border
heel,allevyn
gentle border
multisit,allevyn
heel,allevyn
plus,cuticerin,alle
vyn
tracheostomy,cuti
nova
hydro,durafiber,ci
ca-care,allevyn
thin,iv
strips,amniotic fluid
detection test,vaginal cream
applicator,suppository
container, empty,vaginal
suppository applicator,filter,
disposable ptfe
membrane,allantoin,mineral
oil/aloe
vera/petrolatum,white/sodiu
m lauryl
sulfate,acemannan/alginate
dressing,alginate
dressing/carboxymethylcellu
lose,needleless accessory
device, insulin,alginate
dressing/hydrocolloid
dressing,sterile
field,chlorhexidine
gluconate,blood sugar
diagnostic test strips with
disposable
meter,incontinence bed
sheets,covers,safety seal,
for bags,safety seal, for
vials,safety seal, for
syringes,transfer
set/syringe,
disposable/bandages,compr
ession/tubing,gel
dressing/zinc
acetate/meadowsweet/oak,v
enous flow
controller,cellulose,oxidized/
collagen,activated
charcoal/silver,gel-matrix
pad dressing,
silicone/benzalk chl/vit e/min
oil,cholesterol calibration
controls - high and
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 496
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
3000,pregnancy
test,microbore
extension set,iv
administration
set,solution
transfer
device,beutlich
ph test,hurricaine
dispenser,hurrivie
w,hurricaine luerlock,hurriview
ii,hurricaine spry
extension
tube,lancing
device,ultra thin
lancets,micro thin
lancets,super thin
lancets,proception fertility
pak,wide seal
diaphragm,liqua
spen,precise pain
relieving,aerocha
mber plus flowvu,iv transfer
spike,detachol
adhesive
remover,mastisol,
mastisol
adhesive,boules
quies
earplugs,insulin
syringe,ultra
comfort,easytouch insulin
syringe,condoms,
thermacare,pump
for liquagel,suppository
low,cholesterol test,
strips,cholesterol & blood
glucose meter,prothrombin
time/inr test meter,gel
dressing,
fenestrated,collagen,bovine,
fecal collector w-charcoal
filter/catheter/syringe,
dispos,gravity feeding
set,feeding pump,bloodglucose transmitter/bloodglucose sensor,needles,
subcutaneous set,iv
administration set/needles,
reusable,ring,cath male
external-starter kit,ring
pessary,transcutaneous
electrical nerve stimulators
(tens units),blood pressure
kit-extra large,home hiv test
kit,blood-glucose meter,for
mobile device,hard lens
soak-wet solution,infusion
set with insulin pump
body,insulin pump
controller,propylene
glycol,toe splint,disinfectant
liquid soap cmb4,mineral
oil/non-adherent
bandage/petrolatum,hydrop
hilic,mercury spill clean-up
kit,blood pressure test kitsmall,blood-glucose and
blood pressure meter with
adult cuff
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 497
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
mold,accusure,o
mnitrope pen 5,ocal-ette,pedi-skin
adherent #2,pedipre,pedi-pre tape
spray,hydro
armor ag,hydro
armor ag blister
care,e-z ject
lancets,major
comfort,nasal
strips,ear
syringe,denture
cleanser,optizyme enzymatic
cleaner,micropor
e first aid
paper,micropore
first aid
skintone,micropor
e first aid
plastic,micropore
first aid
waterproof,micro
pore first aid
cloth,tegaderm,m
icropore air
wrming fltr
mask,micropore
pollen filter
mask,micropore
germ filter
mask,coban,resto
n,stomaseal,dura
pore cloth
surgical
tape,durex avanti
bare,personal
biometric test
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 498
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
kit,colostomy
barium enema
kit,aeroeclipse
ii,aerotrach
plus,aerochambe
r z-stat
plus,aerochambe
r with
flowsignal,aeroge
ar asthma action
kit,truzone peak
flow
meter,aerochamb
er
mv,aerochamber
mini,aerobika,3m
cold-hot
pack,relion
prime,relion
confirm,blood
pressure
monitor,relion
micro,digital
thermometer,inst
ant ear
thermometer,trust
ex
condom,trustexria,trustex latex
condom,trustex,f
antasy,stayfree
surefit,stayfree
maxipad,stayfree ultra
thin,carefree
panty shield,tena
serenity,serenity
ultra
plus,drain,bardic
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 499
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
adaptertubing,cunningha
m incontinence
clamp,catheter,fe
male intermittent
catheter,toomey
syringe,urethral
catheter,reliaseal
disc,dispoz-a-bag
leg bag
small,dispoz-abag leg bag
medium,dispoza-bag leg bag
large,leg bag
holder,uro sheath
disposable
bulk,bardic uro
sheath vinyl,male
external
catheter,deluxe
fabric leg
straps,catheter
strap holder,twosided adhesive
strips,latex
extension
tubing,latex leg
straps,bard
center entry close
system,urinary
drainage
bag,infection
control bag,leg
bag
straps,bardex
silicone foley
catheter,rubber
utility
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 500
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
catheter,cleancath,protective
barrier
film,adhesive
remover
wipes,vigilon
wound
dressing,irrigation
tray,basic
irrigation
tray,urethral
catheter
tray,bardex
urethral catheter
tray,universal
foley catheter
tray,davol
complete foley
kit,davol urinary
drainage
bag,bardia
urinary drainage
bag,davol foley
cath insert
tray,davol
universal catheter
tray,davol clsd
sys foley cath
tray,davol
irrigation
syringe,davol
irrigation
tray,davol
urethral catheter
tray,davol
silicone foley
catheter,bardex
closed system
cath tray,infection
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 501
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
control
tray,bardex
lubricath foley
tray,extra
colostomy
pouch,stoma
urine bag,extra
security
pouch,extra
open-end
drain,scanpor
tape,drainable
adhesive
pouch,baby urine
collector,irrigation
sleeve,bard
irrigation
tray,bardex
lubricath
foley,comfeel,filte
red extension
set,rate flow
regulator iv
set,filter
needle,infusion
set,opsite
flexifix,profore,ex
u-dry,skin-bond
cement,uni-solve
adhes remover
wipes,uni-solve
adhesive
remover,remove
wipes,remove
liquid,urikleen,skinprep,no sting skin
prep,hypafix,opsit
e postBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 502
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
op,solosite,opsite
flexigrid
dressing,algisite
m,transigel,replic
are,viscopaste
pb7,opsite
adhesive
dressing,flexigel,
primapore
iv,primapore,covr
site,covrsite
plus,intrasite,alle
vyn cavity
dressing,allevyn
tracheostomy
dressing,unlabele
d refill bottle
240ml,spray
pump,microspon
ge,monoject,mon
oject
syringe,sharpsafe
ty
container,nutripor
t balloon,dover
advantage,dover
premium,dover
pediatric
urine,dover
advantage
drainage,monoje
ct tb
syringe,monoject
luer lock tb
syringe,curity
lumbar puncture
tray,durasorb,sim
plicity
liner,telfa,maxicar
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 503
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
e,rondic,presenc
e,telfa
clear,curity,kerlix,
sure care
protective
underwear,monoj
ect tb,curity
maternity
pad,curity
ultramer 2-way
catheter,webril,to
uch-trol,curity
cleaners
medium,sharpsa-gator,enema
bag,handicare,su
recare,versalon,t
enderskin,kendall
paper tape,sure
care protective
undergmnt,curity
foley catheter
kit,curity cleaners
large,dressing
change-pov-iod
tray,curity
universal w-o
drainage,suretys,
monoject blood
collection,confor
m,monoject luer
adapter,curity
ureth cath closed
systm,curity
amd,curity
urethral
catheter,precision
200 catheter
tray,argyle,nursin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 504
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
g pads
(breast),webril
ii,curity ultramer
irrg 3way
cath,curity o-b
sponges,vistec,ar
gyle connecting
tubes,wings
underpad,t.e.d.
anti-embolism
stocking,lisco,curi
ty bedside
drainage set,wetpruf,sharps a
gator,curity ureth
cath open
system,tensor,ker
lix amd
bandage,urinary
leg medium
bag,kenguard,ad
d-a-foley
tray,foley
catheter,curity
irrigation
tray,heavy
drainage
dressing
steril,robinson
clear vinyl
catheter,specipan
collection
unit,vaseline
petrolatum
gauze,xeroform
petrolatum
dressing,xerofor
m,dermacea,der
macea nonBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 505
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
woven,dermacea
stretch,flexwrap,aquaflo,curit
y thoracentesis
trays,monoject
pharmacy
tray,curity
thoracentesiscath tray,kenline
add-a-foley tray
30cc,add-a-foley
cath-pre-fill
syrn,curity spng
counter bag
strips,curity spng
counter rackscale,curad,curity
surgical,clean
catch-benzalkon
towelets,clean
catch-soap
towelettes,t.e.d.
sequnt compress
device,copa
hydrophilic
foam,argyle
trocar,unigard,wi
ngs classic youth
briefs,wings
classic adult
briefs,wings
classic,wings
choice plus youth
briefs,wings
choice plus adult
briefs,wings
choice adult
brief,foley
catheter
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 506
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
tray,dover foley
catheter,curity
strmlin cath wmono-flo,curity
premium catheter
tray,add-a-foley
cath-mono-flo
drng,curity
bedside-mono-flo
drange,monoflo,tenderol,curity
ureteral drain
set,curity bedside
drainage
bag,simplicity
adult
poly,simplicity,ver
salon
washcloth,curity
washcloths,curity
urine meter,dover
red rubber
robibson
cath,dover
catheter,kendall,p
olyskin ii,kerlix
amd,dover bulb
syringe,wings,ker
lix burn
pack,monoject
safety syr tip
cap,curity
detectable
lap,simplicity
adult flat fold
xl,dover latex
foley
catheter,simplicit
y pants,curity run
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 507
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
arounds,curity
runarounds,curity
sleep
pants,kangaroo
gravity
set,excilon,tender
sorb,kangaroo
nasogastric feed
tube,curasilk,diap
ers-disppolyethylene
back,dover urine
leg bag,telfa
amd,kangaroo
epump set,curity
iodoform,curity
ultra
fits,tenderwrap
unna boot,kerlix
lite,monoject
insulin
syringe,curity
8000 urine
meter,hypodermi
c needle,curity
abdominal,curity
ultramer
catheter,rcra
hazardous
waste,kendall
container,dover
coated latex
foley,curafil,kend
all cloth,maxicare
underpads,wings
supreme,staput,wings
maxima,wings
fluff and
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 508
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
polymer,curistrip,dover
universal,kangaro
o 924 safety
screw,excilon
amd,sharps-agator disposal
system,insertion
tray with
pvp,excilon
washcloth,curity
maternity
belts,curagel,hom
e care
underpads,confor
m stretch
bandage,insertio
n tray with
bzk,foley cath
silicone
retn,curity foley
2-way ped
cath,kendall foam
border,bandaid,non-stick
pads,first aid
tape,first aid cloth
tape,first aid hurtfree
wrap,mirasorb,ba
nd-aid flexible
fabric,gauze
pads,rolled
gauze,soothing
non-stick,kling
rolls,ultraheal,ban
d-aid plus
antibiotic,nursing
pads,adhesive
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 509
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pads,dermicel,wa
terproof
tape,topper
dressing
sponge,eye
pad,surgipad,ulce
r
dressing,release,
proxistrip,healthcare
gloves,nu-gauze
sponge,elastikon,
adaptic,sof-band
bulky
bandage,bioclusi
ve,sof-wick,sofwick drain
sponge,johnson
& johnson filter
mask,johnson's
health care
gloves,cotton
balls,steripak,gau
ze sponge,sports
tape,elastic
bandage,instant
cold pack,rescue
blanket,antiseptic
wipes,triangular
bandage,j & j first
aid
kit,swabs,cotton
rounds,steripad,nugauze,dental
floss,dentotape
ribbon
floss,dental floss
waxed,stim-uBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 510
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
dent,takeoff,baby
wipes,coets,derm
ilite-ii paper
tape,dermicel
hypo-allergenic
tape,dermilite ii
hypoallergenic,dermicl
ear,kling
bandage,waterga
rd,underpads,ban
d-aid gauze
pads,band-aid
rolled
gauze,band-aid
non-stick
pads,band-aid
mirasorb gauze
sponge,band-aid
surgipad
dressing,bandaid cloth
tape,band-aid
paper tape,bandaid waterproof
tape,band-aid
hurt-free,bandaid tough
pads,band-aid
secure-flex,bandaid waterproof
pad,cartridge
filling aid,arm
belt,d-tron,h-tron
power pack,sewin pocket,sport
belt,spectragel,la
ncets,comfort
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 511
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lancets,polymem,
polywic,oasis
ultra,curasol
gel,curasol
hydrogel,wound
matrix,burn
matrix,neuropen,
neuropen
monofilaments,ca
reone,kinney
brand lancets,thin
lancets,incontrol
ultra thin
lancets,unilet
lancets,autolet
mini,advanced
lancing
device,unifine
pentips,pen
needle,incontrol
pen needle,pen
needles,healthy
accents unifine
pentip,autolet
platforms,unifine
pentips
plus,unilet
lancet,unilet gp
lancet,alternate
site lancets,unilet
comfortouch,adv
anced travel
lancets,unilet
excelite,unilet
excelite ii,autolet
lite
clinisafe,unistik,a
urora super thin
lancets,incontrol
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 512
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
super thin
lancets,healthy
accents unilet
lancet,unistik
2,incontrol
lancing
device,autolet
lancing
device,healthy
accents
autolet,autolet
mkii
clinisafe,unistik
3,autoject
2,rapport vacuum
therapy,amielle
vaginal
trainer,rapport
ring loading
system,autopen,n
eurotips,autodrop
,autosqueeze,onthe-go,autolet
lite,ulticare
syringe,ulticare,ul
ticare pen
needle,back
support,rib
belt,pouch arm
sling,wrist brace
reversible,wrist
brace
splint,surgical
binder abdom
support,elbow
brace,wrist
brace,knee
brace,ankle
brace,sacroiliac
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 513
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
brace,herniaaid,surgical
stockings,compre
ssion
stockings,beyond
support,super
socks,compressi
on
pantyhose,athleti
c supporter,cup
supporter wprotector
cup,suspensory,k
nee
comforter,curity
curad flexible
bandages,curity
curad flexible
fabric,curad
ultralite,curad kid
size
bandages,curity
underpads,cane,
bedpan,sitz
bath,urinal,cervic
al pillow,cervical
traction
kit,wheelchair
invalid
ring,wheelchair
cushion,crutch
tip,hand
grips,crutch
pad,cane
tips,walker
tips,knee
support,sport
polartec,sport
neoprene,neopre
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 514
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ne knee
stabilizer,tennis
elbow
support,curity
curad adhesive
bandages,curity
telfa non-stick
pads,curity
nursing
pads,curity telfa
adhesive
pads,curity wetpruf adhesive
tape,curad super
soft puffs,curad
gauze
pads,curad
stretch gauze
bandage,folding
walker,walker
wheels,cervical
soft collar,lancets
thin,lancets ultra
thin,fine 30
universal
lancets,medlance
plus,adjustable
lancing
device,insumed,i
nsupen,glucosour
ce,exel insulin
syringe,insulin
pen
needle,tuberculin
syringeneedle,exel tb
with needle,exel
tuberculin
syringe,exel
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 515
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
allergy
syringe,allergy
syringe,exel
syringe,exel
hypodermic
needle,exel mti
drawing
needle,psv set,iv
catheter,exel
huber,exel huber
needle,yale
needle regular
bevel,yale
needle,yale
needle short
bevel,special
needle,intraveno
us,arterial &
blood,yale needle
huber
bevel,pudendal &
parasympathetic,
whitacre spinal
needle,rosenthal,
osgood,security
bead needle,
local,klatskin,yale
glass tb
syringe,yale
syringe,syringe,c
ornwall syringes
luer-lok tip,plastic
adapter kit for
busher,cornwall
accessories &
parts,cornwall
metal pipeting
holder,tempaway
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 516
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
thermometer
sheath,yale
spinal
needle,quince
spinal
needle,allergist
syringe,allergist
syringe with
needle,allergist
tray,allergist
syringe
tray,tuberculin
syringe,yale
cleaner,asepto
bulb syringe
glass tip,pipette
30ml catheter
tip,pipette 45ml
catheter
tip,asepto bulb
syringe cath
tip,pipette 90ml
catheter
tip,pipette 120ml
catheter
tip,plastic adapter
for busher,bulk
syringe,syringe
bulk,luer-lok
syringe,needle,ca
nnula,interlink
syringe,lever lock
cannula,twinpak
dual
cannula,interlink
syringe wcannula,specialty
use
needles,regular
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 517
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
bevel
needles,needles,
precisionglide,yal
e needles,short
bevel
needles,blunt
needle,thin wall
needles,tampertuf,oral
syringe,nokor
needle,nokor
admix
needle,cornwall
syringe tip
connector,glaspa
k,integra
syringe,integra
needle,sharps
collector,onepiece sharps
collectors,sharps
container,safetylok safety
syringes,safetylok safety
syringe,medsaver
,syringe storage
bin,eclipse
needle,syringeneedle,eclipse
syringe,eclipse
syringeneedle,eclipse
luer-lok
syringe,safety
syringeneedle,syringe tip
cap,safetyglide
needle,safetyglid
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 518
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
e
syringe,safetyglid
e insulin
syringe,safetyglid
e tb
syringe,safetyglid
e allergy
syringe,safetyglid
e allergy,syringeluer tip cap,luerlok syringeneedle,safety-lok
syringes,syringeprecisionglide
needle,syringe
catheter tip,tb
syringe,luer-lok
tip
syringe,luerslip
syringe,bd ultrafine pen
needle,bd ultrafine,bd ultra-fine
ii,lancet
device,magniguide
magnifier,safeclip,auto
injector,autoshiel
d pen
needle,autoshield
duo pen
needle,paradigm
link blood
glucose,vacutain
er blood
transfer,luer-lok
access device,bd
microtainer
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 519
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lancets,microtain
er lancets,safetylok collection
set,vacutainer
collection
set,brite sight
thermometer,insy
te
autoguard,insyte
iv
catheter,angiocat
h iv
catheter,angiocat
h,saf-t-intima iv
catheter,saf-tintima,nexiva,intr
osyte
autoguard,qsyte,e-z set
winged infusion
set,saf-t e-z
collection set,saft e-z
set,myelogram
tray,precise,fever
thermometer,ace
rubber elastic
bandage,trutouch
gloves,durall,sus
pensory with leg
straps,suspensor
y w-o leg
straps,adult
supporter,compre
ssion
shorts,swimmer
supporter,ace
neoprene wrist
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 520
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
brace,ace
neoprene thigh
brace,ace
neoprene elbow
brace,ace
neoprene ankle
brace,ace
neoprene knee
brace,ace
neoprene plus
knee brace,ace
neoprene ankle
wrap,ace tennis
elbow brace,ace
ankle brace,ace
knee brace,ace
wrist brace,ace
elastic
bandage,ace
elbow brace,ace
plus rigid wrist
brace,ace
unibody
supporter,ace
athletic
supporter,ace
swim
supporter,ace
cup
supporter,ace
plus knee
brace,ace sports
underwrap,ace
knee strap,ace
elbow strap,ace
bandage
clips,ace athletic
bandage,ace
sports tape,ace
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 521
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
instant cold
compress,ace
reusable cold
compress,ace
hot-cold
compress,ace
hot-cold
compression
wrap,ace velcro
bandage,ace
back
support,fever
thermometerimprinted,sensica
re,tru-fit knee
support,ace
plastic
gloves,sentinel
thermometer,ther
mometer,basal
thermometer,peg
elastic
bandage,digital
therm probe
cover,thermomet
er probe
covers,hypother
m
thermometer,bd
genie lancet,ace
wrist brace with
splint,ace lumbar
support,slip-tip
syringe,ibgstar,haemolance,
retractable,assur
e id insulin
safety,hypolance,
advance
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 522
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
intuition,assure
pro,assure
platinum,assure
dose,assure
3,assure
4,glucocard
expression,pocke
tchem ez,multilancet
device,micro,gluc
ocard
01,glucocard 01
control,glucocard
01-mini,glucocard
x-meter
control,glucocard
xmeter,glucocard
vital,techlite
lancets,techlite
blood
lancet,techlite,ha
emolance,assure
haemolance
plus,assure
lance,haemolanc
e
plus,quicktek,adv
ance microdraw,advance,sel
ectlite,lanzo,assure
prism
multi,glucocard
shine,assure
lance plus,ultilet
safety,ultilet
classic,ultilet
lancets,publix
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 523
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lancet,ultilet
insulin
syringe,ultilet pen
needle,ultilet
basic,suresite
matrix,tenderwet
active,tenderwet
active
cavity,evencare
g2,safety
lancets,pressure
activated
lancets,silvasorb,
silvasorb
cavity,exuderm
odorshield,evenc
are,skintegrity,me
dfix
ez,stratasorb,bor
dered
gauze,exuderm
satin,evencare
g3,medigrip,carra
syn hydrogel
wound,protection
plus,molicare
classic brief,ultra
soft,dry time
diaper,protection
plus
liner,economy
underpad,underp
ad,anti-stick
insulin,anti-stick
tuberculin,blende
rm,transpore,micr
ofoam,micropore,
durapore,steristrip,3m
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 524
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
nexcare,tegader
m i.v.,tegaderm
i.v.
advanced,medipo
re h,medipore
dressit,medipore,soft
cloth,medipore
plus pad,steristrip wound
closure
syst,tegaderm
hydrocolloid,tega
derm hydrocolloid
thin,tegasorb
thin,tegagen
hi,tegagen
hg,tegaderm ag
mesh,tegaderm
absorbent,tegade
rm
hp,opticlude,blen
derm surgical
tape,reston2,primeaire,quak
e,liteaire,misterne
b
compressor,inspir
ation
elite,inspiration,si
destream,mistern
eb pediatric
compressor,innos
pire
elegance,mistern
eb
nebulizer,sidestre
am
mask,innospire
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 525
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
essence,micro
elite replacement
filter,minielite,mic
ro elite,pflex
trainer,assess,ast
hmapack
i,asthmapack
ii,asthmapack
iii,asthmapack
children's,thresho
ld imt,threshold
pep,asthma
check,asthmame
ntor,personal
best,optihaler,opti
chamber,pediatri
c
mask,sidestream
plus,inspiration
elite filter,micro
plus,innospire
replacement
filter,sidestream
nebulizer,sami
the
seal,litetouch,sa
mi the seal
filter,sami the
seal
mask,sidestream
pediatric,optionho
me,mini plus
nebulizer,mini
elite filter
replacement,optic
hamber
diamond,procha
mber,ventstream
nebulizer,zoey,ae
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 526
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
roneb
go,innospire
deluxe,innospire
mini,aeroneb go
nebulizer,iamin,o
smocyte,dressing
,lo-profile
urostomy
pouch,contour
i,filter security
closed
pouch,stoma cap
w-micropore
adhesive,karaya
drainable ostomy
pouch,karaya
seal closed
stoma
pouch,centerpoin
tlock closed
pouch,stoma cap
w-deodor fltrflange,stoma cap
w/deodor
fltr/flange,karaya
5 drainable
pouch,premium
drainable
pouch,skin
barrier w-floating
flange,convex
syn barr w-float
flange,pouchkins
skin
barrier,pouchkins
pediatric
belt,pouchkins
pouch,pouchkins
drain
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 527
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
tube,pouchkins
drainable
pouch,pouchkins
urostomy
pouch,drainable
pouch with
flange,stoma
irrigator drain wflange,drain
pouch-filterflange,drainable
pouch w-filtrflange,drainable
mini-pouch wflange,cpl
drainable
pouch,drainable
pouch,urostomy
pouch with
flange,ostomy
belt,urostomy
drain tube
adapter,hollihesiv
e skin
barrier,stoma
combo cone-tube
irrg kit,stoma
cone w-connector
unit,stoma combo
cone,tube irrg
drn,medical
adhesive,adhesiv
e remover,odor
eliminator,m9clea
nerdecrystallizer,sto
ma
lubricant,adhesiv
e-barrier remover
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 528
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
wipes,filter
replacement,loop
ostomy bridge,
sterile,premium
skin barrier,adapt
barrier
ring,softflex skin
barrier,karaya,ad
apt stoma
powder,karaya
paste tube,skin
gel protective
dressing,premier
drainable
pouch,premier
urostomy
pouch,premier
lock n roll,premier
drainable minipouch,centerpoin
tlock flextend
skin,drainable
pouch
clamp,flextend
skin
barrier,premier
urostomy
pouch/flange,eve
ryday male
catheter,extende
d male
catheter,extensio
n tubing wconnector,urinary
leg bag,bag-strap
system,bagtubing
system,vent urin
leg bag
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 529
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
sys,combo
pk,wound
drainage
collector,universa
l catheter access
port,drain-tube
sterile clamp,horz
drain-tube attach
device,vertical
drain-tube attach
dev,suction tube
attachment
device,feeding
tube attachment
device,replaceme
nt
neckband,retract
ed penis
pouch,fecal
collector,
drainable,bedside
drainage
collection,female
urinary
pouch,vented
urinary leg bag
system,fecal
collector,new
image skin
barrier,new
image
flexwear,new
image skin
barrierflange,new image
flextend,new
image drainable
pouch,new image
irrigation
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 530
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
sleeve,new
image drainable
mini-pouch,new
image closed
pouch,new image
closed minipouch,new
image,new image
urostomy,new
image urostomy
pouch,new image
colostomy-ileo
kit,new image
kit,new image
drainable kit,new
image urostomy
kit,adapt,adapt
paste,adapt
barrier,adapt
convex
barrier,premier
closed minipouch,premier
pre-sized minipouch,premier
closed
pouch,premier
skn barr w-float
flang,premier
colostomyileostomy,premier
urostomy,advanc
e plus
intermittent,incar
e,firstchoice
drainable
pouch,everyday
self-adhes
catheter,firstchoic
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 531
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
e postop drain
pouch,selfadhesive
catheter,advance
hydro,fc condom,
female,two-piece
stoma
caps,closed-end
pouch,adhesive
barriers,adhesive
barrier,microskin
barrier,system
pouch,microderm
plus,one-piece
drainable
pouch,mini
drainable
pouch,urostomy
pouch,platinum
urostomy
pouch,mini
urostomy
pouch,one-piece
urostomy
pouch,microderm
,cymed seal,ilesorb,night drain
adapter,microskin
applicator,draina
ble pouch
closure,microhesi
ve stoma
paste,clickfine,reli
on pen
needles,blood
glucose
monitoring,smart
sense monitoring
system,advanced
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 532
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
glucose
meter,thalaset,ne
ria,insuflon,tubeg
uard,neria
multi,statlet,mouthpiece,ex
piratory,piko
1,pocket
peak,pocket
chamber,pediatri
c panda
mask,panda
mask,femcap,bio
brane,biobrane
dressing,biobran
e-l,biobrane-l
dressing,biobran
e gloves,pillow
mask,pillow mask
for
children,splash
shield full,splash
shield flex,splash
shield short,co
monitor
replacement t,co
monitor,disposabl
e paper
mouthpiece,miniwright peak flow
meter,airzone &
miniwright afs,incheck oral,incheck nasal with
mask,in-check
dial,windmill
trainer,one way
mouthpiece,pedismall mouth
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 533
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
adaptor,pediatric
mouthpieces,airz
one peak flow
meter,one flow
fvc,one flow
spirometer,one
flow
mouthpiece,filtere
d mouthpiece
attachment,silico
ne
mask,breathrite,n
ose clip,rubber
mouthpiece,all
flow 1000,all flow
2000,all flow
3000 pft,all flow
3000 kit,all flow
4000,all flow
5000,all flow
6000,all flow
7000,disgard
sharps
pad,easygluco
meter starter
kit,easygluco,con
trol,g-4,control
solution,infinity,inf
inity control
solution,acura
starter kit,acura
control solution
normal,acura
meter kit,acura
control
solution,acura
control solution
low,acura
plus,easygluco
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 534
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
plus,easygluco
plus control
normal,compact
ultrasonic
nebulizer,compac
t compressor
nebulizer,autolet
impression,autole
t plus,unistik
czt,unistik 3
extra,unistik 3
comfort,unistik 3
neonatal,seaband,sea-band
for
children,ultracomf
ort,orsini insulin
syringe,glucolead
er,clearblue,easy
pro
plus,easypro,pro
digy count-adose,prodigy
mini-mist,prodigy
pocket,prodigy,pr
odigy
eject,prodigy
voice,prodigy
duo,prodigy
control
solution,prodigy
preferred,prodigy
autocode
pro,prodigy
pocket
pro,prodigy voice
pro,prodigy twist
top lancet,prodigy
lancets,prodigy
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 535
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
lancing
device,prodigy
pen
needle,prodigy
insulin
syringe,prodigy
autocode,actilance,droplet
lancets,medlance
plus special
blade,compresso
r
nebulizer,replace
ment
nebulizer,replace
ment air
filter,healthy
living,easy touch
glucose
monitor,easy
touch lancing
device,easy
touch control
solution,easy
touch,easy touch
insulin
syringe,easy
touch pen
needle,easy
touch
fluringe,easy
touch insulin
safety,easy touch
syr allergy
tray,easy touch
fluringe flu
tray,healthpro
glucose
monitor,healthpro
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 536
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
glucose control
soln,lea's
shield,omnipod,1
st choice
lancets,1st tier
unilet
comfortouch,1st
tier unifine
pentips,1st tier
unifine pentips
plus,iport,thinset,fifty50
safety seal
lancets,fifty50
reservoir,eclipse,
eclipse control
solution,envision,
evolution blood
glucose
meter,evolution
control
solution,element
blood glucose
meter,element
control
solution,smartdia
betes
xpres,smartdiabe
tes
vantage,element
plus,xpres,eleme
nt plus control
solution,glucolab
control,glucolab,e
lement compact
control
soln,element
compact,element
compact
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 537
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
v,smartest,smart
est
lancet,smartest
eject,smartest
protege,smartest
smart
code,smartest
talking,smartest
pronto,smartest
persona,glucoco
m blood
glucose,glucoco
m lancets,blood
glucose
meter,glucocom
control
solution,glucoco
m,glucocom
autolink,glucose
control
solution,glucose
control,bloodglucose
control,duocare,rightest
gm300
system,bionime
rightest gm300
system,rightest
control
solution,rightest
gd500,rightest
gm100
system,rightest
gm550
system,rightest
gl300
lancets,ge100
blood glucose
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 538
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
system,ge100
control solution
normal,rightest
gc250s control
soln,rightest
gm250s
meter,rightest
gm260
meter,nova
sureflex,sureflex,
nova max blood
glucose
meter,nova max
glucose control
soln,novamax
plus,novamax
plus glu-ket,nova
safety
lancets,keynote,
wavesense
control
solution,agamatri
x control,jazz
wireless
2,wavesense
presto,keynote
pro,wavesense
amp,presto
pro,liberty blood
glucose
meter,liberty
control
solution,agamatri
x amp,vgo 40,vgo
30,vgo 20,ear
popper,sterilance
tl,cinis preemie
halo,restore
contact
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 539
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
layer,restore
contact layer
silver,restore,rest
ore trio,restore
duo,restore foam
heel
dressing,restore
odorabsorbent,restore
ex thin
hydrocolloid,resto
re hydrocolloid
dressing,restore
calcium
alginate,restore
hydrogel,restore
hydrogel
gauze,sharps
disposal by
mail,hydrofera
blue,ultraflex,burns-scaldsabrasions,skin
closure,blister
care,bandages,m
edical id for
bracelet,medical
id for
necklace,riteflo,pr
ovent hr,provent
sr,provent,ultratra
k
pro,ultratrak,ultral
ance,ultratrak
ultimate,safesnap
syringe,safesnap
insulin
syringe,safesnap
tuberculin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 540
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
syringe,safesnap
allergy
syringe,conceptio
n,needle-pro
edge,solus
v2,solus v2
lancets,solus v2
lancing
device,solus v2
control
solution,caresens
n,caresens,smart
caresens
n,caresens n
voice,caresens
prem lancing
device,carelance
ult lancing
device,invacare
lancets,gdrive,de
xcom g4,seven
plus,seven
system
sensor,dexcom
g5-g4
sensor,droplet
lancing
device,syringe
without
needle,filter
connector,lifeshie
ld blunt
cannula,transfer
needle,bone
marrow aspir
needle,filter
aspirator
needle,allergist
tray syr-perm
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 541
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
needle,monoject
allergy trayneedle,monoject
tuberculin
syringe,allergist
tray syr-detach
ndl,monoject
insulin safety
syrng,monoject
tuberculin safety
syr,monoject
control
syringe,monoject
syringe pharmacy
tray,monoject
safety
syringe,safety
syringe with
shield,monoject
smartip
cannula,monolet
lancets,monoject
or lancet
device,monolet
thin
lancets,sharps
container
accessory,glove
box,monoject
magellan,finger
grip
extender,magella
n tuberculin
syringe,monoject
megellan tb
syringe,magellan
insulin safety
syrng,magellan
insulin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 542
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
syringe,oral
medication
syringe,extender
caps,kendall
disinfectant
cap,monoject
blunt filter
cannula,kangaro
o pet carrying
case,kangaroo
pet pump
frame,kangaroo
pet charging
cord,petrolatum
gauze,xeroflo
gauze
dressing,viasorb,
blisterfilm,ultec,qtips wood stick
applicator,interso
rb,expandover,ka
ngaroo enteralfeed-irrig
kt,kangaroo
pump extension
set,kangaroo
500ml pump
set,kangaroo
deluxe pump
set,kangaroo
pump
set,kangaroo
1000ml gravity
bag,kangaroo
1200ml deluxe
pump
st,kangaroo
proximal spike
pmp st,kangaroo
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 543
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
screw cap pump
set,kangaroo
1600ml deluxe
pump
st,kangaroo y-site
extension
set,kangaroo
1200ml rigid
containr,kangaro
o rigid
container,kangar
oo plyurethane
feed
tube,kangaroo
100ml rigid
burette,texas
catheter,elastic
foam strap,uridrain,two-sided
adhesive
strap,catheter
with
strap,vaseline
constant
care,kangaroo
1000ml pump
set,rob-nel pvc
catheter,terumo
insulin
syringe,terumo
surguard2,thinpro
insulin
syringe,terumo
surguard,terumo
allergy
syringe,terumo
syringe,terumo
hypodermic
needleBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 544
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
syrin,medihoney,
primer modified
unna boot,algicell
ag,bioguard
gauze,bioguard
packing,bioguard
nonadherent,bioguar
d island,super
denture
adhesive,premier
skn barr w/float
flang,sensitive
eyes
saline,sensitive
eyes
drops,sensitive
eyes plus
saline,sensitive
eyes daily
cleaner,renu
multi-purpose,bio
true,renu
rewetting
drops,renu
multiplus,boston
advance
cleaner,boston
conditioning
solution,boston
simplus
solution,re-nu
fresh,boston
cleaner,saline
solution,sterile
presrv,renu
saline,daily
cleaner,sensitive
eyes
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 545
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
enzymatic,lens
carrying
case,saline
solution,
unpreserved,hyp
o-clear,lens
lubricant,disinfect
ing solution,quiksept,renu weekly
cleaner,concentr
ated
cleaner,wetting &
soaking
solution,disinfecti
ng unit,compact
disinfecting
unit,fashion
case,lens
cup,smoker's
polident,polident,
super poligrip,sensodyne,d
entucreme,dentugel,super
wernet's
denture,ctub,gallon jug
with pump,jetcospray
cannula,dee
fog,zarosen,varn
al,mixing
container with
lid,reveal
pregnancy
test,reveal
ovulation
predictor,stik
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 546
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
it,reveal blood
glucose
meter,reveal get
pregnant
quick,reveal
ovulation
test,snug denture
cushions,thermod
ent,mesalt,mepile
x,tendra mepilex
border,probe
covers,bladder
control pad,water
shield
bandages,antibac
terial
bandages,foam
bandages,gauze
bandage,stretch
gauze
bandage,shield,u
ndergarment,brief
,lamb's
wool,fabric
bandage,clear
bandages,flexible
bandages,plastic
bandages,banda
ges sheer,callus
pads,sheer
bandages,sterile
pads,adhesive
tape,dental
adhesive,hypoallergenic
bandages,cotton
swabs,color
lancets,cosmetic
puffs,cosmetic
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 547
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
squares,flexible
bandage,strong
strips,waterproof
strong
strips,multipurpos
e contact lens
soln,saline
solution,saline
sensitive
eyes,fever flash
thermometer,dent
ure,combine
abd,toothbrush
precision
head,toothpaste,
bandage,cotton
squares,cosmetic
balls,toothbrush
adult deluxe,lens
lustre eyeglass
cleaner,toothbrus
h, total,pill box,pill
planner,pill
divider with pill
box,medicine
dropper,medicine
spoon,forehead
thermometer,brief
, medium,ep
brief,heatwraps,b
andage
roll,contact lens
conditioning,temp
le
thermometer,univ
ersal
1,breatherite,o.a.
d.,woun'dres,com
feel plus,comfeel
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 548
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
plus
clear,comfeel
plus
triangle,comfeel
plus
contour,comfeel
plus pressure
relief,comfeel
ulcer
care,comfeel
film,female self
catheter,selfcath,coloplast
skin
barrier,coloplast
paste,ostomy
paste,coloplast
barrier
ring,coloplast,col
oplast drainable
pouch,coloplast
closed
pouch,irrigation
set,assura
irrigation face
plate,assura 2pc
irrigation
sleeve,filtrodor
pouch filter,pouch
clamp,assura
flange,assura
wound
manager,assura,
assura flange
convex,assura
ostomy
belt,comfeel
seasorb,assura
2pc
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 549
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
drainable,assura
pouch,assura
standard
wear,assura
pediatric
pouch,comfeel
purilon,conveen
coude intermtnt
cath,conveen drip
collector,assura
easiclose,assura
non-convex
drainable,urosto
my night
bag,biatain,assur
a extra,assura
two-piece uro
minicap,assura
light easiclose
drain,assura
ac,urostomy
multichamber,urostom
y multi-chamber
pouch,urostomy
micropouch,easiclose
wide
outlet,coloplast
paste
strip,sensura
easiclose wide
outlet,sensura
click ostomy
pouch,sensura
flex ostomy base
plate,sensura
ostomy base
plate,sensura flex
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 550
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ostomy pouch,ice
bag,overnites,sur
e choice
pantiliners,belted
undergarment,wi
pes,diapers,sensi
tive baby
wipes,bladder
control pads for
women,briefs for
men & women,ezject
lancets,panty
shields,tugaboos
diapers,maxi
pads,panty
liners,hot-cold
compress,multiuse cold
pad,back & neck
cold pad,cloth
first aid
tape,selfgrip,finge
r splints,finger
sleeves,rewetting
,super strip
bandages,flexible
fabric
bandage,flexible
fabric
bandages,tugabo
os
overnights,under
wear for
men,premium
baby wipes,clear
spot
bandages,ovulati
on predictor,kid
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 551
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pants,protective
underwear,surec
hoice,pantiliners,
dental travel
pack,briefs xlarge,cotton,
sterile,sheer
plastic
strip,disposable
razor,adhesive
bandage,fabric
strip extra
large,pro sports
tape,ice
cap,water
bottle,water
bottle-fountain
syringe,foam
insole,cushion
insole,super
moleskin,over
nites,vinyl
gloves,multipurpose
solution,eye
patch,instant heat
therapy,hearing
aid batteries,latex
gloves,true2go
blood glucose
system,self
grip,cotton
gloves,soft touch
pill reminder,linen
fresh,hot & cold
therapy
brace,instant
heat,heat therapy
patches,moist
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 552
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
towelettes,ultra
fine cut n
crush,tablet
cutter,nail
clip,toenail
clip,nail
nippers,disposabl
e probe
covers,alkaline
batteries,toenail
nipper,finger
splint,tubular
gauze,non-slip
underpads,delux
e
underpads,under
wear for
women,foam ear
plugs,guards for
men,underwear
menwomen,blood
pressure cuff
monitor,boxers
for men,surgical
dressing,contact
lens cases,paper
tape,cleaning &
disinfecting
lens,callus
cushions,plantar
fasciitis arch
sleeve,gel bunion
cushion,clear
bandage,pain
free tape,flexible
foam pad,push n
pop pill
reminder,medicin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 553
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
e dropper &
spoon,am-pm
locking pill
reminder,soft-tip
thermometer,und
erwear for men &
women,tugaboos
training
pants,quiet
please foam ear
plugs,blood
glucose
monitor,flexible
foam
bandage,advanc
ed antibacterial
bandage,nitetime
,interdental
stimulators,dispo
sable
brief,rewetting
drops,one step
ovulation
test,truetrack
smart
system,gauze,bla
dder control,heat
wraps,hypoallergenic
bandage,blood
pressure
kit,tender
tape,skin closure
strips,flex fabric
bandage,comfortstretch,premium
comfortstretch,gauze
dressing,one step
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 554
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pregnancy
test,comfortsmooth,fitted
briefs,fitted
brief,blister
relief,ultra-soft
gloves,premium
nitrile
gloves,quick
read,adult
wash,certainty,to
e separators,gel
toe spacers,gel
toe protector,arch
bandage,gel corn
protectors,sleep
pants,truetrack
blood glucose
system,trueresult
blood glucose
systm,flight ear
plugs,sterile
bandage
roll,gentle
adhesive
bandages,plastic
adhesive
bandages,sheer
adhesive
bandages,confor
ming rolled
gauze,deluxe
arm bp
monitor,premium
arm bp
monitor,premium
baby
diaper,premium
training
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 555
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pants,flushable
cleansing
cloths,face
mask,non-stick
pad,ultra-light
rollator,scar
treatment,cloth
tape,trueplus
lancets,pain free
wrap,self
adherent
wrap,gel bunion
guard,sorespot,al
l gel bunion toe
spreader,well
beginnings sleep
pants,early
pregnancy
test,humidifier,cra
yon
bandage,deluxe
instant,easy
read,well
beginnings
diapers,butterfly
closures,athletic
tape,ear-loop
mask,temple
touch mini
thermometer,tem
ple touch prem
thermometer,clea
r tape,transparent
film
dressing,extra
absorbent
shield,extra
absorbent
undergarment,ad
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 556
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ult brief,sheer
strip,wild hot
strips,napkin
hospital
tabbed,foot and
shoe
padding,saline,be
d pad,rgp wetting
and soaking,rigid
gas permeable
cleaner,lubricatin
g
drops,e.p.t.,e.p.t.
digital,sudacare
advanced,pediac
are gentle
vapors,efferdent
plus,efferdent,fre
sh'n
brite,effergrip,sud
acare,children's
sudacare,e-z
spacer,vanishpoi
nt,syringe with
needle disp,sheer
spot
bandages,premiu
m blood
glucose,accuchek spirit,accuchek
tender,accu-chek
rapid d,accuchek,d-tronplus
adapter,accuchek
ultraflex,accuchek ultraflex
ii,accu-chek dBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 557
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
tron plus,flexlink
plus infusion
set,h-tronplus
adapter,h-tron
plus-piston rod,htron plus,eyelid
cleansing
pads,foracare
gd20,choicedm
g20,fora
v30a,fora
g71a,foracare
gd40a,foracare
gd40b,premium
v10,fora v12,test
n'go,sootheneb
mesh
nebulizer,fora
test n'go
voice,fora
gd50,fora test
n'go
bp,kimono,kimon
o maxx,kimono
microthin,kimono
microthin aqua
lube,kimono
textured,digitex
gold,rid,devilbiss
pulmomate,pulm
o-aide,devilbiss
pulmoaide,devilbiss
disposable
nebulizer,devilbis
s
compact,sunrise
compressornebulizer,devilbis
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 558
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
s
traveler,cytosafe
dipensing
pin,exactamed,dual rate
syringe
infuser,bifurcated
fluid tran tube
set,exactamix,elbow
inlet,gravity
mixing set,luer
lock-to-bag,fluid
transfer
extension set,vial
adapter,bag
spike,oral liquid
transfer tube
set,micro volume
inlet,fluid transfer
set,calibration
bag,dual rate syr
infuser
tubing,minibore,
microfuse
minibore,pole
clamp,em2400
valve set,exactamix
calibration,exacta
-mix
eva,micromacro,s
terl fluid transfer
tube set,topical
tip cap,topical
cream
dispenser,topical
dispenser,sterile
fluid tran tube
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 559
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
set,syringe filling
fixture,oral liq
bag-tube set
combo,repeater
pump
stand,pharmacy
pump stand,0.2
micron filter
attachment,gel
bag & tube set
non-sterile,sterile
exacta-med
dispenspin,tamperresistant bag
cap,sterile top fill
bag,sterile empty
collection
bags,adaptacap,microfuse,trif
urcate fluid tran
tube
set,pharmacy
pack liquid
dispenser,repeat
er pump,vaginal
cream
dispenser,luer to
urethral tip
adapter,luer to
catheter tip
adapter,sterile
rapid fill
connector,sterile
gel bag,sterile
two-fer
needle,exactamed tip
extender,supor,la
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 560
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
bels, 1.5" x
1.5",kwikvial,kwik-vial
filling
extension,kwikvial plug
dispenser,t.i. seal
non-sterile
foil,bottle
adapter,3-way
oral port
stopcock,rapid fill
adapter,sterile
rapid fill
adapter,oral-tooral rapid fill
connec,mark-adose,oral
labels,shrinksafe,
port saver sterile
inject port,vaginal
dispenser tip
cap,tip caps, nonsterile,exactamed tip cap,luer
lock tip cap,luer
lock tip caps,
sterile,sterile luer
slip tip caps,luer
slip tip caps,selfrighting luer slip
tip,catheter tip
cap,locking,selfrighting luer tip
cap,self-righting
luer lock
tip,bedside pack
liquid
dispenser,ward
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 561
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pack liquid
dispenser,neothri
ve,rapid-fill,ohaus
scout sc,iv
transfer
needles,venting
pin,catheter tip
cap,winged,comf
ort
bath,toothette,qcare
rx,chemoplus
dispensing pin,p2
hi-risk,p2 safety
plus,p2 safety
plus powder
free,p2 hi-risk
powder free,pro
star powder
free,oncology
plus,chemoplus
powder
free,chemoplus,d
ust-mist
respirator
mask,chemosafet
y container,u.v.
protection
bags,spill proof
prep mat,safelock
bags,chemowast
e
bags,chemolinen
waste
bags,chemolinen
hamper
stand,chemowast
e hamper
stand,chemosafet
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 562
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
y prep
admin,personnel
protection,multimix,designer,che
mo plus,chemo
spill kit,reality,trudent,first aid
paper tape,first
aid skintone
paper,first aid
plastic tape,first
aid waterproof
tape,air warming
mask,dust &
pollen filter
mask,germ filter
protective
mask,cold
comfort,trueplus
insulin
syringe,trueresult
blood glucose
meter,truetrack,tr
ue metrix blood
glucose mtr,true
metrix,truedraw,b
rush 'n
floss,proview eye
pressure
monitor,stretch
bandage,autolancet mini,injectease,insuleze,insulcap,insul-tray,ezvac,ez-lets,insultote,wetstop,autolancet,dermagran
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 563
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
,dermastat,nutras
tat,dermacol,nutr
acol,dermafilm,de
rmasite,reconstitu
be,deluxe tablet
cutter,inspiracha
mber,zymogeneti
cs spray
applicator,vicks
warm steam
vaporizer,health
mist,vicks cool
mist,vicks warm
mist,vaporizer,vic
ks digital
thermometer,vick
s forehead
thermometer,ther
moscan,sensitive
teeth,tartar
control,cetylcide
g,hyde-out,power
cleaner,cetylzyme,replacemen
t j-4
cannula,sanitizer
bottle,mepilex
border,mepilex
ag,mepilex
border
sacrum,mefix,me
pitel,lite
touch,medilance,aurora
healthcare
lancets,lady
lite,phaseal
protector,phaseal
injector
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 564
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
luer,phaseal
connector
luer,phaseal
adapter,phaseal
y-site,phaseal
assembly
fixture,phaseal
infusion,phaseal
secondary
set,space
chamber
plus,compact
space chamber
plus,hard contact
lens cleaner,hard
contact lens
soak,hard contact
lens wet,kotex
fresh & dry,kotex
overnight,depend
,huggies,huggies
pull-ups,huggies
baby
wipes,goodnites,
depend
silhouette,depend
real fit,poise
pads,depend
guards for
men,kotex
security,poise
liners,depend
overnite,depend
protection,huggie
s
goodnites,goodnit
es sleep
shorts,huggies
ultratrim,lavender
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 565
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
nitrile exam
glove,huggies
overnites,depend
shields for
men,huggies slipon,huggies snug
and
dry,kotex,kotex
lightdays,new
freedom
lightdays,kotex
new freedom,lil
swimmer small
pant,lil swimmer
medium pant,lil
swimmer large
pant,poise,depen
d belted
shields,huggies
overnite,huggies
newborn,huggies
convertibles,depe
nd elastic leg
undergarmnt,dep
end fitted
brief,goodnite,hu
ggies
snuggems,huggie
s convertible clip
strip,huggies
supreme,huggies
pure &
natural,first
choice thin
lancets,topcare
belted
shield,topcare
underpad,topcare
maxi
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 566
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
overnight,topcare
pantiliner,topcare
male
guard,topcare
liners,topcare
pads,topcare
maxi
pads,luvs,pamper
s
premium,pamper
s ultra dry
thin,pampers
babydry,pampers
unisex,pampers
cruisers,underja
ms,pampers easy
ups,pampers
extra
protection,pampe
rs swaddlers
sensitive,pamper
s
preemie,pampers
swaddlers,pampe
rs,newborn babydry,washcloth,pa
mpers
premature,pampe
rs ultra
dry,pampers
newborn,pamper
s rash
care,pampers
premie,luvs
overnight,pamper
s nonelasticized,pamp
ers ultra
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 567
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
phases,ultra +
pampers,pamper
s thick
phases,pads,slipon,overnight
protective,refuah
plus,refuah plus
glucose
control,sleep
overs,cuties,cutie
pants,heating
pad,glucopro,ami
go insulin
pump,hugo
cane,hugo rolling
walker,hugo
transport,hugo
folding
walker,airgo
rolling
walker,smart
sense
lancets,topcare
universal1 thin
lancet,ultra thin
plus,smart
sense,ultra thin
plus
lancets,topcare
ultra
comfort,renew
advanced microlancets,renew
advanced lancing
system,topcare
clickfine,relion
thin,bullseye mini
safety
lancets,sms
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 568
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
glucose
control,safetylet,safety seal
lancets,aqua
lance lancing
device,easy twist
& cap
lancets,surechek
glucose
control,sure edge
blood glucose
meter,sure edge
glucose control
soln,alternate site
lancing
device,vocalpoint
glucose
control,vocal
point glucose
control,one step
at a time,pelvic
muscle
trainer,stethosco
pe,babytherm
pacifier
thermometer,bre
ast
pump,nebulizer,fil
ters,mask,ear
thermometer,sph
ygmomanometer,
crutch accessory
kit,underwear,cru
tch,cool
mist,super
underpad,regular
pad,super
pad,cervical
collar,oral
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 569
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
thermometer,bab
y
thermometer,femi
nine combination
syringe,fountain
syringe,feminine
folding
syringe,feminine
bulb
syringe,vaporizer
inhalant,vaporizer
cleaning
tablets,feminine
compact travel
syrnge,attachme
nt set,enema
syringe,nasal
aspirator,rectal
syringe,wheelcha
ir,incontinent
liner,entrust plus
undergarment,ac
apella,lipo cream
base,shrink
band,plastic
white hdpe
bottle,amber
round glass
bottle,topiclick,bottletop
dispenser
adapter,unguator
lid,syringe filter,
millexgp,precisedose
dispenser tip
cap,megapump
mezzo,megapum
p airless,rectalBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 570
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
vaginal
perforation
tip,sterile clear
glass vial,amber
glass serum
bottle,topi-click
filling
nozzle,enema
bottle,adapter
cap,glass
graduated
cylinder,precised
ose dispenser
syringe,posidyne
eld,suppository
shell,syringe
filter, millexgs,adapter pressin bottle,troche
mold,alcohwipe,alcohglove,sterile
nitrile
gloves,amber
glass bottle,clear
glass serum
bottle,luer lock
syringe,luer slip
tip cap,luer-lock
syringe,amber
oral-topical
syringe,luer slip
tip syringe
tray,md pump
actuator b,md
pump actuator
a,md pump bottle
airless,md pen
airless,md
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 571
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
syringe
airless,md jar
airless,purple
nitrile
gloves,sterile
amber glass
vial,md pump
actuator c,sterile
droptainers,therm
ophore,thermoph
ore maxheat,ice
it!,thermophore
arthritis,opsite iv
3000,no-sting
skin-prep
swab,exu-dry slit
tube,conformant
2,drynet,replicare
ultra,replicare
ultra
sacrum,acticoat,a
cticoat 7,acticoat
absorbent,aquap
hor
gauze,acticoat
site,acticoat flex
7,acticoat flex
3,biostep
ag,biostep,replica
re thin,iv3000
frame
delivery,hot &
cold
compress,non
adherent
pads,nonadherent,adhesiv
e
bandages,adhesi
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 572
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ve foam
bandages,baby
darlings
wipes,baby
darlings
diapers,combinati
on water
bottle,thong
liners,tampons,pu
re
cotton,feminine
cleansing
cloths,lice
removal
comb,personal
washcloths,traini
ng
pants,compmist
compressor
nebulizer,minico
mp compressor
nebulizer,earloop
masks,cone
masks,transport
chair,selfgrip,lubricating &
rewetting,everyda
y long
pantiliners,little
darlings,foam toe
bandages,neopre
ne wrist
splint,neoprene
knee support,first
aid kit,slip on
knee,nitrile exam
gloves,sheer
strips,clear
strips,plastic
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 573
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
strips,personal
confidence
pads,beltless
undergarments,p
ersonal
confidence
briefs,overnight
brief,personal
confidence
underpad,flexible
foam strips,slipon
undergarments,b
aby basics,basics
for kids,heavy
duty fabric
strips,personal
confidence
liners,clear
waterproof
strips,natural
care
bandages,camo
bandages,person
al confidence
underwear,icy hot
smart relief
tens,icy hot smart
relief tens
pads,protective
barrier
wipes,reliamed,re
liamed mini
lancing
device,reliamed
safety seal
lancets,transpare
nt thin film
dressing,transpar
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 574
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ent i.v. site
dressing,ostomy
protective
powder,incontrol
bp
monitor,microlife
peak flow,flexiseal fecal,ultilance,dignity
regular,dignity
extra-duty,dignity
regular
duty,dignity
natural
extra,dignity
diaper,dignity
underpad,free &
active
super,dignity,dign
ity plus,dignity
plus
liners,briefmates,
prevent
plus,dignity plus
fitted brief,dignity
plus regular
brief,lady dignity
plus brief,sir
dignity plus
brief,lc d
nebulizer set,lc
plus,baby
nebulizer,lc
star,sinustar,pari
lc plus
nebulizer,lc sprint
nebulizer,pari
sinus aerosol
system,pari lc
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 575
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
sprint sinus,vios
aerosol delivery
system,filter,
valve set for ll &
lc,filter pad,filters
replacement,bab
y conversion
pack 1,baby
conversion pack
2,mask set with
y-piece,mask
vortex,vortex,bub
bles the fish
ii,wing tip
tubing,adult
aerosol
mask,vortex
ladybug
mask,vortex frog
mask,trek s
portable pwr
kit,trek s combo
pack,trek s
compact
compressor,alter
a nebulizer,eflow
scf,eflow scf
aerosol
head,eflow scf
nebulizer
handset,smartma
sk kids,proneb
ultra,proneb ultra
ii,proneb ultra ii
deluxe,adapter
w-disp
mouthpiece,mout
hpiece for
truzone peak
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 576
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
fl,mask,
pediatric,proneb,
pep pressure
monitor,bubbles
the fish,pep
nebulizer,lc
nebulizer,elastogel hot & cold
wrap,elastogel,elasto-gel
plus,toe aid
dressing,elastogel circle
dressing,elastogel cast-splint
padding,boston
rewetting
drops,boston one
step,nite
train'r,microspace
r,microchamber,i
nhaler
companions,asth
ma
control,interlink,e
mpty viaflex-ytransfer set,sub-q
set,empty viaflex
container,easyma
xv
speaking,easyma
x v,easymax
speaking,easyma
x v2,easymax
l,easymax
n,easymax,easy
max ng,easymax
15,easyplus
r13n,easyplus
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 577
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
v,td gold blood
glucose
monitor,td gold
voice glucose
monitor,td gold
level 1 control
sol,td gold level 2
control sol,td gold
level 3 control
sol,fortiscare
blood glucose
syst,fortiscare,ant
i-embolism
stockings,truform
compression
stocking,puralin,s
urgilance
lancets,cut n
crush,moist
wipes,cold
wrap,cold pack
back pad,tennis
elbow
brace,elbow
support,knee
stabilizer,elbow
strap,wrist
support,ankle
support,ace ankle
support,arm
sling,deluxe
laced ankle
brace,backshoulder ice &
heat wrap,multipurpose ice &
heat wrap,deluxe
ankle
brace,contoured
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 578
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
back
support,back
stabilizer,deluxe
back
stabilizer,maxi
super,maxi
deodorant,maxi
regular,thumb
stabilizer,deluxe
wrist
stabilizer,hand
support,warm
steam
vaporizer,selfadhering,flushabl
e moist
wipes,ankle
stabilizer,wrist
immobilizer,delux
e wrist brace,ultra
thin,ace aerosol
cloud
enhancer,easiven
t,daily pill box,hot
& cold
pack,medilice,sheer
adhesive,medico
ol's diasox,bed
underpads,contro
l pads,clear
spots,fabric
bandages,7 day
pill box,fancy pill
box,pill pal,one
weektoday,rubber
finger,dosage
spoon,dosage
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 579
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
syringe,dosage
dropper,hot &
cold
wrap,thermipaq,
myglucohealth,m
yglucohealth
lancets,myglucoh
ealth control
solution,nessi
spacer,protective
pads,jumbo
diapers,supreme
diapers,diapers
mega,kidpant,abs
orbent cotton
balls,blood
glucose monitor
kit,bladder control
pad ultra,guard
male,plastic
swabs,diaper,inst
ant cold therapy
wrap,sleep
comforts,gentle
tape,gloves,nonadhesive
pad,overnight
briefs,cleansing
wipes,saline
sensitive,aloe
vera latex
gloves,flexible
dressing,gauze
sponges,adhesiv
e dressing,selfadherent gentle
wrap,blood
pressure
cuff,contact lens
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 580
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
relief,flex
bandage,ear
plugs,suresite
window,procedur
al face
masks,advanced
non-stick
dressings,nonstick
dressings,surgica
l dressings,allpurpose
dressings,dressin
g sponges,cold
pack,x-abs
underwear,all
purpose cloth
tape,corn
cushion,flex
finger
bandage,callus
cushion,moleskin
plus,portable
sharps
disposal,triple
layer non-stick
pad,qwikstrip,premium
adult wash
cloths,peas cold
therapy,arthritis
heatwraps,calciu
m
alginate,hydrogel
dressing,hydrocol
loid
dressing,contact
lens
case,household
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 581
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
burn kit,reusable
instant heat
pack,elastic
stretch
net,women's
underwear,men's
underwear,weekl
y vitamin
planner,saline
4,disposable
latex-free
gloves,overnites
diaper,adhesive
gauze
pad,needle
collection &
disposal,rolled
absorbent
cotton,sheer
bandage,waterproof
bandages,plastic
strip,super
absorbent
underwear,ultrathin
underwear,polyrayon,nighttime
underpants,surgi
cal pads,iv prep
antiseptic,coverle
t o.r.,blairex
sterile saline
soln,assess peak
flow
meter,personal
best peak flow
meter,heartstart,c
oaguchek,accuBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 582
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
chek safe-t-pro
plus,chemstrip bg
diary,soft
touch,accu-chek
voicemate,accuchek safe-tpro,softclix,accuchek
softclix,microdot,
clip & stor,3m
nexcare
stomaseal,microp
ore paper
surgical
tape,nexcare
gentle paper
tape,3m nexcare
durapore,nexcare
all purpose
mask,futuro
restoring,futuro
antiembolism,nexcar
e tegaderm,paper
first aid tape,3m
paper pre-cut
tape strips,clear
first aid
tape,active
strips,waterproof
adhesive,heat
comfort,foam
sports tape,3m
non-stick
pads,amniscreen,
metercheck,normject,aimsco,aimsc
o ultra thin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 583
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ii,aimsco mini
ultra-thin ii,ultrathin ii,ultra thin
ii,ultra-thin ii
lancets,pcca
accupen15,supposistrip,u
niversal
sleeve,vaginal
cream
applicator,suppos
itory box,filter,
millex-or
syringe,boston
round
natural,vaginal
suppository
applicator,bottle,l
uer lock
adapter,filter,
millex-fg
0.2um,suppositor
y shell,
small,suppository
shell,
medium,syringe
tip rectalvaginal,megapum
p-blue,freedom
precision
airless,antibacteri
al
bandage,antibact
erial pad,fast
read
thermometer,chil
d ear
syringe,infant ear
syringe,watchhal
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 584
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
er,e.p.t. stick
test,carra sorb
h,carra sorb
m,carra
film,diab,pump
for whirlpool
solution,shampoo
& body wash
dispenser,radiafd
g,carrasyn
gel,gauze
packing
strip,wound
dressing,gel
pad,carrasyn
spray gel,carra
gauze
strips,carra
gauze,carrasyn
v,carracolloid,ultr
a-klenz,dermal
wound
gel,primary
dressing,incontin
ence skin
care,carrasmart,c
arradres,radiadre
s,carraginate,sur
esite
iv,suresite,suresit
e
flexigrid,arglaes,a
rglaes
film,arglaes
island,optifoam,e
xuderm
rcd,exuderm,exu
derm lp,exuderm
ultra,exuderm
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 585
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
sacrum,dermagel,medfix,maxor
b,maxorb
extra,tenderwet,e
z smart,ez smart
lancets,ez smart
plus,onetouch
ultra control
soln,one touch
delica,onetouch
verio iq,one touch
verio,onetouch
delica,onetouch
finepoint
lancets,onetouch
suresoft,onetouc
h
ultramini,onetouc
h ultra
system,one touch
glucose control
soln,onetouch
verio,one touch
basic
system,surestep,
penlet plus blood
sampler,onetouc
h
lancets,onetouch
ultra2,onetouch
ultra
smart,onetouch
ultralink,surestep
control
solution,surestep
pro,onetouch
verio sync,grx
wound
gel,alligator
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 586
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
spoon,pre-moist
pads,replacemen
t
pads,aerochamb
er,one touch
lancets,ultra fine
lancets,opsite
flexigrid,opsite,all
evyn cavity
wound
dress,algisite,unif
lex,needle free
syringe kit
a,medi-jector
vision,needle free
syringe kit
b,needle free
syringe kit
c,medi-jector
needle-free syr
a,medi-jector
needle-free syr
b,medi-jector
needle-free syr
c,fibracol,kling
fluff,sofkling,barrier
sterile
field,biopatch,nubrede,topper,tiell
e,bioclusive
select,bioclusive
select
mvp,bioclusive
mvp select,nu-gel
collagen,algosteri
l,nu-gel,raytec,soffoam,band-aid
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 587
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
island
surgical,zonas,de
rmiview,dermifor
m,tielle plus,kling
conforming
gauze
bandage,dynaflex,ultralon
pf,maxxus
pf,micro-touch
pf,allergard,neutr
alon
50,maxxus,neutr
alon,microtouch,microtouch xp,sofloop,surgine,barri
er,surgine
ii,barrier n95,protectivw,protectiv plusw,biovue,protecti
v,lister's suture
removal
kit,barrier
fenestrated strl
field,preptic
shave
prep,preptic 2
shave
prep,chix,sofnet,d
aylee,preptic,prevac
are,starter kit,life
medical
starter,diabetic.co
m starter,prestige
meter,prestige,pr
estige value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 588
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
pack,truecontrol,t
ruetest glucose
control,sidekick,p
restige smart
system,prestige
smart system
iq,liberty lev 1
glucose
control,liberty lev
2 glucose
control,liberty
monitor,sheet
protector,breathe
right,medisense
thin
lancets,medisens
e glucose
ketone,medisens
e glucose ketone
contr,medisense,
precision
xtra,optium,precis
ion,unistik 2
normal,unistik 2
extra,precision
link,autolancet
device wlancets,ultratlc
lancetsdevice,silverseal
hydrogel,hydress,
steritamp,pocketcare
irrigator,elon nail
care
system,flutter,sup
reme glucose
control,supreme
meter,2tek,e-z
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 589
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
spacer
pedspak,e-z
spacer mask,e-z
spacer &
mask,wonderpant
s,up & up maxi
pads,up & up
baby
diaper,telcare,telc
are control
solution,telcare
bgm,sure-ject
insulin
syringe,surelance,sure-fine
pen
needles,sure-test
easyplus
mini,suretouch,surepen,heartstream
fr2,elta
dermal,varithena
administration
pack,deltec
cozmo,infusion,in
sulin
cartridge,adapter,
belt clip,gripper
plus,deltec
cozmo cleo
infusion
set,amerigel,fc2
female
condom,dermafil
mhd,dermasyn,der
magauze,dermav
iew,dermaview
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 590
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
ii,dermaginate,de
rmadress,dermal
evin,actis,flexzan
adhesive
dressing,hydrocol
ii,sorbsan,vial,ste
rile,empty,maxifill
transfer set,steritamp seal,chemo
transfer pin,floweze,mini transfer
pin,hi-volume
pumping
chamber,transfer
pin,universal
syringe tip
adaptor,promogr
an
prisma,promogra
n,actisorb,silverc
el,e.p.t,e.p.t
digital,tear
flo,scar
care,accu-chek
aviva
plus,coaguchek
xs,accutrend
cholesterol,accutr
end
glucose,accutren
d plus,accu-chek
fastclix,accu-chek
compact blue
control,coaguche
k xs pro,accuchek nano
smartview,accuchek
smartview,accuBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 591
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
chek compact
plus
control,comfort,c
artridge
pump,contact
detach infusion
set,cartridge
stamped,onetouc
h ping,insulin
pump,cartridge,in
set infusion
set,animas
2020,inset 30
tubing,infusion
pump,comfort
short,inset 30
infusion
set,ultima,reservo
ir,simplechoice,si
mplechoice
quick,gelpad,wou
ndgard
gauze,coolmagic,
triple helix
collagen,foam
dressing,sanizone ostomy
deodorant,md
turbo,vascuderm
hydrogel
wound,aerocham
ber
plus,primabella,fl
exi-seal fms,surfit natura high
output,visi-flow
irrigation
sleeve,visi-flow
irrig starter
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 592
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
set,little ones
drainable
pouch,little ones
urostomy
pouch,little ones
closed-end
pouch,esteem
drainable
pouch,little ones
skin barrier,visiflow sleeve tail
closures,convate
c night drainage
tubing,versiva
xc,allkare
adhesive
remover
wipes,sur-fit
natura
adaptor,sur-fit
natura lowpressure,convate
c night drain
container,esteem
+ closed
pouch,esteem
closed
pouch,natura
closed
pouch,esteem
synergy closed
pouch,flexi-seal
signal
fms,stomahesive
skin barrier,eakin
cohesive
slims,aquacel
foam,natura
durahesive skin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 593
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
barrier,natura
stomahesive skn
barrier,aquacel
extra,gentlecath,
natura drainable
pouch,esteem
synergy drainable
pouch,aquacelag extra,eakin
cohesive,aquacel
ag foam,aquacel
ag foam
heel,aquacel ag
foam
sacral,aquacel
foam
sacral,esteem
synergy+,harmon
ie,dry comfort
extra,tena,dry
comfort,tena
pants,tena
classic,tena
stretch ultra,tena
classic plus,tena
protective
underwear,brief
youth,promise
pad,flexiflo,y-port
connector,flexiflo
top-fill,flexiflo
feeding
tube,flexiflo topfill bag,enteralite
infinity,flexiflo
magnaport,magnaport,flexiflo overtheBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 594
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
guidewire,flexiflo
easy-feed
500,flexiflo top-fill
enteral
bag,flexiflo
quantum,compan
ion pump,durag,nasoenteric
tube,embrace,em
brace
adapter,embrace
bag set,flexiflo
toptainer,flexiflo
feeding
bag,embrace
pole
clamp,quantum
pump,patrol,gravi
ty feeding
set,tranquility
premium
underwear,atn
brief,select
underwear,select
disposable
briefs,select
underpads,diaper
booster
pad,tranquility
topliner
pads,select kids
briefs,coverlet
eye occlusor,selftaking blood
pressure,a.i.r.s.
nebulizer,airs
disposable
nebulizer,airs
adult aerosol
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 595
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
mask,airs
pediatric
disposable
mask,comp-air
elite compressor
syst,reusable
nebulizer kit,air
tube with air
plugs,micro
air,comp-air
nebulizer
compressor,peak
-air,women's
advanced bp
monitor,airs
pediatric aerosol
mask,visine for
contacts,bengay
moist heat
therapy,ezo,avog
el,sofsensor,guardian
transmitter
tape,guardian rt
starter
kit,paradigm realtime,guardian
realtime,guardian rt
system,replacem
ent pediatric
monitor,minimed
reservoir,1.5 volt
batteries
#357,polyfin,sofset,paradigm
insulin pump
pathway,polyfin
qr,sofBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 596
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
serter,paradigm
infusion,quick
release soft
teflon,sof-set
micro,paradigm,p
aradigm
silhouette,silhoue
tte,silserter,quick-set
paradigm,minime
d,guardian test
plug,minimed
infusion,medtroni
c remote
control,paradigm
remote
control,paradigm
insulin
pump,revel
programmable
pump,guardian rt
charger,minilink
real-time
transmitter,suret,sure-t
paradigm,mio
infusion set,senserter,enlite
glucose
sensor,minimed
530g,enlite
serter,real-time
starter
kit,continuous
glucose
sensor,enlite,iport
advance,suprem
e,options
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 597
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
liners,options
pads,early
ovulation
test,tena
underwear,carefr
ee
pantiliners,bulkee
ii,ultra-soft
plus,ultra-soft
classic,protection
plus
underpad,protecti
on plus
classic,day &
night brief,options
ultra
thins,thermomete
r tip covers,relion
blood pressure
cuff,urological
catheter,active
cath,3 step skin
care,step 2moisture
cream,step 3moisture
barrier,step 1incontinent
cleanser,ultrafresh,sleeve
closure
clamp,irrigation
syringe,enema
bag with
catheter,mountin
g ring,elastic
belt,shut off for
5000 enema
bag,lubriBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 598
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
wipe,compact
irrigator,colostokit
irrigator,hospital
pack
irrigator,female
specimen
catheter,tubing
for irrigator,shut
off for
tubing,quick
disconnectconnector,insertio
n tube
catheter,shield
for insertion
tube,travel
case,laird
tip,freedom t-tap
leg bag
kit,freedom leg
bag,tube &
connector
kit,freedom twist
port leg bag
kit,colostotip,colo
stotip w-quick
disconnect,freedo
m pak
seven,freedom
cath,response
ii,touch ii,piston
ii,economy
pouch,mini-drain
open end
pouch,doublehesive,e-z
hold,gizmo foam
straps,uro-san
plus,clear
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 599
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
advantage,contin
ent urinary
catheter,colostop
ads,cone
tip,dermaguard,uro-san leg
bag,plastic
connector,deluxe
leg bag
straps,comfort
leg bag
straps,freedom
drainage
bag,gizmo,evacar
e pessary,bandaid activ flex,seal
tight,on call plus
meter,on call plus
control,on call
plus lancing
device,on call
plus lancet,on
call lancet,on call
lancing device,on
call vivid
meter,on call
vivid
control,optumrx,o
n call vivid pal,on
call express
meter,on call
express control
soln,tens
502,tens
504,neurostimula
tion
electrodes,home
access hiv-1 test
system,mask
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 600
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
set,erapid
nebulizer,erapid
nebulizer
handset,baby
conversion
kit,vortex vhc
ladybug
mask,vortex vhc
frog mask,ems
anti-embolism
stocking,devilbiss
pulmoneb lt
comp-neb,sure
comfort,poly hub
needle,sure
comfort
lancets,sure
comfort lancing
pen,securely
yours,quickables
washcloths,ezsorb,attends,atte
nds
undergarments,at
tends
insert,attends
underwear,attend
s
guards,tissuepak,
attends light
insert,attends
booster,attends
disposable
underpads,ultima
tuckables,cairpad
,ultima
incontinence,adh
eres,tuffsorb,tuck
ables,attends
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 601
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
washcloths,gmat
e control
solution,gmate
voice
starter,gmate
voice
meter,gmate,gma
te lancing
device,gmate
smart
starter,gmate
smart
meter,gluco
navii,lancing
system,muppet
strips,cleaning
solution,wetting
solution for hard
lens,nonpreserved
saline,oragrip,ho
me pregnancy
test,absorbent
shield,poison first
aid kit,facial
cleansing
sponge,pill
divider,shave
cream,blade
double
edge,lady's
shaver plus lube
strip,weekly pill
planner,effervesc
ent denture
cleansr,effervesc
ent
denture,dental
floss
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 602
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
unwaxed,choiced
m clarus control
soln,choicedm
clarus,snap
insulin pumpinfusion set,snap
insulin pump
controller,quintet,
blood glucose
control,quintet
ac,nasoneb nasal
nebulizer,aeroecli
pse,aerochamber
plus z
stat,monaghan z
stat,easy check
control
solution,easy
step,easy
plus,easy
trak,easy
talk,easy plus
ii,easy comfort
pen needles,easy
comfort insulin
syringe,maxicomfort,mini
ultra-thin ii,mini
lancing
device,t:slim,cleo
90 infusion
set,carefine pen
needle,unistrip,inj
ect ease
lancets,affirm
underwear,affirm
pads,snap
pants,mesh
pants,prevail
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 603
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
bladder
control,cuties
baby wipes,cuties
wash
cloths,prevail,was
hcloths,prevail
wet wipes,prevail
premium
washcloths,ameri
can star
washcloths,proca
re
washcloths,perso
nal cloths,pant
liner large
plus,pant liner
large,prevail
underwear,nu-fit
brief,breezers,per
-fit brief,value
buy,prevail
brief,prevail
stretch fit,nufit
underwear,prevai
l simply stretch
fit,prevail
boxers,procare,pr
evail full
coverage
undrwear,nufit
brief,per-fit
underwear,perfit
brief,prevail perfit,ben-efit,prevail
breezers,prevail
extra
underwear,prevai
l bariatric,prevail
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 604
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
super plus,prevail
protective
underwear,prevai
l
adjustable,prevail
classic fit
underwear,prevai
l pm,prevail ultra
plus,prevail ultra
bladder,prevail
panty liner,prevail
extra plus
bladder,prevail
extra
bladder,prevail
guards for
men,prevail
pads,prevail male
guard,prevail
curve,prevail
smooth fit,prevail
fits to a t,youth
brief,adult frontal
tape brief,prevail
pre-moist bath
cloth,pant
liners,xtremefit
brief,ultrathin,pre
mier adult
brief,prevail
breezers
360,prevail per-fit
360,easy
check,easy
comfort,easy
click,propylene
glycol,easy touch
lancets,diatrue
plus,diatrue,uroc
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 605
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
are urinary
drainage,uro-con
catheter,toe
straightener,up &
up
pantiliners,agiegrx,erase,erase
ras-pouri,geridyne,hydrophor
gauze,karaya
gum,hydrocollgrx,calalgingrx,calalgin-grx
rope,island gardgrx,grx hydrogel
gauze,grx foam
dressing,safe
klean,mercury
klean kit,bloodglucose
meter,profit,quick
response,onestep blood
pressure
monitr,freestyle
insulinx,ultratlc
lancets,medisens
e
control,precision
glucose
control,precision
sof-tact,precision
q-i-d,embrace
glucose control
soln,victory,embr
ace pro,embrace
evo,advocate
control
solution,advocate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 606
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
blood glucose
monitor,advocate
rapidsafe,advocate
lancing
device,advocate
lancet,advocate
redicode,advocate
lancets,advocate
redi-code
duo,advocate
duo,advocate
redicode+,advocate
redi-code+ ctrl
soln,advocate
syringes,advocat
e pen
needles,neopren
e ankle
support,new
generation,sterile
bandages,droppe
r,ankle supportelastic,elbow
supportelastic,wrist splint
support,diabetic
socks,pulmoneb
lt compressor
nebul,clever
choice control
solution,clever
choice hd
glucose
syst,clever choice
blood gluc
sys,clever chek
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 607
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
blood glucose
syst,clever chek
lancets,clever
choice pro,clever
chek,clever
choice,pharmacis
t choice,clever
choice
micro,clever
choice
talk,comfort
ez,fora d10,fora
control
solution,fora
v10,fora v20,fora
v22,fora
g30a,fora
g20,fora d15,fora
d20,fora g90,fora
lancing
device,foracare
lancets,foracare
gdh,freestyle
system,freestyle
sidekick
ii,freestyle
lancets,freestyle
control
solution,freestyle
flash
system,freestyle
unistik 2,freestyle
navigator,freestyl
e lite
meter,freestyle
freedom,freestyle
freedom
lite,freestyle
precision
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 608
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
04/13/2015
Brand Name
Generic Name
nutriheal,boost,co lactose-free food,lactosempleat modified reduced food,nutritional
formula,isosource supplement
,boost plus,boost
high
protein,nutritional
supplement,nutriti
onal supplement
plus,nutridrink,balanced
nutritional,nutritio
nal
drink,nutritional
drink
plus,nutritional
shake,nutrafit
plus,nutrafit,comp
lete
nutrition,complete
nutrition
plus,traumacal,co
mpleat,liquid
nutrition
plus,nutrition
plus,liquid
nutrition,jevity 1
cal,ensure
liquid,osmolite,os
molite 1
cal,ensure active
high
protein,promote,e
nsure high
protein,osmolite
1.2 cal,ensure
active muscle
health,ensure
active
clear,ensure
Type of Change
Previous Value
REMOVE FROM
FORMULARY
New Value
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 609
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
muscle
health,nutritional
shake plus,asoy,high-protein
nutritional
shake,isocal,nutri
tional
liquid,nutritional
plus liquid,ensure
enlive,preferred
plus,kindercal
tf,kindercal,bright
beginnings,ensur
e active heart
health,ensure
active proteinmuscle,ensure
active
light,ensure high
protein-muscle
04/13/2015
melatonin
melatonin
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
acidophilus,probi lactobacillus
otic pearls
acidophilus/bifidobacterium
longum
REMOVE FROM
FORMULARY
Non-Formulary
04/13/2015
povidonepovidone-iodine,lidocaine
iodine,hospital
hcl/benzalkonium
antiseptic,antisep chloride/alcohol
tic,antiseptic
solution,first aid
antiseptic,periwash,grx
dyne,betadine,be
tagen,scrub care
povidone iodine
REMOVE FROM
FORMULARY
Non-Formulary
04/15/2015
ZONEGRAN
ADD TO FORMULARY
Non-Formulary
zonisamide
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 610
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
04/15/2015
CLIMARA PRO
estradiol/levonorgestrel
04/15/2015
HYCET
hydrocodone
bitartrate/acetaminophen
04/15/2015
prudoxin,doxepin doxepin hcl
hcl,zonalon,silen
or
04/15/2015
CLOBEX
clobetasol propionate
04/15/2015
VFEND
04/15/2015
Type of Change
Previous Value
New Value
CHANGE TIER
Non-Formulary
CHANGE UM:
AUTHORIZATION
PA applies
ADD TO FORMULARY
Non-Formulary
CHANGE TIER
Non-Formulary
voriconazole
ADD TO FORMULARY
Non-Formulary
FORTAMET
metformin hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
FORTAMET
metformin hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
KERALYT
salicylic acid
ADD TO FORMULARY
Non-Formulary
04/15/2015
retintretinoin
a,avita,tretinoin,at
ralin,tretinx,tretinoin
acid,retinoic
acid,vesanoid
ADD TO FORMULARY
Non-Formulary
04/15/2015
RETIN-A
tretinoin
ADD TO FORMULARY
Non-Formulary
04/15/2015
tretinoin
tretinoin
CHANGE TIER
Generics
04/15/2015
RETIN-A
tretinoin
ADD TO FORMULARY
Non-Formulary
04/15/2015
tretinoin
tretinoin
CHANGE TIER
Generics
04/15/2015
tretinoin
tretinoin
CHANGE TIER
Generics
04/15/2015
RETIN-A
tretinoin
ADD TO FORMULARY
Non-Formulary
04/15/2015
panoxyl-4
benzoyl peroxide
ADD TO FORMULARY
Generics
04/15/2015
levalbuterol
concentrate
levalbuterol hcl
CHANGE TIER
Generics
04/15/2015
XOPENEX
levalbuterol hcl
CONCENTRATE
CHANGE TIER
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 611
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
duloxetine hcl
duloxetine hcl
CHANGE TIER
Generics
04/15/2015
CYMBALTA
duloxetine hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
duloxetine hcl
duloxetine hcl
CHANGE TIER
Generics
04/15/2015
CYMBALTA
duloxetine hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
duloxetine hcl
duloxetine hcl
CHANGE TIER
Generics
04/15/2015
CYMBALTA
duloxetine hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
MIACALCIN
calcitonin,salmon,synthetic
ADD TO FORMULARY
Non-Formulary
04/15/2015
PARCOPA
carbidopa/levodopa
CHANGE TIER
Non-Formulary
04/15/2015
PARCOPA
carbidopa/levodopa
CHANGE TIER
Non-Formulary
04/15/2015
BOTOX
COSMETIC
onabotulinumtoxina
REMOVE UM: SPECIALTY
Specialty Drug
04/15/2015
BOTOX
COSMETIC
onabotulinumtoxina
REMOVE UM:
AUTHORIZATION
PA applies
04/15/2015
BOTOX
COSMETIC
onabotulinumtoxina
REMOVE UM: CUSTOM
Cosmetic Rider
May Be Required
04/15/2015
BOTOX
COSMETIC
onabotulinumtoxina
REMOVE FROM
FORMULARY
Not Covered
Non-Formulary
04/15/2015
DRITHOCREME anthralin
HP
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SAIZEN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
telmisartan
telmisartan
CHANGE TIER
Generics
04/15/2015
MICARDIS
telmisartan
ADD TO FORMULARY
Non-Formulary
04/15/2015
MICARDIS
telmisartan
ADD TO FORMULARY
Non-Formulary
04/15/2015
telmisartan
telmisartan
CHANGE TIER
Generics
04/15/2015
TIROSINT
levothyroxine sodium
CHANGE TIER
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 612
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Non-Formulary
Generics
04/15/2015
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Non-Formulary
Generics
04/15/2015
amlodipineatorvastatin
amlodipine
besylate/atorvastatin
calcium
ADD TO FORMULARY
Generics
04/15/2015
fenofibrate
fenofibrate,micronized
CHANGE TIER
Generics
04/15/2015
fenofibrate
fenofibrate,micronized
CHANGE TIER
Generics
04/15/2015
eszopiclone
eszopiclone
CHANGE TIER
Generics
04/15/2015
LUNESTA
eszopiclone
CHANGE TIER
Non-Formulary
04/15/2015
eszopiclone
eszopiclone
CHANGE TIER
Generics
04/15/2015
LUNESTA
eszopiclone
CHANGE TIER
Non-Formulary
04/15/2015
LUNESTA
eszopiclone
ADD TO FORMULARY
Non-Formulary
04/15/2015
omega-3 acid
ethyl esters
omega-3 acid ethyl esters
CHANGE TIER
Generics
04/15/2015
RESTORIL
temazepam
ADD TO FORMULARY
Non-Formulary
04/15/2015
temazepam
temazepam
ADD TO FORMULARY
Generics
04/15/2015
ZYLET
tobramycin/loteprednol
etabonate
CHANGE TIER
Non-Formulary
04/15/2015
alprazolam odt
alprazolam
CHANGE TIER
Generics
04/15/2015
alprazolam odt
alprazolam
CHANGE TIER
Generics
04/15/2015
BONIVA
ibandronate sodium
ADD TO FORMULARY
Non-Formulary
04/15/2015
fentanyl
fentanyl
ADD TO FORMULARY
Generics
04/15/2015
DURAGESIC
fentanyl
CHANGE TIER
Non-Formulary
04/15/2015
LAMICTAL XR
lamotrigine
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 613
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
LAMICTAL XR
lamotrigine
ADD TO FORMULARY
Non-Formulary
04/15/2015
LAMICTAL XR
lamotrigine
ADD TO FORMULARY
Non-Formulary
04/15/2015
IMITREX
sumatriptan succinate
ADD TO FORMULARY
Non-Formulary
04/15/2015
LAMICTAL XR
lamotrigine
ADD TO FORMULARY
Non-Formulary
04/15/2015
albuterol sulfate
albuterol sulfate
CHANGE TIER
Generics
04/15/2015
albuterol sulfate
albuterol sulfate
CHANGE TIER
Generics
04/15/2015
METROGEL
metronidazole
ADD TO FORMULARY
Non-Formulary
04/15/2015
onetouch ultra
test strips,one
touch ultra test
strips
blood sugar diagnostic
REMOVE UM:
AUTHORIZATION
04/15/2015
ultima
blood sugar diagnostic
REMOVE UM:
AUTHORIZATION
04/15/2015
ez smart
blood sugar diagnostic
REMOVE UM:
AUTHORIZATION
04/15/2015
ez smart plus
blood sugar diagnostic
REMOVE UM:
AUTHORIZATION
04/15/2015
nova max
glucose test
strips
blood sugar diagnostic
REMOVE UM: GENDER
04/15/2015
infinity test strips blood sugar diagnostic
REMOVE UM:
AUTHORIZATION
04/15/2015
prodigy no coding blood sugar diagnostic
REMOVE UM:
AUTHORIZATION
04/15/2015
clever choice pro blood sugar diagnostic
REMOVE UM: GENDER
PA applies
PA applies
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 614
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
doxycycline
doxycycline hyclate
hyclate,vibramyci
n,periostat,doryx,
oraxyl,morgidox,d
oxy 100,vibratabs,atridox,acticl
ate
ADD TO FORMULARY
Generics
04/15/2015
COLESTID
colestipol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
colestipol hcl
colestipol hcl
CHANGE TIER
Generics
04/15/2015
INCRELEX
mecasermin
CHANGE TIER
04/15/2015
LOPID
gemfibrozil
ADD TO FORMULARY
Non-Formulary
04/15/2015
HYZAAR
losartan
potassium/hydrochlorothiazi
de
ADD TO FORMULARY
Non-Formulary
04/15/2015
clomid,clomiphen clomiphene citrate
e
citrate,serophene
CHANGE UM: CUSTOM
Fertility rider may
be required
04/15/2015
TEV-TROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SEROSTIM
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SAIZEN
somatropin
CHANGE TIER
04/15/2015
HUMATROPE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SEROSTIM
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
HUMATROPE
somatropin
CHANGE TIER
04/15/2015
HUMATROPE
somatropin
CHANGE TIER
04/15/2015
DDAVP
desmopressin acetate
ADD TO FORMULARY
Non-Formulary
04/15/2015
DDAVP
desmopressin acetate
ADD TO FORMULARY
Non-Formulary
04/15/2015
DDAVP
desmopressin acetate
ADD TO FORMULARY
Non-Formulary
04/15/2015
DDAVP
desmopressin acetate (nonrefrigerated)
ADD TO FORMULARY
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 615
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
TRETIN-X
tretinoin/emollient
combination no. 9/skin cln1
CHANGE TIER
Non-Formulary
04/15/2015
TRETIN-X
tretinoin/emollient
combination no. 9/skin cln1
CHANGE TIER
Non-Formulary
04/15/2015
TRETIN-X
tretinoin/emollient
combination no. 9/skin cln1
CHANGE TIER
04/15/2015
tramadol hcl er
tramadol hcl
ADD TO FORMULARY
Generics
04/15/2015
ULTRAM ER
tramadol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
SEROQUEL
quetiapine fumarate
ADD TO FORMULARY
Non-Formulary
04/15/2015
VENTAVIS
iloprost
tromethamine,iloprost
CHANGE TIER
Non-Formulary
04/15/2015
SECTRAL
acebutolol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
SECTRAL
acebutolol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
XODOL 5-300
hydrocodone
bitartrate/acetaminophen,hy
drocodone
bit/acetaminophen
CHANGE TIER
Non-Formulary
04/15/2015
vicodin
hydrocodone
bitartrate/acetaminophen
04/15/2015
ADCIRCA
04/15/2015
Preferred Brands
Non-Formulary
ADD TO FORMULARY
Non-Formulary
Generics
tadalafil
CHANGE TIER
Preferred Brands
Non-Formulary
omeprazolesodium
bicarbonate
omeprazole/sodium
bicarbonate
CHANGE TIER
Generics
04/15/2015
ZEGERID
omeprazole/sodium
bicarbonate
ADD TO FORMULARY
Non-Formulary
04/15/2015
ZEGERID OTC
omeprazole/sodium
bicarbonate
CHANGE TIER
04/15/2015
ZEGERID
omeprazole/sodium
bicarbonate
ADD TO FORMULARY
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 616
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
DIVIGEL
estradiol
04/15/2015
IMITREX
sumatriptan succinate
ADD TO FORMULARY
Non-Formulary
04/15/2015
METADATE CD
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
METADATE CD
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
METADATE CD
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
DAYTRANA
methylphenidate
CHANGE TIER
Non-Formulary
04/15/2015
DAYTRANA
methylphenidate
CHANGE TIER
Non-Formulary
04/15/2015
DAYTRANA
methylphenidate
CHANGE TIER
Non-Formulary
04/15/2015
DAYTRANA
methylphenidate
CHANGE TIER
Non-Formulary
04/15/2015
zyvox,linezolid
linezolid
04/15/2015
primlev
oxycodone
hcl/acetaminophen
CHANGE TIER
Generics
04/15/2015
primlev
oxycodone
hcl/acetaminophen
CHANGE TIER
Generics
04/15/2015
DIOVAN HCT
valsartan/hydrochlorothiazid
e
ADD TO FORMULARY
Non-Formulary
04/15/2015
DIOVAN HCT
valsartan/hydrochlorothiazid
e
ADD TO FORMULARY
Non-Formulary
04/15/2015
ashlyna
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD TO FORMULARY
Preventative
04/15/2015
ashlyna
levonorgestrel/ethinyl
estradiol and ethinyl
estradiol
ADD UM: GENDER
Female
04/15/2015
doxycycline ir-dr
doxycycline monohydrate
ADD TO FORMULARY
Generics
04/15/2015
prenatal-u
prenatal vits without calc
no5/ferrous fumarate/folic
acid
CHANGE TIER
Generics
REMOVE UM:
AUTHORIZATION
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 617
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
pnv-vp-u
prenatal vits without calc
no5/ferrous fumarate/folic
acid
ADD TO FORMULARY
Generics
04/15/2015
pnv-vp-u
prenatal vits without calc
no5/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
04/15/2015
triveen-u
prenatal vits without calc
no5/ferrous fumarate/folic
acid
ADD TO FORMULARY
04/15/2015
OPANA
oxymorphone hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
OPANA
oxymorphone hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
xolox
oxycodone
hcl/acetaminophen
ADD TO FORMULARY
Generics
04/15/2015
oxymorphone hcl oxymorphone hcl
er
CHANGE TIER
Generics
04/15/2015
oxymorphone hcl oxymorphone hcl
er
CHANGE TIER
Generics
04/15/2015
oxymorphone hcl oxymorphone hcl
er
CHANGE TIER
Generics
04/15/2015
oxymorphone hcl oxymorphone hcl
er
CHANGE TIER
Generics
04/15/2015
INVEGA
SUSTENNA
paliperidone palmitate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
INVEGA
SUSTENNA
paliperidone palmitate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
INVEGA
SUSTENNA
paliperidone palmitate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
INVEGA
SUSTENNA
paliperidone palmitate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
INVEGA
SUSTENNA
paliperidone palmitate
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 618
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Non-Formulary
04/15/2015
latrix xm
urea/lactic acid/zinc
undecylenate
CHANGE TIER
04/15/2015
ZIOPTAN
tafluprost/pf
CHANGE TIER
04/15/2015
TERBINEX
terbinafine hcl/hydroxypropyl
chitosan
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
folivane-prx dha
nf
prenatal vit with calcium
no.39/iron fum/folic
acid/dss/dha
CHANGE TIER
Preferred Brands
Generics
04/15/2015
ISOSOURCE 1.5 lactose-reduced food/fiber
CAL TUBE FEED
ADD TO FORMULARY
Non-Formulary
Generics
04/15/2015
ISOSOURCE 1.5 lactose-reduced food/fiber
CAL TUBE FEED
ADD TO FORMULARY
Non-Formulary
Generics
04/15/2015
isosource 1.5 cal lactose-reduced food/fiber
ADD TO FORMULARY
Non-Formulary
Not Covered
04/15/2015
ISOSOURCE 1.5 lactose-reduced food/fiber
CAL
ADD TO FORMULARY
Non-Formulary
Not Covered
04/15/2015
JEVITY 1.2 CAL lactose-reduced food/fiber
ADD TO FORMULARY
Non-Formulary
Not Covered
04/15/2015
KALBITOR
ecallantide
REMOVE UM:
AUTHORIZATION
PA applies
04/15/2015
natalvirt 90 dha
prenatal vit,calcium #64/iron
carb,gluc/folic acid/dss/dha
CHANGE TIER
Generics
04/15/2015
prenaissance 90 prenatal vit,calcium #64/iron
dha
carb,gluc/folic acid/dss/dha
CHANGE TIER
Generics
04/15/2015
taron-bc
prenatal vit with calcium
comb
no.63/iron,carbonyl/fa/b6
CHANGE TIER
Preferred Brands
Generics
04/15/2015
dallergy
chlorpheniramine
maleate/phenylephrine hcl
CHANGE TIER
Preferred Brands
Generics
04/15/2015
SALVAX DUO
PLUS
salicylic acid/urea
CHANGE TIER
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 619
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
CHANGE TIER
Preferred Brands
Generics
04/15/2015
vazobid-pd
brompheniramine
maleate/phenylephrine hcl
04/15/2015
ss 10-2
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Generics
04/15/2015
AVAR-E
LS,AVAR-E LS
CREAM
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Non-Formulary
04/15/2015
sodium
sulfacetamidesulfur
sulfacetamide sodium/sulfur
CHANGE TIER
Generics
04/15/2015
GILTUSS TR
guaifenesin/dextromethorph
an hbr/phenylephrine
ADD TO FORMULARY
Non-Formulary
Not Covered
04/15/2015
PROMACTA
eltrombopag olamine
CHANGE TIER
Preferred Brands
Not Covered
04/15/2015
paire ob plus dha prenatal vitamin no.8/iron ps
complex,asp gl/folic
acid/dha
CHANGE TIER
Preferred Brands
Generics
04/15/2015
sirolimus
sirolimus
CHANGE TIER
04/15/2015
COMFORT PAC- tizanidine hcl/irritants
TIZANIDINE
counter-irritants combination
no.2
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
mexiletine hcl
mexiletine hcl
CHANGE TIER
Preferred Brands
Not Covered
04/15/2015
tranexamic acid
tranexamic acid
CHANGE TIER
Generics
04/15/2015
CLEOCIN
clindamycin phosphate
CHANGE TIER
Non-Formulary
04/15/2015
fioricet
butalbital/acetaminophen/caf
feine
CHANGE TIER
04/15/2015
gatifloxacin
gatifloxacin
CHANGE TIER
Generics
04/15/2015
ZYMAXID
gatifloxacin
ADD TO FORMULARY
Non-Formulary
04/15/2015
tl-care dha
pnv no.20/iron
fumarate/fa/docusate na/fish
oil conc/dha/epa
ADD TO FORMULARY
Generics
Preferred Brands
Non-Formulary
Generics
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 620
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
FOVEX
omega-3 fatty
acids/docosahexanoic
acid/epa/lutein/zeaxanth
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
VIMPAT
lacosamide
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
prenaplus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
CHANGE TIER
04/15/2015
vol-plus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
ADD TO FORMULARY
04/15/2015
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
CHANGE TIER
Generics
04/15/2015
prenatal vitamin
plus low iron
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
CHANGE TIER
Generics
04/15/2015
preplus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
CHANGE TIER
Generics
04/15/2015
VIVELLE-DOT
estradiol
CHANGE TIER
Non-Formulary
04/15/2015
VIVELLE-DOT
estradiol
CHANGE TIER
04/15/2015
CLIMARA
estradiol
CHANGE TIER
Non-Formulary
04/15/2015
CLIMARA
estradiol
CHANGE TIER
Non-Formulary
04/15/2015
CLIMARA
estradiol
CHANGE TIER
Non-Formulary
04/15/2015
CLIMARA
estradiol
CHANGE TIER
04/15/2015
millipred dp
prednisolone
CHANGE TIER
Generics
04/15/2015
millipred dp
prednisolone
CHANGE TIER
Generics
04/15/2015
vol-nate
prenatal vits with calcium
#73/ferrous fumarate/folic
acid
ADD TO FORMULARY
Generics
Non-Formulary
Generics
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 621
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
04/15/2015
PRENATABS FA prenatal vits with calcium
#78/ferrous fumarate/folic
acid
04/15/2015
venatal-fa
04/15/2015
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Non-Formulary
prenatal vits with calcium
#78/ferrous fumarate/folic
acid
CHANGE TIER
Generics
DALIRESP
roflumilast
CHANGE TIER
04/15/2015
URAMAXIN GT
urea
ADD TO FORMULARY
Non-Formulary
04/15/2015
cem-urea
urea
CHANGE TIER
Generics
04/15/2015
COMFORT PAC- meloxicam/irritants counterMELOXICAM
irritants combination no.2
04/15/2015
PREFERA OB
prenatal vit no.21/iron
polysacch,heme
polypep/folic acid
ADD TO FORMULARY
04/15/2015
hemenatal ob
prenatal vit no.21/iron
polysacch,heme
polypep/folic acid
ADD TO FORMULARY
04/15/2015
vp-heme ob
prenatal vit no.21/iron
polysacch,heme
polypep/folic acid
CHANGE TIER
Generics
04/15/2015
vinate dha
prenatal vitamin comb
no.79/iron
fumarat/fa/lmefolate ca/dha
CHANGE TIER
Generics
04/15/2015
SUMAXIN TS
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Non-Formulary
04/15/2015
vena-bal dha
prenatal vit
no.81/sod.feredetate-iron
ps/folic acid/omega-3
CHANGE TIER
Generics
04/15/2015
bal-care dha
prenatal vit
no.81/sod.feredetate-iron
ps/folic acid/omega-3
CHANGE TIER
Generics
04/15/2015
DIFFERIN
adapalene
ADD TO FORMULARY
Non-Formulary
CHANGE TIER
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 622
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
DIFFERIN
adapalene
ADD TO FORMULARY
Non-Formulary
04/15/2015
tl-select
prenatal vit with calcium
no.80/iron fum/folic
acid/dss/dha
ADD TO FORMULARY
04/15/2015
prenaissance
prenatal vit with calcium
no.80/iron fum/folic
acid/dss/dha
CHANGE TIER
Generics
04/15/2015
virt-select
prenatal vit with calcium
no.80/iron fum/folic
acid/dss/dha
CHANGE TIER
Generics
04/15/2015
NESTABS DHA
prenatal vitamins comb
no.87/iron bisgly/folic
acid/dha
ADD TO FORMULARY
Non-Formulary
04/15/2015
tri-tabs dha
prenatal vitamins comb
no.87/iron bisgly/folic
acid/dha
CHANGE TIER
Generics
04/15/2015
hpr plus-mb
hydrogel
emol53/e.water/namgfs/nap
hos/nacl/hypochlorous
acid/nahypocl
CHANGE TIER
Preferred Brands
Generics
04/15/2015
ANALPRAM
ADVANCED
hydrocort ac/pramox
hcl/diosmin#1/aloe
polysacch#1/policos
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
NEPHROCAPS
QT
vitamin b complex with
vitamin c no.13/folic
acid/vitamin d3,vitamin b
complex & vitamin c
no.13/folic acid/vitamin d3
CHANGE TIER
04/15/2015
cyclopentolate
hcl
cyclopentolate hcl
CHANGE TIER
Preferred Brands
Not Covered
04/15/2015
hydrogel
gel base no.41
CHANGE TIER
Preferred Brands
Not Covered
04/15/2015
racepinephrine
hcl
racepinephrine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
Generics
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 623
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
CLINDACIN ETZ clindamycin phosphate/skin
cleanser comb no.19
04/15/2015
VIRASAL
salicylic acid
04/15/2015
LAYOLIS FE
norethindrone-ethinyl
estradiol/ferrous fumarate
04/15/2015
LAMICTAL XR
lamotrigine
04/15/2015
SYLATRON
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SYLATRON 4PACK
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SYLATRON
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SYLATRON 4PACK
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SYLATRON,SYL peginterferon alfa-2b
ATRON 4-PACK
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
VAYACOG
phosphatidyl serine/omega3 fatty acids/dha/epa
CHANGE TIER
Not Covered
Non-Formulary
04/15/2015
VAYARIN
phosphatidyl serine/omega3 fatty acids/dha/epa
CHANGE TIER
Not Covered
Non-Formulary
04/15/2015
CICLODAN
ciclopirox/urea/camphor/me
nthol/eucalyptol
ADD TO FORMULARY
04/15/2015
NATAFORT
prenatal vitamin no.27/iron
carbonyl and fumarate/folic
acid
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
ZYPRAM
hydrocortisone
acetate/pramoxine hcl/skin
cleanser no.16
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
z-pram
hydrocortisone
acetate/pramoxine hcl/skin
cleanser no.16
ADD TO FORMULARY
Non-Formulary
Generics
ADD TO FORMULARY
CHANGE TIER
Non-Formulary
Preventative
Non-Formulary
ADD TO FORMULARY
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 624
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PROCORT
hydrocortisone
acetate/pramoxine hcl
04/15/2015
SUMADAN
sulfacetamide sodium/sulfur
04/15/2015
PUREFE PLUS
prenatal vitamins
no.4/ferrous fumarate/folic
acid
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PUREFE OB
PLUS
prenatal vits #4/iron
fumarate, polysacc
complex/folic acid
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
CONZIP
tramadol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
CONZIP
tramadol hcl
CHANGE TIER
04/15/2015
CONZIP
tramadol hcl
CHANGE TIER
04/15/2015
PROSCAR
finasteride
04/15/2015
DUEXIS
ibuprofen/famotidine
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
UDAMIN
multivitamin-minerals
no.28/folic acid/lycopene
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
UDAMIN SP
multivitamin-minerals
no.9/folic acid/saw palmetto
extract,multivitamins with
min no.9/folic acid/saw
palmetto extract
CHANGE TIER
04/15/2015
SELECT-OB +
DHA
prenatal vitamins combo
no.33/iron ps cmplx/folic
acid/dha
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
M-END MAX D
dexbrompheniramine
maleate/pseudoephedrine
hcl/codeine phos
CHANGE TIER
Preferred Brands
Not Covered
04/15/2015
FLUOROPLEX
fluorouracil
CHANGE TIER
04/15/2015
VIRT-BAL DHA
prenatal vit #94/sodium
feredetate-iron ps/folic
acid/omega3
CHANGE TIER
ADD TO FORMULARY
Non-Formulary
Non-Formulary
Preferred Brands
ADD TO FORMULARY
Non-Formulary
Non-Formulary
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 625
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
VIRT-BAL DHA
PLUS
prenatal vit #94/sodium
feredetate-iron ps/folic
acid/omega3
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
POLY-VI-FLOR
pediatric multivitamin no.33
with sodium fluoride
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
POLY-VI-FLOR
pediatric multivitamin no.33
with sodium fluoride
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
POLY-VI-FLOR
pediatric multivitamin no.33
with sodium fluoride
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
sodium
sulfacetamidesulfur
sulfacetamide
sodium/sulfur/urea
ADD TO FORMULARY
Generics
04/15/2015
SUMADAN
sulfacetamide
sodium/sulfur/skin cleanser
comb no.23
ADD TO FORMULARY
Non-Formulary
04/15/2015
STATUSS
GREEN
chlorcyclizine
hcl/pseudoephedrine
hcl/codeine phosphate
04/15/2015
FIRSTOMEPRAZOLE
omeprazole
04/15/2015
PEDIPIROX-4
ciclopirox/nail lacquer
remover, non-acet/foot
deodorant#4
04/15/2015
FIRSTlansoprazole
LANSOPRAZOL
E
04/15/2015
DUTOPROL
04/15/2015
DUTOPROL
REMOVE FROM
FORMULARY
Preferred Brands
ADD TO FORMULARY
CHANGE TIER
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
CHANGE UM:
AUTHORIZATION
PA applies
metoprolol
succinate/hydrochlorothiazid
e
CHANGE TIER
Non-Formulary
metoprolol
succinate/hydrochlorothiazid
e
CHANGE TIER
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 626
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PROMACTA
eltrombopag olamine
04/15/2015
ULTRAVATE
halobetasol propionate
ADD TO FORMULARY
Non-Formulary
04/15/2015
mb hydrogel
emol53/e.water/namgfs/nap
hos/nacl/hypochlorous
acid/nahypocl
ADD TO FORMULARY
Generics
04/15/2015
ULTRAVATE
halobetasol propionate
ADD TO FORMULARY
Non-Formulary
04/15/2015
OXECTA
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
04/15/2015
ZITHRANOL
anthralin micronized
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SUPRENZA ODT phentermine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SUPRENZA ODT phentermine hcl
REMOVE UM:
AUTHORIZATION
PA applies
04/15/2015
SUPRENZA ODT phentermine hcl
CHANGE TIER
Preferred Brands
04/15/2015
SUPRENZA ODT phentermine hcl
REMOVE UM:
AUTHORIZATION
PA applies
04/15/2015
prena1 plus
prenatal vitamins #39/iron
amino acid chelate/fa
combo#6/dha
ADD TO FORMULARY
Non-Formulary
Generics
04/15/2015
AFINITOR
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
MITOSOL
mitomycin
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
ZYCLARA
imiquimod
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
ZOVIRAX
acyclovir
CHANGE TIER
04/15/2015
POLY-VI-FLOR
pediatric multivitamin no.37
with sodium fluoride
CHANGE TIER
04/15/2015
MOBIC
meloxicam
ADD TO FORMULARY
Non-Formulary
04/15/2015
MOBIC
meloxicam
ADD TO FORMULARY
Non-Formulary
04/15/2015
RETIN-A MICRO tretinoin microspheres
PUMP
ADD TO FORMULARY
Non-Formulary
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 627
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
04/15/2015
RETIN-A MICRO tretinoin microspheres
PUMP
04/15/2015
VASCULERA
04/15/2015
diosmin complex no.1
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Non-Formulary
CHANGE TIER
Not Covered
Non-Formulary
BAL-CARE DHA prenatal vit 100/iron sod
ESSENTIAL
edta,ps complex/folic
acid/omega-3
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
FABIOR
tazarotene
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
MAVIK
trandolapril
ADD TO FORMULARY
Non-Formulary
04/15/2015
MAVIK
trandolapril
ADD TO FORMULARY
Non-Formulary
04/15/2015
CITRANATAL B- prenatal vitamin
CALM
no.48/iron,carbonyl,gluconat
e/folic acid/b6
ADD TO FORMULARY
Non-Formulary
04/15/2015
CESINEX
albumen (egg white)/tannic
acid
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
QSYMIA
phentermine hcl/topiramate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
QSYMIA
phentermine hcl/topiramate
REMOVE UM:
AUTHORIZATION
PA applies
04/15/2015
NIRON
KOMPLETE
ferrous fumarate/iron
bisgly/folic acid/vit c/vit e/vit
b12
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
QSYMIA
phentermine hcl/topiramate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
QSYMIA
phentermine hcl/topiramate
REMOVE UM:
AUTHORIZATION
PA applies
04/15/2015
QSYMIA
phentermine hcl/topiramate
CHANGE TIER
Preferred Brands
04/15/2015
QSYMIA
phentermine hcl/topiramate
REMOVE UM:
AUTHORIZATION
PA applies
04/15/2015
QSYMIA
phentermine hcl/topiramate
CHANGE TIER
Preferred Brands
04/15/2015
QSYMIA
phentermine hcl/topiramate
REMOVE UM:
AUTHORIZATION
PA applies
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 628
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
VP-PNV-DHA
prenatal vitamins combo
no.52/ferrous
fumarate/fa/dha
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
TUDORZA
PRESSAIR
aclidinium bromide
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
RAYOS
prednisone
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
RAYOS
prednisone
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
RAYOS
prednisone
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SUPRAX
cefixime
CHANGE TIER
04/15/2015
SUPRAX
cefixime
CHANGE TIER
04/15/2015
SUPRAX
cefixime
CHANGE TIER
04/15/2015
KADIAN
morphine sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
KADIAN
morphine sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
KADIAN
morphine sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
KADIAN
morphine sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
XTANDI
enzalutamide
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
EXELON
rivastigmine
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
VASCEPA
icosapent ethyl
CHANGE TIER
Not Covered
Non-Formulary
04/15/2015
FML
fluorometholone
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
EPISIL
oral mucositis and stomatitis
anti-inflammatory agent
comb 2
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
TRUSOPT
dorzolamide hcl
04/15/2015
SUPRAX
cefixime
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
SUPRAX
cefixime
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
XELJANZ
tofacitinib citrate
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 629
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
TL-SELECT DHA prenatal vitamin no.57/iron
fum/folic acid/dss/dha
ADD TO FORMULARY
Non-Formulary
04/15/2015
prenatal plus
prenatal vits with calcium
#72/iron,carbonyl/folic acid
CHANGE TIER
Generics
04/15/2015
ADASUVE
loxapine
CHANGE TIER
04/15/2015
ZYPREXA ZYDIS olanzapine
ADD TO FORMULARY
Non-Formulary
04/15/2015
ZYPREXA ZYDIS olanzapine
ADD TO FORMULARY
Non-Formulary
04/15/2015
nateglinide
nateglinide
CHANGE TIER
Generics
04/15/2015
STARLIX
nateglinide
ADD TO FORMULARY
Non-Formulary
04/15/2015
POMALYST
pomalidomide
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
POMALYST
pomalidomide
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
FOLTX
cyanocobalamin/levomefolat
e calcium/pyridoxine hcl
ADD TO FORMULARY
04/15/2015
pnv folic acid +
iron
prenatal vitamins combo
no.60/ferrous fumarate/folic
acid
CHANGE TIER
04/15/2015
LIDORX
lidocaine hcl
04/15/2015
KARBINAL ER
carbinoxamine maleate
04/15/2015
PRESERA
emollient combination no.80
04/15/2015
EPIFIX
AMNIOTIC
MEMBRANE
04/15/2015
04/15/2015
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
ADD TO FORMULARY
Generics
Non-Formulary
CHANGE TIER
Preferred Brands
Non-Formulary
REMOVE UM: GENDER
Female
human regenerative tissue
matrix
CHANGE TIER
Preferred Brands
Non-Formulary
EPIFIX
AMNIOTIC
MEMBRANE
human regenerative tissue
matrix
CHANGE TIER
Preferred Brands
Non-Formulary
SIMBRINZA
brinzolamide/brimonidine
tartrate
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 630
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
ADD TO FORMULARY
Previous Value
New Value
04/15/2015
CEREFOLIN
NAC
levomefolate
ca/acetylcysteine/mecobala
min/schiz. algal oil
Non-Formulary
04/15/2015
DORYX
doxycycline hyclate
CHANGE TIER
Generics
Non-Formulary
04/15/2015
PODIAPN
pyridoxal
phos/methyltetrahydrofolate
gluc/mecobalamin/ala
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
FOSTEUM PLUS calcium comb
no.19/phosphate/genistein/d
3/citrated zinc/k2
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
DIAMOX
SEQUELS
acetazolamide
ADD TO FORMULARY
04/15/2015
BELVIQ
lorcaserin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PROVIDA OB
prenatal vits no.65/iron
fumarate,polysac
complex/folic acid
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
ACTIVE OB
prenatal vitamins combo
no.66/iron,carbonyl/folic
acid/dha
ADD TO FORMULARY
Non-Formulary
04/15/2015
MICROZIDE
hydrochlorothiazide
ADD TO FORMULARY
Non-Formulary
04/15/2015
prenatal 19
prenatal vitamins comb
no.119/iron fumarate/folic
acid/dss,prenatal vitamins
comb no.115/iron
fumarate/folic acid/dss
ADD TO FORMULARY
Generics
04/15/2015
prenatal 19
prenatal vits with
calcium#118/ferrous
fumarate/folic acid,prenatal
vitamins comb no.115/iron
fumarate/folic acid
CHANGE TIER
Generics
04/15/2015
MONSEL'S
ferric subsulfate
CHANGE TIER
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 631
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
hydrocodonehydrocodone
chlorpheniramne polistirex/chlorpheniramine
er
polistirex
CHANGE TIER
Generics
04/15/2015
cyclophene
cyclobenzaprine hcl
CHANGE TIER
04/15/2015
ZAROXOLYN
metolazone
ADD TO FORMULARY
Non-Formulary
04/15/2015
ZAROXOLYN
metolazone
ADD TO FORMULARY
Non-Formulary
04/15/2015
GENADUR
biotin/carbitol/equisetum
xt/ethanol/hydroxypropyl
chito/msm
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
HIZENTRA
immune globulin,gamma
(igg)/proline/iga 0 to 50
mcg/ml
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PRO-RED AC
dexchlorpheniramine
maleate/phenylephrine
hcl/codeine
CHANGE TIER
Preferred Brands
Not Covered
04/15/2015
PRO-RED AC
dexchlorpheniramine
maleate/phenylephrine
hcl/codeine
REMOVE UM:
AUTHORIZATION
PA applies
04/15/2015
VALCHLOR
mechlorethamine hcl
CHANGE TIER
Preferred Brands
04/15/2015
OTREXUP
methotrexate/pf
04/15/2015
PRILOSEC
04/15/2015
04/15/2015
Preferred Brands
Non-Formulary
Non-Formulary
CHANGE UM:
AUTHORIZATION
PA applies
omeprazole
ADD TO FORMULARY
Non-Formulary
metoclopramide
hcl odt
metoclopramide hcl
ADD TO FORMULARY
Generics
HALFLYTELYBISACODYL
bisacodyl/sodium
chlor/sodium
bicarb/potassium chl/peg
3350
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 632
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
peg-prep
bisacodyl/sodium
chlor/sodium
bicarb/potassium chl/peg
3350
ADD TO FORMULARY
Generics
04/15/2015
JADENU
deferasirox
ADD TO FORMULARY
Preferred Brands
04/15/2015
JADENU
deferasirox
ADD UM: SPECIALTY
Specialty Drug
04/15/2015
JADENU
deferasirox
ADD UM: AUTHORIZATION
PA applies
04/15/2015
JADENU
deferasirox
ADD TO FORMULARY
Preferred Brands
04/15/2015
JADENU
deferasirox
ADD UM: SPECIALTY
Specialty Drug
04/15/2015
JADENU
deferasirox
ADD UM: AUTHORIZATION
PA applies
04/15/2015
EXJADE,JADEN deferasirox
U
CHANGE TIER
Preferred Brands
04/15/2015
EXJADE,JADEN deferasirox
U
CHANGE UM: SPECIALTY
Specialty Drug
04/15/2015
EXJADE,JADEN deferasirox
U
ADD UM: AUTHORIZATION
PA applies
04/15/2015
PROAIR
RESPICLICK
albuterol sulfate
ADD TO FORMULARY
Non-Formulary
04/15/2015
SAXENDA
liraglutide
ADD TO FORMULARY
Non-Formulary
04/15/2015
PHENYLADE
GMP
nut. tx for pku with iron #57
ADD TO FORMULARY
Non-Formulary
04/15/2015
sodium
sulfacetamidesulfur
sulfacetamide
sodium/sulfur/avobenzone/o
ctinoxate/octyl sal
ADD TO FORMULARY
Generics
04/15/2015
ketone,ketostix
urine acetone test,strips
reagent,diascree
n 1k
reagent,ketone
care,chemstrip
k,ketocare
CHANGE TIER
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 633
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
04/15/2015
ketone care
urine acetone test,strips
04/15/2015
levofloxacin
levofloxacin
04/15/2015
04/15/2015
Type of Change
Previous Value
New Value
REMOVE UM: GENDER
CHANGE TIER
Non-Formulary
diascreen
urine multiple test
2gp,diascreen
strips,urine multiple test
4ph,diascreen 1b
reagent,diascree
n 4nl
reagent,chekstix,multistix 10
sg,multistix
9,multistix 9
sg,multistix 8
sg,multistix
7,uristix
4,multistix,labstix
reagent,hemacombistix,combist
ix reagent,uristix
reagent,multistix
5,chemstrip
9,chemstrip 10
with sg,chemstrip
7,chemstrip
50b,chemstrip 2
gp,chemstrip
CHANGE TIER
Non-Formulary
keto-diastix
urine glucose-acet test
reagent,diascree strip,urine gluc-acet
n 10,diascreen 3 comb.tst,strip
reagent,diascree
n 5,diascreen
6,diascreen
7,diascreen
8,diascreen
9,diascreen 2gk
reagent,diascree
n 4obl,chemstrip
ugk
CHANGE TIER
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 634
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
LUZU
luliconazole
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
TL-ICARE
multivitamin-minerals
no.43/lutein/omega3/dha/epa
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PROTHELIAL
sucralfate malate,
polymerized
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PROTHELIAL
sucralfate malate,
polymerized
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PROTHELIAL
sucralfate malate,
polymerized
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
prothelial
sucralfate malate,
polymerized
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
GRASTEK
allergenic extract,grass
pollen-timothy,standard
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
GRASTEK
allergenic extract,grass
pollen-timothy,standard
ADD UM: SPECIALTY
04/15/2015
ORENITRAM ER treprostinil diolamine
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
ORENITRAM ER treprostinil diolamine
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
ORENITRAM ER treprostinil diolamine
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
ORENITRAM ER treprostinil diolamine
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PRODRIN
isometheptene
mucate/caffeine/acetaminop
hen
04/15/2015
ULTRASAL-ER
salicylic acid
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
VELPHORO
sucroferric oxyhydroxide
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
GLYTACTIN RTD nutritional therapy for pku
10 PE
with iron no.41
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
HETLIOZ
CHANGE TIER
Preferred Brands
Non-Formulary
tasimelteon
Specialty Drug
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 635
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
RHEUMATE
methyltetrahydrofolate
gluc/mecobalamin/herbal
no.236
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
NICADAN
niacinamide/vit b6/vit
c/fa/copper/mg cit/zn
gluc/alip acid
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
VINATE DHA RF prenatal no.64/iron fum/lmefolate ca/algal oil/soy
lecithin
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PROSOURCE TF amino acids/protein
hydrolysate/whey protein
isolate
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
AVEED
REMOVE UM:
AUTHORIZATION
PA applies
04/15/2015
GLYTACTIN RTD nutritional therapy for pku
15 PE
with iron no.41
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
DERMANIC
niacin no.1/fa/b12/iron/acyst zn/chrom poly/inos
niac/a-cys
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
GLUTASOLVE
glutamine
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
NEOCATE
SPLASH
nutritional therapy for
impaired digestive function
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
XARTEMIS XR
oxycodone
hcl/acetaminophen
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PLEXION
sulfacetamide sodium/sulfur
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
sodium
sulfacetamidesulfur
sulfacetamide sodium/sulfur
ADD TO FORMULARY
04/15/2015
PLEXION
sulfacetamide sodium/sulfur
CHANGE TIER
testosterone undecanoate
Generics
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 636
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
sodium
sulfacetamidesulfur
sulfacetamide sodium/sulfur
ADD TO FORMULARY
Generics
04/15/2015
PLEXION
sulfacetamide sodium/sulfur
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
PLEXION
sulfacetamide sodium/sulfur
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
sodium
sulfacetamidesulfur
sulfacetamide sodium/sulfur
ADD TO FORMULARY
04/15/2015
VP CH ULTRA
prenatal vit no.34/iron
carb,fum/folic
acid/docusate/dha
04/15/2015
BYDUREON
PEN
04/15/2015
Generics
CHANGE TIER
Preferred Brands
Non-Formulary
exenatide microspheres
ADD TO FORMULARY
Non-Formulary
Preferred Brands
BYDUREON
exenatide microspheres
ADD TO FORMULARY
Non-Formulary
Preferred Brands
04/15/2015
RAGWITEK
allergenic extract-weed
pollen-short ragweed
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
endoform
extracellular matrix (ecm),
ovine derived fenestrated
CHANGE TIER
Preferred Brands
Generics
04/15/2015
endoform
extracellular matrix (ecm),
ovine derived fenestrated
CHANGE TIER
Preferred Brands
Generics
04/15/2015
endoform
extracellular matrix (ecm),
ovine derived
CHANGE TIER
Preferred Brands
Generics
04/15/2015
endoform
extracellular matrix (ecm),
ovine derived
CHANGE TIER
Preferred Brands
Generics
04/15/2015
ZYKADIA
ceritinib
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
VITAMEDMD
REDICHEW RX
prenatal vitamins
combination no.42/folic acid
04/15/2015
VITAFOL NANO prenatal vitamins comb
no.75/ferrous
fumarate/folate comb #1
ADD TO FORMULARY
Non-Formulary
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 637
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
TOPAMAX
topiramate
ADD TO FORMULARY
Non-Formulary
04/15/2015
TOPAMAX
topiramate
ADD TO FORMULARY
Non-Formulary
04/15/2015
TOPAMAX
topiramate
ADD TO FORMULARY
Non-Formulary
04/15/2015
TOPAMAX
topiramate
ADD TO FORMULARY
Non-Formulary
04/15/2015
THERAMINE
PLUS
choline bitartrate/aa
no.10/gaba/herb
#129/protein/soy lecit
ADD TO FORMULARY
Non-Formulary
04/15/2015
FOLET ONE
prenatal vit no.80/iron
carb,bisgl/methylfolate
gluc/dss/dha
ADD UM: GENDER
Female
04/15/2015
INVOKAMET
canagliflozin/metformin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
04/15/2015
ACTICLATE
doxycycline hyclate
CHANGE TIER
Generics
Non-Formulary
04/15/2015
ACTICLATE
doxycycline hyclate
CHANGE TIER
Generics
Non-Formulary
04/15/2015
CAMINO PRO 15 nutritional therapy for msud
PE MSUD
with iron
04/15/2015
CONTRAVE
naltrexone hcl/bupropion hcl
04/15/2015
OXYCONTIN
04/15/2015
ADD TO FORMULARY
Non-Formulary
REMOVE UM:
AUTHORIZATION
PA applies
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
OXYCONTIN
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
04/15/2015
OXYCONTIN
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
04/15/2015
OXYCONTIN
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
04/15/2015
PROAIR
RESPICLICK
albuterol sulfate
ADD TO FORMULARY
Non-Formulary
Preferred Brands
04/15/2015
prednicarbate
prednicarbate
CHANGE TIER
Generics
04/15/2015
prednicarbate
prednicarbate
CHANGE TIER
Generics
04/15/2015
colchicine
colchicine
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 638
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
ALEVICYN
hypochlorous acid/sod
chlor/sod sulfate/sod
phosphate,mono
ADD TO FORMULARY
Non-Formulary
04/15/2015
FOLET DHA
prenatal vit no.86/iron
carb,bisgl/methylfolate
gluc/dss/dha
ADD UM: GENDER
Female
04/15/2015
EMBEDA
morphine sulfate/naltrexone
hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
IBRANCE
palbociclib
CHANGE TIER
04/15/2015
FELBATOL
felbamate
ADD TO FORMULARY
04/15/2015
felbamate
felbamate
ADD TO FORMULARY
04/15/2015
HYDREA
hydroxyurea
ADD TO FORMULARY
Non-Formulary
04/15/2015
LEVATOL
penbutolol sulfate
CHANGE TIER
Preferred Brands
04/15/2015
BETAPACE AF
sotalol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
BETAPACE
sotalol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
BETAPACE
sotalol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
BETAPACE AF
sotalol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
BETAPACE
sotalol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
BETAPACE AF
sotalol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
BETAPACE
sotalol hcl
ADD TO FORMULARY
Non-Formulary
04/15/2015
MEGACE
megestrol acetate
ADD TO FORMULARY
Non-Formulary
04/15/2015
dynacin
minocycline hcl
ADD TO FORMULARY
Generics
04/15/2015
dynacin
minocycline hcl
ADD TO FORMULARY
Generics
04/15/2015
MONODOX
doxycycline monohydrate
ADD TO FORMULARY
Non-Formulary
04/15/2015
MONODOX
doxycycline monohydrate
ADD TO FORMULARY
Non-Formulary
04/15/2015
ANCOBON
flucytosine
ADD TO FORMULARY
Non-Formulary
04/15/2015
ANCOBON
flucytosine
ADD TO FORMULARY
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 639
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/15/2015
METROLOTION metronidazole
ADD TO FORMULARY
Non-Formulary
04/15/2015
METROCREAM
metronidazole
ADD TO FORMULARY
Non-Formulary
04/15/2015
VOLTAREN
diclofenac sodium
CHANGE TIER
Non-Formulary
04/15/2015
ELOCON
mometasone furoate
ADD TO FORMULARY
Non-Formulary
04/15/2015
ELOCON
mometasone furoate
ADD TO FORMULARY
Non-Formulary
04/15/2015
ropivacaine hcl
ropivacaine hcl/pf
CHANGE TIER
Generics
04/15/2015
PRISTIQ ER
desvenlafaxine succinate
ADD TO FORMULARY
Preferred Brands
04/16/2015
SAXENDA
liraglutide
ADD UM: CUSTOM
Benefit Rider
May Be Required
04/16/2016
active injection kit dexamethasone sodium
d
phosphate/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
b-12 kit
cyanocobalamin (vitamin b12)
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
hydrocortisone
hydrocortisone
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
hydrocortisone
hydrocortisone
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
hydrocortisone
hydrocortisone
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
hydrocortisone
hydrocortisone
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
hydrocortisone
hydrocortisone
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
ulticare pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
04/16/2016
ulticare pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
04/16/2016
ulticare pen
needle
pen needle, diabetic
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 640
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/16/2016
ulticare insulin
syringe
syringe with needle,insulin
0.3 ml (half unit mark)
ADD TO FORMULARY
Generics
04/16/2016
push button
safety lancets
lancets
ADD TO FORMULARY
Generics
04/16/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Generics
04/16/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Generics
04/16/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Generics
04/16/2016
pen needle
pen needle, diabetic
ADD TO FORMULARY
Generics
04/16/2016
ORAL RELIEF
LOZENGES
saliva stimulant combination
no.6
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
NEOKE ALCAR
acetylcarnitine
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
antifungal nail
pen
undecylenic acid
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
medicated foot
menthol
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
daytime-nighttime dextromethorphan
cold-flu
hbr/phenylephrine/acetamin
ophen/doxylamine
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
daytime severe
cold-flu
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
smooth
calcium carbonate
dissolving antacid
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
fiber therapy
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
smooth
calcium carbonate
dissolving antacid
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
hair regrowth
treatment
REMOVE FROM
FORMULARY
Non-Formulary
phenylephrine
hcl/dextromethorphan
hbr/acetaminophen/guaifen
calcium polycarbophil
minoxidil
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 641
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/16/2016
fast mucus rlf
congest-cough
guaifenesin/dextromethorph
an hbr/phenylephrine
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
biotin
biotin
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever pm
acetaminophen/diphenhydra
mine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever pm
acetaminophen/diphenhydra
mine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
naproxen sodium naproxen sodium
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
naproxen sodium naproxen sodium
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
cold-allergy
chlorpheniramine
maleate/phenylephrine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
mucus relief pe
guaifenesin/phenylephrine
hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
sinus-allergy
chlorpheniramine
maleate/phenylephrine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
daytime cold-flu
relief plus
dextromethorphan
hbr/phenylephrine
hcl/acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 642
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/16/2016
cold-flu relief plus dextromethorphan
day-night
hbr/phenylephrine/acetamin
ophen/doxylamine
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
laxative peg 3350 polyethylene glycol 3350
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
laxative peg 3350 polyethylene glycol 3350
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
airshield
multivit-min/vit c/ascorb
na/glutamine/lysin hcl/herb
no.124
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
mucus relief d
guaifenesin/pseudoephedrin
e hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
mucus relief d
guaifenesin/pseudoephedrin
e hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever pm
acetaminophen/diphenhydra
mine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever pm
acetaminophen/diphenhydra
mine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
naproxen sodium naproxen sodium
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
naproxen sodium naproxen sodium
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
cold-allergy
REMOVE FROM
FORMULARY
Non-Formulary
chlorpheniramine
maleate/phenylephrine hcl
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 643
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/16/2016
mucus relief pe
guaifenesin/phenylephrine
hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
sinus-allergy
chlorpheniramine
maleate/phenylephrine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
pain reliever
acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
daytime cold-flu
relief plus
dextromethorphan
hbr/phenylephrine
hcl/acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
cold-flu relief plus dextromethorphan
day-night
hbr/phenylephrine/acetamin
ophen/doxylamine
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
laxative peg 3350 polyethylene glycol 3350
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
laxative peg 3350 polyethylene glycol 3350
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
psyllium
psyllium husk
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
adults 50+
multivitamin
multivitamin with
minerals/folic
acid/lycopene/lutein
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
ACZONE
dapsone
ADD TO FORMULARY
Non-Formulary
04/16/2016
ACZONE
dapsone
ADD TO FORMULARY
Non-Formulary
04/16/2016
CLADOSPORIU allergenic extractM
cladosporium
CLADOSPORIOI cladosporioides
DES
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
ACACIA
REMOVE FROM
FORMULARY
Non-Formulary
allergenic extract-tree
pollen-acacia
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 644
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/16/2016
VITAFOL
GUMMIES
prenatal vit
no.112/iron/fa/omega3/dha/epa/other omega-3s
ADD TO FORMULARY
Non-Formulary
04/16/2016
OTREXUP
methotrexate/pf
ADD TO FORMULARY
Non-Formulary
04/16/2016
PROMACTA
eltrombopag olamine
04/16/2016
OTREXUP
methotrexate/pf
ADD TO FORMULARY
Non-Formulary
04/16/2016
OTREXUP
methotrexate/pf
ADD TO FORMULARY
Non-Formulary
04/16/2016
OTREXUP
methotrexate/pf
ADD TO FORMULARY
Non-Formulary
04/16/2016
WILATE
antihemophilic factor,
human/von willebrand
factor,human
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
WILATE
antihemophilic factor,
human/von willebrand
factor,human
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
VENCLEXTA
venetoclax
ADD TO FORMULARY
Non-Formulary
04/16/2016
VENCLEXTA
venetoclax
ADD TO FORMULARY
Non-Formulary
04/16/2016
VENCLEXTA
venetoclax
ADD TO FORMULARY
Non-Formulary
04/16/2016
VENCLEXTA
venetoclax
ADD TO FORMULARY
Non-Formulary
04/16/2016
VENCLEXTA
venetoclax
ADD TO FORMULARY
Non-Formulary
04/16/2016
VENCLEXTA
venetoclax
ADD TO FORMULARY
Non-Formulary
04/16/2016
VENCLEXTA
STARTING
PACK
venetoclax
ADD TO FORMULARY
Non-Formulary
04/16/2016
CATTLE
EPITHELIUM
allergenic extract-cattle
epithelium
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
GERMAN
COCKROACH
allergenic extract-german
cockroach
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
ALDER
allergenic extract-tree
pollen-alder white
REMOVE FROM
FORMULARY
Non-Formulary
CHANGE TIER
Not Covered
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 645
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/16/2016
COCKLEBUR
allergenic extract-weed
pollen-cocklebur
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
ROUGH MARSH allergenic extract-weed
ELDER
pollen-true marsh elder
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
WESTERN
JUNIPER
allergenic extract-tree
pollen-juniper, western
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
QUEEN PALM
allergenic extract-tree
pollen-palm, queen
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
XRYLIX
diclofenac
sodium/kinesiology tape
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
PAIN RELIEF
COLLECTION
naproxen/capsaicin/menthol/
methyl salicylate
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
IMPAVIDO
miltefosine
ADD TO FORMULARY
Non-Formulary
04/16/2016
CALIFORNIA
PEPPER TREE
allergenic extract-tree
pollen-pepper tree, california
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
vancomycin hcl0.9% nacl
vancomycin in 0.9 % sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
hydromorphbupivac-0.9%
nacl
hydromorphone
hcl/bupivacaine hcl in 0.9%
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
bupivacaine hcl0.9% nacl
bupivacaine hcl in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
sodium
sodium phosphate in 0.9 %
phosphate-0.9% sodium chloride
nacl
REMOVE FROM
FORMULARY
Non-Formulary
04/16/2016
progesterone
micronized
progesterone,micronized
ADD TO FORMULARY
Not Covered
04/20/2015
gavilyte-h and
bisacodyl
bisacodyl/sodium
chlor/sodium
bicarb/potassium chl/peg
3350
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 646
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/20/2015
levonorgestreleth estradiol
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
04/20/2015
levonorgestreleth estradiol
levonorgestrel-ethinyl
estradiol
ADD TO FORMULARY
Preventative
04/20/2015
no-stick glucose
urine glucose test strip
REMOVE FROM
FORMULARY
Non-Formulary
04/20/2015
insulin syringe
syringe with
needle,insulin,0.3 ml
ADD TO FORMULARY
Generics
04/20/2015
insulin syringe
syringe with
needle,insulin,0.5 ml
ADD TO FORMULARY
Generics
04/20/2015
insulin syringe
syringe with
needle,disposable,insulin 1
ml
ADD TO FORMULARY
Generics
04/20/2015
insulin syringe
syringe with
needle,insulin,0.3 ml
ADD TO FORMULARY
Generics
04/20/2015
insulin syringe
syringe with
needle,insulin,0.5 ml
ADD TO FORMULARY
Generics
04/20/2015
insulin syringe
syringe with
needle,disposable,insulin 1
ml
ADD TO FORMULARY
Generics
04/20/2015
PEDIALYTE
sodium/potassium/chloride/d
extrose
REMOVE FROM
FORMULARY
Non-Formulary
04/20/2015
PEDIALYTE
sodium/potassium/chloride/d
extrose
REMOVE FROM
FORMULARY
Non-Formulary
04/20/2015
SUPER DAILY
D3
cholecalciferol (vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
04/20/2015
ARANESP
darbepoetin alfa in
polysorbate 80
ADD TO FORMULARY
Preferred Brands
04/20/2015
ARANESP
darbepoetin alfa in
polysorbate 80
ADD TO FORMULARY
Preferred Brands
04/20/2015
klor-con m10
potassium chloride
ADD TO FORMULARY
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 647
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/20/2015
stomach relief
bismuth subsalicylate
REMOVE FROM
FORMULARY
Non-Formulary
04/20/2015
lubricant eye
carboxymethylcellulose
sodium/glycerin/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/20/2015
lubricant eye
carboxymethylcellulose
sodium/glycerin
REMOVE FROM
FORMULARY
Non-Formulary
04/20/2015
despec dm
guaifenesin/dextromethorph
an hbr/phenylephrine
REMOVE FROM
FORMULARY
Non-Formulary
04/20/2015
ARANESP
darbepoetin alfa in
polysorbate 80
ADD UM: AUTHORIZATION
PA applies
04/20/2015
ARANESP
darbepoetin alfa in
polysorbate 80
ADD UM: SPECIALTY
Specialty Drug
04/20/2015
SANDOSTATIN
LAR DEPOT
octreotide acetate,
microspheres
ADD TO FORMULARY
Non-Formulary
04/20/2015
SANDOSTATIN
LAR DEPOT
octreotide acetate,
microspheres
ADD UM: SPECIALTY
Specialty Drug
04/20/2015
SANDOSTATIN
LAR DEPOT
octreotide acetate,
microspheres
ADD UM: AUTHORIZATION
PA applies
04/20/2015
NAMZARIC
memantine hcl/donepezil hcl
ADD TO FORMULARY
Non-Formulary
04/20/2015
klor-con m10
potassium chloride
CHANGE TIER
Non-Formulary
04/22/2016
ORALAIR
grass pollen-orchard/sweet
vernal/rye/kentucky/timothy,
std.
ADD TO FORMULARY
Non-Formulary
04/22/2016
COLY-MYCIN S
neomycin sulfate/colistin
sulfate/hydrocort ac/thonzon
brom
ADD TO FORMULARY
Non-Formulary
04/22/2016
flurandrenolide
flurandrenolide
ADD TO FORMULARY
Generics
04/22/2016
hydromorphone
hcl-0.9% nacl
hydromorphone hcl in 0.9 %
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 648
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/22/2016
fentanyl citrate0.9% nacl
fentanyl citrate in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
restizan
emollient combination no.60
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
relief knee
stocking
compression stocking, knee
high, regular length, medium
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
inspirachamber
inhaler, assist devices
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
notraum
foam bandage
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
notraum
foam bandage
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
notraum extra
foam bandage
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
notraum extra
foam bandage
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
t:30 infusion set
infusion set for insulin pump
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
CENTRUM
multivitamin with
MULTIGUMMIES minerals/folic acid
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
OCUVITE EYE
HEALTH
vitamin c/vitamin e
acetate/zinc
citrate/lutein/zeaxanthin
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
RHINASE
polyethylene gly/potassium
chl/propylene gly/sodium
chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
fast mucus relief phenylephrine
severe cold
hcl/dextromethorphan
hbr/acetaminophen/guaifen
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
nighttime sleep
aid
REMOVE FROM
FORMULARY
Non-Formulary
diphenhydramine hcl
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 649
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/22/2016
nighttime severe dextromethorphan
cold-flu
hbr/phenylephrine/acetamin
ophen/doxylamine
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
daytime-cold
nighttime-cld-flu
diphenhydramine/phenyleph
rin/dextromethorph/acetamin
ophen/gg
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
budesonide
budesonide
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
mucinex fast-max dextromethorphan
congest-head
hbr/phenylephrine
hcl/acetaminophen
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
MIXED
FEATHERS
allergenic extract-mixed
feathers, chicken, duck,
goose
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
WHITE PINE
allergenic extract-tree
pollen-pine, white
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
PRIVET
allergenic extract-tree
pollen-privet
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
RENACIDIN
citric
acid/gluconolactone/magnes
ium carbonate
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
ONZETRA XSAIL sumatriptan succinate
ADD TO FORMULARY
Non-Formulary
04/22/2016
SMARTRX
GABA-V KIT
gabapentin/capsaicin/methyl
salicylate/menthol
REMOVE FROM
FORMULARY
Non-Formulary
04/22/2016
hydromorphone
hcl
hydromorphone hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/23/2015
BETASERON
interferon beta-1b
ADD TO FORMULARY
Preferred Brands
04/23/2015
COPAXONE
glatiramer acetate
REMOVE UM:
AUTHORIZATION
04/23/2015
REBIF
REBIDOSE
interferon beta-1a/albumin
human
PA applies
ADD UM: QUANTITY
1 / 180 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 650
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/23/2015
REBIF
REBIDOSE
interferon beta-1a/albumin
human
ADD UM: QUANTITY
12 / 28 days
04/23/2015
REBIF
REBIDOSE
interferon beta-1a/albumin
human
ADD UM: QUANTITY
12 / 28 days
04/23/2015
PLEGRIDY
peginterferon beta-1a
PEN,PLEGRIDY
04/23/2015
PLEGRIDY
peginterferon beta-1a
ADD UM: QUANTITY
1 / 180 days
04/23/2015
PLEGRIDY PEN peginterferon beta-1a
ADD UM: QUANTITY
1 / 180 days
04/23/2015
PLEGRIDY PEN peginterferon beta-1a
ADD UM: QUANTITY
2 / 28 days
04/23/2015
PLEGRIDY
peginterferon beta-1a
ADD UM: QUANTITY
2 / 28 days
04/28/2015
naratriptan
hcl,naratriptan
naratriptan hcl
CHANGE TIER
Generics
04/28/2015
naratriptan
hcl,naratriptan
naratriptan hcl
CHANGE TIER
Generics
04/29/2016
ibuprofen lysine
ibuprofen lysine/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
ibuprofen lysine
ibuprofen lysine/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
verapamil hcl
verapamil hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
fentanyl citrate0.9% nacl
fentanyl citrate in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
morphine sulfate- morphine sulfate in 0.9 %
0.9% nacl
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
roweepra
levetiracetam
ADD TO FORMULARY
Generics
04/29/2016
procto-med hc
hydrocortisone
ADD TO FORMULARY
Generics
04/29/2016
midazolam-0.9% midazolam hcl in 0.9 %
nacl
sodium chloride
REMOVE FROM
FORMULARY
Non-Formulary
ADD TO FORMULARY
Non-Formulary
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 651
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
04/29/2016
promethazine
hcl-0.9% nacl
04/29/2016
Generic Name
promethazine hcl in 0.9 %
sodium chloride
Type of Change
Previous Value
New Value
REMOVE FROM
FORMULARY
Non-Formulary
fluticasone
fluticasone propionate,
propionate micro micronized
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
fluticasone
fluticasone propionate,
propionate micro micronized
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
fluticasone
fluticasone propionate,
propionate micro micronized
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
ulticare insulin
syringe
syringe with
needle,insulin,0.3 ml
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
ulticare insulin
syringe
syringe with
needle,insulin,0.5 ml
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
ulticare insulin
syringe
syringe with
needle,disposable,insulin 1
ml
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
ulticare insulin
syringe
syringe with
needle,insulin,0.5 ml
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
ulticare insulin
syringe
syringe with
needle,insulin,0.3 ml
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
ulticare insulin
syringe
syringe with
needle,disposable,insulin 1
ml
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
huggies little
snugglers
diaper/brief,infant-toddler,
disposable
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
eakin cohesive
stomawrap
ostomy barrier seal
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
sure comfort
insulin syringe
syringe with
needle,insulin,0.5 ml
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
sure comfort
insulin syringe
syringe with
needle,insulin,0.3 ml
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 652
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/29/2016
sure comfort
insulin syringe
syringe with
needle,disposable,insulin 1
ml
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
OPTIMAL D3 M
cholecalciferol (vitamin d3)
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
CALCOR
calc/magnesium/k
bicarb/boron hvp
chelt/lys/threo/silicon ox
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
genteal tears
dextran 70/hypromellose
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
digestive relief
bismuth subsalicylate
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
digestive relief
bismuth subsalicylate
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
eye health adult
50+
antioxidant multivit
no.11/omega3/dha/epa/lutein/zeaxanthin
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
headache relief
aspirin/acetaminophen/caffei
ne
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
acid reducer
ranitidine hcl
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
wart remover
salicylic acid
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
fluticasone
propionate
fluticasone propionate
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
fluticasone
propionate
fluticasone propionate
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
react
levonorgestrel
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 653
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/29/2016
xyzbac
multivitamin combination
no.34/folic
acid/nadh/ubiquinone
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
sulfzix
sulfur/sodium sulfate/sodium
thiosulf/methyltetrahydrofola
te
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
ULTRAVATE
halobetasol propionate
ADD TO FORMULARY
Non-Formulary
04/29/2016
ORALAIR
grass pollen-orchard/sweet
vernal/rye/kentucky/timothy,
std.
ADD TO FORMULARY
Non-Formulary
04/29/2016
MOUSE
EPITHELIUM
allergenic extract-mouse
epithelium
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
RABBIT
EPITHELIUM
allergenic extract-rabbit
epithelium
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
RABBIT
EPITHELIUM
allergenic extract-rabbit
epithelium
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
FIRE ANT
allergenic extract-fire ant
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
CURVULARIA
allergenic extract-curvularia
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
WHITE BIRCH
allergenic extract-tree
pollen-white birch
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
FIRE ANT
allergenic extract-fire ant
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
CARELESSWEE allergenic extract-weed
D
pollen-carelessweed
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
ARIZONA
CYPRESS
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
BALD CYPRESS allergenic extract-tree
pollen-bald cypress
REMOVE FROM
FORMULARY
Non-Formulary
allergenic extract-tree
pollen-arizona cypress
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 654
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
allergenic extract-cockroach
(american and german)
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
MIXED
COCKROACH
04/29/2016
SHEEP SORREL allergenic extract-weed
pollen-sheep sorrel
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
YELLOW DOCK allergenic extract-weed
pollen-yellow dock
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
CEDAR ELM
allergenic extract-tree
pollen-elm, cedar
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
KOCHIA
allergenic extract-weed
pollen-kochia (firebush)
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
RED MAPLE
allergenic extract-tree
pollen-red maple
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
RED MULBERRY allergenic extract-tree
pollen-mulberry, red
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
RED OAK
allergenic extract-tree
pollen-red oak
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
OLIVE TREE
allergenic extract-tree
pollen-olive
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
AUSTRALIAN
PINE
allergenic extract-tree
pollen-australian pine
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
BLACK WILLOW allergenic extract-tree
pollen-black willow
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
SHORT
RAGWEED
allergenic extract-weed
pollen-short ragweed
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
CABOMETYX
cabozantinib s-malate
ADD TO FORMULARY
Non-Formulary
04/29/2016
CABOMETYX
cabozantinib s-malate
ADD TO FORMULARY
Non-Formulary
04/29/2016
CABOMETYX
cabozantinib s-malate
ADD TO FORMULARY
Non-Formulary
04/29/2016
CAPXIB
celecoxib/capsaicin/menthol
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 655
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
04/29/2016
CAPXIB
celecoxib/capsaicin/menthol
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
EPICOCCUM
allergenic extract-epicoccum
nigrum
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
amiodarone hcld5w
amiodarone hcl/dextrose 5
% in water
REMOVE FROM
FORMULARY
Non-Formulary
04/29/2016
hydromorphhydromorphone
ropiva-0.9% nacl hcl/ropivacaine in 0.9 %
sodium chloride/pf
REMOVE FROM
FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 656
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
May, 2015
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/01/2015
rabeprazole
sodium
rabeprazole sodium
CHANGE TIER
Generics
05/01/2015
esomeprazole
magnesium
esomeprazole magnesium
ADD TO FORMULARY
Generics
05/01/2016
imatinib mesylate imatinib mesylate
CHANGE TIER
Generics
Not Covered
05/01/2016
imatinib mesylate imatinib mesylate
CHANGE TIER
Generics
Not Covered
05/01/2016
imatinib mesylate imatinib mesylate
REMOVE FROM
FORMULARY
Not Covered
Non-Formulary
05/01/2016
imatinib mesylate imatinib mesylate
REMOVE FROM
FORMULARY
Not Covered
Non-Formulary
05/01/2016
imatinib mesylate imatinib mesylate
REMOVE UM: SPECIALTY
Specialty Drug
05/01/2016
imatinib mesylate imatinib mesylate
REMOVE UM:
AUTHORIZATION
PA applies
05/01/2016
imatinib mesylate imatinib mesylate
REMOVE UM: SPECIALTY
Specialty Drug
05/01/2016
imatinib mesylate imatinib mesylate
REMOVE UM:
AUTHORIZATION
PA applies
05/01/2016
VIBERZI
eluxadoline
REMOVE UM: SPECIALTY
Specialty Drug
05/01/2016
KEPIVANCE
palifermin
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
KEYTRUDA
pembrolizumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
KRYSTEXXA
pegloticase
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 657
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/01/2016
KYPROLIS
carfilzomib
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
LUCENTIS
ranibizumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
MYOZYME,LUMI alglucosidase alfa
ZYME
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
MACUGEN
pegaptanib sodium
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
MACUGEN
pegaptanib sodium
ADD UM: SPECIALTY
Specialty Drug
05/01/2016
hydroxyprogester hydroxyprogesterone
one
caproate
caproate,makena
CHANGE UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
MEKINIST
trametinib dimethyl sulfoxide
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
MOZOBIL
plerixafor
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
MUGARD
glycerin/carbomer
homopolymer type
a/potassium hydroxide
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
NINLARO
ixazomib citrate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 658
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/01/2016
HUMATROPE,G somatropin
ENOTROPIN,NO
RDITROPIN
NORDIFLEX,NO
RDITROPIN
FLEXPRO,NORD
ITROPIN,OMNIT
ROPE,SEROSTI
M,SAIZEN,ZORB
TIVE,NUTROPIN
,NUTROPIN
AQ,NUTROPIN
AQ
NUSPIN,TEVTROPIN,ZOMAC
TON
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
ODOMZO
sonidegib phosphate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
OPDIVO
nivolumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
OZURDEX
dexamethasone
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
PERJETA
pertuzumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
OTEZLA
apremilast
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
PLEGRIDY
peginterferon beta-1a
PEN,PLEGRIDY
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 659
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
REMOVE UM:
AUTHORIZATION
PA applies
New Value
05/01/2016
PLEGRIDY
peginterferon beta-1a
PEN,PLEGRIDY
05/01/2016
PRALUENT
alirocumab
PEN,PRALUENT
SYRINGE
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
POMALYST
pomalidomide
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
PROMACTA
eltrombopag olamine
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
QUTENZA
capsaicin/skin cleanser
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
REPATHA
evolocumab
SYRINGE,REPA
THA
SURECLICK
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
REVLIMID
lenalidomide
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
RIASTAP
fibrinogen
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
RITUXAN
rituximab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
SIMPONI,SIMPO golimumab
NI ARIA
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
SOLIRIS
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
eculizumab
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 660
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/01/2016
SOMATULINE
DEPOT
lanreotide acetate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
SUPPRELIN LA
histrelin acetate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
PEGINTRON,SY peginterferon alfa-2b
LATRON,SYLAT
RON 4PACK,PEGINTR
ON REDIPEN
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
SYLVANT
siltuximab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
SYNAGIS
palivizumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
TAFINLAR
dabrafenib mesylate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
TARCEVA
erlotinib hcl
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
TASIGNA
nilotinib hcl
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
tecfidera,dimethyl dimethyl fumarate
fumarate
CHANGE UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
THALOMID
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
thalidomide
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 661
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/01/2016
THYROGEN
thyrotropin alfa
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
TIKOSYN
dofetilide
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
TYKERB
lapatinib ditosylate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
VANTAS
histrelin acetate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
VELCADE
bortezomib
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
VISUDYNE
verteporfin
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
VIVITROL
naltrexone microspheres
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
VOTRIENT
pazopanib hcl
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
VPRIV
velaglucerase alfa
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
XEOMIN
incobotulinumtoxina
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
XOLAIR
omalizumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 662
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/01/2016
YERVOY
ipilimumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
YONDELIS
trabectedin
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
ZALTRAP
ziv-aflibercept
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
ZELBORAF
vemurafenib
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/01/2016
ZYTIGA
abiraterone acetate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/04/2015
cefixime
cefixime
ADD TO FORMULARY
Generics
05/04/2015
SUPRAX
cefixime
CHANGE TIER
05/04/2015
cefixime
cefixime
ADD TO FORMULARY
Generics
05/04/2015
ciferex
cholecalciferol (vit d3)/folic
acid
ADD TO FORMULARY
Generics
05/04/2015
pramipexole er
pramipexole di-hcl
ADD TO FORMULARY
Generics
05/04/2015
KENALOG
triamcinolone acetonide
CHANGE TIER
05/04/2015
triamcinolone
acetonide
triamcinolone acetonide
ADD TO FORMULARY
Generics
05/04/2015
aripiprazole
aripiprazole
ADD TO FORMULARY
Generics
05/04/2015
ABILIFY
aripiprazole
CHANGE TIER
Non-Formulary
05/04/2015
aripiprazole
aripiprazole
ADD TO FORMULARY
Generics
05/04/2015
ABILIFY
aripiprazole
CHANGE TIER
Preferred Brands
Non-Formulary
05/04/2015
ABILIFY
aripiprazole
CHANGE TIER
Preferred Brands
Non-Formulary
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 663
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/04/2015
aripiprazole
aripiprazole
ADD TO FORMULARY
Generics
05/04/2015
aripiprazole
aripiprazole
ADD TO FORMULARY
Generics
05/04/2015
ABILIFY
aripiprazole
CHANGE TIER
Non-Formulary
05/04/2015
ABILIFY
aripiprazole
CHANGE TIER
Non-Formulary
05/04/2015
aripiprazole
aripiprazole
ADD TO FORMULARY
Generics
05/04/2015
ABILIFY
aripiprazole
CHANGE TIER
05/04/2015
aripiprazole
aripiprazole
ADD TO FORMULARY
Generics
05/04/2015
benzonatate
benzonatate
ADD TO FORMULARY
Generics
05/04/2015
bimatoprost
bimatoprost
ADD TO FORMULARY
Generics
05/04/2015
blanche
hydroquinone
ADD TO FORMULARY
Generics
05/04/2015
ADVANCED DNA lidocaine hcl/glycerin
MEDICATED
COLLECT
REMOVE UM: GENDER
05/04/2015
ADVANCED DNA lidocaine hcl/glycerin
MEDICATED
COLLECT
ADD TO FORMULARY
Non-Formulary
05/04/2015
dynamic
ADD TO FORMULARY
Generics
05/09/2016
venlafaxine hcl er venlafaxine hcl
05/15/2015
lidocaine hcl/glycerin
Preferred Brands
Non-Formulary
ADD TO FORMULARY
Non-Formulary
Generics
dexmethylphenid dexmethylphenidate hcl
ate hcl er
CHANGE TIER
Preferred Brands
Generics
05/15/2015
FOCALIN XR
dexmethylphenidate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2015
clozapine odt
clozapine
ADD TO FORMULARY
Generics
05/15/2015
clozapine odt
clozapine
ADD TO FORMULARY
Generics
05/15/2015
levomefolpyridoxal-mecalgal
levomefolate ca/pyridoxal
phos/mecobalamin/schiz.
algal oil
CHANGE TIER
Generics
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 664
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
05/15/2015
foltanx rf
levomefolate ca/pyridoxal
phos/mecobalamin/schiz.
algal oil
05/15/2015
l-methylfolatelevomefolate
mecobalaminca/acetylcysteine/mecobala
nac,levomefola- min/schiz. algal oil
nac-mecobalmalgal,levomefolat
e-nac-mecobalalgal
05/15/2015
SAPHRIS
05/15/2015
Type of Change
Previous Value
New Value
ADD TO FORMULARY
Non-Formulary
Generics
CHANGE TIER
Generics
asenapine maleate
ADD TO FORMULARY
Non-Formulary
FOSRENOL
lanthanum carbonate
ADD TO FORMULARY
Preferred Brands
05/15/2015
FOSRENOL
lanthanum carbonate
ADD TO FORMULARY
Preferred Brands
05/15/2015
VIIBRYD
vilazodone hcl
ADD TO FORMULARY
Non-Formulary
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD UM: QUANTITY
30 / 30 days
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD UM: QUANTITY
30 / 30 days
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD UM: QUANTITY
30 / 30 days
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD UM: QUANTITY
30 / 30 days
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD UM: QUANTITY
30 / 30 days
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD UM: QUANTITY
30 / 30 days
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD TO FORMULARY
Non-Formulary
05/15/2015
APTENSIO XR
methylphenidate hcl
ADD UM: QUANTITY
30 / 30 days
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 665
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/15/2015
MACUZIN
folic acid/vit c/vit
e/zinc/cupric
oxide/lutein/zeaxanthin
ADD TO FORMULARY
Non-Formulary
05/15/2015
TIVORBEX
indomethacin,
submicronized
ADD TO FORMULARY
Non-Formulary
05/15/2015
TIVORBEX
indomethacin,
submicronized
ADD TO FORMULARY
Non-Formulary
05/15/2015
ZARXIO
filgrastim-sndz
ADD TO FORMULARY
Non-Formulary
05/15/2015
ZARXIO
filgrastim-sndz
ADD TO FORMULARY
Non-Formulary
05/15/2015
midazolam hcl
midazolam hcl
CHANGE TIER
Generics
05/15/2016
PLEGRIDY PEN peginterferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
PLEGRIDY PEN peginterferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
euflexxa
hyaluronate sodium
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
AVONEX PEN
interferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NORDITROPIN
FLEXPRO
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
HUMIRA
adalimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
AVONEX PEN
interferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
HUMIRA
PEDIATRIC
CROHN'S
adalimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
OMNITROPE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
REBIDOSE
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
HUMIRA
PEDIATRIC
CROHN'S
adalimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NORDITROPIN
FLEXPRO
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 666
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/15/2016
TECFIDERA
dimethyl fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
TECFIDERA
dimethyl fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
REBIDOSE
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
HUMIRA
adalimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
COPAXONE
glatiramer acetate
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
TECFIDERA
dimethyl fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
SIMPONI
golimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
SIMPONI
golimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
PLEGRIDY
peginterferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NUTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NUTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
PLEGRIDY
peginterferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NUTROPIN AQ
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
AVONEX PEN
interferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
OMNITROPE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NORDITROPIN
NORDIFLEX
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 667
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/15/2016
PLEGRIDY PEN peginterferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
AVONEX
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
ENBREL
etanercept
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
REBIDOSE
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
COPAXONE
glatiramer acetate
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
ENBREL
etanercept
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NUTROPIN AQ
NUSPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
REBIDOSE
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
ENBREL
etanercept
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NUTROPIN AQ
NUSPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
ENBREL
etanercept
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
SIMPONI
golimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NUTROPIN AQ
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
ENBREL
etanercept
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
ENBREL
etanercept
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
PLEGRIDY
peginterferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
OMNITROPE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NUTROPIN AQ
NUSPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 668
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/15/2016
AVONEX
interferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
SIMPONI
golimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
COPAXONE
glatiramer acetate
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NUTROPIN AQ
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
ORTHOVISC
hyaluronate sodium
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
OMNITROPE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
AVONEX
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
AVONEX
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
ENBREL
etanercept
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
REBIDOSE
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
AVONEX
interferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NORDITROPIN
FLEXPRO
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
HUMIRA
adalimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
NORDITROPIN
FLEXPRO
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
SYNVISC-ONE
hylan g-f 20
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 669
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/15/2016
OMNITROPE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
GENOTROPIN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
SYNVISC
hylan g-f 20
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
AVONEX
interferon beta-1a
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
ENBREL
etanercept
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
HUMIRA PEN
PSORIASISUVEITIS
adalimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
HUMIRA PEN
adalimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
HUMIRA PEN
CROHN-UC-HS
STARTER
adalimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
REBIF
interferon beta-1a/albumin
human
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
HUMIRA PEN
adalimumab
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
MENOPUR
menotropins
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
MENOPUR
menotropins
ADD UM: PS
Preferred
Specialty
05/15/2016
MENOPUR
menotropins
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
MENOPUR
menotropins
ADD UM: PS
Preferred
Specialty
05/15/2016
MIRENA
levonorgestrel
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
MIRENA
levonorgestrel
ADD UM: PS
Preferred
Specialty
05/15/2016
CETROTIDE
cetrorelix acetate
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
CETROTIDE
cetrorelix acetate
ADD UM: PS
Preferred
Specialty
05/15/2016
ENDOMETRIN
progesterone,micronized
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 670
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/15/2016
ENDOMETRIN
progesterone,micronized
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
ENDOMETRIN
progesterone,micronized
ADD UM: PS
Preferred
Specialty
05/15/2016
MIRENA
levonorgestrel
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
MIRENA
levonorgestrel
ADD UM: PS
Preferred
Specialty
05/15/2016
ENDOMETRIN
progesterone,micronized
CHANGE TIER
05/15/2016
ENDOMETRIN
progesterone,micronized
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
ENDOMETRIN
progesterone,micronized
ADD UM: PS
Preferred
Specialty
05/15/2016
ENDOMETRIN
progesterone,micronized
CHANGE TIER
05/15/2016
ENDOMETRIN
progesterone,micronized
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
ENDOMETRIN
progesterone,micronized
ADD UM: PS
Preferred
Specialty
05/15/2016
OVIDREL
choriogonadotropin alfa
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
OVIDREL
choriogonadotropin alfa
ADD UM: PS
Preferred
Specialty
05/15/2016
SKYLA
levonorgestrel
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
SKYLA
levonorgestrel
ADD UM: PS
Preferred
Specialty
05/15/2016
CETROTIDE
cetrorelix acetate
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
CETROTIDE
cetrorelix acetate
ADD UM: PS
Preferred
Specialty
05/15/2016
REMICADE
infliximab
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
XTANDI
enzalutamide
REMOVE UM: CUSTOM
05/15/2016
XTANDI
enzalutamide
ADD UM: SPECIALTY
05/15/2016
accu-chek
compact
blood sugar diagnostic,
drum-type
CHANGE TIER
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
Specialty Drug
Specialty Drug
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 671
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/15/2016
accu-chek
compact plus
blood sugar diagnostic,
drum-type
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
accu-chek
comfort curve
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
accu-chek aviva
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
accu-chek aviva
plus
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
accu-chek
smartview
blood sugar diagnostic
CHANGE TIER
Preferred Brands
Non-Formulary
05/15/2016
MAKENA
hydroxyprogesterone
caproate
05/15/2016
CETROTIDE
05/15/2016
ADD UM: SPECIALTY
Specialty Drug
cetrorelix acetate
ADD UM: AUTHORIZATION
PA applies
CETROTIDE
cetrorelix acetate
ADD UM: AUTHORIZATION
PA applies
05/15/2016
MAKENA
hydroxyprogesterone
caproate
ADD UM: GENDER
Female
05/15/2016
MAKENA
hydroxyprogesterone
caproate
ADD UM: CUSTOM
Specialty Drug
05/15/2016
MAKENA
hydroxyprogesterone
caproate
ADD UM: PS
Preferred
Specialty
05/15/2016
MAKENA
hydroxyprogesterone
caproate
ADD UM: SPECIALTY
Specialty Drug
05/15/2016
MAKENA
hydroxyprogesterone
caproate
ADD UM: AUTHORIZATION
PA applies
05/16/2016
REVLIMID
lenalidomide
ADD UM: CUSTOM
Dispensing
restricted to
Magellan
Specialty
Pharmacy
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 672
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/16/2016
POMALYST
pomalidomide
ADD UM: CUSTOM
Dispensing
Limited to
Magellan
Specialty
Pharmacy
05/16/2016
THALOMID
thalidomide
ADD UM: CUSTOM
Dispensing
Limited to
Magellan
Specialty
Pharmacy
05/16/2016
MIRENA
levonorgestrel
ADD TO FORMULARY
Non-Formulary
Preferred Brands
05/16/2016
MIRENA
levonorgestrel
CHANGE TIER
Preferred Brands
Non-Formulary
05/16/2016
HUMATROPE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/16/2016
SEROSTIM
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
05/17/2016
ACTEMRA
tocilizumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
ADCETRIS
brentuximab vedotin
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
ZORTRESS,AFI everolimus
NITOR,AFINITO
R DISPERZ
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
AVASTIN
bevacizumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
BENLYSTA
belimumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
BETHKIS
tobramycin
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 673
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/17/2016
CERDELGA
eliglustat tartrate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
CEREZYME
imiglucerase
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
COSENTYX PEN secukinumab
(2
PENS),COSENT
YX
PEN,COSENTYX
SYRINGE,COSE
NTYX (2
SYRINGES)
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
dacogen,decitabi decitabine
ne
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
DAKLINZA
daclatasvir dihydrochloride
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
DARZALEX
daratumumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
DYSPORT
abobotulinumtoxina
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
ELAPRASE
idursulfase
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
EMPLICITI
elotuzumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 674
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/17/2016
ENTYVIO
vedolizumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
EYLEA
aflibercept
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
FARYDAK
panobinostat lactate
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
GAZYVA
obinutuzumab
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
privigen,hizentra immune globulin,gamma
(igg)/proline/iga 0 to 50
mcg/ml
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
hycamtin,topotec topotecan hcl
an hcl
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
INTRON A
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
EXJADE,JADEN deferasirox
U
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
KADCYLA
ado-trastuzumab emtansine
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/17/2016
KANUMA
sebelipase alfa
ADD UM: CUSTOM
Limited
Distribution Magellan Rx
05/18/2016
XURIDEN
uridine triacetate
ADD UM: PS
Preferred
Specialty
interferon alfa-2b,recomb.
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 675
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
05/18/2016
XURIDEN
uridine triacetate
ADD UM: SPECIALTY
Specialty Drug
05/20/2016
HUMIRA
adalimumab
ADD UM: QUANTITY
2 / 28 days
05/25/2015
lidocainetetracaine
lidocaine/tetracaine
ADD TO FORMULARY
Generics
05/25/2015
jinteli
norethindrone acetateethinyl estradiol
CHANGE TIER
05/25/2015
jinteli
norethindrone acetateethinyl estradiol
REMOVE UM:
AUTHORIZATION
05/25/2015
norethindronethinyl estradiol
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Generics
05/25/2015
norethindronethinyl estradiol
norethindrone acetateethinyl estradiol
ADD TO FORMULARY
Generics
05/25/2015
TASMAR
tolcapone
CHANGE TIER
05/25/2015
tolcapone
tolcapone
ADD TO FORMULARY
Generics
05/25/2015
virtrate-2
citric acid/sodium citrate
ADD TO FORMULARY
Generics
05/25/2015
virtrate-k
potassium citrate/citric acid
ADD TO FORMULARY
Generics
05/25/2015
ENBRACE HR
prenatal vitamins no.92/iron
cysteine gly/folate no.8/psdha
ADD TO FORMULARY
Non-Formulary
05/25/2015
ENBRACE HR
prenatal vitamins no.92/iron
cysteine gly/folate no.8/psdha
ADD UM: GENDER
Female
05/27/2015
ATELVIA
risedronate sodium
CHANGE TIER
05/27/2015
risedronate
sodium dr
risedronate sodium
ADD TO FORMULARY
Generics
05/27/2015
vanatol lq
butalbital/acetaminophen/caf
feine
ADD TO FORMULARY
Non-Formulary
05/27/2015
JUXTAPID
lomitapide mesylate
ADD TO FORMULARY
Non-Formulary
05/27/2015
TESTONE CIK
testosterone cypionate
ADD TO FORMULARY
Non-Formulary
Preferred Brands
Preferred Brands
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 676
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
05/27/2015
TESTONE CIK
testosterone cypionate
05/27/2015
JUXTAPID
05/27/2015
JUXTAPID
Type of Change
Previous Value
New Value
ADD UM: GENDER
Male
lomitapide mesylate
CHANGE UM:
AUTHORIZATION
PA applies
lomitapide mesylate
CHANGE UM: SPECIALTY
Specialty Drug
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 677
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
June, 2014
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/01/2014
OPSUMIT
macitentan
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/01/2015
TOUJEO
SOLOSTAR
insulin glargine,human
recombinant analog
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/05/2015
alosetron hcl
alosetron hcl
ADD TO FORMULARY
06/05/2015
LOTRONEX
alosetron hcl
CHANGE TIER
06/05/2015
alosetron hcl
alosetron hcl
ADD TO FORMULARY
Generics
06/05/2015
IONSYS
fentanyl hcl
ADD TO FORMULARY
Non-Formulary
06/05/2015
IONSYS
fentanyl hcl
ADD UM: AUTHORIZATION
PA applies
06/05/2015
STIOLTO
RESPIMAT
tiotropium
bromide/olodaterol hcl
ADD TO FORMULARY
Non-Formulary
06/05/2015
UREVAZ
urea
ADD TO FORMULARY
Non-Formulary
06/09/2015
COSENTYX PEN secukinumab
ADD UM: QUANTITY
1 / 30 days
06/09/2015
COSENTYX
SYRINGE
ADD UM: QUANTITY
1 / 30 days
06/09/2015
COSENTYX PEN secukinumab
(2
PENS),COSENT
YX
PEN,COSENTYX
SYRINGE,COSE
NTYX (2
SYRINGES)
06/10/2015
ACTONEL
06/10/2015
06/10/2015
secukinumab
Generics
Preferred Brands
Non-Formulary
REMOVE UM:
AUTHORIZATION
PA applies
risedronate sodium
CHANGE TIER
Preferred Brands
risedronate
sodium
risedronate sodium
ADD TO FORMULARY
Generics
risedronate
sodium
risedronate sodium
ADD UM: QUANTITY
30 / 30 days
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 678
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Non-Formulary
06/10/2015
ACTONEL
risedronate sodium
CHANGE TIER
06/10/2015
risedronate
sodium
risedronate sodium
ADD TO FORMULARY
Generics
06/10/2015
risedronate
sodium
risedronate sodium
ADD UM: QUANTITY
4 / 30 days
06/10/2015
ACTONEL
risedronate sodium
CHANGE TIER
06/10/2015
risedronate
sodium
risedronate sodium
ADD TO FORMULARY
Generics
06/10/2015
risedronate
sodium
risedronate sodium
ADD UM: QUANTITY
30 / 30 days
06/10/2015
larin 24 fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
06/10/2015
larin 24 fe
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
06/10/2015
junel fe 24
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD TO FORMULARY
Preventative
06/10/2015
junel fe 24
norethindrone acetateethinyl estradiol/ferrous
fumarate
ADD UM: GENDER
Female
06/10/2015
levonorg-eth
levonorgestrel/ethinyl
estrad eth estrad estradiol and ethinyl
estradiol
ADD TO FORMULARY
Preventative
06/10/2015
levonorg-eth
levonorgestrel/ethinyl
estrad eth estrad estradiol and ethinyl
estradiol
ADD UM: GENDER
Female
06/10/2015
naftifine hcl
naftifine hcl
ADD TO FORMULARY
Generics
06/10/2015
IRENKA
duloxetine hcl
ADD TO FORMULARY
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 679
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
compact
blood sugar diagnostic,
drum-type
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
smartview
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
smartview
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
compact plus
blood sugar diagnostic,
drum-type
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
smartview
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek aviva
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 680
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
compact plus
blood sugar diagnostic,
drum-type
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
smartview
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek
compact
blood sugar diagnostic,
drum-type
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
ADD TO FORMULARY
Non-Formulary
Preferred Brands
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
compact
blood sugar diagnostic,
drum-type
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
smartview
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
smartview
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
compact plus
blood sugar diagnostic,
drum-type
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 681
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
smartview
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
comfort curve
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek aviva
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
compact plus
blood sugar diagnostic,
drum-type
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
smartview
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek
compact
blood sugar diagnostic,
drum-type
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/14/2016
accu-chek aviva
plus
blood sugar diagnostic
REMOVE FROM
FORMULARY
Preferred Brands
Non-Formulary
06/16/2015
EXJADE,JADEN deferasirox
U
REMOVE UM:
AUTHORIZATION
PA applies
06/19/2014
HUMULIN R
insulin regular, human
ADD TO FORMULARY
Not Covered
06/19/2014
NOVOLIN R
insulin regular, human
ADD TO FORMULARY
Not Covered
06/19/2014
HUMULIN 70-30 insulin nph human
isophane/insulin regular,
human
ADD TO FORMULARY
Not Covered
06/19/2014
NOVOLIN 70-30 insulin nph human
isophane/insulin regular,
human
ADD TO FORMULARY
Not Covered
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 682
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/19/2014
HUMULIN N
insulin nph human isophane
ADD TO FORMULARY
Not Covered
06/19/2014
NOVOLIN N
insulin nph human isophane
ADD TO FORMULARY
Not Covered
06/23/2015
tramadol hcl er
tramadol hcl
ADD TO FORMULARY
Generics
06/23/2015
tramadol hcl er
tramadol hcl
ADD TO FORMULARY
Generics
06/23/2015
tramadol hcl er
tramadol hcl
ADD TO FORMULARY
Generics
06/23/2015
tramadol hcl er
tramadol hcl
ADD TO FORMULARY
Generics
06/23/2015
duloxetine hcl
duloxetine hcl
ADD TO FORMULARY
Generics
06/23/2015
salicylic acid er
salicylic acid
ADD TO FORMULARY
Generics
06/23/2015
K-TAB ER
potassium chloride
ADD TO FORMULARY
Non-Formulary
06/23/2015
TUZISTRA XR
codeine
polistirex/chlorpheniramine
polistirex
ADD TO FORMULARY
Non-Formulary
06/23/2015
kimidess
desogestrel-ethinyl
estradiol/ethinyl estradiol
ADD TO FORMULARY
Preventative
06/23/2015
thrivite 19
prenatal vitamins comb
no.119/iron fumarate/folic
acid/dss
ADD TO FORMULARY
Generics
06/23/2015
thrivite 19
prenatal vitamins comb
no.119/iron fumarate/folic
acid/dss
ADD UM: GENDER
Female
06/23/2015
BREO ELLIPTA
fluticasone furoate/vilanterol
trifenatate
ADD TO FORMULARY
Preferred Brands
06/23/2015
TRISTART DHA
prenatal vitamins no.93/iron
carbonyl/fa cmb#9/dha
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 683
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
06/25/2014
prozac
weekly,symbyax,
cymbalta,zyprexa
,evista,zyprexa
zydis,livalo,hydre
a,zerit,pravachol,
naprosyn,klonopi
n,copegus,boniva
,cellcept,xeloda,a
naprox,anaprox
ds,ecnaprosyn,prinivil,f
osamax,propecia,
proscar,singulair,
maxalt,zocor,hyz
aar,mevacor,coz
aar,pepcid,maxalt
mlt,sinemet 10100,sinemet 25100,sinemet 25250,sinemet
cr,dyazide,coreg,
parnate,requip
xl,requip,effexor
xr,protonix,rapam
une,cordarone,co
rtef,halcion,medr
ol,didrex,xanax,pr
overa,xanax
xr,cleocin
hcl,colestid,ansai
d,glynase,cleocin
palmitate,ogen,d
etrol,detrol
la,aromasin,azulfi
dine,mycobutin,m
egace,sanctura,s
anctura
xr,demerol,drisdo
fluoxetine
hcl,olanzapine/fluoxetine
hcl,duloxetine
hcl,olanzapine,raloxifene
hcl,pitavastatin
calcium,hydroxyurea,stavudi
ne,pravastatin
sodium,naproxen,clonazepa
m,ribavirin,ibandronate
sodium,mycophenolate
mofetil,capecitabine,naproxe
n
sodium,lisinopril,alendronate
sodium,finasteride,monteluk
ast sodium,rizatriptan
benzoate,simvastatin,losarta
n
potassium/hydrochlorothiazi
de,lovastatin,losartan
potassium,famotidine,carbid
opa/levodopa,triamterene/hy
drochlorothiazide,carvedilol,t
ranylcypromine
sulfate,ropinirole
hcl,venlafaxine
hcl,pantoprazole
sodium,sirolimus,amiodaron
e
hcl,hydrocortisone,triazolam,
methylprednisolone,benzph
etamine
hcl,alprazolam,medroxyprog
esterone
acetate,clindamycin
hcl,colestipol
hcl,flurbiprofen,glyburide,mic
ronized,clindamycin
palmitate
hcl,estropipate,tolterodine
ADD TO FORMULARY
Previous Value
New Value
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 684
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
l,kayexalate,plaq
uenil,uroxatral,a
mbien,ambien
cr,xyzal,avapro,a
valide,lomotil,ald
actone,aldactazid
e,daypro,arthrote
c 50,arthrotec
75,cytotec,inspra,
flagyl,calan,calan
sr,norpace,paxil,p
axil
cr,prometrium,fel
batol,soma,dema
dex,bifera
rx,diabeta,lasix,tr
ental,amaryl,gluc
otrol
xl,antivert,cardur
a,vfend,diflucan,g
eodon,glucotrol,z
oloft,marinol,rem
eron,desogen,cyc
lessa,dolophine
hcl,diskets,coum
adin,grifulvin
v,norpramin,hipre
x,rifadin,tessalon
perle,vibramycin,
norvasc,caduet,p
rocardia,procardi
a
xl,zithromax,zithr
omax tripak,feldene,revati
o,minipress,vistar
il,dilantin,lipitor,ac
curetic,zarontin,n
ardil,neurontin,ac
tartrate,exemestane,sulfasal
azine,rifabutin,megestrol
acetate,trospium
chloride,meperidine
hcl,ergocalciferol (vitamin
d2),sodium polystyrene
sulfonate,hydroxychloroquin
e sulfate,alfuzosin
hcl,zolpidem
tartrate,levocetirizine
dihydrochloride,irbesartan,ir
besartan/hydrochlorothiazid
e,diphenoxylate hcl/atropine
sulfate,spironolactone,spiron
olactone/hydrochlorothiazide
,oxaprozin,diclofenac
sodium/misoprostol,misopro
stol,eplerenone,metronidazo
le,verapamil
hcl,disopyramide
phosphate,paroxetine
hcl,progesterone,micronized
,felbamate,carisoprodol,tors
emide,iron polysacchar
complx/iron heme
polypeptide/folic
acid/b12,glyburide,furosemi
de,pentoxifylline,glimepiride,
glipizide,meclizine
hcl,doxazosin
mesylate,voriconazole,fluco
nazole,ziprasidone
hcl,sertraline
hcl,dronabinol,mirtazapine,d
esogestrel-ethinyl
estradiol,methadone
hcl,warfarin
sodium,griseofulvin,
microsize,desipramine
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 685
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
cupril,lopid,dilanti
n125,vicoprofen,m
avik,biaxin,tevete
n,cardizem
la,niaspan,biaxin
xl,synthroid,depa
kote
er,zemplar,depak
ene,depakote
sprinkle,tricor,dep
akote,k-tab
er,trilipix,ddavp,ril
utek,parlodel,cloz
aril,lescol,lamisil,
sandimmune,neo
ral,femara,diovan
hct,exelon,comta
n,trileptal,starlix,l
otrel,famvir,ritalin
la,focalin,myfortic
,stalevo
50,stalevo
100,stalevo
150,focalin
xr,cataflam,ritalin,
ritalin-sr,voltarenxr,lotensin,lotensi
n
hct,lopressor,lopr
essor
hct,tegretol,tegret
ol xr,stalevo
200,stalevo
75,stalevo
125,imdur,rebetol
,temodar,clarinex
,adalat
cc,avelox,avelox
hcl,methenamine
hippurate,rifampin,benzonat
ate,doxycycline
hyclate,doxycycline
monohydrate,amlodipine
besylate,amlodipine
besylate/atorvastatin
calcium,nifedipine,azithromy
cin,piroxicam,sildenafil
citrate,prazosin
hcl,hydroxyzine
pamoate,phenytoin,atorvast
atin calcium,quinapril
hcl/hydrochlorothiazide,etho
suximide,phenelzine
sulfate,phenytoin sodium
extended,gabapentin,quinap
ril
hcl,gemfibrozil,hydrocodone/
ibuprofen,trandolapril,clarithr
omycin,eprosartan
mesylate,diltiazem
hcl,niacin,levothyroxine
sodium,divalproex
sodium,paricalcitol,valproic
acid,valproic acid (as
sodium salt) (valproate
sodium),fenofibrate
nanocrystallized,potassium
chloride,fenofibric acid
(choline),desmopressin
acetate,riluzole,bromocriptin
e
mesylate,clozapine,fluvastati
n sodium,terbinafine
hcl,cyclosporine,cyclosporin
e,
modified,letrozole,valsartan/
hydrochlorothiazide,rivastig
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 686
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
abc
pack,biltricide,levi
tra,glucophage,gl
ucophage
xr,glucovance,vid
ex ec,allegra-d
24 hour,allegra
odt,arava,verelan
,univasc,uniretic,
verelan pm,colyte
with flavor
packets,robaxin750,venlafaxine
hcl
er,valium,soriatan
e,macrodantin,di
dronel,prandin,ac
tivella,wellbutrin
sr,wellbutrin,lano
xin,zantac,ceftin,
zofran,lamictal,m
epron,zyban,ame
rge,valtrex,zofran
odt,lamictal
(blue),epivir
hbv,malarone,imit
rex,lamictal
xr,lovaza,innopra
n
xl,rythmol,rythmol
sr,zovirax,ferralet
90,urocitk,citranatal
harmony,citranat
al 90
dha,citranatal bcalm,citranatal
rx,citranatal
assure,citranatal
mine
tartrate,entacapone,oxcarba
zepine,nateglinide,amlodipin
e besylate/benazepril
hcl,famciclovir,methylphenid
ate hcl,dexmethylphenidate
hcl,mycophenolate
sodium,carbidopa/levodopa/
entacapone,diclofenac
potassium,diclofenac
sodium,benazepril
hcl,benazepril
hcl/hydrochlorothiazide,meto
prolol tartrate,metoprolol
tartrate/hydrochlorothiazide,
carbamazepine,isosorbide
mononitrate,temozolomide,d
esloratadine,moxifloxacin
hcl,praziquantel,vardenafil
hcl,metformin
hcl,glyburide/metformin
hcl,didanosine,fexofenadine
hcl/pseudoephedrine
hcl,fexofenadine
hcl,leflunomide,moexipril
hcl,moexipril
hcl/hydrochlorothiazide,peg
3350/sod sulf/sod
bicarbonate/sod
chloride/potassium
chl,methocarbamol,diazepa
m,acitretin,nitrofurantoin
macrocrystal,etidronate
disodium,repaglinide,estradi
ol/norethindrone
acetate,bupropion
hcl,digoxin,ranitidine
hcl,cefuroxime
axetil,ondansetron
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 687
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
dha,tindamax,ata
cand,atacand
hct,vimovo,prilos
ec,entocort
ec,toprol
xl,nexium,vasote
c,vaseretic,bontril
pdm,wellbutrin
xl,cardizem,cardi
zem
cd,mestinon,anco
bon,librax,nephro
caps,anaspaz,klo
r-con 8,klor-con
10,pacerone,folg
ard
os,prenexa,folgar
d
rx,gastrografin,flu
oritab,tenormin,te
noretic
50,tenoretic
100,zestril,zestor
etic,arimidex,sero
quel,accolate,cas
odex,maxzide,ma
xzide-25
mg,phenytek,met
hadose,anafranil,
pamelor,restoril,t
ofranil,tofranilpm,doryx,sarafe
m,actonel,femcon
fe,estrostep
fe,ovcon35,estrace,armou
r
thyroid,flumadine,
esgic-
hcl,lamotrigine,atovaquone,
naratriptan hcl,valacyclovir
hcl,ondansetron,lamivudine,
atovaquone/proguanil
hcl,sumatriptan
succinate,omega-3 acid
ethyl esters,propranolol
hcl,propafenone
hcl,acyclovir,iron
carbonyl,gluc/folic acid/vit
b12/vit c/docusate
sodium,potassium
citrate,prenatal vitamins
combo no.59/iron,carb/folic
acid/dss/dha,prenatal
vit,calcium #64/iron
carb,gluc/folic
acid/dss/dha,prenatal
vitamin
no.48/iron,carbonyl,gluconat
e/folic acid/b6,prenatal vit
no.22/iron cbn,gluc/folic
acid/docusate
sodium,prenatal vitamin
no.38/iron carb,gluc/folic
acid/docusat/dha,prenatal vit
no.22/iron cbn,glucon/folic
acid/docusate/dha,tinidazole
,candesartan
cilexetil,candesartan
cilexetil/hydrochlorothiazide,
naproxen/esomeprazole
magnesium,omeprazole,bud
esonide,metoprolol
succinate,esomeprazole
magnesium,enalapril
maleate,enalapril
maleate/hydrochlorothiazide
,phendimetrazine
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 688
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
plus,tessalon,lev
othroid,lexapro,ti
azac,campral,cel
exa,prograf,uroge
sic-blue,k-phos
neutral,lunglaid,d
eplin,cerefolin,cer
efolin nac,neevo
dha,foltx,deplinalgal
oil,metanx,unithro
id,esgic,adderall,
catapres,persanti
ne,mobic,micardi
s,micardis
hct,viramune,flom
ax,mirapex,viram
une
xr,twynsta,marge
sic,martentab,prozac,caferg
ot,lorcet
plus,lorcet 10650,grispeg,zanaflex,fero
trinsic,pamine,pa
mine
forte,adoxa,absor
ica,vitamedmd
one
rx,vitamedmd
plus
rx,vitamedmd
redichew
rx,hematronaf,relagesic,supp
ort-500,uretron ds,fibricor,colcrys,
bactrim,bactrim
tartrate,pyridostigmine
bromide,flucytosine,chlordia
zepoxide/clidinium
bromide,vitamin b complex
and vitamin c no.20/folic
acid,hyoscyamine
sulfate,calcium carb/mag
oxide/vitamin d3/vit
b12/fa/vit b6/boron,prenatal
vit with calcium no.66/iron
fum/folic
acid/dss/dha,cyanocobalami
n/folic
acid/pyridoxine,diatrizoate
meglumine/diatrizoate
sodium,sodium
fluoride,atenolol,atenolol/chl
orthalidone,lisinopril/hydroch
lorothiazide,anastrozole,que
tiapine
fumarate,zafirlukast,bicaluta
mide,clomipramine
hcl,nortriptyline
hcl,temazepam,imipramine
hcl,imipramine
pamoate,risedronate
sodium,norethindroneethinyl estradiol/ferrous
fumarate,norethindrone
acetate-ethinyl
estradiol/ferrous
fumarate,norethindroneethinyl
estradiol,estradiol,thyroid,po
rk,rimantadine
hcl,butalbital/acetaminophen
/caffeine,escitalopram
oxalate,acamprosate
calcium,citalopram
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 689
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
ds,qualaquin,hyc
et,tl-select
dha,minocin,prod
rin,monodox,ribat
ab,l-methylfolate
formula,fazaclo,ni
ravam,parcopa,g
astrocrom,tri-viflor,exalgo,roxico
done,reprexain,in
deral la,cardene
sr,cardiotekrx,lodosyn,antara
,rocaltrol,prelone,
dantrium,nicazel,
silenor,zenpep,au
gmentin es600,augmentin,a
ugmentin
xr,serophene,vhist,cedax,uta,sp
s,kadian,neptaza
ne,phoslo,eldepry
l,combivir,epivir,r
etrovir,trizivir,ziag
en,synalgosdc,dynacin,questr
an,questran
light,betapace,bet
apace af,yasmin
28,yaz,cipro,cipro
xr,precose,levaqu
in,modicon,orthonovum,ortho tricyclen,ortho
micronor,orthocept,orthocyclen,sporanox,r
isperdal,risperdal
hydrobromide,tacrolimus,me
thenamine/sodium
phosphate,monobasic/meth
blue/hyosc sul,phosphorus
#1,borage oil/fish oil
(anchovy,sardine)/fructose/s
oy lecithin,levomefolate
calcium,cyanocobalamin/lev
omefolate
calcium/pyridoxine/riboflavin
,acetylcysteine/mecobalami
n/levomefolate
calcium,prenatal vitamin
comb no.79/iron
fumarat/fa/lmefolate
ca/dha,cyanocobalamin/levo
mefolate calcium/pyridoxine
hcl,levomefolate
calcium/schizochytrium algal
oil,levomefolate ca/pyridoxal
phos/mecobalamin/schiz.
algal oil,dextroamphetamine
sulfsaccharate/amphetamine
sulf-aspartate,clonidine
hcl,dipyridamole,meloxicam,
telmisartan,telmisartan/hydr
ochlorothiazide,nevirapine,ta
msulosin hcl,pramipexole dihcl,telmisartan/amlodipine
besylate,butalbital/acetamin
ophen,ergotamine
tartrate/caffeine,hydrocodon
e
bitartrate/acetaminophen,gri
seofulvin
ultramicrosize,tizanidine
hcl,ferrous
fumarate/ascorbic acid/b12-
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 690
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
m-tab,razadyne
er,razadyne,tylen
ol-codeine
no.3,tylenolcodeine
no.4,concerta,par
afon forte
dsc,topamax,ultra
cet,ultram
er,ultram,ditropan
xl,keppra,keppra
xr,lortab,flexeril,n
estabs
dha,foltrate,ibudo
ne,ziac,zebeta,lo
estrin,loestrin
fe,seasonique,no
rdette28,loseasonique,
mircette,aygestin,
antabuse,vivactil,
urecholine,diamo
x sequels,plan b
onestep,dexedrine,ro
baxin,golytely,axi
d,nulytely with
flavor
packs,macrobid,n
orco,nor-qd,brevicon,norinyl
1+35,trinorinyl,dilacor
xr,loxitane,microz
ide,actigall,fiorina
l,fiorinal with
codeine
#3,fioricet with
codeine,nephro-
if/folic
acid,methscopolamine
bromide,isotretinoin,prenatal
vitamins combo no.25/iron
fumarate/fa
combo#6/dha,prenatal
vitamins #39/iron amino acid
chelate/fa
combo#6/dha,prenatal
vitamins comb no.42/folic
acid comb
no.6,iron,carbonyl/docusate
sodium/b12-if/folic
acid/multivitmin,acetaminophen/phenylt
oloxamine citrate,b complex
with vitamin
c,methenamine/methylene
blue/salicylate/sodium
phos/hyoscy,methenamine/
methylene blue/sod
phos/p.salicylate/hyoscyami
ne,fenofibric
acid,colchicine,sulfamethoxa
zole/trimethoprim,quinine
sulfate,prenatal vitamin
no.57/iron fum/folic
acid/dss/dha,minocycline
hcl,isometheptene
mucate/caffeine/acetaminop
hen,cromolyn
sodium,pediatric
multivitamin a,c,and d3
no.38 with sodium
fluoride,hydromorphone
hcl,oxycodone
hcl,nicardipine hcl,folic
acid/arginine
hcl/cyanocobalamin/pyridoxi
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 691
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
vite rx,hemocytef,concept
ob,concept
dha,integra
f,integra
plus,hemocyte
plus,tandem
plus,tussionex,m
etadate
cd,zaroxolyn,agry
lin,carbatrol,adde
rall
xr,oxandrin,carnit
or,truvada,tusnel
pediatric,cafcit,lys
teda,prosedds,adipexp,purinethol,hect
orol,renvela,prote
ct
plus,escavite,ben
tyl,carafate,urso,
urso forte,ms
contin,dilaudid,pl
etal,keflex,robinul
,robinul
forte,ponstel,fura
dantin,sular,forta
met,kapvay,orapr
ed,methylin,xodol
10-300,xodol 5300,xodol 7.5300,fexmid,orbiva
n,prenatabs
fa,trinate,prenata
bs
rx,tapazole,cytom
el,skelaxin,sonat
a,corzide,avinza,
ne/pepper
ext,carbidopa,fenofibrate,mi
cronized,calcitriol,prednisolo
ne,dantrolene
sodium,niacinamide/azelaic
acid/zinc oxide/vit
b6/copper/fa,doxepin
hcl,lipase/protease/amylase,
amoxicillin/potassium
clavulanate,clomiphene
citrate,brompheniramine
maleate/phenylephrine
hcl,ceftibuten
dihydrate,sodium
polystyrene
sulfonate/sorbitol
solution,morphine
sulfate,methazolamide,calci
um acetate,selegiline
hcl,lamivudine/zidovudine,zi
dovudine,abacavir
sulfate/lamivudine/zidovudin
e,abacavir
sulfate,aspirin/caffeine/dihyd
rocodeine
bitartrate,cholestyramine
(with
sugar),cholestyramine/aspar
tame,sotalol hcl,ethinyl
estradiol/drospirenone,ciprof
loxacin
hcl,ciprofloxacin,ciprofloxaci
n/ciprofloxacin
hcl,acarbose,levofloxacin,no
rgestimate-ethinyl
estradiol,norethindrone,itrac
onazole,risperidone,galanta
mine hbr,acetaminophen
with codeine
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 692
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
corgard,levoxyl,ti
gan,altace,hepse
ra,reglan,buphen
yl,aciphex,aricept
,zonegran,salage
n,aricept
odt,doral,evoxac,l
unesta,provigil,ga
bitril,percodan,op
ana,percocet,plav
ix,icar-c
plus,zutripro,ativa
n,isordil
titradose,viva
dha,prevacid,acto
s,actoplus
met,duetact,prev
pac,zomig,zomig
zmt,trandate,imur
an,zyloprim,firstomeprazole,colaz
al,donnatal,ribasp
here ribapak,duet
dha
balanced,mysolin
e,vancocin
hcl,mucotrol,lipof
en,tricare
prenatal dha
one,desoxyn,tran
xene ttab,alinia,obtrex
dha,digex
nf,sectral,tenex,z
egerid,ob
complete,corvite,
corvite
150,fosteum,wym
zya fe,prefera-ob
phosphate,chlorzoxazone,to
piramate,tramadol
hcl/acetaminophen,tramadol
hcl,oxybutynin
chloride,levetiracetam,cyclo
benzaprine hcl,prenatal
vitamins comb no.87/iron
bisgly/folic
acid/dha,cyanocobalamin/fol
ic acid,bisoprolol
fumarate/hydrochlorothiazid
e,bisoprolol
fumarate,norethindrone
acetate-ethinyl
estradiol,levonorgestrel/ethi
nyl estradiol and ethinyl
estradiol,levonorgestrelethinyl estradiol,desogestrelethinyl estradiol/ethinyl
estradiol,norethindrone
acetate,disulfiram,protriptylin
e hcl,bethanechol
chloride,acetazolamide,levo
norgestrel,dextroamphetami
ne sulfate,nizatidine,sodium
chloride/sodium
bicarbonate/potassium
chloride/peg,nitrofurantoin
monohydrate/macrocrystals,
loxapine
succinate,hydrochlorothiazid
e,ursodiol,butalbital/aspirin/c
affeine,codeine
phosphate/butalbital/aspirin/
caffeine,butalbital/acetamino
phen/caffeine/codeine
phosphate,vitamin b complx
no.3/folic acid/ascorbic
acid/biotin,ferrous
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 693
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
plus dha,prefera
ob,prefera-ob
one,levsin,levbid,l
uvox cr,vospire
er,myambutol,lith
obid,aceon,tamb
ocor,solodyn,lmethylfolate
forte,bystolic,cher
atussin
ac,pediapred,nuvi
gil,prezista,isentr
ess,active
ob,camrese
lo,khedezla,renag
el,tamiflu,kalexat
e,xifaxan,lyrica,tiv
icay,sulfatrim,ciali
s,erythrocin
stearate,zebutal,
welchol,vitapearl,i
nderal
xl,pyridium,zetia,
compazine,abilify
,q-tabs,prena1
chew
fumarate/folic acid,prenatal
vitamin no.15/iron
fumarate,polysac comp/folic
acid,prenatal vit no.16/iron
fum,ps complex/folic
acid/omega-3,iron
fumarate,polysac comp/folic
acid/vitamin
c/niacinamide,iron
fumarate,polysac cplex/folic
acid/vit b comp with c
#9,ferrous fumarate/folic
acid/multivitamin-minerals
no.15,iron fumarate-iron
polysacch cplex/folic
acid/multivit
no.18,hydrocodone
polistirex/chlorpheniramine
polistirex,metolazone,anagr
elide
hcl,oxandrolone,levocarnitin
e,levocarnitine (with
sugar),emtricitabine/tenofovi
r disoproxil
fumarate,guaifenesin/dextro
methorphan
hbr/pseudoephedrine
hcl,caffeine
citrated,tranexamic
acid,methenamine/methylen
e blue/benzoic
acid/salicylate/hyoscy,phent
ermine
hcl,mercaptopurine,doxercal
ciferol,sevelamer
carbonate,amino
acids/multivit,th iron,other
min,pediatric multivitamin
no.47 with iron and sodium
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 694
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
fluoride,dicyclomine
hcl,sucralfate,cilostazol,ceph
alexin,glycopyrrolate,mefena
mic
acid,nitrofurantoin,nisoldipin
e,prednisolone sod
phosphate,prenatal vits with
calcium #78/ferrous
fumarate/folic acid,prenatal
vits with calcium #73/ferrous
fumarate/folic acid,prenatal
vits with calcium
#76/iron,carbonyl/folic
acid,methimazole,liothyronin
e
sodium,metaxalone,zaleplon
,nadolol/bendroflumethiazid
e,nadolol,trimethobenzamid
e hcl,ramipril,adefovir
dipivoxil,metoclopramide
hcl,sodium
phenylbutyrate,rabeprazole
sodium,donepezil
hcl,zonisamide,pilocarpine
hcl,quazepam,cevimeline
hcl,eszopiclone,modafinil,tia
gabine hcl,oxycodone
hcl/aspirin,oxymorphone
hcl,oxycodone
hcl/acetaminophen,clopidogr
el
bisulfate,iron,carbonyl/ascor
bic
acid/cyanocobalamin/folic
acid,hydrocodone
bitart/chlorpheniramine
maleate/pseudoephedrine,lo
razepam,isosorbide
dinitrate,prenatal vitamins
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 695
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
no.11/ferrous fumarate/folic
acid/omega3,lansoprazole,pioglitazone
hcl,pioglitazone
hcl/metformin
hcl,pioglitazone
hcl/glimepiride,lansoprazole/
amoxicillin
trihydrate/clarithromycin,zol
mitriptan,ceftibuten,labetalol
hcl,azathioprine,allopurinol,b
alsalazide
disodium,phenobarbital/hyos
cyamine sulf/atropine
sulf/scopolamine hb,prenatal
vitamin no.105/iron edta
&polysaccha/fa/om3/dha/ep
a,primidone,vancomycin
hcl,mucositis & stomatitis
combo 1,fenofibrate,pnv
no.20/iron
fumarate/fa/docusate na/fish
oil
conc/dha/epa,methampheta
mine hcl,clorazepate
dipotassium,nitazoxanide,pr
enatal vitamins
no.12/iron,carbonyl/fa/docus
ate/omega-3,hyoscyamine
sulfate/phenyltoloxamine
citrate,acebutolol
hcl,guanfacine
hcl,omeprazole/sodium
bicarbonate,iron,carbonyl/fol
ic acid/multivitamin with
minerals,folic
acid/multivitamin,ther and
minerals/lycopene/lutein,iron
,carbonyl/folic acid/vit
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 696
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
c/pyridoxine hcl/vit
b12/zinc,genistein/citrated
zinc bisglycinate/vitamin
d3,prenatal vitamin combo
no.22/iron/folic acid/omega3/dha,prenatal vit no.21/iron
polysacch,heme
polypep/folic acid,prenatal
vitamin no.19/iron
polysac,iron heme/folic
acid/dha,fluvoxamine
maleate,albuterol
sulfate,ethambutol
hcl,lithium
carbonate,perindopril
erbumine,flecainide
acetate,nebivolol
hcl,guaifenesin/codeine
phosphate,levomefolate
ca/acetylcysteine/mecobala
min/schiz. algal
oil,armodafinil,darunavir
ethanolate,raltegravir
potassium,prenatal vitamins
combo
no.66/iron,carbonyl/folic
acid/dha,desvenlafaxine,sev
elamer hcl,oseltamivir
phosphate,rifaximin,pregaba
lin,dolutegravir
sodium,tadalafil,erythromyci
n stearate,colesevelam
hcl,prenatal vit no.71/iron
fum-sodium feredetate/folic
acid/dha,phenazopyridine
hcl,ezetimibe,prochlorperazi
ne
maleate,aripiprazole,methylt
etrahydrofolate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 697
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
glucosamine,prenatal
vitamins combination
no.42/folic acid,prenatal vit
no.76/iron carbony,gluc/folic
acid/docusate/dha,prenatal
vit no.81/iron
carbonyl,gluc/folic
acid/docusate
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 698
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
06/25/2014
TRUSOPT,COS
OPT,XALATAN,A
CULAR,ZYMAXI
D,BETAGAN,PO
LYTRIM,ALPHA
GAN
P,ELESTAT,ACU
LAR
LS,OPTIVAR,MY
DRIACYL,CYCL
OGYL,MAXITRO
L,OMNIPRED,TO
BREX,TOBRADE
X,CILOXAN,IOPI
DINE,ALCAINE,I
SOPTO
CARPINE,ISOPT
O
ATROPINE,ISOP
TO
HOMATROPINE,
BLEPH-10,PRED
FORTE,FML,OC
UFLOX,OCUFEN
,FLURESS,BRO
MDAY,FLUOR-ISTRIP
AT,TIMOPTICXE,TIMOPTIC,G
ARAMYCIN,ILOT
YCIN,VIROPTIC,
ISTALOL,PROLE
NSA,LASTACAF
T,COSOPT
PF,ZIOPTAN,LO
TEMAX,VIGAMO
X
dorzolamide hcl,dorzolamide
hcl/timolol
maleate,latanoprost,ketorola
c
tromethamine,gatifloxacin,le
vobunolol hcl,polymyxin b
sulfate/trimethoprim,brimoni
dine tartrate,epinastine
hcl,azelastine
hcl,tropicamide,cyclopentola
te hcl,neomycin/polymyxin b
sulfate/dexamethasone,pred
nisolone
acetate,tobramycin,tobramy
cin/dexamethasone,ciproflox
acin hcl,apraclonidine
hcl,proparacaine
hcl,pilocarpine hcl,atropine
sulfate,homatropine
hbr,sulfacetamide
sodium,fluorometholone,oflo
xacin,flurbiprofen
sodium,benoxinate
hcl/fluorescein
sodium,bromfenac
sodium,fluorescein
sodium,timolol
maleate,gentamicin
sulfate,erythromycin
base,trifluridine,alcaftadine,d
orzolamide hcl/timolol
maleate/pf,tafluprost/pf,lotep
rednol
etabonate,moxifloxacin hcl
ADD TO FORMULARY
Previous Value
New Value
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 699
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
SAPHRIS,SUBO asenapine
XONE,LEVSIN- maleate,buprenorphine
SL,NITROSTAT hcl/naloxone
hcl,hyoscyamine
sulfate,nitroglycerin
ADD TO FORMULARY
Non-Formulary
06/25/2014
ARIXTRA,LOVE
NOX,EXTAVIA,I
MITREX,ALSUM
A,SEROSTIM,SA
IZEN,EGRIFTA,B
ETASERON,IPRI
VASK,TEVTROPIN,LYMPH
AZURIN,NOVOL
OG
FLEXPEN,ZOLA
DEX,LANTUS
SOLOSTAR,HU
MALOG MIX 7525
ADD TO FORMULARY
Non-Formulary
fondaparinux
sodium,enoxaparin
sodium,interferon beta1b,sumatriptan
succinate,somatropin,tesam
orelin
acetate,desirudin,isosulfan
blue,insulin aspart,goserelin
acetate,insulin
glargine,human recombinant
analog,insulin lispro
protamine and insulin lispro
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 700
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
06/25/2014
ULTANE,TOBI,P
ROVENTIL
HFA,VENTOLIN
HFA,PULMICOR
T,ETHRANE,FO
RANE,SPIRIVA,
HYPERSAL,DUONEB,A
CCUNEB,ATROV
ENT
HFA,PROAIR
HFA,XOPENEX,
XOPENEX
CONCENTRATE,
FLOVENT
DISKUS,COMBI
VENT
RESPIMAT,ADV
AIR
DISKUS,SYMBIC
ORT
sevoflurane,tobramycin in
0.225 % sodium
chloride,albuterol
sulfate,budesonide,enfluran
e,isoflurane,tiotropium
bromide,sodium chloride for
inhalation,ipratropium
bromide/albuterol
sulfate,ipratropium
bromide,levalbuterol
hcl,fluticasone
propionate,fluticasone
propionate/salmeterol
xinafoate,budesonide/formot
erol fumarate
CHANGE TIER
Previous Value
New Value
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 701
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
06/25/2014
CLEOCIN
T,BACTROBAN,
RETIN-A,RETINA MICRO,RETINA MICRO
PUMP,BIAFINE,
PRUDOXIN,XEN
ADERM,BENZAC
LIN,DERMATOP,
BENZAMYCIN,K
LARON,PENLAC
,ELOCON,DIPR
OLENE
AF,DIPROLENE,
LOTRISONE,DR
YSOL,LUXIQ,EV
OCLIN,VELTIN,D
UAC,AVAR-E
LS,AVAR
LS,OVACE
PLUS,OVACE
PLUS
WASH,OVACE,E
LDOPAQUE
FORTE,ZOVIRA
X,EFUDEX,ALUV
EA,VECTICAL,B
ENZAC
AC,METROGEL,
METROCREAM,
METROLOTION,
CLOBEX,CLIND
AGEL,DESOWE
N,DIFFERIN,ALA
-CORT,ALASCALP,AVITA,M
ENTAX,PREATTACHED LTA
KIT,TEMOVATE,
clindamycin
phosphate,mupirocin,mupiro
cin calcium,tretinoin,tretinoin
microspheres,emollient
combination no.10,doxepin
hcl,trypsin/balsam
peru/castor oil,clindamycin
phosphate/benzoyl
peroxide,prednicarbate,eryth
romycin base/benzoyl
peroxide,sulfacetamide
sodium,ciclopirox,mometaso
ne furoate,betamethasone
dipropionate/propylene
glycol,clotrimazole/betameth
asone
dipropionate,aluminum
chloride,betamethasone
valerate,clindamycin
phosphate/tretinoin,sulfacet
amide
sodium/sulfur,hydroquinone/
ferric
oxide,acyclovir,fluorouracil,u
rea,calcitriol,benzoyl
peroxide,metronidazole,clob
etasol
propionate,desonide,adapal
ene,hydrocortisone,butenafi
ne hcl,lidocaine
hcl,clobetasol
propionate/emollient
base,fluticasone
propionate,hydrocortisone
acetate/pramoxine
hcl,protectives combination
no.2/ceramides 1,3,611,silver
sulfadiazine,hydrocortisone
ADD TO FORMULARY
Previous Value
New Value
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 702
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
TEMOVATE
EMOLLIENT,CU
TIVATE,PRAMO
SONE,TETRIX,T
HERMAZENE,CA
RMOL
HC,KEROL,SOL
ARAZE,ZONALO
N,LACHYDRIN,ULTRA
VATE,WESTCO
RT,ULTRAVATE
PAC,FINACEA,D
ESONATE,KERA
LYT,SALEX,LOC
OID,LOCOID
LIPOCREAM,CL
ARIFOAM
EF,SALKERA,HY
LATOPIC,BENZE
FOAM,HYLATOP
ICPLUS,BENZEF
OAM
ULTRA,AURSTA
T,PENNSAID,HY
DRO 40,DERMASMOOTHEFS,VIRASAL,SU
MAXIN,PACNEX,
SUMAXIN
TS,SUMADAN,U
RAMAXIN,URAM
AXIN
GT,CENTANY,CI
CLODAN,SYNAL
AR,SSD,TACLO
NEX,DOVONEX,
NIZORAL,SULFA
MYLON,TRIPLE
acetate/urea,urea/lactic
acid/salicylic acid,diclofenac
sodium,ammonium
lactate,halobetasol
propionate,hydrocortisone
valerate,halobetasol
propionate/ammonium
lactate,azelaic acid,salicylic
acid,salicylic acid/ceramides
1,3,6-11,hydrocortisone
butyrate,hydrocortisone
butyrate/emollient
base,salicylic
acid/ammonium lactate/aloe
vera,emollient combination
no.44,emollient combination
no.53,emol53/e.water/namgf
s/naphos/nacl/hypochlorous
acid/nahypocl,fluocinolone
acetonide/shower
cap,fluocinolone
acetonide,sulfacetamide
sodium/sulfur/skin cleanser
comb
no.23,ciclopirox/urea/camph
or/menthol/eucalyptol,calcip
otriene/betamethasone
dipropionate,calcipotriene,ke
toconazole,mafenide
acetate,gentian
violet/brilliant
green/proflavine,desoximeta
sone,malathion,spinosad,po
dofilox,lidocaine/prilocaine,li
docaine,eflornithine
hcl,emollient combination
no.43,clocortolone
pivalate,vitamin e acet
(dl,tocopheryl)/grape/hyaluro
Type of Change
Previous Value
New Value
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 703
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
DYE,TOPICORT,
OVIDE,NATROB
A,CONDYLOX,SI
LVADENE,OLUX
,EXTINA,OLUXE,EMLA,LIDODE
RM,VANIQA,PR
OMISEB,CLODE
RM,UMECTA,LO
PROX,ATOPICL
AIR,ALDARA,ZIA
NA,VANOS,EPIF
IX AMNIOTIC
MEMBRANE,LID
ORX,GRAFIX
CORE,GRAFIX
PRIME
nic
acid,imiquimod,fluocinonide,
human regenerative tissue
matrix
06/25/2014
DIASTAT
ACUDIAL,ANALP
RAM
E,ANALPRAM
HC,SPS,CORTE
NEMA,PROCTO
CORT,DIASTAT,
SFROWASA,RO
WASA,COMPAZI
NE
diazepam,hydrocortisone
acetate/pramoxine/emollient
/pramoxine
comb#1,hydrocortisone
acetate/pramoxine
hcl,sodium polystyrene
sulfonate/sorbitol
solution,hydrocortisone,hydr
ocortisone
acetate,mesalamine,mesala
mine with cleansing
wipes,prochlorperazine
ADD TO FORMULARY
Non-Formulary
06/25/2014
PHYSIOLYTE,A
MINOACETIC
ACID,PHYSIOSO
L,NEOSPORIN
G.U. IRRIGANT
physiological irrigating
solution combo #1,glycine
urologic solution,neomycin
sulfate/polymyxin b sulfate
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 704
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
ASTELIN,ASTEP
RO,NASACORT
AQ,DDAVP,MIA
CALCIN,FLONA
SE,IMITREX,RHI
NOCORT
AQUA,MIGRANA
L,FORTICAL,AT
ROVENT,NASO
NEX
azelastine hcl,triamcinolone
acetonide,desmopressin
acetate,desmopressin
acetate (nonrefrigerated),calcitonin,salm
on,synthetic,fluticasone
propionate,sumatriptan,bude
sonide,dihydroergotamine
mesylate,ipratropium
bromide,mometasone
furoate
ADD TO FORMULARY
Non-Formulary
06/25/2014
VOSOL
HC,DERMOTIC,
CORTISPORIN,C
ETRAXAL,CIPR
ODEX
acetic
acid/hydrocortisone,fluocinol
one acetonide oil,neomycin
sulfate/polymyxin b
sulfate/hydrocortisone,ciprofl
oxacin hcl,ciprofloxacin
hcl/dexamethasone
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 705
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
06/25/2014
kenalog40,kenalog10,azactam,roce
phin,depomedrol,cleocin
phosphate,solucortef,auviq,claforan,unasyn
,ddavp,sandostati
n,desferal,desfer
al
mesylate,celesto
ne,glucagen,lano
xin,zinacef,zanta
c,fortaz,maxipime
,carbocaine,isupr
el,marcaine,marc
aineepinephrine,marc
aine
spinal,pontocaine
,quelicin,indigo
carmine,cortrosy
n,ativan,duramor
ph,phenergan,rob
inul,anectine,winr
ho sdf,gamunexc,fentanyl
citrate,alfentanil
hcl,ic
green,adrenalin
chloride,colymycin m
parenteral,ketalar
,pitocin,pitressin,
epipen 2pak,haldol,epoge
n,dilaudid,dilaudi
d-
triamcinolone
acetonide,aztreonam,ceftria
xone
sodium,methylprednisolone
acetate,clindamycin
phosphate,hydrocortisone
sod
succinate,epinephrine,cefota
xime sodium,ampicillin
sodium/sulbactam
sodium,desmopressin
acetate,octreotide
acetate,deferoxamine
mesylate,betamethasone
acetate/betamethasone
sodium
phosphate,glucagon,human
recombinant,digoxin,cefuroxi
me sodium,ranitidine
hcl,ceftazidime,cefepime
hcl,mepivacaine
hcl/pf,mepivacaine
hcl,isoproterenol
hcl,bupivacaine
hcl/pf,bupivacaine
hcl,bupivacaine
hcl/epinephrine/pf,bupivacai
ne
hcl/epinephrine,bupivacaine
hcl/dextrosewater/pf,tetracaine
hcl/pf,succinylcholine
chloride,indigotindisulfonate
sodium,cosyntropin,lorazepa
m,morphine
sulfate/pf,promethazine
hcl,glycopyrrolate,rho(d)
immune
globulin/maltose,immune
ADD TO FORMULARY
Previous Value
New Value
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 706
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
hp,vidaza,procrit,
hepagam
b,astramorphpf,sensorcainempf
epinephrine,sens
orcainempf,sensorcaine,
nesacainempf,xylocaine
with
epinephrine,xyloc
aine,xylocainempf with
epinephrine,xyloc
ainempf,d.h.e.45,cog
entin,vitrase,gam
maked,adrenaclic
k,swabflush,cere
byx,sculptra
globulin,gamm(igg)/glycine/i
ga greater than 50
mcg/ml,fentanyl
citrate/pf,alfentanil
hcl,indocyanine
green,colistin (as
colistimethate
sodium),ketamine
hcl,oxytocin,vasopressin,hal
operidol lactate,epoetin
alfa,hydromorphone
hcl/pf,azacitidine,hepatitis b
immune
globulin/maltose,chloroproca
ine hcl/pf,lidocaine
hcl/epinephrine,lidocaine
hcl,lidocaine
hcl/epinephrine/pf,lidocaine
hcl/pf,dihydroergotamine
mesylate,benztropine
mesylate,hyaluronidase,ovin
e,0.9 % sodium
chloride,fosphenytoin
sodium,poly-l-lactic
acid/carboxymethylcellulose
sodium/mannitol
Type of Change
Previous Value
New Value
06/25/2014
ACTOPLUS MET pioglitazone hcl/metformin
XR
hcl
ADD UM: GENDER
Female
06/25/2014
ACTOPLUS MET pioglitazone hcl/metformin
XR
hcl
ADD UM: GENDER
Female
06/25/2014
ACTOS
pioglitazone hcl
ADD UM: GENDER
Female
06/25/2014
ADOXA
doxycycline monohydrate
ADD UM: GENDER
Female
06/25/2014
ADVICOR
niacin/lovastatin
ADD UM: GENDER
Female
06/25/2014
ADVICOR
niacin/lovastatin
ADD UM: GENDER
Female
06/25/2014
alprazolam odt
alprazolam
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 707
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
alprazolam odt
alprazolam
ADD UM: GENDER
Female
06/25/2014
alprazolam odt
alprazolam
ADD UM: GENDER
Female
06/25/2014
ANIMI-3
omega3/dha/epa/d3/b12/folic
acid/pyridox hcl/phytosterol
ADD UM: GENDER
Female
06/25/2014
ANIMI-3 WITH
VITAMIN D
omega3/dha/epa/d3/b12/folic
acid/pyridox hcl/phytosterol
ADD UM: GENDER
Female
06/25/2014
ANORO
ELLIPTA
umeclidinium
bromide/vilanterol trifenatate
ADD UM: GENDER
Female
06/25/2014
BIAXIN XL
clarithromycin
ADD UM: GENDER
Female
06/25/2014
BIAXIN XL
clarithromycin
ADD UM: GENDER
Female
06/25/2014
BREVICON
norethindrone-ethinyl
estradiol
ADD UM: GENDER
Female
06/25/2014
CAVERJECT
alprostadil
ADD UM: GENDER
Male
06/25/2014
CAVERJECT
alprostadil
ADD UM: GENDER
Male
06/25/2014
CAVERJECT
alprostadil
ADD UM: GENDER
Male
06/25/2014
CAVERJECT
alprostadil
ADD UM: GENDER
Male
06/25/2014
CAYSTON
aztreonam lysine
ADD UM: GENDER
Male
06/25/2014
CEDAX
ceftibuten dihydrate
ADD UM: GENDER
Male
06/25/2014
CEDAX
ceftibuten
ADD UM: GENDER
Male
06/25/2014
CENESTIN
estrogens,conj.,synthetic a
ADD UM: GENDER
Female
06/25/2014
CENESTIN
estrogens,conj.,synthetic a
ADD UM: GENDER
Female
06/25/2014
CEREFOLIN
NAC
levomefolate
ca/acetylcysteine/mecobala
min/schiz. algal oil
ADD UM: GENDER
Female
06/25/2014
CESAMET
nabilone
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 708
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
CETACAINE
ANESTHETIC
tetracaine/benzocaine/buta
mben
ADD UM: GENDER
Female
06/25/2014
CLARINEX
desloratadine
ADD UM: GENDER
Female
06/25/2014
CLARINEX
desloratadine
ADD UM: GENDER
Female
06/25/2014
CLARINEX
desloratadine
ADD UM: GENDER
Female
06/25/2014
clever choice pro blood sugar diagnostic
ADD UM: GENDER
Female
06/25/2014
clever choice talk blood sugar diagnostic
ADD UM: GENDER
Female
06/25/2014
CLIMARA
estradiol
ADD UM: GENDER
Female
06/25/2014
CLIMARA
estradiol
ADD UM: GENDER
Female
06/25/2014
CLIMARA
estradiol
ADD UM: GENDER
Female
06/25/2014
CLIMARA
estradiol
ADD UM: GENDER
Female
06/25/2014
CLIMARA
estradiol
ADD UM: GENDER
Female
06/25/2014
CLIMARA PRO
estradiol/levonorgestrel
ADD UM: GENDER
Female
06/25/2014
CLINDACIN ETZ clindamycin phosphate/skin
cleanser comb no.19
ADD UM: GENDER
Female
06/25/2014
CLINDACIN PAC clindamycin phosphate/skin
cleanser comb no.19
ADD UM: GENDER
Female
06/25/2014
CLINDESSE
clindamycin phosphate
ADD UM: GENDER
Female
06/25/2014
clonidine
clonidine
ADD UM: GENDER
Female
06/25/2014
COZAAR
losartan potassium
ADD UM: GENDER
Female
06/25/2014
ketone care
urine acetone test,strips
ADD UM: GENDER
Female
06/25/2014
CYCLESSA
desogestrel-ethinyl estradiol
ADD UM: GENDER
Female
06/25/2014
cyclopentolate
hcl
cyclopentolate hcl
ADD UM: GENDER
Female
06/25/2014
DESOXYN
methamphetamine hcl
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 709
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
ADVANCED DNA lidocaine hcl/glycerin
MEDICATED
COLLECT
ADD UM: GENDER
Female
06/25/2014
DONNATAL
phenobarbital/hyoscyamine
sulf/atropine
sulf/scopolamine hb
ADD UM: GENDER
Female
06/25/2014
DONNATAL
phenobarbital/hyoscyamine
sulf/atropine
sulf/scopolamine hb
ADD UM: GENDER
Female
06/25/2014
EDEX
alprostadil
ADD UM: GENDER
Male
06/25/2014
EDEX
alprostadil
ADD UM: GENDER
Male
06/25/2014
eemt
estrogens,esterified/methylt
estosterone
ADD UM: GENDER
Male
06/25/2014
EFFEXOR XR
venlafaxine hcl
ADD UM: GENDER
Male
06/25/2014
EFFEXOR XR
venlafaxine hcl
ADD UM: GENDER
Male
06/25/2014
EFFEXOR XR
venlafaxine hcl
ADD UM: GENDER
Male
06/25/2014
FEMHRT
norethindrone acetateethinyl estradiol
ADD UM: GENDER
Female
06/25/2014
fenofibrate
fenofibrate,micronized
ADD UM: GENDER
Female
06/25/2014
fenofibrate
fenofibrate,micronized
ADD UM: GENDER
Female
06/25/2014
fenofibrate
fenofibrate,micronized
ADD UM: GENDER
Female
06/25/2014
FOLLISTIM AQ
follitropin beta,recomb
ADD UM: GENDER
Female
06/25/2014
GEODON
ziprasidone hcl
ADD UM: GENDER
Female
06/25/2014
HETLIOZ
tasimelteon
ADD UM: GENDER
Female
06/25/2014
HIZENTRA
immune globulin,gamma
(igg)/proline/iga 0 to 50
mcg/ml
ADD UM: GENDER
Female
06/25/2014
LEVITRA
vardenafil hcl
ADD UM: GENDER
Male
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 710
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
LEVITRA
vardenafil hcl
ADD UM: GENDER
Male
06/25/2014
LEVITRA
vardenafil hcl
ADD UM: GENDER
Male
06/25/2014
levofloxacin
levofloxacin
ADD UM: GENDER
Male
06/25/2014
levofloxacin
levofloxacin
ADD UM: GENDER
Male
06/25/2014
levofloxacin
levofloxacin
ADD UM: GENDER
Male
06/25/2014
lofibra
fenofibrate,micronized
ADD UM: GENDER
Female
06/25/2014
lofibra
fenofibrate,micronized
ADD UM: GENDER
Female
06/25/2014
lofibra
fenofibrate
ADD UM: GENDER
Female
06/25/2014
MAVIK
trandolapril
ADD UM: GENDER
Female
06/25/2014
METADATE CD
methylphenidate hcl
ADD UM: GENDER
Female
06/25/2014
METADATE CD
methylphenidate hcl
ADD UM: GENDER
Female
06/25/2014
MUSE
alprostadil
ADD UM: GENDER
Male
06/25/2014
MUSE
alprostadil
ADD UM: GENDER
Male
06/25/2014
MUSE
alprostadil
ADD UM: GENDER
Male
06/25/2014
MUSE
alprostadil
ADD UM: GENDER
Male
06/25/2014
MUSE
alprostadil
ADD UM: GENDER
Male
06/25/2014
MYOBLOC
rimabotulinumtoxinb
ADD UM: GENDER
Male
06/25/2014
MYRBETRIQ
mirabegron
ADD UM: GENDER
Male
06/25/2014
MYRBETRIQ
mirabegron
ADD UM: GENDER
Male
06/25/2014
nateglinide
nateglinide
ADD UM: GENDER
Female
06/25/2014
nateglinide
nateglinide
ADD UM: GENDER
Female
06/25/2014
NEORAL
cyclosporine, modified
ADD UM: GENDER
Female
06/25/2014
NEORAL
cyclosporine, modified
ADD UM: GENDER
Female
06/25/2014
NEORAL
cyclosporine, modified
ADD UM: GENDER
Female
06/25/2014
NEUPRO
rotigotine
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 711
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
NEUPRO
rotigotine
ADD UM: GENDER
Female
06/25/2014
NEUPRO
rotigotine
ADD UM: GENDER
Female
06/25/2014
nova max
glucose test
strips
blood sugar diagnostic
ADD UM: GENDER
Female
06/25/2014
NYMALIZE
nimodipine
ADD UM: GENDER
Female
06/25/2014
NYMALIZE
nimodipine
ADD UM: GENDER
Female
06/25/2014
NYMALIZE
nimodipine
ADD UM: GENDER
Female
06/25/2014
OLEPTRO ER
trazodone hcl
ADD UM: GENDER
Female
06/25/2014
OLUX
clobetasol propionate
ADD UM: GENDER
Female
06/25/2014
OXISTAT
oxiconazole nitrate
ADD UM: GENDER
Female
06/25/2014
oxycodone hcl
oxycodone hcl
ADD UM: GENDER
Female
06/25/2014
pnv folic acid +
iron
prenatal vitamins combo
no.60/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
PODIAPN
pyridoxal
phos/methyltetrahydrofolate
gluc/mecobalamin/ala
ADD UM: GENDER
Female
06/25/2014
poly-tussin d
chlorcyclizine
hcl/pseudoephedrine
hcl/codeine phosphate
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 712
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
poly-tussin
chlorcyclizine hcl/codeine
phosphate
ADD UM: GENDER
Female
06/25/2014
prenaissance
prenatal vit with calcium
no.80/iron fum/folic
acid/dss/dha
ADD UM: GENDER
Female
06/25/2014
PRENAISSANCE prenatal vit/folic
NEXT-B
acid/b6/calcium carb/ginger
ADD UM: GENDER
Female
06/25/2014
prenaplus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
PRENATA
prenatal vitamins combo
no.37/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
PRENATABS FA prenatal vits with calcium
#78/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal 19
prenatal vitamins comb
no.115/iron fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal 19
prenatal vitamins comb
no.115/iron fumarate/folic
acid/dss
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/iron,carbonyl/folic acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/iron,carbonyl/folic acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/iron,carbonyl/folic acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 713
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal plus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal vitamin
plus low iron
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal vitamin
plus low iron
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
prenatal-u
prenatal vits without calc
no5/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
PRENATE AM
prenatal vitamins
no.114/methyltetrahydfolate
gluc,fa/ginger
ADD UM: GENDER
Female
06/25/2014
PRENATE DHA
prenatal vitamins no.38/iron
fumarate/folate comb
no.6/dha
ADD UM: GENDER
Female
06/25/2014
PRENATE ELITE prenatal vitamins combo
#36/ferrous fumarate/folate
combo #6
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 714
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
PRENATE ELITE prenatal vitamins combo
#36/ferrous fumarate/folate
combo #6
ADD UM: GENDER
Female
06/25/2014
PRENATE
ENHANCE
prenatal vitamin combo
no.68/iron fumarate/fa
combo no.6/dha
ADD UM: GENDER
Female
06/25/2014
PRENATE
ESSENTIAL
pnv no.35/iron
fumarate/folate comb.
#6/dha
ADD UM: GENDER
Female
06/25/2014
PRENATE MINI
prenatal vitamins
#44/iron,carbonyl/folic
acid/dha
ADD UM: GENDER
Female
06/25/2014
PRENATE
RESTORE
prenatal vitamins combo
no.69/iron fumarate/fa comb
no.6/dha
ADD UM: GENDER
Female
06/25/2014
preplus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
preplus
prenatal vits with calcium
#72/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
PREPOPIK
sodium
picosulfate/magnesium
oxide/citric acid
ADD UM: GENDER
Female
06/25/2014
PREPOPIK
sodium
picosulfate/magnesium
oxide/citric acid
ADD UM: GENDER
Female
06/25/2014
PRESERA
emollient combination no.80
ADD UM: GENDER
Female
06/25/2014
PREVACID
lansoprazole
ADD UM: GENDER
Female
06/25/2014
STIVARGA
regorafenib
ADD UM: GENDER
Male
06/25/2014
STIVARGA
regorafenib
ADD UM: GENDER
Male
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 715
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
STRATTERA
atomoxetine hcl
ADD UM: GENDER
Male
06/25/2014
TEVETEN HCT
eprosartan
mesylate/hydrochlorothiazid
e
ADD UM: GENDER
Male
06/25/2014
TEVETEN HCT
eprosartan
mesylate/hydrochlorothiazid
e
ADD UM: GENDER
Male
06/25/2014
tl-select
prenatal vit with calcium
no.80/iron fum/folic
acid/dss/dha
ADD UM: GENDER
Female
06/25/2014
TL-SELECT DHA prenatal vitamin no.57/iron
fum/folic acid/dss/dha
ADD UM: GENDER
Female
06/25/2014
TOBI
PODHALER
tobramycin
ADD UM: GENDER
Female
06/25/2014
TOBI
PODHALER
tobramycin
ADD UM: GENDER
Female
06/25/2014
TOBI
PODHALER
tobramycin
ADD UM: GENDER
Female
06/25/2014
TRETIN-X
tretinoin
ADD UM: GENDER
Male
06/25/2014
TRETIN-X
tretinoin/emollient
combination no. 9/skin cln1
ADD UM: GENDER
Male
06/25/2014
triveen-prx rnf
prenatal vit with calcium
no.66/iron fum/folic
acid/dss/dha
ADD UM: GENDER
Female
06/25/2014
triveen-prx rnf
prenatal vit with calcium
no.66/iron fum/folic
acid/dss/dha
ADD UM: GENDER
Female
06/25/2014
triveen-u
prenatal vits without calc
no5/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 716
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
tri-vitamin with
fluoride
pediatric multivit with a,c,d3
no.21/sodium fluoride
ADD UM: GENDER
Female
06/25/2014
tri-vitamin with
fluoride
pediatric multivit with a,c,d3
no.21/sodium fluoride
ADD UM: GENDER
Female
06/25/2014
TROKENDI XR
topiramate
ADD UM: GENDER
Female
06/25/2014
VERAMYST
fluticasone furoate
ADD UM: GENDER
Female
06/25/2014
VIRASAL
salicylic acid
ADD UM: GENDER
Female
06/25/2014
virt-select
prenatal vit with calcium
no.80/iron fum/folic
acid/dss/dha
ADD UM: GENDER
Female
06/25/2014
VITAMEDMD
REDICHEW RX
prenatal vitamins
combination no.42/folic acid
ADD UM: GENDER
Female
06/25/2014
vol-plus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
ADD UM: GENDER
Female
06/25/2014
XALATAN
latanoprost
ADD UM: GENDER
Female
06/25/2014
XALKORI
crizotinib
ADD UM: GENDER
Female
06/25/2014
YAZ
ethinyl
estradiol/drospirenone
ADD UM: GENDER
Female
06/25/2014
zaleplon
zaleplon
ADD UM: GENDER
Female
06/25/2014
zaleplon
zaleplon
ADD UM: GENDER
Female
06/25/2014
zaleplon
zaleplon
ADD UM: GENDER
Female
06/25/2014
ACTEMRA
tocilizumab
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ACTIVE FE
iron,carbonyl/folic
acid/multivitamin with
minerals
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ACTIVE OB
prenatal vitamins combo
no.66/iron,carbonyl/folic
acid/dha
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 717
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
ACTIVELLA
estradiol/norethindrone
acetate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
alanine
alanine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
alanine
alanine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ALREX
loteprednol etabonate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ALREX
loteprednol etabonate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ALREX
loteprednol etabonate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ARICEPT
donepezil hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ARICEPT
donepezil hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ARIXTRA
fondaparinux sodium
ADD UM: AUTHORIZATION
PA applies
06/25/2014
AURSTAT
sod mag
ADD UM: AUTHORIZATION
fluorosilic/cyclometh/phosph
ac/sod bicarb/sod chlor
PA applies
06/25/2014
AURSTAT
emol#53/na mg
ADD UM: AUTHORIZATION
fluorosilicate/cyclometh/pho
sph ac/nahco3/nacl
PA applies
06/25/2014
AVINZA
morphine sulfate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
BENEFIX
factor ix human recombinant ADD UM: AUTHORIZATION
PA applies
06/25/2014
BENEFIX
factor ix human recombinant ADD UM: AUTHORIZATION
PA applies
06/25/2014
BENZEFOAM
benzoyl peroxide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
BENZEFOAM
benzoyl peroxide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
BENZEFOAM
ULTRA
benzoyl peroxide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
BETASERON
interferon beta-1b
ADD UM: AUTHORIZATION
PA applies
06/25/2014
BETASERON
interferon beta-1b
ADD UM: AUTHORIZATION
PA applies
06/25/2014
BEYAZ
drospirenone/ethinyl
estradiol/levomefolate
calcium
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 718
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
BEYAZ
drospirenone/ethinyl
estradiol/levomefolate
calcium
ADD UM: AUTHORIZATION
PA applies
06/25/2014
BIAXIN XL
clarithromycin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
bp foam
benzoyl peroxide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
bp foam
benzoyl peroxide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
bp foam
benzoyl peroxide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
BREVICON
norethindrone-ethinyl
estradiol
ADD UM: AUTHORIZATION
PA applies
06/25/2014
CEDAX
ceftibuten
ADD UM: AUTHORIZATION
PA applies
06/25/2014
chemstrip 10 with urine multiple test strips
sg
ADD UM: AUTHORIZATION
PA applies
06/25/2014
cyclopentolate
hcl
cyclopentolate hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
EYLEA
aflibercept
ADD UM: AUTHORIZATION
PA applies
06/25/2014
E-Z DISK
barium sulfate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ez smart plus
blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ez smart
blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
FIRSTlansoprazole
LANSOPRAZOL
E
ADD UM: AUTHORIZATION
PA applies
06/25/2014
FIRSTlansoprazole
LANSOPRAZOL
E
ADD UM: AUTHORIZATION
PA applies
06/25/2014
FOLLISTIM AQ
follitropin beta,recomb
ADD UM: AUTHORIZATION
PA applies
06/25/2014
FOLLISTIM AQ
follitropin beta,recomb
ADD UM: AUTHORIZATION
PA applies
06/25/2014
foltanx
mecobalamin/levomefolate ADD UM: AUTHORIZATION
calcium/pyridoxal phosphate
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 719
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
FOLTX
cyanocobalamin/levomefolat ADD UM: AUTHORIZATION
e calcium/pyridoxine hcl
PA applies
06/25/2014
FORFIVO XL
bupropion hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
FOSAMAX PLUS alendronate
D
sodium/cholecalciferol
(vitamin d3)
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GLYTACTIN 15 nutritional therapy for pku
PE BETTERMILK with iron no.41
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GLYTACTIN RTD nutritional therapy for pku
10 PE
with iron no.41
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GLYTACTIN RTD nutritional therapy for pku
10 PE
with iron no.41
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GLYTACTIN RTD nutritional therapy for pku
15 PE
with iron no.41
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GLYTACTIN RTD nutritional therapy for pku
15 PE
with iron no.41
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GRALISE
gabapentin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GRALISE
gabapentin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GRALISE
gabapentin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GRALISE
gabapentin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GRANIX
tbo-filgrastim
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GRANIX
tbo-filgrastim
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GRANIX
tbo-filgrastim
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GRANIX
tbo-filgrastim
ADD UM: AUTHORIZATION
PA applies
06/25/2014
GRASTEK
allergenic extract,grass
pollen-timothy,standard
ADD UM: AUTHORIZATION
PA applies
06/25/2014
HELIXATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 720
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
HELIXATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
HELIXATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
HELIXATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
HELIXATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
hema-combistix
urine multiple test strips
ADD UM: AUTHORIZATION
PA applies
06/25/2014
hemenatal ob +
dha
prenatal vitamin combo
ADD UM: AUTHORIZATION
no.22/iron/folic acid/omega3/dha
PA applies
06/25/2014
hemenatal ob
prenatal vit no.21/iron
polysacch,heme
polypep/folic acid
ADD UM: AUTHORIZATION
PA applies
06/25/2014
hpr plus
emollient combination no.53 ADD UM: AUTHORIZATION
PA applies
06/25/2014
hpr plus
emollient combination no.53 ADD UM: AUTHORIZATION
PA applies
06/25/2014
hpr plus-mb
hydrogel
emol53/e.water/namgfs/nap ADD UM: AUTHORIZATION
hos/nacl/hypochlorous
acid/nahypocl
PA applies
06/25/2014
HUMATROPE
somatropin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
HUMATROPE
somatropin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
HYCET
hydrocodone
bitartrate/acetaminophen
ADD UM: AUTHORIZATION
PA applies
06/25/2014
HYDREA
hydroxyurea
ADD UM: AUTHORIZATION
PA applies
06/25/2014
hydrocodonehydrocodone
chlorpheniramne polistirex/chlorpheniramine
er
polistirex
ADD UM: AUTHORIZATION
PA applies
06/25/2014
IMBRUVICA
ADD UM: AUTHORIZATION
PA applies
ibrutinib
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 721
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
06/25/2014
INFERGEN
06/25/2014
Generic Name
interferon alfacon-1
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
infinity test strips blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
infinity test strips blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
INLYTA
axitinib
ADD UM: AUTHORIZATION
PA applies
06/25/2014
INVEGA
SUSTENNA
paliperidone palmitate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
INVEGA
SUSTENNA
paliperidone palmitate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
INVOKANA
canagliflozin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
INVOKANA
canagliflozin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
INVOKANA
canagliflozin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
JAKAFI
ruxolitinib phosphate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
JAKAFI
ruxolitinib phosphate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
JENTADUETO
linagliptin/metformin hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
JENTADUETO
linagliptin/metformin hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
JENTADUETO
linagliptin/metformin hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
jinteli
norethindrone acetateethinyl estradiol
ADD UM: AUTHORIZATION
PA applies
06/25/2014
KADIAN
morphine sulfate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
KADIAN
morphine sulfate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
KARBINAL ER
carbinoxamine maleate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
KAZANO
alogliptin
benzoate/metformin hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
KOATE-DVI
antihemophilic factor,
human
ADD UM: AUTHORIZATION
PA applies
06/25/2014
KOATE-DVI
antihemophilic factor,
human
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 722
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KOGENATE FS
antihemophilic factor (fviii)
ADD UM: AUTHORIZATION
recomb,full length (alb-free)
PA applies
06/25/2014
KORLYM
mifepristone
ADD UM: AUTHORIZATION
PA applies
06/25/2014
KORLYM
mifepristone
ADD UM: AUTHORIZATION
PA applies
06/25/2014
KRISTALOSE
lactulose
ADD UM: AUTHORIZATION
PA applies
06/25/2014
l-alanine
alanine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
l-alanine
alanine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
matzim la
diltiazem hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
matzim la
diltiazem hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
METADATE CD
methylphenidate hcl
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 723
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
METADATE CD
methylphenidate hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
MYRBETRIQ
mirabegron
ADD UM: AUTHORIZATION
PA applies
06/25/2014
NEEVODHA
prenatal no.64/iron fum/lmefolate ca/algal oil/soy
lecithin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
NORDITROPIN
NORDIFLEX
somatropin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
NORINYL 1+50
norethindrone-mestranol
ADD UM: AUTHORIZATION
PA applies
06/25/2014
normlgel ag
silver carbonate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
NOROXIN
norfloxacin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
omeprazolesodium
bicarbonate
omeprazole/sodium
bicarbonate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OMNITROPE
somatropin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OMNITROPE
somatropin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
onetouch ultra
test strips
blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
onetouch ultra
test strips
blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
onetouch ultra
test strips
blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ONMEL
itraconazole
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ONMEL
itraconazole
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OPANA
oxymorphone hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ORENITRAM ER treprostinil diolamine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ORENITRAM ER treprostinil diolamine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OTREXUP
methotrexate/pf
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OTREXUP
methotrexate/pf
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 724
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
OTREXUP
methotrexate/pf
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OTREXUP
methotrexate/pf
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OTREXUP
methotrexate/pf
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OVCON-35
norethindrone-ethinyl
estradiol
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OVIDREL
choriogonadotropin alfa
ADD UM: AUTHORIZATION
PA applies
06/25/2014
OXECTA
oxycodone hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
oxycodone hcl
oxycodone hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
POMALYST
pomalidomide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
POMALYST
pomalidomide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
POMALYST
pomalidomide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
POMALYST
pomalidomide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
POMALYST
pomalidomide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
POTIGA
ezogabine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
POTIGA
ezogabine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
POTIGA
ezogabine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
prodigy no coding blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
prodigy no coding blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
PROMACTA
eltrombopag olamine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
PROMACTA
eltrombopag olamine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
PRO-RED AC
dexchlorpheniramine
maleate/phenylephrine
hcl/codeine,pyrilamine
maleate/phenylephrine
hcl/codeine phosphate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
PROSCAR
finasteride
ADD UM: AUTHORIZATION
PA applies
06/25/2014
PROSCAR
finasteride
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 725
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
06/25/2014
REBETOL
06/25/2014
Generic Name
ribavirin
Type of Change
Previous Value
New Value
ADD UM: AUTHORIZATION
PA applies
RECOMBINATE antihemophilic factor viii,
human recombinant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBINATE antihemophilic factor viii,
human recombinant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBIVAX
HB
hepatitis b virus vaccine
recombinant/pf
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBIVAX
HB
hepatitis b virus vaccine
recombinant/pf
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBIVAX
HB
hepatitis b virus vaccine
recombinant/pf
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBIVAX
HB
hepatitis b virus vaccine
recombinant/pf
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RECOMBIVAX
HB
hepatitis b virus vaccine
recombinant/pf
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RELENZA
zanamivir
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RELENZA
zanamivir
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RELENZA
zanamivir
ADD UM: AUTHORIZATION
PA applies
06/25/2014
REMODULIN
treprostinil sodium
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 726
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
REMODULIN
treprostinil sodium
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RENVELA
sevelamer carbonate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RENVELA
sevelamer carbonate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RENVELA
sevelamer carbonate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
REZYST
saccharomyces boulardii
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RHEUMATE
methyltetrahydrofolate
gluc/mecobalamin/herbal
no.236
ADD UM: AUTHORIZATION
PA applies
06/25/2014
RHINOCORT
AQUA
budesonide
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SALVAX DUO
PLUS
salicylic acid/urea
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SANCTURA
trospium chloride
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SANDIMMUNE
cyclosporine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SOMAVERT
pegvisomant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SOMAVERT
pegvisomant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SOMAVERT
pegvisomant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SOMAVERT
pegvisomant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SOMAVERT
pegvisomant
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SONATA
zaleplon
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SONATA
zaleplon
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SONATA
zaleplon
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SPORANOX
itraconazole
ADD UM: AUTHORIZATION
PA applies
06/25/2014
STENDRA
avanafil
ADD UM: AUTHORIZATION
PA applies
06/25/2014
STENDRA
avanafil
ADD UM: AUTHORIZATION
PA applies
06/25/2014
STRATTERA
atomoxetine hcl
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 727
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
STRATTERA
atomoxetine hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SUBOXONE
buprenorphine hcl/naloxone ADD UM: AUTHORIZATION
hcl
PA applies
06/25/2014
SYLATRON
peginterferon alfa-2b
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SYLATRON
peginterferon alfa-2b
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SYMLINPEN 120 pramlintide acetate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SYMLINPEN 60
pramlintide acetate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
SYNALAR
fluocinolone
acetonide/emollient
combination no.65
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TAMIFLU
oseltamivir phosphate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TAMIFLU
oseltamivir phosphate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TARGRETIN
bexarotene
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TARKA
trandolapril/verapamil hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TARKA
trandolapril/verapamil hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TECFIDERA
dimethyl fumarate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TEGRETOL XR
carbamazepine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TEGRETOL XR
carbamazepine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
THEO-24
theophylline anhydrous
ADD UM: AUTHORIZATION
PA applies
06/25/2014
THEO-24
theophylline anhydrous
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TOPAMAX
topiramate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TOPAMAX
topiramate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
TOPAMAX
topiramate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ultima
blood sugar diagnostic
ADD UM: AUTHORIZATION
PA applies
06/25/2014
VIDEX
didanosine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
VIDEX EC
didanosine
ADD UM: AUTHORIZATION
PA applies
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 728
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/25/2014
VINATE DHA RF prenatal no.64/iron fum/lmefolate ca/algal oil/soy
lecithin
ADD UM: AUTHORIZATION
PA applies
06/25/2014
VIRAMUNE XR
nevirapine
ADD UM: AUTHORIZATION
PA applies
06/25/2014
XELJANZ
tofacitinib citrate
ADD UM: AUTHORIZATION
PA applies
06/25/2014
XERESE
acyclovir/hydrocortisone
ADD UM: AUTHORIZATION
PA applies
06/25/2014
YASMIN 28
ethinyl
estradiol/drospirenone
ADD UM: AUTHORIZATION
PA applies
06/25/2014
YAZ
ethinyl
estradiol/drospirenone
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ZONALON
doxepin hcl
ADD UM: AUTHORIZATION
PA applies
06/25/2014
ZYVOX
linezolid
ADD UM: AUTHORIZATION
PA applies
06/26/2014
ROBAXIN
methocarbamol
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
cosyntropin
cosyntropin
CHANGE TIER
Generics
Not Covered
06/26/2014
cosyntropin
cosyntropin
CHANGE TIER
Generics
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
VANIQA
eflornithine hcl
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
VASCEPA
icosapent ethyl
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
ROBAXIN
methocarbamol
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
kendall 0.9% nacl 0.9 % sodium chloride
with cap
CHANGE TIER
Generics
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
ARISTOSPAN
triamcinolone hexacetonide
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
VAYACOG
phosphatidyl serine/omega3 fatty acids/dha/epa
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 729
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
LATISSE
bimatoprost
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
BOTOX
COSMETIC
onabotulinumtoxina
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
ARISTOSPAN
triamcinolone hexacetonide
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
VAYAROL
phytosterol/omega-3 fatty
acids/dha/epa/fish oil
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
kendall 0.9% nacl 0.9 % sodium chloride
with cap
CHANGE TIER
Generics
Not Covered
06/26/2014
cosyntropin
cosyntropin
CHANGE TIER
Generics
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
cosyntropin
cosyntropin
CHANGE TIER
Generics
Not Covered
06/26/2014
CATHFLO
ACTIVASE
alteplase
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
VASCULERA
diosmin complex no.1
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
ARISTOSPAN
triamcinolone hexacetonide
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
kendall 0.9% nacl 0.9 % sodium chloride
with cap
CHANGE TIER
Generics
Not Covered
06/26/2014
VAYARIN
phosphatidyl serine/omega3 fatty acids/dha/epa
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
oxytocin
oxytocin
CHANGE TIER
Generics
Not Covered
06/26/2014
cosyntropin
cosyntropin
CHANGE TIER
Generics
Not Covered
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 730
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
CATHFLO
ACTIVASE
alteplase
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
VANIQA
eflornithine hcl
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
LATISSE
bimatoprost
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
LATISSE
bimatoprost
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
cosyntropin
cosyntropin
CHANGE TIER
Generics
Not Covered
06/26/2014
VENELEX
balsam peru/castor oil
CHANGE TIER
Preferred Brands
Not Covered
06/26/2014
FIRAZYR
icatibant acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
temazepam
temazepam
CHANGE TIER
06/26/2014
FIRAZYR
icatibant acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FANAPT
iloperidone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KALBITOR
ecallantide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DENAVIR
penciclovir
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
temazepam
temazepam
CHANGE TIER
06/26/2014
SYNALAR
fluocinolone
acetonide/emollient
combination no.65
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OSPHENA
ospemifene
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PROTOPIC
tacrolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ACIPHEX
SPRINKLE
rabeprazole sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lortab
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LANOXIN
digoxin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SUBOXONE
buprenorphine hcl/naloxone
hcl
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 731
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
SUBOXONE
buprenorphine hcl/naloxone
hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FANATREX
gabapentin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lortab
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
adipex-p
phentermine hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ZYFLO
zileuton
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PEXEVA
paroxetine mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
vol-plus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
CHANGE TIER
06/26/2014
FEMHRT
norethindrone acetateethinyl estradiol
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EXELDERM
sulconazole nitrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
POLIBAR ACB
barium sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
POLIBAR ACB
barium sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYSTOLIC
nebivolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
dynacin
minocycline hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
RAPAFLO
silodosin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
POLY-VI-FLOR
WITH IRON
pediatric multivitamin
no.33/sodium fluoride/iron
carbonyl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
MIRAPEX ER
pramipexole di-hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ATRAPRO
HYDROGEL
emollient combination no.60
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 732
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
ONGLYZA
saxagliptin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TIKOSYN
dofetilide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SILVRSTAT
silver
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TIKOSYN
dofetilide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SPRIX
ketorolac tromethamine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SILVRSTAT
silver
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NAPRELAN
naproxen sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZORBTIVE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CLARINEX-D 24 desloratadine/pseudoephedr
HOUR
ine sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EXFORGE
amlodipine
besylate/valsartan
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OSENI
alogliptin
benzoate/pioglitazone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SPRIX
ketorolac tromethamine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VENTAVIS
iloprost tromethamine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
THEO-24
theophylline anhydrous
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NALFON
fenoprofen calcium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EXFORGE HCT
amlodipine
besylate/valsartan/hydrochlo
rothiazide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
REZYST IM
lactobacillus
acidophilus/bifidobacterium
bifidum/b. longum
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
QUFLORA
pediatric multivitamin no.63
with sodium fluoride
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 733
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
PROTONIX
pantoprazole sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PROTONIX
pantoprazole sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
TRACLEER
bosentan
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PROTOPIC
tacrolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ULTRAVATE X
halobetasol propionate/lactic
acid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TRACLEER
bosentan
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CARAC
fluorouracil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ASTAGRAF XL
tacrolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AMRIX
cyclobenzaprine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VIIBRYD
vilazodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
KERAFOAM
urea
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ULTRAVATE
PAC
halobetasol
propionate/ammonium
lactate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DEMEROL
meperidine hcl/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CARNITOR SF
levocarnitine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYSTOLIC
nebivolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
JUVISYNC
sitagliptin
phosphate/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
HORIZANT
gabapentin enacarbil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 734
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
JUVISYNC
sitagliptin
phosphate/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
INFERGEN
interferon alfacon-1
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RAPAFLO
silodosin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NORDITROPIN
FLEXPRO
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LAMICTAL XR
(GREEN)
lamotrigine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TIKOSYN
dofetilide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZOLPIMIST
zolpidem tartrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SAVELLA
milnacipran hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RIFATER
rifampin/isoniazid/pyrazinam
ide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
LAMISIL
terbinafine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LAMISIL
terbinafine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CYTOSE
ribose
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ESCAVITE LQ
pediatric multivitamin no.86
with iron & sodium fluoride
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tramadol hcl er
tramadol hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SYNERA
lidocaine/tetracaine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tri-vitamin with
fluoride
pediatric multivit with a,c,d3
no.21/sodium fluoride
CHANGE TIER
06/26/2014
FABIOR
tazarotene
CHANGE TIER
06/26/2014
vol-plus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
CHANGE TIER
06/26/2014
FABIOR
tazarotene
CHANGE TIER
Non-Formulary
Preferred Brands
Non-Formulary
Non-Formulary
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 735
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
z-pram
hydrocortisone
acetate/pramoxine hcl/skin
cleanser no.16
CHANGE TIER
Generics
Non-Formulary
06/26/2014
NYMALIZE
nimodipine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FACTIVE
gemifloxacin mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ERIVEDGE
vismodegib
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FACTIVE
gemifloxacin mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
06/26/2014
lofibra
fenofibrate
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ADDERALL
dextroamphetamine sulfsaccharate/amphetamine
sulf-aspartate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ACTOPLUS MET pioglitazone hcl/metformin
XR
hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morgidox
doxycycline hyclate
CHANGE TIER
Generics
Non-Formulary
06/26/2014
tri-vitamin with
fluoride
pediatric multivit with a,c,d3
no.21/sodium fluoride
CHANGE TIER
Generics
Non-Formulary
06/26/2014
avar-e
sulfacetamide sodium/sulfur
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OPSUMIT
macitentan
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MAXIDONE
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
hecoria
tacrolimus
CHANGE TIER
Generics
Non-Formulary
06/26/2014
AZASITE
azithromycin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
LAMISIL
CHANGE TIER
Preferred Brands
Non-Formulary
terbinafine hcl
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 736
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
vicodin
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ZORVOLEX
diclofenac submicronized
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RANEXA
ranolazine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
PACNEX LP
benzoyl peroxide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ALDACTAZIDE
spironolactone/hydrochlorot
hiazide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CARDIZEM LA
diltiazem hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
JUVISYNC
sitagliptin
phosphate/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lofibra
fenofibrate,micronized
CHANGE TIER
06/26/2014
OPSUMIT
macitentan
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RESPA A.R.
pseudoephedrine
hcl/chlorpheniramine
maleate/bellad alk
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
AURSTAT
sod mag
fluorosilic/cyclometh/phosph
ac/sod bicarb/sod chlor
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VENTAVIS
iloprost tromethamine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NEXIUM
esomeprazole magnesium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
virt-vite forte
cyanocobalamin/folic
acid/pyridoxine
CHANGE TIER
Generics
Non-Formulary
06/26/2014
GLYCATE
glycopyrrolate
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 737
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Non-Formulary
06/26/2014
ATRAPRO CP
emollient combination
no.47/emollient combination
no.60
CHANGE TIER
06/26/2014
tl-care dha
pnv no.20/iron
fumarate/fa/docusate na/fish
oil conc/dha/epa
CHANGE TIER
06/26/2014
SORILUX
calcipotriene
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SORILUX
calcipotriene
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CELESTONE
betamethasone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LIPTRUZET
ezetimibe/atorvastatin
calcium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VIIBRYD
vilazodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LANOXIN
PEDIATRIC
digoxin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NUCYNTA
tapentadol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
NUCYNTA
tapentadol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DUET DHA
prenatal vitamin no.106/sod
ferede-iron
poly/fa/om3/dha/epa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LAMICTAL ODT
lamotrigine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GILENYA
fingolimod hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GESTICARE
DHA
prenatal vit with calcium
#60/iron/folic acid/dha
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYSTOLIC
nebivolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MAXARON
FORTE
iron glycin,sulfumu/vitc/b12/methyltetrahy
drofolate calcium
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 738
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
LAMICTAL ODT
(ORANGE)
lamotrigine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CORVITE FE
iron,carbonyl/methyltetrahyd
rofolate gluc,fa/mv, min
no.40
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
AZASITE
azithromycin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MAXAIR
AUTOHALER
pirbuterol acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXISTAT
oxiconazole nitrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ICLUSIG
ponatinib hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SAVELLA
milnacipran hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZAVESCA
miglustat
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZENZEDI
dextroamphetamine sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MAXIDONE
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EPICERAM
emollient combination no.32
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
vol-plus
prenatal vits with calcium
#74/ferrous fumarate/folic
acid
CHANGE TIER
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SYNERA
lidocaine/tetracaine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
AZOPT
brinzolamide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXTELLAR XR
oxcarbazepine
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 739
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
REZYST IM
lactobacillus
acidophilus/bifidobacterium
bifidum/b. longum
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OVIDREL
choriogonadotropin alfa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TOZAL
multivitamin-minerals
no.22/lutein/omega3/dha/epa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LIPTRUZET
ezetimibe/atorvastatin
calcium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DEMEROL
meperidine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BOTOX
onabotulinumtoxina
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AZOPT
brinzolamide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tizanidine hcl
tizanidine hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
NORPACE CR
disopyramide phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FINACEA PLUS
azelaic acid/ceramides
(1,3,6-11)
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EXELDERM
sulconazole nitrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZORTRESS
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lorcet hd
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
INOVA
benzoyl peroxide/vitamin e
mixed
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
vicodin
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ZORTRESS
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
HORIZANT
gabapentin enacarbil
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 740
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
JUVISYNC
sitagliptin
phosphate/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TROPAZONE
emollient combination no.48
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RIAX
benzoyl peroxide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PREVACID
lansoprazole
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FOLLISTIM AQ
follitropin beta,recomb
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GILOTRIF
afatinib dimaleate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ACTIVE FE
iron,carbonyl/folic
acid/multivitamin with
minerals
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TAFINLAR
dabrafenib mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SAIZEN
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
REZYST
saccharomyces boulardii
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MEKINIST
trametinib dimethyl sulfoxide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
vicodin es
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SUBSYS
fentanyl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NORPACE CR
disopyramide phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VESICARE
solifenacin succinate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ORAPRED ODT prednisolone sod phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morgidox
doxycycline hyclate
CHANGE TIER
Generics
Non-Formulary
06/26/2014
EXELON
rivastigmine tartrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FOSAMAX PLUS alendronate
D
sodium/cholecalciferol
(vitamin d3)
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TRADJENTA
linagliptin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
STRATTERA
atomoxetine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 741
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
VESICARE
solifenacin succinate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CARAC
fluorouracil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
UCERIS
budesonide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LAMICTAL
lamotrigine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OSENI
alogliptin
benzoate/pioglitazone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FAZACLO
clozapine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
JAKAFI
ruxolitinib phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
dynacin
minocycline hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
NEXIUM
esomeprazole magnesium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VIRT-VITE PLUS folic acid/vitamin b complex
with vitamin c no.17
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PRENATE ELITE prenatal vitamins combo
#36/ferrous fumarate/folate
combo #6
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
vicodin hp
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SILENOR
doxepin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
INNOPRAN XL
propranolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TRADJENTA
linagliptin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OB COMPLETE
PETITE
prenatal no56/iron
carbonyl,asparto
glycinate/folic acid/dha
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KRISTALOSE
lactulose
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SIGNIFOR
pasireotide diaspartate
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 742
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
CENESTIN
estrogens,conj.,synthetic a
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FETZIMA
levomilnacipran hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AVAR LS
sulfacetamide sodium/sulfur
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TROKENDI XR
topiramate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SIMCOR
niacin/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SILENOR
doxepin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LANOXIN
digoxin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GLUTARADE
GA-1
nutritional therapy, glutaric
aciduria 1/flaxseed/fiber
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CUVPOSA
glycopyrrolate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PAXIL
paroxetine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lorcet
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OTREXUP
methotrexate/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OTREXUP
methotrexate/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
temazepam
temazepam
CHANGE TIER
06/26/2014
tramadol hcl er
tramadol hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
CENESTIN
estrogens,conj.,synthetic a
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
TROKENDI XR
topiramate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TARKA
trandolapril/verapamil hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LOESTRIN 24
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TRIGLIDE
fenofibrate nanocrystallized
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
THYROLAR-3
liotrix
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 743
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
INVOKANA
canagliflozin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LO LOESTRIN
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CETACAINE
ANESTHETIC
tetracaine/benzocaine/buta
mben
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ALTOPREV
lovastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CETACAINE
ANESTHETIC
tetracaine/benzocaine/buta
mben
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tramadol hcl er
tramadol hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
GLYTACTIN 10 nutritional therapy for pku
PE BETTERMILK with iron no.41
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NESTABS
prenatal vitamin no.86/iron
bis-glycinate/folic acid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LIPTRUZET
ezetimibe/atorvastatin
calcium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SYNALAR
fluocinolone
acetonide/emollient
combination no.65
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SELRX
selenium sulfide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KERAFOAM
urea
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NYMALIZE
nimodipine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LIPTRUZET
ezetimibe/atorvastatin
calcium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DUET DHA EC
prenatal vitamin no.107/sod
ferede-iron
poly/fa/om3/dha/epa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
THYROLAR-1/2
liotrix
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FULYZAQ
crofelemer
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 744
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
EXFORGE HCT
amlodipine
besylate/valsartan/hydrochlo
rothiazide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NYMALIZE
nimodipine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
THEO-24
theophylline anhydrous
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
temazepam
temazepam
CHANGE TIER
06/26/2014
FANAPT
iloperidone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SAVELLA
milnacipran hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZYDONE
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RECTIV
nitroglycerin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NESTABS ABC
prenatal vitamin comb
no.86/iron ps cmplx/folic
acid/dha/epa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
06/26/2014
KERAFOAM
urea
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EDECRIN
ethacrynic acid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TRADJENTA
linagliptin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SUBSYS
fentanyl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SIGNIFOR
pasireotide diaspartate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
INVEGA
paliperidone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZORTRESS
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TOPICORT
desoximetasone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AFINITOR
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SYMLINPEN 120 pramlintide acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NUCYNTA ER
CHANGE TIER
Preferred Brands
Non-Formulary
tapentadol hcl
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 745
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
SUBSYS
fentanyl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
JUVISYNC
sitagliptin
phosphate/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FLO-PRED
prednisolone acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NAPRELAN
naproxen sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AFINITOR
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SUMAVEL
DOSEPRO
sumatriptan succinate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
LIPTRUZET
ezetimibe/atorvastatin
calcium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
vicodin es
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
PRENATE
ENHANCE
prenatal vitamin combo
no.68/iron fumarate/fa
combo no.6/dha
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lofibra
fenofibrate,micronized
CHANGE TIER
06/26/2014
VALCYTE
valganciclovir hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CLINDACIN PAC clindamycin phosphate/skin
cleanser comb no.19
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZMAX
azithromycin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CORVITE 150
iron,carbonyl/methyltetrahyd
rofolate gluc,fa/mv, min
no.41
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AROMASIN
exemestane
06/26/2014
PROTOPIC
tacrolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EGRIFTA
tesamorelin acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CARDIZEM LA
diltiazem hcl
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
ADD TO FORMULARY
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 746
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
vicodin hp
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
AFINITOR
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OMECLAMOXPAK
omeprazole/clarithromycin/a
moxicillin trihydrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PRENATE AM
prenatal vitamins
no.114/methyltetrahydfolate
gluc,fa/ginger
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FETZIMA
levomilnacipran hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZYTIGA
abiraterone acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TARGRETIN
bexarotene
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
mirtazapine
mirtazapine
CHANGE TIER
06/26/2014
ARCALYST
rilonacept
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EURAX
crotamiton
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PRENATE
ESSENTIAL
pnv no.35/iron
fumarate/folate comb.
#6/dha
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ONGLYZA
saxagliptin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
JUVISYNC
sitagliptin
phosphate/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FOLLISTIM AQ
follitropin beta,recomb
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 747
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
iron/folate no.8/ps-dha/psepa/fad/nadh/betaine/multivi
t #47
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ENLYTE
06/26/2014
VICTOZA 2-PAK liraglutide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VICTOZA 3-PAK liraglutide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FROVA
frovatriptan succinate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FAZACLO
clozapine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tl-care dha
pnv no.20/iron
fumarate/fa/docusate na/fish
oil conc/dha/epa
CHANGE TIER
06/26/2014
KOMBIGLYZE
XR
saxagliptin hcl/metformin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SUMAVEL
DOSEPRO
sumatriptan succinate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LEVITRA
vardenafil hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ORBIVAN
butalbital/acetaminophen/caf
feine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lindane
lindane
CHANGE TIER
06/26/2014
SUBSYS
fentanyl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ibudone
hydrocodone/ibuprofen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
AFINITOR
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
zenzedi
dextroamphetamine sulfate
CHANGE TIER
Generics
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
AVAR LS
sulfacetamide sodium/sulfur
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TARGRETIN
bexarotene
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TOPICORT
desoximetasone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TOPICORT
desoximetasone
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 748
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
SUBSYS
fentanyl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TOPICORT
desoximetasone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tizanidine hcl
tizanidine hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
PRENATE ELITE prenatal vitamins combo
#36/ferrous fumarate/folate
combo #6,prenatal vitamins
no.79/ferrous aspart
glycinate/folate no.1
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LIPTRUZET
ezetimibe/atorvastatin
calcium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GRALISE
gabapentin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CARDIZEM LA
diltiazem hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ONFI
clobazam
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NOROXIN
norfloxacin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FANAPT
iloperidone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BRINTELLIX
vortioxetine hydrobromide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
pacerone
amiodarone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
MYRBETRIQ
mirabegron
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FML FORTE
fluorometholone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OB COMPLETE
ONE
pnv no.85/iron
carb,aspart.glycinate/folic
acid/dha/fish oil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VIDEX
didanosine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KRISTALOSE
lactulose
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 749
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
THYROLAR-1/4
liotrix
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
JENTADUETO
linagliptin/metformin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NORDITROPIN
FLEXPRO
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SAVELLA
milnacipran hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GRALISE
gabapentin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
STAXYN
vardenafil hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NORINYL 1+50
norethindrone-mestranol
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SILENOR
doxepin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AFINITOR
DISPERZ
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
PRILOSEC
omeprazole magnesium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
COSOPT PF
dorzolamide hcl/timolol
maleate/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
mirtazapine
mirtazapine
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FACTIVE
gemifloxacin mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FML FORTE
fluorometholone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FACTIVE
gemifloxacin mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYSTOLIC
nebivolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 750
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
TECFIDERA
dimethyl fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SOVALDI
sofosbuvir
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GLYTACTIN 15 nutritional therapy for pku
PE BETTERMILK with iron no.41
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZEGERID
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AMRIX
cyclobenzaprine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GRALISE
gabapentin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EDARBI
azilsartan medoxomil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ARICEPT
donepezil hcl
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
INTERMEZZO
zolpidem tartrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CORTANE-B
hydrocortisone/pramoxine
hcl/chloroxylenol
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CENTANY AT
mupirocin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
STENDRA
avanafil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
mirtazapine
mirtazapine
CHANGE TIER
06/26/2014
SUBSYS
fentanyl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RAPAMUNE
sirolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TYVASO REFILL treprostinil/nebulizer
KIT
accessories
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
omeprazole/sodium
bicarbonate
oxycodone hcl
ADD TO FORMULARY
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 751
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
TYVASO
STARTER KIT
treprostinil/nebulizer and
accessories
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RAPAMUNE
sirolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MONUROL
fosfomycin tromethamine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CYSTARAN
cysteamine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
POTIGA
ezogabine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXISTAT
oxiconazole nitrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
HORIZANT
gabapentin enacarbil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYDUREON
exenatide microspheres
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PRENATA
prenatal vitamins combo
no.37/ferrous fumarate/folic
acid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CARDENE SR
nicardipine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FIRSThydrocortisone
HYDROCORTIS
ONE
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ENABLEX
darifenacin hydrobromide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LUXIQ
betamethasone valerate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
mirtazapine
mirtazapine
CHANGE TIER
06/26/2014
NEXA SELECT
prenatal vitamin no.58/iron
fumarate/folic acid/dss/dha
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RIOMET
metformin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RIOMET
metformin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ALTOPREV
lovastatin
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 752
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
SYLATRON 4PACK
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SYLATRON
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
rosadan
metronidazole
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SUBSYS
fentanyl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LASTACAFT
alcaftadine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VERSACLOZ
clozapine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
JUVISYNC
sitagliptin
phosphate/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lortab
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
NORPACE CR
disopyramide phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FETZIMA
levomilnacipran hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tramadol hcl er
tramadol hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ENABLEX
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
RENVELA
sevelamer carbonate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NAFTIN
naftifine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
pacerone
amiodarone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SYMLINPEN 60
pramlintide acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RENVELA
sevelamer carbonate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
darifenacin hydrobromide
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 753
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
VESICARE
solifenacin succinate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SIGNIFOR
pasireotide diaspartate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AVAR
sulfacetamide sodium/sulfur
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AFINITOR
DISPERZ
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
LORZONE
chlorzoxazone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
HALOG
halcinonide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AUBAGIO
teriflunomide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ENJUVIA
estrogens,conj.,synthetic b
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NUCORT
hydrocortisone acetate/aloe
vera
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
COSOPT PF
dorzolamide hcl/timolol
maleate/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
HELIDAC
bismuth
subsalicylate/metronidazole/
tetracycline hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
COSOPT PF
dorzolamide hcl/timolol
maleate/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYSTOLIC
nebivolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KINERET
anakinra
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PROTECT
NATAL
pnv cmb#82/iron ps
cmplx/folic acid/omega
3/dha/epa/fish oil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CEFTIN
cefuroxime axetil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
hecoria
tacrolimus
CHANGE TIER
Generics
Non-Formulary
06/26/2014
INFERGEN
interferon alfacon-1
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PLIAGLIS
lidocaine/tetracaine
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 754
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
LAMICTAL
(ORANGE)
lamotrigine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EURAX
crotamiton
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GENADUR
carbitol/equisetum
ext/ethanol/hydroxypropyl
chitosan/msm
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FORFIVO XL
bupropion hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NEXIUM
esomeprazole magnesium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FARXIGA
dapagliflozin propanediol
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EXFORGE
amlodipine
besylate/valsartan
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ONFI
clobazam
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SYNERA
lidocaine/tetracaine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PROCYSBI
cysteamine bitartrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KUVAN
sapropterin dihydrochloride
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KRISTALOSE
lactulose
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
THYROLAR-2
liotrix
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NORPACE CR
disopyramide phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LAMICTAL ODT
lamotrigine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
MAXALT
rizatriptan benzoate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AVAR
sulfacetamide sodium/sulfur
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
mirtazapine
mirtazapine
CHANGE TIER
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 755
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
MINASTRIN 24
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ENJUVIA
estrogens,conj.,synthetic b
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CEFTIN
cefuroxime axetil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OTREXUP
methotrexate/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DUET DHA
BALANCED
prenatal vitamin no.110/iron
edta
&polysaccha/fa/om3/dha/ep
a
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OTREXUP
methotrexate/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ACTOPLUS MET pioglitazone hcl/metformin
XR
hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SYNERA
lidocaine/tetracaine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LAMICTAL ODT
lamotrigine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GLUMETZA
metformin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
RIFAMATE
rifampin/isoniazid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DELZICOL
mesalamine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FYCOMPA
perampanel
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AUGMENTIN
amoxicillin/potassium
clavulanate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AUGMENTIN
amoxicillin/potassium
clavulanate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EDARBI
azilsartan medoxomil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
STRATTERA
atomoxetine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 756
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AUGMENTIN
amoxicillin/potassium
clavulanate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LANOXIN
PEDIATRIC
digoxin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MYRBETRIQ
mirabegron
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TYVASO
treprostinil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SOMAVERT
pegvisomant
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
IPRIVASK
desirudin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SOMAVERT
pegvisomant
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GIAZO
balsalazide disodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KOMBIGLYZE
XR
saxagliptin hcl/metformin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PLIAGLIS
lidocaine/tetracaine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AVAR
sulfacetamide sodium/sulfur
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ASTAGRAF XL
tacrolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tramadol hcl er
tramadol hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
VIIBRYD
vilazodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AZOR
amlodipine
besylate/olmesartan
medoxomil
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NAFTIN
naftifine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 757
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
PERFOROMIST formoterol fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OMNITROPE
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PEDIADERM HC hydrocortisone/emollient
combination no.45
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MARNATAL-F
prenatal vit with calcium
comb no.65/iron polysacch
cmplx/fa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ketodan
ketoconazole
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SOMAVERT
pegvisomant
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
THEO-24
theophylline anhydrous
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NUCYNTA ER
tapentadol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXTELLAR XR
oxcarbazepine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BRINTELLIX
vortioxetine hydrobromide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SYLATRON
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
reprexain
hydrocodone/ibuprofen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SOMAVERT
pegvisomant
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
IPRIVASK
desirudin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GLYTACTIN 15 nutritional therapy for pku
PE BETTERMILK with iron no.41
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PERCOCET
oxycodone
hcl/acetaminophen
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
STELARA
ustekinumab
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lortab
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SYLATRON 4PACK
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EMEND
aprepitant
CHANGE TIER
Preferred Brands
Non-Formulary
somatropin
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 758
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
EMEND
aprepitant
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EMEND
aprepitant
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZORTRESS
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CARDURA XL
doxazosin mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MEDIHONEY
honey
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ANGELIQ
drospirenone/estradiol
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXISTAT
oxiconazole nitrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GLYSET
miglitol
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ANGELIQ
drospirenone/estradiol
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MEDIHONEY
honey
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VEREGEN
sinecatechins
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
SUMAXIN CP
sulfacetamide
sodium/sulfur/skin cleanser
comb no.23
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CORVITE FE
iron,carbonyl/ferrous asparto
glycinate/folic acid/mvmin27
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OB COMPLETE
WITH DHA
prenatal vit no.30/iron
carbonyl,asp glyc/folic
acid/omega-3
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OMNITROPE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZENZEDI
dextroamphetamine sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 759
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
VIMOVO
naproxen/esomeprazole
magnesium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TECFIDERA
dimethyl fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SOLODYN
minocycline hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TREXIMET
sumatriptan
succinate/naproxen sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AFINITOR
DISPERZ
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ADVICOR
niacin/lovastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CANASA
mesalamine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DUET DHA EC
prenatal vitamin no.107/sod
ferede-iron
poly/fa/om3/dha/epa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MIACALCIN
calcitonin,salmon,synthetic
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ARICEPT
donepezil hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CENESTIN
estrogens,conj.,synthetic a
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KINERET
anakinra
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FOLLISTIM AQ
follitropin beta,recomb
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DEMEROL
meperidine hcl/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYSTOLIC
nebivolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NAFTIN
naftifine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CICLODAN
ciclopirox olamine/skin
cleanser combination no.28
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
avar-e
sulfacetamide sodium/sulfur
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ZOMIG ZMT
zolmitriptan
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NEXIUM
esomeprazole magnesium
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 760
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
DYMISTA
azelastine hcl/fluticasone
propionate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SOLODYN
minocycline hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MINASTRIN 24
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
MIRAPEX ER
pramipexole di-hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BEPREVE
bepotastine besilate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LYCELLE
citric/citronellyl/hydroxyprop
yl/methyl salicylate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PERCURA
choline/amino acid
#21/gaba/inositol/griffonia/gl
ucose/creat
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KORLYM
mifepristone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ADVICOR
niacin/lovastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RITALIN LA
methylphenidate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZOMIG
zolmitriptan
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
KORLYM
mifepristone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NUCYNTA
tapentadol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ADEMPAS
CHANGE TIER
Preferred Brands
Non-Formulary
riociguat
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 761
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
NUCYNTA
tapentadol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CANASA
mesalamine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ADEMPAS
riociguat
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ORAPRED ODT prednisolone sod phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LAMISIL
terbinafine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZOHYDRO ER
hydrocodone bitartrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OVACE PLUS
sulfacetamide sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MIRAPEX ER
pramipexole di-hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RAPAMUNE
sirolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
METOZOLV ODT metoclopramide hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYSTOLIC
nebivolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VENLAFAXINE
HCL ER
venlafaxine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tramadol hcl er
tramadol hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
VENLAFAXINE
HCL ER
venlafaxine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DIGIBAR
barium sulfate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ADEMPAS
riociguat
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZORVOLEX
diclofenac submicronized
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ADEMPAS
riociguat
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MYRBETRIQ
mirabegron
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VEREGEN
sinecatechins
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 762
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
LAMISIL
terbinafine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RAPAMUNE
sirolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LAMISIL
terbinafine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ARIMIDEX
anastrozole
06/26/2014
PERFOROMIST formoterol fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZYVOX
linezolid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VITAFOL-PN
prenatal vit with calcium
cmb 11/ferrous
fumarate/folic acid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZYVOX
linezolid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
HALOG
halcinonide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZYDONE
hydrocodone
bitartrate/acetaminophen
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DENAVIR
penciclovir
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
JENTADUETO
linagliptin/metformin hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
rosadan
metronidazole
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KINERET
anakinra
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EXFORGE HCT
amlodipine
besylate/valsartan/hydrochlo
rothiazide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EPANED
enalapril maleate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MIRAPEX ER
pramipexole di-hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ARICEPT
donepezil hcl
ADD TO FORMULARY
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
ADD TO FORMULARY
Non-Formulary
Non-Formulary
Generics
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 763
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
NESINA
alogliptin benzoate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
INLYTA
axitinib
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
ANTARA
fenofibrate,micronized
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AFINITOR
DISPERZ
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
HALOG
halcinonide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VICTRELIS
boceprevir
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VICTRELIS
boceprevir
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OSENI
alogliptin
benzoate/pioglitazone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MENOPUR
menotropins
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MENOPUR
menotropins
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
VITAFOLOB+DHA
prenatal vitamins comb
10/ferrous fumarate/folic
acid/dha
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXISTAT
oxiconazole nitrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ENJUVIA
estrogens,conj.,synthetic b
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NALFON
fenoprofen calcium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SOMATULINE
DEPOT
lanreotide acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
INVEGA
paliperidone
CHANGE TIER
Preferred Brands
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 764
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
JAKAFI
ruxolitinib phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYSTOLIC
nebivolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TREXIMET
sumatriptan
succinate/naproxen sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
METVIXIA
methyl aminolevulinate hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
HALOG
halcinonide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FIRSTlansoprazole
LANSOPRAZOL
E
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DERMASORB
HC
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FIRSTlansoprazole
LANSOPRAZOL
E
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DEMEROL
meperidine hcl/pf
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
INFERGEN
interferon alfacon-1
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
temazepam
temazepam
CHANGE TIER
06/26/2014
INVEGA
paliperidone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FINACEA
azelaic acid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
MAGNACET
CHANGE TIER
Preferred Brands
Non-Formulary
hydrocortisone/skin cleanser
combination no.35
oxycodone
hcl/acetaminophen
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 765
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
SUCLEAR
polyethylene glycol
3350/bowel prep #2,two part
prep
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NOXAFIL
posaconazole
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OVACE PLUS
sulfacetamide sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
temazepam
temazepam
CHANGE TIER
06/26/2014
OLEPTRO ER
trazodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TARKA
trandolapril/verapamil hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SYLATRON 4PACK
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SYLATRON
peginterferon alfa-2b
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NAPRELAN
naproxen sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
foltanx rf
levomefolate ca/pyridoxal
phos/mecobalamin/schiz.
algal oil
CHANGE TIER
Generics
Non-Formulary
06/26/2014
MINASTRIN 24
FE
norethindrone acetateethinyl estradiol/ferrous
fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MEGACE ES
megestrol acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
MAGNACET
oxycodone
hcl/acetaminophen
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GABADONE
aa comb.no8/acetylcarnitine
hcl/grape/cocoa/hrb cb126
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
AXERT
almotriptan malate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FIRSTlansoprazole
LANSOPRAZOL
E
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 766
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
CEDAX
ceftibuten
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CEDAX
ceftibuten
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CEDAX
ceftibuten
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AFINITOR
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
XYREM
sodium oxybate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
REPRONEX
menotropins
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PEXEVA
paroxetine mesylate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SUBSYS
fentanyl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
FYCOMPA
perampanel
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
TACHOSIL
fibrinogen/thrombin (human
plasma derived)
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
STRATTERA
atomoxetine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
VYTORIN
ezetimibe/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PRILOSEC
omeprazole magnesium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PYLERA
colloidal bismuth
subcitrate/metronidazole/tetr
acycline hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PREPOPIK
sodium
picosulfate/magnesium
oxide/citric acid
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 767
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
Preferred Brands
Non-Formulary
06/26/2014
PREPOPIK
sodium
picosulfate/magnesium
oxide/citric acid
CHANGE TIER
06/26/2014
lindane
lindane
CHANGE TIER
06/26/2014
PACNEX MX
benzoyl peroxide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZOHYDRO ER
hydrocodone bitartrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CITRANATAL 90 prenatal vit no.72/iron
DHA
carbony,gluc/folic
acid/docusate/dha
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SOMATULINE
DEPOT
lanreotide acetate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OMNITROPE
somatropin
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AFINITOR
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
NOXAFIL
posaconazole
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
IMBRUVICA
ibrutinib
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
venlafaxine hcl er venlafaxine hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
hemenatal ob
prenatal vit no.21/iron
polysacch,heme
polypep/folic acid
CHANGE TIER
06/26/2014
DUET DHA EC
prenatal vitamin no.107/sod
ferede-iron
poly/fa/om3/dha/epa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
venlafaxine hcl er venlafaxine hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
JUVISYNC
sitagliptin
phosphate/simvastatin
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 768
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
PROTECT IRON multivitamin-minerals
no.24/iron polysaccharide
complex/fa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXECTA
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DENAVIR
penciclovir
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tl-select
prenatal vit with calcium
no.80/iron fum/folic
acid/dss/dha
CHANGE TIER
06/26/2014
BYSTOLIC
nebivolol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
pnv-ob with dha
prenatal vitamins comb
10/ferrous fumarate/folic
acid/dha
CHANGE TIER
Generics
Non-Formulary
06/26/2014
NAPRELAN
naproxen sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
INVEGA
paliperidone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DENAVIR
penciclovir
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BYDUREON
exenatide microspheres
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ARICEPT ODT
donepezil hcl
ADD TO FORMULARY
06/26/2014
INVEGA
paliperidone
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
IMBRUVICA
ibrutinib
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
GLYTACTIN 15 nutritional therapy for pku
PE BETTERMILK with iron no.41
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
tramadol hcl er
tramadol hcl
CHANGE TIER
Generics
Non-Formulary
06/26/2014
CAMBIA
diclofenac potassium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BEPREVE
bepotastine besilate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
KERAFOAM
urea
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CAMBIA
diclofenac potassium
CHANGE TIER
Preferred Brands
Non-Formulary
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 769
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
INTUNIV
guanfacine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
XOLAIR
omalizumab
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NUCYNTA
tapentadol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OPANA ER
oxymorphone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NUCYNTA
tapentadol hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DERMASORB
TA
triamcinolone
acetonide/emollient
combination no.86
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
PROTOPIC
tacrolimus
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
lofibra
fenofibrate
CHANGE TIER
06/26/2014
GILOTRIF
afatinib dimaleate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
CITRANATAL
ASSURE
prenatal vit no.73/iron
carbony,gluc/folic
acid/docusate/dha
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
LESCOL XL
fluvastatin sodium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ARICEPT
donepezil hcl
ADD TO FORMULARY
06/26/2014
ONMEL
itraconazole
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
Generics
Non-Formulary
06/26/2014
morphine sulfate morphine sulfate
er
CHANGE TIER
06/26/2014
INTUNIV
guanfacine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
RELENZA
zanamivir
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
HALOG
halcinonide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
INTUNIV
guanfacine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
oxycodone hcl
oxycodone hcl
CHANGE TIER
Generics
Non-Formulary
Non-Formulary
Non-Formulary
Non-Formulary
BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics.
PAGE 770
UPDATED 10/2016
4D Pharmacy Managed Formulary Updates
Effective Date
Brand Name
Generic Name
Type of Change
Previous Value
New Value
06/26/2014
DICLEGIS
doxylamine
succinate/pyridoxine hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ZETONNA
ciclesonide
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
POTIGA
ezogabine
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
OXYCONTIN
oxycodone hcl
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
SIRTURO
bedaquiline fumarate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
JAKAFI
ruxolitinib phosphate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
BOTOX
onabotulinumtoxina
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
DUET DHA EC
prenatal vitamin no.107/sod
ferede-iron
poly/fa/om3/dha/epa
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
QNASL
beclomethasone
dipropionate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
EXELDERM
sulconazole nitrate
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
ONMEL
itraconazole
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
NEXIUM
esomeprazole magnesium
CHANGE TIER
Preferred Brands
Non-Formulary
06/26/2014
AFINITOR
everolimus
CHANGE TIER
Preferred Brands
Non-Formulary
0

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